Inspection on 03/05/07 for Woodpeckers, St Anne`s Opportunity Centre

This inspection was carried out on 3rd May 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 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.

Other inspections for this house

Woodpeckers, St Anne`s... 22/11/05

Woodpeckers, St Anne`s... 06/07/05

Woodpeckers, St Anne`s... 14/01/05

Woodpeckers, St Anne`s... 11/10/04

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

CARE HOME ADULTS 18-65 Woodpeckers, St Anne`s Opportunity Centre 5 Barn Elm Cottages, Dark Lane Bradfield Berkshire RG7 6DD Lead Inspector Steve Webb Unannounced Inspection 3rd May 2007 09:45 Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.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 Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.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. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodpeckers, St Anne`s Opportunity Centre Address 5 Barn Elm Cottages, Dark Lane Bradfield Berkshire RG7 6DD 0118 9744093 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) St Anne`s Opportunity Centre Limited Post Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2005 Brief Description of the Service: St Annes Opportunity Centre, is registered as a non profit-making limited company, to provide personal care and accommodation for three younger adults who have mild to moderate learning difficulties and complex emotional needs. Woodpeckers is a rented semi detached property situated in a rural area on the outskirts of Theale near to Bradfield college. Service users have access to local pubs, shops and leisure facilities based within Bradfield College. The town of Reading is within 7 miles. A local bus service provides transport into Reading and Newbury. There is car parking space available next to the property. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 9.45am until 6.45pm on 3rd of May 2007. This report also includes reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from conversation with the manager and staff members on duty, and the three residents. Some additional time was spent observing the interactions between staff and residents as they went about their daily activities. Written feedback was obtained from residents, befrienders, and others. The inspector also toured the premises, and ate lunch with the residents. What the service does well: The needs of prospective residents are effectively assessed and they receive information about the home to help them decide if it will meet their needs. The needs and wishes of the residents are addressed within their care plans and their other records. Residents are supported and enabled to make decisions in their daily lives, within the context of an effective risk assessment system. Each resident has a regular programme of planned activities and the residents have very good community links. The home supports family contact where appropriate and residents also have very supportive links with the local church. Residents are involved in the daily household routines and are offered a healthy diet. They are involved in the planning of menus, as well as shopping for food and meal preparation. Residents are supported in line with their preferences and needs, and individual guidance is well documented to maximise staff consistency. The health needs of residents are also met effectively. Although residents cannot manage their own medication, this is managed effectively on their behalf. The views of residents are listened to, and all were aware of how to complain, and the service has good systems in place to protect residents from harm. Residents are provided with a safe and homely environment, which is appropriately furnished and mostly well maintained. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 6 Support is provided by a competent staff team, who are familiar with residents’ needs, and provided with an effective core training package, for the most part, and good progress is being made with NVQ within the team. Residents are protected by the home’s recruitment and vetting systems for new staff, and the residents benefit from a well run home, which meets their needs effectively. The operation of the home is monitored well by the provider and the health and safety of residents is effectively promoted by the home. 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. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.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 Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.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): Standard 2: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are assessed and they are provided with information to help them decide if they want to come to the home. EVIDENCE: Examination of the files for one tracked resident, who was the most recent admission, indicated a detailed review of their assessed needs just after their move to Woodpeckers. The documentation also includes identified wishes and preferences. The resident transferred from another of the provider’s services so their needs were already well-known. The resident also visited Woodpeckers on more than one occasion prior to transferring, and was given information about the home. Feedback from the three residents also confirmed they had received information about the home prior to moving in. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.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): Standards 6, 7 and 9: Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The identified needs and wishes of residents are addressed within their care plans and associated records. Residents are enabled to make choices and decisions in their daily lives, within the context of an effective and detailed risk assessment system. EVIDENCE: The examined care plan and other case records contained detailed information about the identified needs, wishes etc. of the resident, including how to offer support to the individual with daily living, and to access the community. A “strengths and needs” profile had been completed, and there was also a detailed activities programme for planned activities. Information on individual communication was also included, although all three residents are able to verbally communicate their wishes. