Inspection on 09/05/07 for Woodleigh House

This inspection was carried out on 9th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 5 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 07/03/06

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 Susan Hargreaves Unannounced Inspection 9th May 2007 09:30 Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 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.V333103.R01.S.doc Version 5.2 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.V333103.R01.S.doc Version 5.2 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 10 Category(ies) of Learning disability (9), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Once this named service user leaves the property, then the registration should revert back to a maximum of 10 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. Up to 9 service users in the category of LD requiring personal care. One service user in the category MD requiring personal care. 3. 4. Date of last inspection 7th March 2006 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. The current fees charged at Woodleigh House are £1000 per week. A statement of purpose and service user guide was available to prospective residents and their relatives on request. Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. • • • • • • • The inspector came to Woodleigh House on 9 May 2007 to do a key inspection. The inspector spoke to the people staying at the home. The inspector also spoke to the manager and 2 members of staff. The care records of 2 people staying at the home were inspected Records about how the home is run were also looked at. One resident showed the inspector round the home. 7 residents filled in questionnaires. These stated Woodleigh House was a nice place to live. 5 relatives of residents filled in questionnaires. These stated Woodleigh House was a good place to live. One relative wrote ‘Woodleigh House is a wonderful place.’ • What the service does well: • Members of staff were friendly and got on well with the residents. One resident said she had enjoyed going out for a meal with a member of staff. 2 members of staff said they liked working at Woodleigh House. There were lots of things for residents to do. These included, going swimming, bowling and shopping. One resident said, “I like going on trips out with the other residents.” On special occasions like Valentines Day residents and staff organised a party. Residents planned and helped to cook the meals. All the residents asked said the meals were good. Resident’s relatives wrote on their questionnaires, ‘They really care about the people they look after.’ ‘They create a happy family atmosphere.’ DS0000009633.V333103.R01.S.doc Version 5.2 Page 6 • • • • • • Woodleigh House What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 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.V333103.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A thorough admissions procedure ensures the needs of people using the service were identified and met. EVIDENCE: There have been no new admissions to the home for almost a year. The care records of the most recent admission to the home were inspected. This resident had been to Woodleigh for respite care prior to admission. The care records contained a copy of the assessment carried out by the social worker. The manager had also interviewed and assessed this resident prior to admission. This information provided useful information for the care plan. Following admission the resident was asked to complete a questionnaire about the admissions procedure. One resident commented on the survey form, ‘I came on a few visits for meals and then I also had a few overnight stays before moving in permanently.’ Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s involvement in care planning makes sure their decisions are respected and their care needs are addressed. EVIDENCE: The individual care plans of two residents were inspected. These plans identified the needs of each resident and explained how these needs were to be met. Residents were involved with developing their own care plan, which included individual likes and dislikes relating to diet and activities. The care plan about personal care for one resident was illustrated and clearly written to promote understanding. Care plans were up dated when the needs of the resident changed. Care plans were reviewed regularly and up dated when the needs of the resident changed. A detailed report was completed during each shift about the health and wellbeing of the resident and the activities they had chosen. Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 Page 10 Residents were encouraged to make decisions and choices about their lifestyle including daily routine and activities. The seven residents who completed surveys all stated that they chose what to do during the day and evening and at the weekend. Appropriate risk assessments had been completed for each resident. These included information about how the risks were managed. Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents were supported to have an active and fulfilling lifestyle. Residents planned all meals to their own tastes and needs. EVIDENCE: Residents were encouraged and supported to continue with their education. This included learn direct courses in computers, maths and English. Two residents attended Burnley college on four days every week. One resident went to Bury college on two and a half days every week. Residents were also encouraged and supported to find suitable employment if possible. One resident worked at a friends business for one day a week and another resident helped in a charity shop for half a day a week. Residents were encouraged to help with household tasks for half a day per week. This involved tidying and cleaning their own bedroom, changing the bed and helping to prepare meals. Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 Page 12 A variety of leisure activities were available these included swimming, bowling, cookery class, art & craft, gardening group, computer classes, shopping, gym, youth club & meals out. Trips out were arranged to various attractions including, Knowsley safari park, Blackpool, Bolton Abbey, canal boat trip. Residents had been to the X-factor concert and concerts performed by local amateurs. Holidays were also arranged to, Ribey Hall, Anglesey & Blackpool. Parties were organised to celebrate special occasions e.g. Valentines day, Ascot ladies day. Friends and relatives were invited to these events. Visits from family and friends were usually by arrangement to ensure the resident would be at home. Residents were also encouraged to visit their families and transport for this was provided. The relative of one resident wrote on the survey, ‘My son meets me every Saturday and we keep in touch by phone 3-4 times a week.’ Residents were responsible for planning all meals. All the residents asked said the meals were good. One resident said she liked the meals and enjoyed cooking. Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of each resident were identified and met. Medication was managed in a way that put some residents at risk. EVIDENCE: Personal care was carried out in the privacy of the resident’s own room or bathroom. Members of staff were observed speaking to residents in a friendly and professional manner. All the residents asked said the staff were nice. The two care plans inspected included detailed information about the healthcare needs of each resident. Residents were registered with a GP and had access to other healthcare professionals. Policies and procedures for the management of medication were in place. Medication was stored in cupboards inside a locked utility room. Members of staff responsible for the administration of medication had received appropriate training. The medication administration records for three residents were inspected. Only one of these records was up to date and indicated that medication had been given to the resident as prescribed by the doctor. One of Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 Page 14 the medication administration records included handwritten instructions which were not signed or witnessed. These instructions stated ‘Diazepam 5mg 1 tab when required’. There was no information about how many doses could be taken in 24 hours. Written guidance for staff stating when the resident needed this medication was not in place. Administration of the Diazepam had been recorded mostly in the ‘as required medication’ book and twice on the medication administration record. Moreover, it was evident that 10mg of Diazepam had been administered in a sinlge dose on several occasions. The handwritten instructions on the medication administration record for another resident stated that two 25mg tablets should be given twice a day. The packet the medication had been dispensed in by the chemist stated that one 25mg tablet should be taken four times a day. The manager was asked to inform the resident’s GP the next day and verify exactly the dose and times of administration for this medication. Discussion with the manager also confirmed that he had not received training in the management of medication. Records of the receipt of medication were in place for previous months but had not been recorded for the current month commencing 23/04/07. Records of unused medication returned to the pharmacy were seen. Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents felt able to express their concerns. Staff had a good understanding of protection issues. EVIDENCE: All residents have access to an illustrated copy of the complaints procedure. One complaint has been made to the manager since the last inspection. Details of the compaint and the response to the complainant were available. One resident explained how he would talk to the manager or another member of staff if he had any complaints. Two residents who completed surveys stated that they kenw who to go to if had a complaint. Detailed policies and procedures for safeguarding vulnerable adults were in place. These policies provided clear guidance for staff to follow if allegations of abuse were made including the telephone numbers of people to inform. The procedure also informed staff not to take statements from the people involved. Policies and procedures were also in place for, whistle blowing, racial harrassment, challenging behaviour and physical intervention. Safeguarding vulnerable adults was discussed with two members of staff they knew the procedure and said they would report any concerns immediately. Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The house was well maintained and provided a comfortable and ‘homely’ environment for the residents. EVIDENCE: The home was clean, tidy and well maintained. Communal rooms were suitable for a variety of social and cultural activities. Residents had personalised their bedrooms to suit their own needs and interests. To ensure the premises continued to provide a homely and attractive environment for the residents a detailed maintenance plan was in place. This included redecoration and improvements to an en suite bathroom, a new bathroom on first floor and tarmacing the area to the front of the house. Laundry facilities were suitable for the size of the home. Residents were encouraged to do their own washing with help and supervision for members of Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 Page 17 staff if necessary. An infection control policy was available Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Members of staff had the skills and knowledge necessary in order to meet the needs of the residents. EVIDENCE: Examination of the duty rota confirmed that a sufficient number of staff were on duty for all shifts in order to meet the assessed needs of the residents. The number of staff on duty varied according to the activities taking place. Training for all members of staff was actively encouraged. Indution training was in place for all new employes. Learning disabilities Award Framework (LDAF) training was included in the induction programme. Training for all members of staff included, fire awareness training, moving and handling, basic food hygiene and first aid. An external training provider did medication training in house. Thirteen members of staff had achieved NVQ qualifications, six at level 2, five at level 3 and one at level 4. One member of staff was working towards NVQ level 2. Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 Page 19 The files of three members of staff appointed since the last inspection were examined. Two of these files indicated that all the required pre-employment checks to ensure protection of the residents had been completed prior to appointment. However, it was evident from the other file that this member of staff had started working at the home before a CRB/POVA check had been obtained. The date and signature of the referee was missing from the reference form. Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was effectively managed and provided person centred care for all residents. EVIDENCE: The registered manager has experience of caring for people with learning difficulties. He has completed the NVQ ‘registered Manager’s award’. He has also received training in dementai care, epilepsy and person centred planning. The home has achieved the nationally accredited Investors in People award. This award was successfully reassessed in March 2007. Questionnaires about the care and services provided at the home were distrubuted periodiaclly to residents. Completed ones were seen in the care Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 Page 21 records of several residents. The manager explained that residents meetings were held every two to three months and more often if they were planning a special event e.g. Christmas and Halloween parties. Minutes were not taken at these meetings and the manager was advised to record the dates, times and issues discussed at these meetings. An up to date business to help monitor the quality of the service and further improve outcomes for residents was in place. Relatives were encouraged to give feedback about the care provided informally when they visited the home. Relatives were, if possible, involved in care planning. Staff meetings were held monthly and minutes were seen. A staff survey had been completed in November 2006. Feed back from this survey was discussed at staff meetings and areas for improvement were identified. Fire alarms were tested weekly. Emergency lighting was checked every three months. The manager said the last fire drill had taken place in September 2006 but records to support were not available. Although fire awareness training took place every six months the manager was advised to hold regular fire drills, keep records of them and a record of the staff and residents present to ensure all members of staff and residents received this training. A fire risk assessment was in place. General risk assessments including information about how to manage the risk were in place these included, moving and handling objects, vacuuming etc. Records of routine servicing of equipment were seen. These included up to date gas safety and electrical installation certificates. The testing of small electrical appliances had taken place in March 2007. Although the temperature of the fridge and freezer were checked and recorded on some days, the manager was advised to ensure this was done every day. Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 Page 22 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 2 X Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 Page 23 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. YA20 Standard Regulation 13(2) Requirement To make sure individual residents are given the correct dose of their medication the registered manager must ensure that all medication is administered in accordance with the instructions written on the prescription by the doctor. Accurate records must also be kept of the administration of all medication including the time the medication is given to the resident. A record of all medication received into the home must be kept. This will make sure all medication is accounted for. To improve the management of medication and the safety of residents the registered manager must undertake training in the management of medication. A CRB/POVA check must be obtained for all new employees before they start working at the home in order to protect residents from abuse. Fire drills must be held regularly and records of these kept to make sure all members of staff DS0000009633.V333103.R01.S.doc Timescale for action 10/05/07 2. YA20 3. YA20 13(2) 10/05/07 9(2)(b)(i) 29/06/07 4 YA34 19(1)(b) Schedule 2. 23(4)(e) 10/05/07 5 YA42 31/08/07 Woodleigh House Version 5.2 Page 24 and residents know what to do if there is a fire. 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 YA20 2 YA20 3 YA34 4 YA42 Refer to Standard Good Practice Recommendations All handwritten instructions on the medication administration records should be signed and witnessed. Written guidance should be in place explaining when medication prescribed ‘when required’ should be given. The reference should allow space for the date and signature of the referee. The temperature of the fridge and freezer should be checked and recorded every day. Woodleigh House DS0000009633.V333103.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V333103.R01.S.doc Version 5.2 Page 26 - 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. 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