CARE HOME ADULTS 18-65
Woodlea Residential Care Home Woodlea 196 Upper Chorlton Road Manchester M16 7SF Lead Inspector
Val Bell Unannounced Inspection 16th December 2005 10:00 Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Woodlea Residential Care Home Address Woodlea 196 Upper Chorlton Road Manchester M16 7SF 0161 862 9521 0161 882 0744 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr S Pascau Mrs Dorothy Heaton Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A All the service users will fall within the category of mental disorder and may also have an associated learning disability.(One named service user currently accomodated is agreed 65 years or over). 13th September 2005 Date of last inspection Brief Description of the Service: Woodlea is a private home providing 24-hour personal care and accommodation for up to 15 adults with enduring mental ill health. Some of the residents may also have a physical disability. The home is a large converted Edwardian house set in a residential area in Trafford. Shops and a post office are within walking distance from the home. Public transport routes into Manchester city centre and surrounding areas are close by. The philosophy of the home is to maximise the potential of each resident and to develop and maintain independence. Accommodation is provided in 15 single bedrooms, none of which have en-suite facilities. Each bedroom is fitted with a wash-hand basin. Sufficient toilet and bathroom facilities are provided to meet the needs of the residents. Communal space comprised of a lounge with a connecting dining room and a separate nonsmoking lounge on the lower ground floor. There is a large private garden to the rear of the property and off-road parking space at the front. Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted during daytime hours on 16th December 2005. The focus of the inspection was to assess progress on the twelve outstanding requirements made at the previous inspection. It was encouraging to note that these eleven requirements had been met. During the inspection records, including care plans, were examined, conversations were held with staff and residents and a tour of the premises was undertaken. What the service does well: What has improved since the last inspection?
Significant improvements had been made in response to the requirements made in the previous inspection report. This included an ongoing redecoration, refurbishment and renewal programme and the health and safety systems within the home were being well managed. A safe system of medication administration had been implemented. The home had researched the community facilities available to residents and this had provided residents with new opportunities to develop their selfawareness and to engage in activities of personal interest.
Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 6 Cleaning schedules had been introduced and this had resulted in a cleaner and more hygienic living environment for the residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The home provides prospective residents with clear and comprehensive information to enable them to make a decision whether the home is the right place for them to live. EVIDENCE: Since the previous inspection the Statement of Purpose had been reviewed and updated to ensure that it included all the information required. Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Care plans had been subject to review on a monthly basis. This ensured that the changing needs of residents continued to be met. EVIDENCE: Significant progress had been made since the last inspection in developing key workers skills to become involved in the care planning process. Key workers had received training and guidance on report writing and had taken on responsibility for writing residents monthly reviews. The inspector was told that this would be further developed once key workers were competent and confident in taking more responsibility in developing care plans. Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Considerable progress on researching what facilities were available in the local community had provided residents with a varied choice of activities and new life experiences in which they could become involved. EVIDENCE: The home had made good progress in developing structured activity programmes in consultation with individual residents. Examples included opportunities for residents to engage in voluntary and supported employment, visiting a drop-in centre and undertaking a variety of hobbies and leisure pursuits such as handicrafts, writing poetry and music and choir sessions. Residents also had access to a support group for discussion relating to personal experiences of living with a mental health issue. Considerable research had been undertaken into finding out what community facilities were available. Information leaflets had been obtained and these were held in a folder and made available to residents.
Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 11 There was considerable evidence in care plans that the home placed a high importance on supporting residents to develop and maintain personal relationships. This was also confirmed in conversation with several residents. Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 EVIDENCE: Considerable improvements had been made to the homes system of medication administration since the last inspection. The storage of medication had been moved to a more suitable room, which was found to be clean and well ordered. Access to the medication room involved residents going down a flight of stairs and this had been suitably risk assessed. The home had obtained a copy of the Royal Pharmaceutical Society’s guidelines on the administration of medication in care homes and its guidance had been followed to develop a safe system. No excess stock was being held on the day of inspection and records appeared to be accurate and up to date. A full audit trail of medication administration was in place and medication training had been arranged for staff in the New Year. The home demonstrated a commitment to ensuring that the assessed needs of individual residents were being met. This was particularly evident in the care plan of one resident, as the home had successfully acquired funding for 6 additional hours of care per day to meet the resident’s specific needs.
Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 13 The home had recently experienced the death of a resident. Records and conversations with staff provided evidence that this had been handled sensitively ensuring that the wishes of the resident concerned were respected. Other residents living in the home had been supported through the bereavement process. The home received a commendation for best practice in this area. Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The large board situated at the front of the home, advertising for care staff draws the public’s attention to the personal needs of the people who live there. This does not respect their right to have privacy and dignity in their lives. EVIDENCE: Since the previous inspection the Commission had received an anonymous complaint. The nature of the complaint related to the large advertising board situated at the front of the home. This board advertises for care staff. The complainant felt that this draws attention to the fact that Woodlea is a home for people with mental ill health and that it is not in keeping with the values of privacy and dignity. The complainant also felt that as the board stated that care staff were ‘always wanted’ this gave the impression that the home had difficulty retaining staff. The registered manager said that she sympathised with this view and had previously discussed this issue with the homeowner, although no definitive decision on the removal of the board had been agreed. The home must be conducted in a manner that respects the privacy and dignity of residents and the home should adopt a more suitable recruitment policy. Consequently, this complaint was upheld and a requirement was made for the board to be removed. Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Ongoing improvements to the homes environment provided residents with a more comfortable and safer home in which to live. EVIDENCE: Since the last inspection all requirements relating to the environment and health and safety had been addressed. No further issues relating to health and safety were identified during the December inspection. The homes redecoration, renewal and refurbishment programme was ongoing and several significant improvements had been made to the home’s environment. On a tour of the home the premises were found to be clean and hygienic and cleaning schedules were in place. The manager stated that she was in discussion with a member of staff regarding taking on the role of housekeeper. This would ensure that a clean environment is maintained and enable carers to spend more time with residents. Residents had been consulted on the issue of smoking and it had been agreed that the downstairs lounge would be designated as a smoke-free area. Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 16 A planned programme of replacement bedroom furniture was underway. The new furniture will include a lockable facility for residents’ money and valuables. The home had acquired a digital thermometer and were undertaking weekly monitoring of all hot water outlets. Assessments were in place to identify the risks from contact with hot surfaces in the home, such as radiators. Where the risk of burning could not be managed, radiator guards had been ordered. Food stores were examined during the inspection and all food was found to be stored and labelled correctly. The inspector was told that maintenance and planning of the garden area to provide more suitable facilities for residents would be discussed at a residents meeting in spring 2006. Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the Standards in this section were assessed on this occasion. Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 41 and 42 Residents’ were confident that staff would consult them about day-to-day issues within the home and that their views would be taken seriously and acted upon. Considerable improvements in health and safety monitoring protected the welfare of people living in the home. EVIDENCE: Regular residents meetings had been held and written records were held. Residents confirmed that staff also consulted them on a daily basis. On a tour of the premises it was noticed that only half of the home’s certificate of registration was being displayed. A requirement was made accordingly. As detailed in the environment section, significant progress had been made on improving health and safety within the environment. No further health and safety issues were identified during this inspection. Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X X Standard No 22 23 Score 1 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Woodlea Residential Care Home Score 3 3 3 4 Standard No 37 38 39 40 41 42 43 Score X X 3 X 2 3 X DS0000005637.V270569.R02.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA22 YA41 Regulation 12 (4) 17 Requirement The registered person must remove the advertising board at the front of the home. The registered person must ensure that the homes certificate of registration is displayed in full within the home. Timescale for action 16/03/06 16/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodlea Residential Care Home DS0000005637.V270569.R02.S.doc Version 5.0 Page 21 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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