Inspection on 06/12/07 for Woodmere

This inspection was carried out on 6th December 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodmere 25/01/07

Woodmere 17/01/06

Woodmere 23/06/05

Woodmere 09/02/05

Woodmere 11/08/04

Woodmere 23/02/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Woodmere Lower Wokingham Road Crowthorne Berkshire RG45 6BT Lead Inspector Denise Debieux Key Unannounced Inspection 6th December 2007 09:30 DS0000051693.V345455.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 DS0000051693.V345455.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. DS0000051693.V345455.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodmere Address Lower Wokingham Road Crowthorne Berkshire RG45 6BT 0118 929 7900 0118 9297958 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) www.new-support.org.uk New Support Options Limited Ms Esther Callaghan Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000051693.V345455.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2007 Brief Description of the Service: Woodmere provides accommodation for six adults with learning disabilities. It is set in a residential area close to local amenities and the town centre. The home consists of two single flats with lounge, toilet/bathroom and kitchen and two double flats with private bedrooms and shared lounge, kitchen/dining room and shared bathroom/toilet. The accommodation that is provided is all within the same building and all of the bedrooms are single occupancy. The home also has its own vehicle to assist the service users with transport, or they can use public transport if preferred. The range of care needs within the home is diverse and complex. Several of the service users have needs which can challenge the service. The home currently has six service users. The current scale of charges as at December 2007 is £1538.96 per week. There are additional charges for haircuts, toiletries, meals out and some activities. DS0000051693.V345455.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This unannounced visit formed part of a ‘key’ inspection, took place over 7.5 hours and was carried out by Denise Débieux, Regulation Inspector. The Registered Manager and Area Manager were present as the representatives for the establishment. It was a thorough look at how well the service is doing. It took into account detailed information provided by the manager and any information that CSCI has received about the service since the last inspection. During this visit the inspector was also accompanied by an ‘expert by experience’. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The expert by experience spent the time speaking with the service users. A tour of the premises took place. On the day of this visit there were six service users living at the home. All six service users and four on-duty staff were spoken with during the visit. Prior to the inspection, survey forms were sent to service users, their relatives and/or advocates and to staff employed at the home. Survey forms were returned by three service users, four members of staff and four relatives/advocates. Some of the comments made to the inspector, made to the expert by experience and made on the survey forms are quoted in this report. Not all service users are able to communicate verbally and observations of the interactions between staff and these service users were also used to form the judgements reached in this report. The home had completed an annual quality assurance assessment (AQAA) and service users’ care plans, staff recruitment and training records, health and safety check lists, menus, activity records, policies, procedures, medication records and storage were all sampled on the day of this visit. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this visit and the service users, relatives, advocates and staff who participated in the surveys. What the service does well: DS0000051693.V345455.R01.S.doc Version 5.2 Page 6 Service users are supported and encouraged to make personal choices and decisions about their own lives, to participate in the day to day running of their home and to expand and develop a social life, both inside and outside their home based on their individual interests and hobbies. Service users spoken with told the inspector how they were happy living at the home and that they felt safe living there. Service users benefit from the management approach at the home providing an open, positive and inclusive atmosphere. One staff member commented that ‘the people we support have a lot of choice in their life.’ One relative commented that: ‘Living in a flat at Woodmere with twenty-four hour care is just the best possible way for my relative to live.’ 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. DS0000051693.V345455.R01.S.doc Version 5.2 Page 7 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. DS0000051693.V345455.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection DS0000051693.V345455.R01.S.doc Version 5.2 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. 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. The pre-admission procedures at the home ensure that service users’ needs and aspirations are fully assessed prior to admission to make sure that their needs can be met. EVIDENCE: No new service users have moved to the home since the last inspection in January 2007. At that inspection the records for a recently admitted service user were seen and indicated that a full needs assessment had been obtained on the prospective service user prior to admission to the home for a trial period. Following a period of settling in supported by home staff, social care professionals and relatives, a meeting took place to decide whether the home was able to meet the service user’s needs. Service user records of the admission and settling in period were comprehensive and well maintained. In the AQAA, to demonstrate what the home does well, the manager stated that care management assessments are obtained for all new referrals to the home and that a detailed transitional plan is put in place with visits to the home arranged for the prospective service user to ‘test drive’ the service. The pre-admission assessment also explores any needs in relation to equality and diversity that a service user may have. The manager stated that at this DS0000051693.V345455.R01.S.doc Version 5.2 Page 10 stage they would ensure that the home was able to meet these needs by seeking advice and further information plus staff training as necessary. Data provided in the home’s AQAA does not identify any service users with specific religious, racial or cultural needs at this time. However, from the evidence seen by the inspector and discussion with the manager, the inspector considers that the home would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. All service users have copies of their statement of terms and conditions with the home and all service users surveyed said that they were asked if they wanted to move to the home and that they were given enough information before they decided to move in. DS0000051693.V345455.R01.S.doc Version 5.2 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. 