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Inspection on 16/01/06 for Woodley House Care Home

Also see our care home review for Woodley House Care Home for more information

This inspection was carried out on 16th January 2006.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents receive good quality care, and are supported and encouraged by trained and enthusiastic staff. Care plans are detailed, and encompass all aspects of daily living, managed within a risk assessment framework, which are regularly reviewed. Residents have experienced a wide variety of recreational activities, which have included day trips and holidays and evening events.

What has improved since the last inspection?

Improvements to record keeping include care planning, risk assessment management files and general administration has improved the information available to staff, which is now readily accessible. Residents have contributed to the development of their recreational pursuits by the introduction of Person Centred Planning meetings. Policies and procedures have been reviewed. Staff have accessed various training sessions, to promote resident health, welfare and safety.

What the care home could do better:

Daily records could be used with greater effect by encompassing detail of a resident`s life, including contact with others, along with their views and choices, which is written from the resident`s perspective. The administration and recording of medication could be improved to promote the health and welfare of residents.Staff training could be improved by underpinning existing training, which would enable staff to have a greater understanding of individuals with a Learning Disability and the development of care plans and the accessing of community resources. Learning Disability Award Framework training and level 3 National Vocational Qualification training in The Promoting of Independence would support this. The promotion of Quality Assurance could be improved, by the introduction of a newsletter and further development of questionnaires, which are distributed to relatives and health and social care professionals who have a stake in resident care at Woodley House.

