CARE HOME ADULTS 18-65
Woodleigh House Woodlea Road Waterfoot Rossendale, Lancashire BB4 7BD Lead Inspector
Christine Mulcahy Unannounced 11 July 2005 10:00 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 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 Stationary 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. Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Woodleigh House Address Woodlea Road Waterfoot Rossendale Lancashire BB4 7BD 01706 227418 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Anna Geraldine Ellis Mrs Diane Coglan Care Home Only Personal Care (PC) 9 Category(ies) of Learning disability (LD) 8 registration, with number of places Mental disorder, excluding learning disability or dementia (MD) 1 Male Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1 That within the total of 9 places there can be a maximum of 8 service users requiring personal care who fall into the category LD. 2 That within the total of 9 places there can be a maximum of 1 service user requiring personal care who falls into the category MD. 3 Once this named service user leaves the property, then the registration should revert back to a maximum of 9 service users with LD. Date of last inspection 23 and 24 November 2004 Brief Description of the Service: Woodleigh House is registered with the Commission for Social Care Inspection to provide care and accommodation to nine younger adults who have a learning disability and one adult who has a mental illness. Woodleigh House is a large detached property situated in its own grounds in the village of Waterfoot in Rossendale. The home is located on a main bus route and service users can use transport provided by The home to access facilities in or out of the area. Accommodation is homely and is provided on two levels. Access to the first floor is via a passenger lift. All bedrooms are on the first floor which provides large single bedrooms with accompanying individual service user lounge areas. The ground floor consists of a lounge with attached conservatory, a dining area and a modern kitchen. Confidential information and medication are both stored securely in separate rooms. The home is decorated, equipped and furnished to a good standard. Furnishings are domestic and modern in character. There are enclosed garden areas surrounding the property. Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The summary below is an overview of the findings of an unannounced inspection conducted at Woodleigh House on Monday 11th July 2005. The service was inspected against the National Minimum Standards for Adults (18 – 65). Woodleigh House is registered to provide care and accommodation to 9 younger adults with learning disabilities including 1adult who has a mental illness. At some time during the inspection all service users were accommodated at the home and the inspector spoke to all of them. Throughout the report there are various references to “case tracking” this is a method where the inspector focuses on a small representative group of service users. All records pertaining to these people are examined along with the rooms they occupy. Observations of the care provided are made and the service users are invited to have a discussion with the inspector to discuss their experiences at life at the home. This process is not to the exclusion of other service users who are all involved in the inspection process in various ways. Case tracking was also used as an inspection tool with regard to staff working in the home. This inspection involved discussion with service users and the registered manager, observations of the care staff as they carried out their duties. Notes, discussions with staff and observations, taken from a previous introductory visit made to Woodleigh House on Friday 17th June 2005 are also included in this report. Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 6 What the service does well: What has improved since the last inspection?