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. The service users’ individual plans are clear and comprehensive including details of needs and goals. They also incorporate known or indicated preferences. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: Prior to this visit, relatives and advocates were sent survey forms, four forms were returned, with three relatives stating that the home always gives the support or care that their relative needs and one answering ‘sometimes’. Care plans for three service users were sampled and all were seen to be comprehensive, well set out and easy to follow. Care plans and person centred plans are drawn up with service users and are reviewed on a three monthly basis, or more often, if needs change or a new concern arises. DS0000051693.V345455.R01.S.doc Version 5.2 Page 12 The care plans were all seen to be very individualised and included the service users’ personal preferences and also risk assessments for all activities, with clear guidelines for staff to follow to minimise any associated risks. The manager has also developed a quality assurance form which is completed on a regular basis to ensure that care plans are to the home’s required standard. The staff document daily in a separate diary for each service user. At present the daily recording does not always evidence that all identified needs are being met. It was discussed and a recommendation has been made that the manager look at ways that the staff can relate their daily report writing more directly to the actions and goals set out in the care plans to evidence that individual goals and needs are being met. Three completed service user survey forms were received prior to this inspection. All service users stated that they could do what they wanted to do during the day, in the evening and at weekends. On the day of this visit, service users were seen to be choosing what they did and where they went within the home. Staff were seen to be helpful and offered assistance where needed or requested. It was also observed that staff had a good rapport with service users that were not able to communicate their wishes verbally, where they indicated that they wanted assistance, this was quickly understood by the staff and the assistance provided. Feedback received by the inspector from the expert by experience included: • Sounds like residents make lots of choices in their daily lives, although one resident said he would like to cook for himself more. • One staff member said that residents are involved in the running of the home. He said that “this is their home. They are involved and their choice comes first”. • The staff give choices using pictures, they have a picture menu at mealtimes. Otherwise, they point to objects to give choices. In the AQAA, to demonstrate what the home does well, the manager stated that a key worker system is in place, service users are treated with respect and dignity and that risk management strategies are in place and actions are taken to minimise risks. At present two service users have no family or independent advocate support. This was discussed and the inspector was advised that there is a shortage of advocates in the area. However, the home had just heard that one service user is confirmed as now being on the waiting list with a local advocacy group and the second service user has applied to be included on the waiting list and is waiting for confirmation. However, should a situation occur where a service user needed an advocate for a specific situation, the local organisation would be able to provide someone to support the service user. DS0000051693.V345455.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that service users’ rights are respected. Meals are well-balanced and varied. EVIDENCE: The daily routines at the home reflect the requirement to promote independence, individual choice and freedom of movement. Service users confirmed they could choose what to do, when they wanted. This was also confirmed by observations made by the inspector on the day of this visit. One service user has a part time job and another service user is hoping to have a job soon, staff are working with the service user and have identified a potential, suitable job in the local area that is expected to be available soon. DS0000051693.V345455.R01.S.doc Version 5.2 Page 14 In the AQAA, to demonstrate what the home does well, the manager stated that one service user has been supported to have a job and attend training to maintain this job plus is supported to work with the local authority in quality monitoring of other services. Plans for improvement in the next twelve months include supporting service users to experience challenging and new activities. Each service user has a weekly activity schedule that is based on his or her known interests and hobbies. The activity schedules sampled were seen to be varied and included activities both within and outside the home in the local community. One service user spoke with the inspector about the plans that were being made for his birthday the day after this inspection. During the day service users were going out and returning, one service user went to the gym with a member of staff, another service user went to the local shops independently. It was obvious during this inspection that the staff team are open and flexible and that no two days were the same. Although each service user has an activity schedule, this is treated more as a guide. Service