CARE HOME ADULTS 18-65 Woodley House Care Home Woodley Street Ruddington Nottingham NG11 6EP Lead Inspector Linda Clarke Unannounced Inspection 16th January 2005 10:30 Woodley House Care Home DS0000008768.V272846.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 Woodley House Care Home DS0000008768.V272846.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. Woodley House Care Home DS0000008768.V272846.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodley House Care Home Address Woodley Street Ruddington Nottingham NG11 6EP 0115 9848069 0115 9456020 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 Brian McKean Miss Rachael Louise Stevenson Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Woodley House Care Home DS0000008768.V272846.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2005 Brief Description of the Service: Woodley House is an adapted period property that sits in its own grounds close to the centre of the village of Ruddington with its range of shops, churches and public houses. The accommodation is registered to accept up to 13 service users with a learning disability and offers personal care and support. The accommodation comprises both single and double rooms and spans over three floors without a vertical lift so any potential service users would have to be fully mobile. There are a number of communal facilities and these are used flexibly. There are secluded gardens and car parking to the front and side of the building. Woodley House Care Home DS0000008768.V272846.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection that took place between 10.30am and 3.30pm. When undertaking Inspections, the Commission for Social Care Inspection focuses on the outcomes of individuals staying in the home. To support this, three residents were ‘case tracked’. This means that the care records and care plans of these residents were checked. Various records were looked at as part of this inspection financial records, medication records, care plans and daily resident records. What the service does well: What has improved since the last inspection? What they could do better: Daily records could be used with greater effect by encompassing detail of a resident’s life, including contact with others, along with their views and choices, which is written from the resident’s perspective. The administration and recording of medication could be improved to promote the health and welfare of residents. Woodley House Care Home DS0000008768.V272846.R01.S.doc Version 5.0 Page 6 Staff training could be improved by underpinning existing training, which would enable staff to have a greater understanding of individuals with a Learning Disability and the development of care plans and the accessing of community resources. Learning Disability Award Framework training and level 3 National Vocational Qualification training in The Promoting of Independence would support this. The promotion of Quality Assurance could be improved, by the introduction of a newsletter and further development of questionnaires, which are distributed to relatives and health and social care professionals who have a stake in resident care at Woodley House. 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. Woodley House Care Home DS0000008768.V272846.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 Woodley House Care Home DS0000008768.V272846.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): EVIDENCE: Standards within this section were not inspected on this occasion, but core standards were inspected at the inspection, which took place earlier in the year. Woodley House Care Home DS0000008768.V272846.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): 6, 8, 9 and 10. Individual plans of care are in place ensuring that individuals receive the care they need with elements of risk managed to promote independence, welfare and safety. Records detailing resident’s daily lives could be used to greater effect. EVIDENCE: The care plan and records of three individuals were viewed; the care plan provides information as to the individuals wishes in relation to the provision of care including how this is to be implemented, supported by factors important to the individual which promotes their care and quality of life. Care plans detail possible triggers and contributory factors to behaviour residents display, and provide information as to how these situations are to be managed. Elements of care, which have a degree of risk, which includes the management of behaviour are assessed, detailing as to how the risk is to be managed consistent with the promotion of independence, welfare and safety. Woodley House Care Home DS0000008768.V272846.R01.S.doc Version 5.0 Page 10 The Registered Manager and the staff group have worked closely with day care providers, to develop within Person Centred Planning, “Talking Maps”, which is a method of attaining information as to individual preferences, when the individual’s communication is not verbal. The Registered Manager advised that photographs were taken of various activities, which residents then viewed and identified their preferences, the information gathered has been developed to produce day care services and leisure, recreational and activities tailored to individual need within Woodley House. One resident whose records were viewed, are supported by two staff to access community resources and activities. The Inspector spoke with three members of care staff who confirmed that the format of care plans has been revised since the last inspection, and that they had been involved in their development and review. Staff have designated areas of responsibility, including specific roles for identified residents. Staff were able to highlight areas of individual care, and were observed putting guidance into practice upon residents return from day care placements. The daily records of three residents were viewed, which reflect care plans, however it is recommended that daily records be used with greater effect, and incorporate increased detail as to aspects of care detailed within care plans and include when residents decline services offered, to record contact with relatives, whether in person, telephone or through correspondence, along with the participation in activities and recreational pursuits. Elements of records were written from a care staff perspective, as opposed to the residents, it is therefore recommended that the practice of daily records be reviewed. Woodley House Care Home DS0000008768.V272846.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): 13, 14 and 15. Resident’s social, leisure and recreational needs are met. EVIDENCE: Residents access various formal day care services, whilst care staff of Woodley House supports others. Records viewed identified resident’s weekly timetables, which include a variety of recreational and leisure pursuits, both indoors and within the community. One resident upon his return to Woodley House confirmed to staff that he’d been to the gymnasium. Records evidenced that a majority of individuals have regular contact with relatives, which for some includes visits and over night stays. Three residents attend the local Church for Mass on Sunday. The Registered Manager stated that all residents had been to Matlock for a holiday last year, with a holiday already planned for this year. Woodley House Care Home DS0000008768.V272846.R01.S.doc Version 5.0 Page 12 Group activities have included visits to Ruddington Country Park, a Christmas Meal at a local restaurant, a pantomime trip to see Jack and the Beanstalk at The Theatre Royal in January, and a further pantomime at Ruddington Youth Centre. Future planned activities include Dance on Ice at the National Ice Arena, a barbeque in July of this year, with parties planned for Halloween. Woodley House Care Home DS0000008768.V272846.