Control and restraint policies and procedure had been updated and reviewed to provide a safer working environment for staff and a safer living environment for service users. The control and restraint policy and procedure was clear, robust and clarified the actions staff may take to avoid the use of restraint. With the staff skills, expertise and knowledge of the service user group service users needs were met and a safe environment was maintained. The appointment of a service manager has highlighted some service deficiencies that are now being addressed and steps to improve areas of the service are underway. Steps to ensure that one service user is better supported and needs are better met are being introduced by the management team. Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 7 Care plans have recently been reviewed and a new care plan format introduced to improve on the existing ones. Although comprehensive and detailed the plans clearly describe the service user needs in the words of the service user. Service users have written some of the plans themselves with help from the staff. The plans enable service user to become real people once written by themselves and address their personal aspirations in their own words. Emotional and social care needs, routines, likes and dislikes, allergies, health needs, personal hygiene and general health remain part of the care plan format. The new format ensures service users and staff work together more to create a comprehensive picture of the service user and their individual needs. Policies and procedures for medicines management have been reviewed in line with current legislation. Consent to administration of medication is now recorded on service user care plans. Training to ensure that some staff are authorised to administer medication has begun. A staff signature list, medication returns list, and medication leaving the home list are now in place to ensure that medicines are handled safely. 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. Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 9 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 standard(s) YA 2, 4, 5 Service users admissions had been based on a full assessment. Service users could visit the home before moving in. A written contract was not available for the service user. EVIDENCE: Examination of two service user case files confirmed that service users had been referred through care management arrangements. Due to the challenging behaviour displayed by the service users there was a great emphasis on detailed assessments being carried out. Assessments and management of risk, physical and mental health care, specific condition related needs, specialist input and methods of communication were all sections that made up a comprehensive plan of care. It was apparent that assessments had been considered against the Statement of Purpose to ensure that the service was able to meet the complex needs of the service users. One service user said, “I came to the home before I moved in and I met some of the people who live here.” A copy of the contract was not available on the service user file. The service user said that she did not have a copy of a written contract. Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 10 The registered manager stated that the new service manager was in the process of arranging for these to be introduced although a date had not yet been set. The registered manager was required to ensure that all service users were provided with a copy of the terms and conditions of accommodation and other conditions between the home and the service user. Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 11 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 standard(s) YA 6, 9 All service users had an individual care plan. Some risk management strategies were agreed and recorded in service users plans. Service users plans of care were reviewed regularly. EVIDENCE: Case tracking confirmed that with the guidance of the registered manager, key workers had developed and agreed with service users an individual plan. The plans set out any restrictions on choice and freedom that has been agreed with the service user. The plans also highlighted how service user specialist needs would be met. The care plans examined clearly detailed individual procedures for those service users who were likely to display challenging behaviour focusing on the use of diffusing strategies, positive behaviour, ability and willingness. When asked a service user confirmed they had been involved with drawing up the plan along with their key worker. “The staff help me,” she said. Care plans were written in a style that could be understood by the service users. Plain English, bold print, photographs and pictures were used where
Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 12 necessary. The care plans examined had been recently reviewed to ensure that service users changing needs were recorded and instructions were carried out. Risks to service users were assessed prior to admission to the home and the care plans examined contained risk assessments for activities where potential risks were apparent. One service user had been assessed with regard to their personal safety out of the home. In this circumstance the care plan made clear where the risks were apparent and the service user was given training about their personal safety. This was done without limiting the service users preferred activity or choice. Safeguards were in place to ensure that any restrictions were legally and ethically bound and included the agreement of the service user, their relatives and or representatives. Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 13 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 standard(s) YA 11, 13, 17 Service users had opportunities to learn and use practical life skills. Staff supported service users to be part of the local community. Service users were offered a choice of suitable meals. EVIDENCE: Case tracking confirmed that service users had the opportunities to learn and use practical skills. One service user attended the local college on a full time basis. The service user attended an “essential skills for life” course. The course covered topics like, IT, advocacy, citizenship, health and fitness, health and safety, home management and relationships. When asked the service user made positive comments about the course and although the course had ended for the summer, the service user was looking forward to returning to collage in the autumn to continue studying. Although there was a vehicle provided by the home for service users, it was apparent they were encouraged by staff to use public transport in accordance with assessed needs and the individual plan. Service users told the inspector that they regularly visited places of interest, took walks to the pub and went on shopping trips together as a small group. Other activities like swimming,
Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 14 had been arranged on an individual basis and staff were available in appropriate numbers to accommodate these activities. It was apparent that service users health and well being was promoted due to the varied choice of meals offered. When asked one service user said, “The food here is good, we can have what we want.” Others told the inspector of their favourite foods and how they enjoyed take-away meals at certain times during the week. Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 15 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 standard(s) YA 19, 20 There were appropriate procedures in place to address service user health care needs. Service user health care needs were monitored and potential complications identified. The control of medication was well managed promoting good health. EVIDENCE: Case tracking confirmed that service users were registered with a G.P and when necessary received other health care support like dental and eye care when appropriate. Visits to these services were encouraged by staff to ensure normal living skills took place. A record of all current medicines for service users was maintained in a secure area of the home. Records examined confirmed that medicines in the home were handled safely to protect service users from risk of harm. A staff training matrix was examined and the registered manager confirmed that 2 staff had recently completed medicines training ensuring the safe handling of medicines in the home. Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 16 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 standard(s) This section was not assessed on this occasion. EVIDENCE: Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 17 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 standard(s) YA 24, 30 Facilities in the home met the criteria for its stated purpose. Some areas in the home had been refurbished. The home was clean, pleasant, and hygienic. EVIDENCE: Woodleigh House is a large detached property situated in its own grounds. Accommodation is homely and is provided on two levels accessed via a passenger lift. All bedrooms are on the first floor which provides large single bedrooms with accompanying individual service user lounge areas. The ground floor consists of a lounge with attached conservatory, a dining area and a modern kitchen. The home is decorated, equipped and furnished to a good standard. Furnishings are domestic and modern in character. A tour of the home showed a good standard of cleanliness and hygiene. As part of the case tracking process the inspector examined 2 bedrooms and one service user private lounge area. It was apparent that service users felt able to personalise their own rooms with their own style that reflected service users personalities. Kitchen and dining room areas were examined and seen to be clean and hygienic. Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 18 The ground floor bathroom area had recently been refurbished to a high standard to create a “wet room”. The bathroom comprised a new power shower, toilet and adaptable bath to ensure the safety of service users and staff. When asked one service user made positive comments like “nobody uses the other bathroom now, we all like to use this one.” Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) YA 32, 35 Training and development was linked to the homes aims and service user needs. Staff were trained well enough to ensure the needs of service users were met. EVIDENCE: Case tracking of one staff file and discussion with the registered manager highlighted that staff had received induction and foundation training to meet the needs of the service users. There was a staff training and development plan that identified individual staff and their training needs. The plan was also a record of training attended such as health and safety, first aid, manual handling, fire safety, epilepsy, food hygiene, physical intervention, abuse, risk assessments, National Vocational Qualification Level 2/3 and medication training. The registered manager has introduced a staff induction booklet to the home called “Developing Competent Carers” the booklet comprises of lists of induction topics which are discussed with individual staff during staff supervision. Each topic is ticked off to confirm staff knowledge in the specific subject area. Case tracking of one staff file and discussion confirmed that he had undertaken a number of the induction training courses to ensure service user needs were better met.
Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) YA 39, 42 The management and staff provide a safe and homely environment for the service users to live in. Some policies and procedures needed reviewing to ensure that service users were protected from risk of harm. EVIDENCE: Service users and staff health and safety was promoted through robust safety procedures and risk assessments. These were examined and seen to be well documented, recorded and available to staff to ensure safe working practices. Systems were in place to ensure that challenging situations involving service users and staff were risk assessed to ensure both were safe from harm. Some of the homes policies and procedures need reviewing to ensure that service users are protected and safe working practices are in place. Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 21 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 x 3 x 3 2 Standard No 22 23
ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 x x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 x x x x 3 Standard No 31 32 33 34 35 36 Score x 3 x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Woodleigh House Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 22 NO Are there any outstanding requirements from the last inspection? 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. Standard YA 5 Timescale for action Regulation The registered manager is Monday 5 required to ensure that all 12th service users are provided with a September copy of a contract that states the 2005 terms and conditions of accommodation and other conditions between the home and the service user. Regulation The registered manager shall 17 ensure that all records including the homes policies and procedures are reviewed and up dated regularly to ensure safe working practices at the home. Monday 29th August 2005 Regulation Requirement 2. YA 42 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Woodleigh House F57 F07 S9633 Woodleigh House V231810 110705 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 1st Floor, Unit 4 Petre Road, Clayton-Le-Moors Accrington Lancashire. BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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