users were seen to be making decisions, at the time, as to whether they wanted to do what was on their schedule or to do something different. The home has it’s own transport that is available to facilitate activities and trips for the service users. All service users plan and take holidays during the year, with support from staff where needed. One relative commented that her son has been holiday with a member of staff this year and had a wonderful time. Feedback received by the inspector from the expert by experience included: • The staff get involved with residents with lots of activities, like painting and puppet making. • Residents seem to have lots of activities they do outside the home. The menu for the week of this visit was seen to be varied and well-balanced, advice is sought from a local dietician, for individual service users, as and when needed. The inspector was advised that service users plan and prepare their meals, usually on a daily basis, with assistance and guidance from the staff where needed. The home have worked hard and developed photograph and picture cards of different foods, these cards are used to enable service users, who have difficulty communicating, participate in and make choices when planning meals. The lunchtime meal was taking place during this visit, the food was presented in an appetising manner, staff were eating with the service users in the dining room and there was a relaxed family atmosphere. The service users invited the expert by experience to join them for lunch and his feedback was very positive about the food and atmosphere in the dining room. DS0000051693.V345455.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance was seen to be provided, where needed, in a respectful and sensitive manner. Sound policies and practices are in place for the administration and management of medications. EVIDENCE: During this visit three care plans were sampled and it was seen that all health care needs were incorporated into the care plans. Diary notes evidenced that staff take prompt action to deal with any new health problem that may occur and care plans were specific with information for staff to follow when supporting service users to manage any long-term conditions. Each service user also had a medication care plan that included the medicines they were taking, the purpose of the medicines and signs of side effects to look for. Medication is provided mostly in the blister pack system. The administration of some medications was observed and the medication administration records (MAR), medication storage, policies and procedures were all sampled and found to be in good order. DS0000051693.V345455.R01.S.doc Version 5.2 Page 16 In the AQAA, to demonstrate what the home does well, the manager stated that key workers support service users to attend GP and hospital outpatient appointments. Plans for improvement in the next twelve months include to work with the GP practice to ensure each individual has an annual health check. During this inspection, all interactions observed between staff and service users were polite and respectful. Staff never entered service user’s private rooms without knocking and awaiting permission to enter. All personal care was carried out behind closed doors. Relatives who returned survey forms all stated that they were always kept up to date with important issues that affected their relative, two answered that they felt the home always met the needs of their relative and one answered ‘usually’. DS0000051693.V345455.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. All required policies and procedures are in place to ensure that service users feel their views will be listened to. Policies and practices are in place to protect service users from abuse and neglect. EVIDENCE: The home has a complaint’s procedure in place that is available to all service users, has been individualised to the home and is available in an easy read, picture format if required. Four complaints have been made to the home by a service user since the last inspection. These were clearly documented, showing the investigation and subsequent action taken, where necessary. No complainant has contacted the Commission with information regarding a complaint or allegation made to the service since the last inspection. There is a whistle blowing policy in place and the home have a copy of the latest Berkshire Multi-agency Procedure for the Protection of Vulnerable Adults. Following a requirement made at the last inspection, all staff have received training or updates in the protection of vulnerable adults, this is clearly recorded in the home’s training record. Evidence was also seen that the staff at the home act swiftly and appropriately in any report of possible abuse. DS0000051693.V345455.R01.S.doc Version 5.2 Page 18 Service users surveyed and spoken with all knew how to make a complaint and who they would talk to if they were not happy. The staff surveyed all stated that they knew what to do if a service user or their relatives raised concerns about the home. Clear policies and procedures are in place for the management of the service users’ money and the records are audited on a yearly basis. In the AQAA, to demonstrate what the home does well, the manager stated that they respond positively to complaints or concerns; encourage service users to voice their opinions and work pro-actively with relatives when there are concerns. The manager also stated that staff are trained in vulnerable adults procedures and service users’ finances are audited and robust records kept. DS0000051693.V345455.R01.S.doc Version 5.2 Page 19 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): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and well-maintained. The home was found to be clean and hygienic and to meet service users’ individual and collective needs in a comfortable and homely way. EVIDENCE: Woodmere is set in a residential area close to local amenities and the town centre. The home consists of two single flats with lounge, toilet/bathroom and kitchen and two double flats with private bedrooms and shared lounge, kitchen/dining room and shared bathroom/toilet. Service users spoken with expressed their satisfaction with the accommodation provided at the home. Two of the service users surveyed said that the home was always