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): 19, 20 and 21. Residents are looked after well in respect of their health and personal care needs. Medication procedures are not in all circumstances being managed appropriately. EVIDENCE: Records of three residents were viewed which evidenced contact with health care professionals, which included General Practitioners, Dentists, Chiropodist and Specialists. Records were in the form of a booklet, which recorded the date of the visit, the health professional seen and was supported by pictorial symbols, to promote the understanding of residents. The medication records of two residents were viewed, one residents medication had been dispensed from the wrong day of the week in error, whilst half a tablet remained for one resident, which had been signed as administered. It is recommended that a system for the checking of administration processes be adopted, and that policies and procedures for the administration of medication be discussed in a staff meeting. Care plans of individuals whose records were viewed detailed their wishes in relation to death, including wishes for burial, cremation and Church Services. Woodley House Care Home DS0000008768.V272846.R01.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): Management systems provide opportunities for concerns to be raised, and safeguard residents from abuse, neglect and self-harm. EVIDENCE: It is not possible to communicate sufficiently with residents who were at the home to identify whether they knew how to make a complaint, but the process for making a complaint is incorporated within the Service User Guide, a copy of which is in all resident care plans. The complaints record was viewed; the home has not received a complaint since the Inspector last viewed the complaint records. The financial records of one resident were viewed, money kept by the Registered Manager within the safe reflected the amount detailed within the financial records of the individual. . Woodley House Care Home DS0000008768.V272846.R01.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): 25 and 30. Resident’s bedrooms suit their needs and lifestyle and were clean and tidy. EVIDENCE: The bedroom of two residents were viewed, both were decorated to a good standard, and had some items, which personalised the room. One bedroom was a shared room, which had a curtain to promote privacy. Bedrooms were clean and tidy. Woodley House Care Home DS0000008768.V272846.R01.S.doc Version 5.0 Page 16 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): 32, 33 and 35. Staff are trained and supported, and employed in sufficient numbers to meet the needs of residents. EVIDENCE: The Registered Manager confirmed that nineteen care staff are employed, of which four staff have attained a level 2 National Vocational Qualification in Care, whilst five members of staff are currently working towards level 2 and seven members of staff are working towards level 3. It is recommended that staff achieve a level 3 National Vocational Qualification in Promoting Independence, as this award incorporates the assessing and development of individuals with regards to the development of care plans and includes supporting individuals in accessing community resources. Three members of care staff and one person in a managerial role support residents when at home during the day, whilst during the night two care staff are on duty. Two members of care staff, to promote recreational and leisure pursuits support one resident who remains at Woodley House during the day. Staff have received training in Skills For Care, Abuse, Food Handling, Moving and Handling and Health and Safety since the last inspection. Future training has been planned in Fire Awareness, Management of Violence and Aggression, Medication Administration and Note Writing. Woodley House Care Home DS0000008768.V272846.R01.S.doc Version 5.0 Page 17 It is recommended that that staff undertake the Learning Disability Award Framework accredited training, as this award is specific to the resident group to which Woodley House offers care and accommodation. Staff spoken with confirmed the training they had undertaken, and confirmed they were working towards a National Vocational Qualification. Woodley House Care Home DS0000008768.V272846.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): 39. Systems for the contribution of residents and others to comment on the reviewing and development of the home could be improved. EVIDENCE: The Registered Manager confirmed that questionnaires are available for individuals to comment at to the management and running of the home, however there were no completed questionnaires, which could be viewed by the Inspector. The promotion of Quality Assurance was discussed with the Registered Manager; it is recommended that questionnaires supplied by the Commission for Social Care Inspection and those devised by Woodley House be sent to relatives, and health care professionals as appropriate, and that a newsletter developed and published by Woodley House accompanies these. Woodley House Care Home DS0000008768.V272846.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 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 2 Standard No 24 25 26 27 28 29 30 STAFFING Score X 3 X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 2 X 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodley House Care Home Score X 3 2 3 Standard No 37 38 39 40 41 42 43 Score X X 2 X X X X DS0000008768.V272846.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 13(2) Requirement The Registered Person to ensure that all medication is administered and recorded consistent with the prescription issued by the General Practitioner. Timescale for action 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA10 Good Practice Recommendations It is recommended that the information recorded within residents daily records is reviewed, to provide evidence of an holistic approach to care, recording individual choices and experiences, reflects resident care plan and is written from the individuals perspective. It is recommended that policies and procedures for the administration of medication are discussed with the staff team, and that a system is adopted which checks on the medication administration process. It is recommended that staff access National Vocational Qualification training at level 3 in the Promoting of Independence. It is recommended that staff undertake the Learning DS0000008768.V272846.R01.S.doc Version 5.0 Page 21 2 YA20 3 4 YA32 YA35 Woodley House Care Home 5 YA39 Disability Award Framework accredited training It is recommended that the homes Quality Assurance be used to greater effect, and is supported by a newsletter devised and published by Woodley House. Woodley House Care Home DS0000008768.V272846.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Woodley House Care Home DS0000008768.V272846.R01.S.doc Version 5.0 Page 23 - 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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