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 10 A new Person Centred Plan (PCP) format has been introduced for the residents, which further focuses on the preferences, likes and dislikes of the individual and has also been discussed with them. All that remained to be done was the addition of some further pictorial content regarding likes and dislikes, for one resident. Each resident has a daily report book for general information about day and night events, augmented by separate information sheets to record any significant event or information. The case-tracked resident’s care had been reviewed in July 2006. Residents receive their full weekly personal allowance, and receive any necessary support from the staff, where appropriate. Each individual also receives £5 per week, from their ‘work experience’ to supplement their funds. Residents each have individual bank accounts for DLA funding and any surplus allowance monies. The residents also make decisions for themselves in other areas, daily with support and encouragement from staff. Appropriate individual risk assessments were also in place for any identified risks, such as those attached to activities or daily tasks. These were especially thorough and detailed in the case of one resident, and had been discussed and reviewed with the individual the day before the inspection. The manager described the risk assessment, which was about to be undertaken for one resident, with regard to an upcoming community-based activity, and demonstrated a thorough understanding of the confidentiality issues surrounding the disclosure of relevant information to third parties. Staff demonstrated a good grasp of the principles of risk assessment and appropriate and detailed steps were in place to safeguard all three residents. Feedback from residents and others expressed general satisfaction with the support offered to residents. Residents confirmed that they were able to make day-to-day decisions in their lives and were generally supported and enabled by staff. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.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): Standards 12, 13, 15, 16 and 17: Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have a detailed programme of planned activities and have very good community links and support. Contact with family is supported where appropriate and residents also have very supportive links with the local church. Residents are involved in the daily household routines and tasks and their individuality and differing needs are respected. They are offered a healthy diet and are involved in the planning of menus, as well as food-shopping and meal preparation. Restrictions are in place for some residents around mail and mobile phone access, subject to appropriate risk assessments. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 12 EVIDENCE: As already noted, each resident has a detailed personal programme within their care plan file, which includes planned activities both within and outside the home, work experience, college and domestic tasks such as laundry and cleaning, as well as specific relaxation times. The programmes are specific and time-specific, in order to support the needs of the residents, all of whom have previously demonstrated more extensive challenges in their behaviour. Individuals are encouraged to carry out their programme to maintain a supportive structure and regular routine, but are consulted about the individual elements of the programme. Community involvement is good and the staff provide varying degrees of support to individuals in accordance with their risk assessment. One resident works part-time at a local older persons’ home, and two take part in part-time work experience at a local riding stables. Last summer, all three residents chose to go to Bognor for their holiday, and one also went to the Isle of Wight. Although the home is usually staffed by one person at a time, the provider operates a flexible staffing regime across this and their other two services, whereby staff can move between homes to provide additional cover where this is needed, for a specific activity or to support a resident’s medical appointment. The senior managers also provide on-call cover on a rota basis. This is backed-up by a clear on-call rota and a written emergency/crisis policy, though it should also be supported by an overall risk assessment of the staffing strategy. This staffing regime does not appear to detract from the level of available activities and community involvement, given the level of residents’ skills and their additional support network via the local church. One staff member comes regularly, two days per week to escort residents to church activities and singing. Family contact is supported and maintained where appropriate, by the staff and all three residents have made very strong links to the local church, where one also undertakes work experience helping with grounds maintenance. All three residents also choose to attend church services regularly. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 13 The church invites residents to its social events and five of the congregation fulfil the role of Godparents to the three residents. All three of the residents have chosen to be christened and confirmed at the church. Residents talked about their family contact, which was appropriately supported by staff where necessary. Residents exercise choice in their activities and in shopping for their clothes, with varying levels of staff support. One resident showed the inspector the clothing she had chosen on a recent shopping trip, and described the event and the staff support received. During the inspection the residents made hot drinks for themselves, the staff and the inspector at various times. The residents each have mobile phones, with appropriate staff input around their usage, where necessary, staff may also support residents with their mail where appropriate. One resident described the home as relaxed and said “I like living here”, and another confirmed they enjoyed working at the riding stables. Written feedback from residents also confirmed that they were able to make choices and decisions on a daily basis, though one suggested that the daytime programme provided less opportunity for making choices, than at evenings and weekends. Residents are involved in planning the menus for the main meals, and each has their own individual menu for week’s other meals, planned within a set budget. They also take part in the food shopping and meal preparation. Staff are working to encourage more healthy options within the menus. Staff demonstrated their involvement of the residents in the home’s daily routines, throughout the inspection. Residents indicated they were happy with the meals and enjoyed the lunch during the inspection, which at least one of them had been involved in preparing. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 14 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): Standards 18, 19 and 20: Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The support provided to residents takes into account their preferences and needs, and is well documented in detail in order to maximise staff consistency. The health needs of residents are met effectively. Although residents cannot manage their own medication, this is managed effectively on their behalf, and staff receive good training in this area. EVIDENCE: Although all three residents have complex needs, the routines of their life in the home provide a level of daily structure to support each resident to maintain a good quality of life and access to a range of activities within the local community. The mode of support of each individual is documented within care plans and individual guidelines to ensure a consistent approach, within an effective risk assessment structure. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 15 The views and choices of residents are evident within the support plans, and observation during the inspection confirms that the residents are consulted about, and actively involved in the daily life of the home. Support is offered where it is needed, to help individuals remain relaxed and comfortable, and residents are encouraged to do as much as they can for themselves. Staff demonstrated awareness of the possible safety and gender issues in the home, and appropriate steps were in place to address these. One resident has additional monitoring in place to help them remain safe, and staff are vigilant in this. Staff and management liaise appropriately with outside agencies to obtain support where necessary and also in order to facilitate work experience opportunities in the community. Residents’ individual care records include appointment records for key healthcare professionals, and included recent entries. A health action plan is also being completed for the resident whose file was examined, which will provide detailed information on all aspects of healthcare needs. These were reported to be in place for the other two residents but were not examined on this occasion. None of the residents is able to manage their own medication, but the home has an appropriate system in place to manage this on their behalf. A pharmacist inspection was undertaken in September 2006. The medication file includes individual medication profiles, records for PRN (as required), medication, and medication administration record, (MAR) sheets for each resident, which are supported by weekly medication audit sheets, which provide an audit trail for medication. All staff receive training on medication from the pharmacist and will also undertake a comprehensive twelve week course on medication management. The provider also has a qualified person to provide updates to medication training in-house. All staff also receive first aid training. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of residents are listened to and all of them were aware of how to complain. Issues raised have been addressed with due regard for the protection of vulnerable adults, and the service has systems in place to protect residents from harm. EVIDENCE: The service has an appropriate complaints procedure, which is also available in a more accessible, pictorial format. All three of the residents would be able to raise a concern with either the home’s staff or their befriender/god-parent, or family. This was confirmed by the residents. The complaints log has two entries for 2007, one of which had been addressed, and the other which was ongoing, awaiting discussions with relevant other parties. The manager was appropriately pursuing a strategy meeting to facilitate progress on the latter issue. From discussions with the manager it is apparent that the service has made appropriate contact with external professionals when necessary, in the past to discuss issues of adult protection, and the manager discussed the merits of this in the context of current decision making around one resident. It is clear that the service works hard to address the issue of protection on a daily basis, given the specific vulnerabilities of the residents, and has a system of risk assessment and monitoring in place to maximise their safety. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 17 The service acts appropriately to protect residents’ funds and to support the development of some budgeting skills on the part of one individual. Around half of the staff across the provider’s services have received recent POVA training and this training is again scheduled in June. There are two accredited POVA trainers within the organisation. The staff spoken to during the inspection demonstrated a good understanding of the POVA issues within their daily practice. The local multi-agency vulnerable adults protection procedure was available to staff in the home. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 18 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): Standards 24 and 30: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a safe and homely environment, which is appropriately furnished and maintained for the most part. The home was found to be clean and hygienic. EVIDENCE: The communal areas of the home were decorated and furnished in a homely style, with lots of ornaments and pictures etc. The kitchen has recently been fitted with new cupboards, but the worktops have not yet been replaced. Given that some parts of the worktop are damaged and cannot be effectively cleaned, this is a potential health and safety issue, which should be addressed with the landlord. Bedrooms are individualised reflecting their occupant and the residents each have their own computer/laptop. They had been redecorated in July 2006, but Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 19 some of the ceiling paper was peeling in one bedroom, though there was no obvious evidence of the cause. The manager said that the resident had indicated they wanted the ceiling repainted a different colour, and had been told this would be done once the kitchen was completed. The home is provided with a bathroom/toilet and a shower/toilet. No specialist adaptations are required by the residents to meet their needs. There is a large rear garden, which consisted mainly of lawn, with some garden furniture available. One resident proudly showed the inspector the vegetable patch they had prepared and planted. This resident was also responsible for cutting the lawn and explained how he undertook this task. The home was provided with domestic laundry equipment in the kitchen, which meets the needs of residents, whilst remaining homely and readily accessible to them to undertake their own laundry. The home was found to be clean and hygiene standards were good. Residents take part in the daily household tasks in the home, including the cleaning. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 20 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): Standards 32, 33, 34 and 35: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a competent staff team, who are familiar with their needs, and are provided with an effective core training package, for the most part, though some training needs to be updated as a priority. Good progress is being made with NVQ within the team. Residents are protected by the home’s recruitment and vetting systems for new staff. The single-staffing situation should be covered by a risk assessment in the context of the residents’ needs. EVIDENCE: Observations of the staff during the inspection indicated a good level of understanding of their role as facilitators, supporting the residents to maintain and develop their skills. The staff were familiar with the needs and vulnerabilities of the residents and supported them effectively, within the context of their written individual plans and guidance. The relationship between staff and residents was relaxed and informal. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 21 One staff member is undertaking NVQ level 3, and her assessor was present during the early part of the inspection. Overall around 55 of the staff have attained their NVQ, and further staff are due to enrol. One other staff member has a BA in social work. The manager reported that the home has a good record of staff retention and very rarely uses agency staff, preferring to cover flexibly from within the overall team across the provider’s three homes, and from its in-house bank. This helps to maintain the consistency of routine and monitoring, necessary for the residents and ensures they are supported by staff with whom they are familiar. Examination of the recruitment records for the two most recent recruits, indicated an appropriately rigorous recruitment and vetting process, and copies of the required records were made available to enable this to be verified. References had been sought from overseas for staff new to this country, and appropriate papers had also been copied, in addition to those for ID verification purposes. Records of interview and application forms had also been retained. The service provides an induction and core training package, and most staff who provide cover within Woodpeckers have receive the required core training. However, there are some exceptions, including POVA training, which was needed for three of the staff, and a further six staff would benefit from an update of this training to refresh their knowledge, given that they last received it in 2003 or 2004. The manager said that this would be provided for, in house as the organisation had two accredited POVA trainers, and it was confirmed that this training was scheduled for the 6th of June. The manager clarified that the home operates a no-restraint policy and though staff have previously received some ‘breakaway’ training, further training in non-physical interventions is being sought to support the home’s policy. Staffing is based on a single staff member on site at all times, with additional cover being provided from the staff team across the provider’s other homes on both a planned, and, ‘as and when required’ basis, for specific events, activities or appointments. Discussion with residents and staff, and examination of activities records, did not indicate a significant impact on the level of activities or community access by the residents, who are largely self-caring, arising from these staffing levels. The staff member on duty has access to an on-call rota and there is a written emergency/crisis policy, though the single-staffing situation should also be supported by an overall risk assessment of the staffing strategy, based on the needs of residents. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 22 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): Standards 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. The residents benefit from a well run home, which meets their needs effectively, though the provider needs to put forward an appropriate candidate for registration as manager. The views of residents and others have been sought as part of a quality assurance process, and the responses are due to be collated and fed back to participants. The operation of the home is monitored well by the provider. The health and safety of residents is effectively promoted by the home. EVIDENCE: The home has not had a registered manager and has been managed on a dayto-day basis by the organisation’s general manager, who is appropriately qualified but also has other duties outside of the home. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 23 The provider must put forward an appropriate person for registration as manager of the home, as a priority. Notwithstanding the above, the home is evidently being well run and meets the needs of residents effectively. There are clear policies and procedures in place and staff are supported effectively. A cycle of quality assurance questionnaires was sent out in February 2007, to residents, family and care managers, and the returned forms indicated very positive feedback, though they had yet to be collated into a summary report, to be made available to participants. The manager was due to do this and described her plans to produce this document. An annual development plan for the home for 2007/8 was available, which included good detail about future plans. Although at present the general manager is in charge of the home on a daily basis, another director still undertakes monthly Regulation 26 monitoring visits and provides reports, which is good practice. Examination of a sample of health and safety-related service certification indicated that servicing was regular and up to date, and regular in-house checks also take place. As already noted above, there is also a comprehensive set of general and individual risk assessments available, which were clearly actively used and reviewed as necessary. Fire safety training updates are provided annually and specific extinguisher training is also provided. The home has an up to date fire risk assessment, last reviewed in March 2007. The home does not use the new tear-off accident recording pads, which comply with new legislation, and a collective minor injuries book was still in use. In order to fully comply with current legislation, new tear-off accident pads should be obtained, (ideally separate ones for staff and residents/visitors). Copies of all accident forms should be held together as a collective record and also be placed on the relevant resident’s case record. The residents had experienced few accidents. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 24 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 3 X X 4 X Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 YA37 Regulation 8 Requirement The provider must put forward an appropriate candidate for registration as manager. Timescale for action 05/08/07 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 2 3 Refer to Standard YA30 YA33 YA42 Good Practice Recommendations The manager should pursue the replacement of the kitchen worktops, with the landlord, as they present a potential health and safety hazard. The manager should address the single staffing situation and emergency procedures in the home within a risk assessment, taking into account the needs of residents. The manager should ensure that the accident recording and monitoring system complies with legislation, and provides for effective monitoring of this aspect of resident wellbeing. Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Woodpeckers, St Anne`s Opportunity Centre DS0000011179.V331576.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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