Inspection on 24/04/06 for Woodrow Cottage

This inspection was carried out on 24th April 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodrow Cottage 28/09/07

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

CARE HOME ADULTS 18-65 Woodrow Cottage Hills Close Fair Oak Hampshire SO50 7HD Lead Inspector Craig Willis Unannounced Inspection 24th April 2006 09:00 Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 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 Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 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. Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodrow Cottage Address Hills Close Fair Oak Hampshire SO50 7HD 01420 544118 01420 544140 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) ILIACE Limited Miss Jennifer Howard Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection This is the first inspection of this service. Brief Description of the Service: Woodrow Cottage is registered to provide care and accommodation to five people between the ages of 18 and 65 who have a learning disability. Each service user has a single bedroom, with either en-suite facilities or the use of an adjacent bathroom. Service users share the use of a main lounge, dining room, kitchen and quiet lounge. There is an enclosed garden to the side and rear of the home that service users are able to access. The home is situated approximately half a mile out of Fair Oak, which has local shops, pubs and public transport. The home has a car that service users are able to use when there is a staff member on duty who is registered to drive. The manager provided information to the CSCI on 18/4/06 that the range of fees at the home was from £1400 to £1700 per week, depending on the assessed needs of service users. Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of Woodrow Cottage since it opened. The evidence used to write this report was gained from a review of the information the provider sent to the Commission for Social Care Inspection (CSCI) following their registration and a site visit to the home on 24th April 2006. During the site visit the inspector met all of the service users, spoke with care staff on duty and the manager. Due to the communication needs of service users, the inspector did not talk with them in detail about the care they receive. A tour of the building was made and the inspector observed the way staff were supporting service users. Comment cards were received from relatives of three service users. Documents relating to the running of the home were inspected during the visit. What the service does well: What has improved since the last inspection? Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 6 This is not applicable, as this is the first inspection of the home. 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. Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 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 Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 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): 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are excellent systems in place to assess service users prior to moving in to the home, which ensures that their needs can be met. Providing service users and their representatives with a statement of terms and conditions would give them a greater understanding of the services that the home provides. EVIDENCE: The records of all four service users were looked at during the visit. Each service user had a comprehensive assessment of their needs and aspirations that was completed prior to them moving into the home. Prospective service users are visited in their current homes and at any educational or leisure activities that they participate in. Consultation takes place with the prospective service user where possible and with their relatives and representatives and other professionals who know them, such as teachers and other service providers. Each service user has a transitional period, lasting up to three months, where staff from Woodrow Cottage work with them in their home or other residential setting to ensure that their needs can be met. The manager reported that none of the service users or their representatives has been supplied with a statement of terms and conditions of residence. The manager said this was an oversight and she would ensure they were provided. Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 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, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has good systems to develop care plans which set out how staff should meet service users’ needs and support service users to make decisions. Additional information is needed in risk assessments so that staff can take action to minimise the risks to service users. EVIDENCE: The files of all four service users were viewed during the visit. Each service user had a detailed care plan, which set out how their assessed needs should be met. All of these plans had been reviewed since service users moved into the home and had been amended where necessary. All of the plans had specific sections on communication, and set out the most effective ways for staff to communicate with service users, for example through Makaton sign language and objects of reference. Staff were observed using Makaton when communicating with service users and providing support for service users to make decisions about the activities they took part in. A number of the objects of reference are kept in drawers by Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 10 the front door, and used to support service users to make decisions about the activities they take part in. All service users have some risk assessments in place, which set out the risk to them and action that staff should take to minimise the risk. However, risk assessments were not in place where it was identified that service users may throw objects and injure other people, be physically aggressive towards other service users, or may injure themselves. The manager said that she would take action to complete these assessments, including detailed actions that staff should take to minimise the risks. Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 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): 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 home has good arrangements to support service users to take part in community activities they enjoy and provides a varied menu, which meets the dietary needs of service users. EVIDENCE: Service users are supported to take part in a wide range of activities, including trampolining, swimming, horse riding, music and movement, cookery and horticulture. One service user showed the inspector a number of videos, which they enjoyed watching and the manager reported that one service user enjoyed playing games on the computer. One service user attends courses at a local college, although the manager reported that this placement was under review to ensure that it was suitable to meet the needs of the service user. The manager reported that the home has established good relationships with their neighbours. Service users take part in activities in their local community, such attending a local church and visits to the local pub and library. Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 12 Service users are supported to maintain contact with their friends and family, with staff providing support for service users to visit family where necessary. Three family members returned comment cards to the Commission for Social Care Inspection, stating that the home provided good care and staff treat their relative well. Service users are supported to take part in various household jobs, such as cleaning their bedroom, preparing food for meals and washing laundry. Details of the support that service users need with these tasks are included in their care plans. The home has a planned menu, which provides a balanced a nutritious diet. The likes and dislikes of service users are recorded as part of their care plans and alternative meals are offered if service users want them. Mealtimes are flexible to fit round service users’ activities and snacks are available at any time. One comment card received from a relative of a service user stated that their relative liked the food. On the day of the visit service users had a meal out as part of their planned activity. Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 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): 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. The home has good systems to meet the health and personal care needs of service users and ensures that medication is safely managed, which protects service users. EVIDENCE: Care plans for all service users set out what their personal care needs are and how they should be met. The assessment of service users prior to them moving into the home included gathering information from their current carers as to how personal care needs should be met. Service users are supported to attend several health services including GP, dentist, speech and language therapy and hospital outpatient appointments. Only one service user has been supported to attend an optician appointment. This was discussed with the manager during the visit, who said she would make arrangements for all service users to have their eyes checked. The home uses a monitored dosage system to manage service users’ medication. Medication is stored in a locked cabinet and medication administration records have been fully completed. Staff spoken with confirmed that they had received medication training and were currently completing a more in-depth medication course through a local college. None Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 14 of the service users have been assessed as being able to administer their own medication. Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 home has good systems to deal with complaints, concerns and allegations, which protects service users and ensures their views are listened to and acted upon. EVIDENCE: The home has a complaints procedure, which has been supplied to service users and their representatives. This procedure has been made more accessible for service users by presenting it in a pictorial format. The manager reported that Iliace was currently in the process of reviewing this document to see if it can be made more accessible for service users. The three comment cards received from relatives of service users stated that they were aware of what to do if they wanted to make a complaint. No complaints have been received since the home opened. The home has adult protection procedures and has copies of the procedures for reporting allegations of abuse to the local authority. All staff have received adult protection training. Staff spoken with demonstrated a good understanding of abuse and the actions they should take if abuse was reported or suspected. Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 home provides a comfortable, homely and safe environment for service users. EVIDENCE: A tour of the home was made during the visit. The home is maintained to a high standard, with good quality, domestic furniture and fittings. Service users have free access to a lounge, dining room, quiet lounge and kitchen. There is a planned maintenance and renewal programme and the manager reported that the maintenance team responds quickly to requests. There is a raised patio in the rear garden. The manager reported that she has requested that a rail is fitted around the edge to prevent falls. Before this happens, the manager reported that service users are not being left alone in the garden. This information needs to be added to service users’ risk assessments. The home has a separate, domestic laundry that is situated in a utility room next to the kitchen. There are procedures in place to ensure that laundry is not taken through the kitchen whilst food is being prepared. The home is clean throughout and there are no offensive odours. Hand washing facilities are suitably situated in the kitchen, laundry, toilets and bathrooms. Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 17 Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff receive good training, which helps them to meet the needs of service users. The home’s planned support for staff to complete formal qualifications will enable staff to demonstrate their competence. The home’s recruitment procedures are generally thorough, although the failure to obtain two written references for one staff member may not protect service users. EVIDENCE: The manager reported that one of the eleven staff currently holds the National Vocational Qualification (NVQ) in care at level 2. Of the remaining staff, the manager said they were keen to complete the qualification but were waiting for Iliace to set up as an NVQ assessment centre. The manager was not aware of when this assessment centre would be up and running, but was aware of the need for 50 of the staff to attain the qualification. Staff observed during the visit demonstrated a knowledge of service users’ needs, including specific communication methods. The files of four members of staff were viewed during the visit. These demonstrated that all staff had obtained an enhanced disclosure from the Criminal Records Bureau (CRB), however, there was only one written reference for one member of staff. Other staff had two written references on file. The manager reported that all applicants had completed an Iliace application form prior to being interviewed, however these are being held at a central office. Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 19 Staff spoken with said that Iliace provided good training, which helped them to meet the needs of service users. Training attended included communication skills, fire safety, adult protection, epilepsy, the administration of rectal medication, first aid, autism, physical interventions and moving and handling. All staff had completed the learning disability award framework induction as part of their induction on starting work. Iliace has a planned training programme and a centrally based training manager. The manager reported that she was able to access courses for staff when she needed to. Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed by a competent manager and the safety and welfare of service users and staff are maintained. The introduction of a quality assurance system that gathers the views of service users and their representatives will help to ensure the service improves. EVIDENCE: The manager has the NVQ level 4 in advanced management for care and has previously been registered as the manager of another Iliace service. Through the registration process with the CSCI the manager demonstrated her knowledge of the service user group and relevant legislation. The manager reported that Iliace was introducing a new quality assurance system, which will include obtaining the views of families, staff and service users where possible. This will form the basis of a development plan for the service that will be assessed during visits by the company’s senior managers. The manager was not sure when this system would be introduced. The Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 21 arrangements for the management of the service have recently changed, with the introduction of an Area Manager post. The manager was aware of these developments and said she would have formal supervision meetings with the area manager, although this has not yet happened. Monthly visits are made to the home by a senior manager of Iliace and a report of the visit sent to the CSCI. These reports contain actions that are required to improve the service and who is responsible for completing it. The staff complete weekly tests of the fire alarms and fire safety equipment has been serviced within the last six months. The home’s electrical wiring was checked in September 2005 and the manager reported that the oil burning central heating was being serviced during the week of the visit. Infection control procedures to prevent laundry being taken through the kitchen whilst food was being prepared or eaten were in place. The temperature of hot water is restricted at each tap to prevent service users being scalded and windows on the first floor are restricted to prevent falls. Records are made of accidents and incidents to service users and staff. Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 2 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 2 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 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 2 X X 3 X Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 YA5 Regulation 5 (1b) Requirement The registered person must provide service users with a statement of terms and conditions of residence. The registered person must ensure that all identified risks for service users are assessed and action taken to minimise the risk. The registered person must ensure that two written references are obtained for all staff prior to them commencing work in the home. Timescale for action 31/05/06 2 YA9 13 (4) 31/05/06 3 YA34 19 (1) 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Woodrow Cottage DS0000064287.V288960.R01.S.doc Version 5.1 Page 25 - 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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