fresh and clean and one answered ‘usually’. The home was toured during this visit. The furniture and furnishings were seen to be of a good quality and specialist equipment is provided if needed by DS0000051693.V345455.R01.S.doc Version 5.2 Page 20 the service users. Personal bedrooms were all seen to be highly personalised to the individual service user’s wishes. Since the last inspection the home have made a number of improvements to the communal and individual areas of the home. Requirements made at the last inspection that related to the environment have all been met. Since the last inspection a new system has been put in place to ensure that any needed repairs are carried out promptly and the home has a repair person that visits the home on a monthly basis to carry out routine repairs and maintenance. A number of areas have been redecorated on the ground floor following a substantial water leak. The home are waiting for plasterwork to dry out completely before the hallway can be redecorated. In the AQAA, to demonstrate what the home does well, the manager stated that they ensure repairs are reported and actions taken by the landlord to rectify deficits. Plans for improvement in the next twelve months include reviewing the planned maintenance/renewal plan and all staff to be trained in infection control. There is a private and well-maintained garden at the back of the house. The service users and staff work together in maintaining the garden. Laundry facilities are sited on the ground floor with washing machines suitable for the needs of the service users at the home. On the day of this visit the home was found to be warm and bright with a homely atmosphere and a good standard of housekeeping apparent. Feedback received by the inspector from the expert by experience included: • The flats were really nice, lovely kitchen and lounge. • It was clean and tidy. They made us welcome. DS0000051693.V345455.R01.S.doc Version 5.2 Page 21 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, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a staff induction, training and staff supervision programme which is designed to ensure that service users are supported by competent and qualified staff. However, the organisation needs to take steps to ensure that service users’ well-being is further protected. There needs to be a plan of action to increase the percentage of care staff that are qualified to NVQ level 2 in care without further delay and to ensure that mandatory safe working practice training is kept updated for all staff. The home has a staff recruitment procedure which is designed to ensure, as far as reasonably possible, that service users are supported and protected. EVIDENCE: The staff rota evidenced that staff are provided in sufficient numbers to meet the needs of the service users at the home. The morning shift is covered by four care workers, four care workers cover the afternoon/evening shift and the night staff consists of one waking care worker and one sleeping on the premises and available if needed. Cover for staff annual leave and/or sickness DS0000051693.V345455.R01.S.doc Version 5.2 Page 22 is provided by a stable team of bank staff, occasionally the home uses agency staff but only when the agency workers have previous worked at the home and are known to the service users. Recruitment of staff is an ongoing concern to the manager, this situation is mostly due to the home’s proximity to large facilities that also employ care workers. However, since the last inspection the manager feels that the situation has eased and the home are currently advertising for additional full time staff. Since the last inspection there have been no new staff recruited, additional staff now working at the home have transferred from other homes within the organisation. Recruitment files were assessed at the last inspection and it was found that the home has robust recruitment procedures in place. The organisation now have a policy of service user involvement in staff recruitment. Service users are asked to participate in developing a staff person specification for working at Woodmere and then are supported to develop specific questions that will be asked of prospective staff at interview. Of the fifteen care staff, four are qualified to National Vocational Qualification (NVQ) level 2, or above, in care. At the last inspection, in January 2007, a requirement was made that the home develop an action plan to achieve 50 of staff qualified to NVQ level 2. The inspector was shown the home’s action plan, which is reliant on the training department of the organisation providing. The plan shows that remaining unqualified staff are still on the waiting list for places on the NVQ training courses. Whilst the requirement has been met in that the manager has developed an action plan, it is disappointing that New Support Options Ltd are not being more pro-active in ensuring that staff in their homes are suitably qualified. The National Minimum Standards required that at least 50 of care staff be qualified to a minimum of NVQ level 2 in care by the end of December 2005 and a requirement has been made. At the inspection in January 2007, a requirement was also made that all staff receive training/updating in mandatory safe working practices. The training log was sampled at this inspection and it was seen that all staff have received training in: first aid; food hygiene; health and safety and the protection of vulnerable adults. However, seven staff had not received updates in fire safety and eight had not received training/updates in moving and handling. The inspector was shown an e-mail, sent in July, from the manager to the organisation’s training department requesting the training. The timescale for the requirement to be met was 25/04/07. This delay is unacceptable and could potentially be placing service users at risk. It is acknowledged that the manager did all she could to meet the requirement but New Support Options Ltd must review their current system for ensuring that training and updates required by legislation is provided to all staff as and when required. DS0000051693.V345455.R01.S.doc Version 5.2 Page 23 Following this inspection the manager has obtained dates for the staff to receive the missing training/updates. The inspector was advised that fire