Inspection on 07/03/06 for Woodleigh House

This inspection was carried out on 7th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodleigh House 20/02/08

Woodleigh House 09/05/07

Woodleigh House 11/07/05

Woodleigh House 09/12/04

Woodleigh House 08/11/04

Woodleigh House 03/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Woodleigh House Woodlea Road Waterfoot Rossendale Lancashire BB4 7BD Lead Inspector Mrs Christine Mulcahy 7th March 2006 Unannounced Inspection 10:00 07 March 2006 th Woodleigh House DS0000009633.V273090.R01.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 Woodleigh House DS0000009633.V273090.R01.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. Woodleigh House DS0000009633.V273090.R01.S.doc Version 5.0 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 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) Mrs Anna Geraldine Ellis Mr John Stevenson Lord Care Home 9 Category(ies) of Learning disability (8), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Woodleigh House DS0000009633.V273090.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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 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 Once this named service user leaves the property, then the registration should revert back to a maximum of 9 service users with LD The service should employ a suitably qualified and experience person who is registered with the Commission for Social Care Inspection as manager of Woodleigh House only. 11th July 2005 Date of last inspection 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 and each are large single bedrooms with accompanying individual 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 DS0000009633.V273090.R01.S.doc Version 5.0 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 7th March 2006. The service was inspected against the National Minimum Standards for Adults (18 – 65) At the time of the inspection 8 service users were accommodated at the home. The inspection involved discussion with service users, the registered manager, care staff and the service manager. Observations were made throughout the visit and records were examined. There are various references to ‘case tracking’ throughout this report. All records relating to these people are inspected, along with the rooms they occupy in the home. What the service does well: What has improved since the last inspection? All service users had been provided with a copy of a contract that states the terms and conditions of accommodation and other conditions between the home and the service user. All records including the homes policies and procedures were in the process of review. Safety procedures were posted around the home and clearly explained areas of health and safety to staff and service users. Woodleigh House DS0000009633.V273090.R01.S.doc Version 5.0 Page 6 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 DS0000009633.V273090.R01.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 Woodleigh House DS0000009633.V273090.R01.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): This section was not assessed at this inspection. EVIDENCE: Woodleigh House DS0000009633.V273090.R01.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): YA 6, 7, 9 Service user care plans detailed how their needs would be met and included opportunities to make decisions about their own lives. A risk managed environment enabled service users to take responsibilities. EVIDENCE: Service user case tracking confirmed they had been assessed and described how the service would meet their current and changing needs, aspirations and achieve goals. The plan was drawn up with the involvement of the service user and was generated from a care management assessment and the homes own assessment. It covered all aspects of personal, social and healthcare support and clearly described the steps needed to support the service user to meet the agreed goals. The care plan consisted of an initial form with the service user name, age, address and next of kin. There was a list of likes and dislikes including food and activities and a life profile that highlighted the service user background. The inspector observed staff demonstrating an understanding and professional approach to service users and it was apparent they were keen to ensure service users maximised control over their own lives. Woodleigh House DS0000009633.V273090.R01.S.doc Version 5.0 Page 10 When asked a service user confirmed they were able to make choices about the menu and daytime and evening activities including educational activities. This information was recorded in care plans along with decisions made by staff and others and why this was the case. Care plans had been reviewed regularly and care plan review sheets had been completed and signed by staff and service users. Included in the care plan were individualized procedures and risk assessments to be followed by staff, as her health condition was likely to cause her harm. Treatment given including medical professional involvement was well documented. Specific risk assessments with regard to absconding, outside activities, safety in the kitchen, personal property and money were also included in the care plan. The care plan addressed areas of need that the service user would encounter on a day-to-day basis and included personal hygiene, social skills, relationships, medication and physical aggression. Woodleigh House DS0000009633.V273090.R01.S.doc Version 5.0 Page 11 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): YA 12, 15, 16 Service users took part in fulfilling and valued activities through community and social inclusion and family links. Daily routines promoted independence. EVIDENCE: Staff helped service users continue their education through support and encouragement. On the day of the inspection a number of service users were attending college for further education, literacy, numeracy and life skills training. The registered manager confirmed this had been organised by service users and staff to ensure the activities suited their abilities. Service users who did not take part in these activities were supported to help with day-to-day activities such as shopping, menu planning or daily life skills. Other community facilities like shops, library, cinema, pubs and leisure centres were used. Transport was always available and was provided by the home. Some service users were encouraged to use public transport to promote independence as identified in their care plan Woodleigh House DS0000009633.V273090.R01.S.doc Version 5.0 Page 12 The care plan examined highlighted service user family links and friendships and described how regular contact with his parents and other family members has had a positive effect on his wellbeing. Photographs in the home showed how service users had opportunities to meet and make friends with people who do not have a disability. While personal and intimate relationships were not encouraged by staff service users were able to develop and maintain relationships with people of their choice. A care plan confirmed this was managed through risk assessments and specialist guidance was provided to help the service user to