safety training has been arranged for the 17th December 2007, moving and handling training has been booked for the 4th January 2008 and that all staff whose training is overdue will be required to attend those dates. For this reason CSCI has decided that enforcement action will not be taken at this stage. The provider must notify CSCI in writing once all staff are up to date with mandatory safe working practice training. The requirement made at the last inspection has been carried forward with a short extended timescale but must now be actioned in full and without further delay. The manager is aware of the Skills for Care new mandatory common induction standards. As there have been no new staff employed at the home since the last inspection it was not possible to assess this standard in full, however the inspector was shown the organisation’s new induction documentation, which was seen to be in line with the new standards. Additional training is also provided in: effective communication; infection control; epilepsy; person centred planning; mental health and autism. The manager has now introduced formal staff supervision, staff records were sampled that show that staff have individual or group supervision at least six times a year. This was confirmed by the staff members surveyed. Service users surveyed all stated that the staff always listen and act on what they say. Two service users said that the staff always treat them well and one answered ‘usually’. Of the relatives/advocates surveyed, two answered that the staff always have the right skills and experience to look after people properly, one answered ‘usually’ and one answered ‘sometimes’. One relative spoken with just prior to this inspection said: ‘Woodmere is a wonderful place, we cannot find fault with them. We really appreciate the work they do’. Feedback received by the inspector from the expert by experience included: • The staff were very welcoming. • The staff seemed to get on well with residents. Staff seemed to have a good understanding of residents and good communication with them. • One resident said the staff were brilliant. DS0000051693.V345455.R01.S.doc Version 5.2 Page 24 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): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the management approach at the home providing an open, positive and inclusive atmosphere. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users. Policies and procedures are in place to ensure, so far as is reasonably practicable, the health, safety and welfare of service users and staff. EVIDENCE: The manager has now completed her Registered Manager’s Award and has been working in care for over twenty years. She has been the manager at Woodmere since the year 2000. Following the last inspection the manager advised that she now makes sure she has adequate time ‘off rota’ to carry out her managerial responsibilities. DS0000051693.V345455.R01.S.doc Version 5.2 Page 25 Service users’ views are sought on a regular basis and monthly visits by a representative of the responsible individual take place as required. The organisation carry out a yearly survey which seeks the views of service users, family, friends and other stakeholders in the community (i.e. district nurses etc.) The report of this year’s survey was seen at this inspection. All necessary health and safety checks are carried out by the staff at the home with documentary evidence inspected of routine fire practices and evacuations. Fire equipment checks, daily checks of fridge and freezer temperatures and a number of up to date maintenance certificates were seen. All records were up to date and well maintained. As mentioned earlier in this report, not all staff training in safe working practices is up to date, however, staff were observed to be following appropriate health and safety practices as they went about their work. The fire alarm system was accidentally triggered during meal preparation on the day of this inspection, staff dealt with the situation calmly and appropriate actions were taken. All previous requirements made under this outcome group have been met. Relatives who returned comment cards stated that they were always kept up to date with important issues affecting their relatives and that they felt the home meets the different needs of the service users (two answered ‘always’ and two answered ‘usually’). One relative commented: ‘The manager is very dedicated – my relative is absolutely happy there’ In the AQAA, to demonstrate what the home does well, the manager stated that the home has quality assurance audits by WEBCAS/LA (advocacy group); health and safety audits and monthly audits by the area manager. Plans for improvement in the next twelve months include gaining accreditation from the National Autistic Society. All interactions observed between the staff and service users were inclusive, caring and respectful. DS0000051693.V345455.R01.S.doc Version 5.2 Page 26 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 3 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 1 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 2 x DS0000051693.V345455.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES 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 YA32 Regulation Requirement Timescale for action 06/04/08 2 YA35 YA42 18(1)(c)(i) The provider must take steps to ensure that enough staff are enrolled on, and begin, NVQ level 2 training in care to bring the percentage of qualified staff up to at least 50 and to ensure that service users are cared for by suitably qualified staff. 18(1)(c)(i) That all staff receive training/ 11/01/08 updating in mandatory subjects. The provider to confirm to CSCI in writing when all staff are up to date with fire safety and moving and handling training. Previous timescale of 25/04/07 not met. 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 YA6 Good Practice Recommendations It is recommended that the manager look at ways that the staff can relate their daily report writing more directly to the actions and goals set out in the care plans to evidence DS0000051693.V345455.R01.S.doc Version 5.2 Page 28 that the service users’ goals and needs are being met. DS0000051693.V345455.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. 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