make appropriate decisions when necessary. Woodleigh House DS0000009633.V273090.R01.S.doc Version 5.0 Page 13 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): YA 18, 19, 20 The health care needs of service users were met and identified through care plans. Medication required better storage and management. EVIDENCE: Case tracking confirmed that service user healthcare needs were addressed through care plans. Daily records were examined and confirmed that service users were supported to make decisions about their own health care needs where possible. A care plan examined clearly described the staff and specialist intervention. The service user received regular health checks paying attention to specific needs that included health routines, medication, mobility, physical needs, social skills, personal hygiene and support. Records were kept of all prescribed medicines received, administered and leaving the home to ensure there was no mishandling. Most medicines were stored in a secure medicine cabinet within a room next to the office. A number of medication administration records sheets (MAR) were examined and had been signed by staff. Controlled Drugs were stored appropriately however the Controlled Drugs register did not give an accurate record of tablets prescribed and held at the home for one service user. Homely remedies were not recorded as received into the home or when administered to service users. A key was not available to lock the medication room door and some medicines were being stored out of Woodleigh House DS0000009633.V273090.R01.S.doc Version 5.0 Page 14 the locked cabinet due to lack of space. The registered manager was required to ensure that he ensures compliance with the home’s policy and procedure for the recording, handling, storage and administration of medicines including homely remedies. Woodleigh House DS0000009633.V273090.R01.S.doc Version 5.0 Page 15 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): YA 22, 23 The homes clear and effective complaints procedure included the stages and timescales for the process. Service users were protected from risk of harm. EVIDENCE: A record of complaints was not available for inspection. The registered person was required to ensure that a record of complaints made by service users or representatives or relatives is kept and is available for inspection. There was a robust procedure for responding to suspicions or evidence of abuse or neglect (including whistle-blowing) that ensured the safety and protection of service users. Staff said they had received abuse training and understood the definitions of types of abuse. When asked one member of staff said the staff team were aware of whom to contact if they suspected service user abuse. Risk assessments were available and were examined along with care plans to ensure that service users were protected from harm at all times including during the use of physical intervention. The homes policies and procedures regarding service users money and financial affairs ensured safe storage of money and valuables within the home. Service users were encouraged to have separate savings accounts or relatives took responsibility for this. Woodleigh House DS0000009633.V273090.R01.S.doc Version 5.0 Page 16 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): YA 24, 26, 30 Service users live in a safe environment. Bedrooms promoted service user independence. The home is clean and hygienic. EVIDENCE: A tour of the building confirmed that it was accessible safe and well maintained meeting service users individual and collective needs. Doors to service user bedrooms were fitted with locks and service users were provided with a key as requested. Bedrooms seen had been furnished by the home with good quality furniture. Some bedrooms had been personalised by service users who had brought their own furniture and possessions with them. The home was clean and hygienic throughout. Systems and routines were included in care plans to ensure service users were involved in the day-to-day cleanliness of the home. Woodleigh House DS0000009633.V273090.R01.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): YA 33, 34 Robust recruitment policies and procedures were in place to protect service users. Ongoing training ensured up to date information for staff. EVIDENCE: Case tracking of a two new employees confirmed they had been recruited using the homes thorough recruitment procedure. All necessary employment checks to protect service users had been carried out. Further discussion with staff confirmed that training and development opportunities were frequently available to ensure service user needs were understood and met. When asked staff confirmed they had received training in Health and safety, first aid, NVQ 2, medication training, and fire training. The inspector discreetly observed staff working with service users and using skills and techniques that were appropriate demonstrating they were competent to meet service user needs. Woodleigh House DS0000009633.V273090.R01.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): YA 37, 42 The management and staff provide a safe and well-run environment for service users to live in. Policies and procedures at the home safeguarded service users rights and best interests. EVIDENCE: The registered manger is qualified, competent and experienced to run the home. He has many years experience of working with adults with a learning disability and has numerous work related qualifications. He will complete the Registered Managers Award (RMA) by August 2006. The health safety and wellbeing of staff and service users were promoted through the homes policies and procedures. Policies and procedures were found to be up to date and ensured compliance with relevant health and safety legislation. A review of the homes policies and procedures had begun and would take place in their priority order. The newly revised policies and procedures on adult protection and abuse met all elements of the national minimum standard. All employees had signed to confirm their understanding of both documents. Woodleigh House DS0000009633.V273090.R01.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 X X X X X Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodleigh House Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 x X X X 3 X DS0000009633.V273090.R01.S.doc Version 5.0 Page 20 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 YA20 Regulation Requirement Timescale for action 07/03/06 2 YA22 Regulation The registered manager was 12(2) required to ensure that staff complied with the home’s policy and procedure for the recording, handling and administration of medicines. Regulation The registered manager must 07/03/06 22(8) ensure that a record is kept of all issues raised or complaints made by service users. Details of any investigation, action taken and outcome. This record must be checked at least 3 monthly. 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 Woodleigh House DS0000009633.V273090.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Woodleigh House DS0000009633.V273090.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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