Inspection on 28/09/07 for Woodrow Cottage

This inspection was carried out on 28th September 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodrow Cottage 24/04/06

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 28th September 2007 09:30 Woodrow Cottage DS0000064287.V352693.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 Woodrow Cottage DS0000064287.V352693.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. Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodrow Cottage Address Hills Close Fair Oak Hampshire SO50 7HD 01420 544118 02380 695057 woodrow@iliace.com 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 7 Category(ies) of Learning disability (7) registration, with number of places Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th April 2006 Brief Description of the Service: Woodrow Cottage is registered to provide care and accommodation to seven people between the ages of 18 and 65 who have a learning disability. Each person has a single bedroom, with either en-suite facilities or the use of an adjacent bathroom. People 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 people 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 people are able to use when there is a staff member on duty who is registered to drive. The range of fees at the home is from £1290 to £1537 per week, depending on assessed needs. Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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) since the last visit. This information included incident reports sent to CSCI, an annual quality assurance assessment and comment cards from three people who live in the home and three relatives. A site visit to the home was made on 28 September 2007. During the visit the inspector met two of the residents and observed the interactions between residents and staff. The inspector also spoke with the regional manager, quality assurance manager and three members of staff on duty. The communal areas of the building were viewed and documents relating to the running of the home were inspected during the visit. What the service does well: There are good systems to assess people’s needs before they move into the home. This gives people confidence that the home will be able to meet their needs. There are good care planning and risk assessment systems, which supports people to make decisions about their lives and helps staff to provide the support that people need. The home provides good support for people to take part in activities they enjoy. People’s personal care is well met by staff and people are supported to attend the health services they need. There are good systems for dealing with complaints and protecting people from abuse. This gives people confidence that any complaints will be taken seriously and responded to. The home is well maintained and provides a clean, comfortable and safe environment for people. Staff are well trained, which helps them to meet people’s needs. Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 6 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. Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 comprehensive assessments of people’s needs before they move into the home, which reassures people that the home will be able to meet their needs. People living in the home have been provided with information about their rights and responsibilities; however, this information is not in an accessible format for all of them. EVIDENCE: The manager reported in the annual quality assurance assessment for CSCI that people have a full needs assessment before they move into the home. The records of three people who live in the home were inspected during the visit. Each person had a full assessment, which was completed by the company’s placements team and the manager. The assessment was carried out in people’s previous placement, for example in their school or at the family home. The assessment covers all aspects of the person’s needs, including health, self help skills, academic skills, participation in activities, social skills, community skills, personal relationships and sexuality and challenging behaviour. Following this assessment a transition programme is put in place, involving visits to the home to meet with other residents and staff and to make choices about room décor and furniture. Each person had at least one overnight stay before moving in. Three comment cards were received from Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 9 people who live in the home; two said they received enough information about the home to decide whether it was the right place for them, one person did not answer the question. Three comment cards were received from relatives; all three said the home always meets the needs of their relative. Since the last inspection all people living in the home have been provided with a statement of terms and condition of residency. These were all in written format and are not accessible for all people who live in the home due to their communication needs. The manager should look at ways of making this information more accessible to people. Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 10 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 good. This judgement has been made using available evidence including a visit to this service. There are good care planning and risk assessment systems, which supports people to make decisions about their lives and helps staff to provide the support that people need. EVIDENCE: The records of three people who live in the home were inspected during the visit. People had a care plan, which set out how their assessed needs should be met. The care plans seen reflected the information that was included in the initial assessment. There was programme for regularly reviewing the care plans and it was clearly recorded where people’s needs had changed. Details of how people should be supported to make decisions are set out in the care plans, for example, through the use of objects of reference or through Makaton sign language. A number of the objects of reference are kept in drawers by the front door, and used to support people to make decisions about Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 11 the activities they take part in. During the visit, staff were observed providing support for people to make decisions about the days activities. Risk assessments have been completed for all people living in the home and include actions that should be taken to minimise the identified hazards. Since the last inspection the risk assessments have been expanded and now cover all of the hazards that were identified in the assessments and care plans. These assessments have been regularly reviewed and amended where necessary. Staff spoken with said they thought the information in care plans and risk assessments was accurate and helped them support people. Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. The home provides good support for people to take part in activities they enjoy and meet their lifestyle choices. EVIDENCE: People are supported to take part in a wide range of activities, including trampolining, swimming, horse riding, attending a local activity centre, cookery and horticulture. Each person has a programme of activities run through the Adults Continuing Education (ACE) service, which is operated by the company. People take part in activities in their local community, such attending a local church and visits to the local pub and library. Three people who live in the home completed a CSCI comment card. All three said they were able to do what they want to during the day, in the evenings and at weekends. On the day of the visit, four of the people who live in the home were away on a holiday. Activities for the day are set out on a picture display, which is attached to the fridge in the kitchen. During the visit staff were observed Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 13 using this display to explain to one person who lives in the home what activities were arranged. People are supported to maintain contact with their friends and family, with staff providing support for service users to visit family where necessary. Three relatives completed a CSCI comment card; all three said the home always helps their relative to keep in touch with them. People are supported to take part in various household jobs, such as cleaning their bedroom, preparing food for meals and shopping. Details of the support that people need with these tasks are included in their care plans. The home has a planned menu, which provides a balanced and nutritious diet. People’s likes and dislikes are recorded as part of their care plans and alternative meals are offered if people want them. Mealtimes are flexible to fit round activities and snacks are available at any time. Woodrow Cottage DS0000064287.V352693.R01.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 adequate. This judgement has been made using available evidence including a visit to this service. People’s personal care is well met by staff who know what their needs are and people attend the health services they need. The lack of clear guidance for staff for variable dosage medication and incomplete medication administration records does not demonstrate safe practice. EVIDENCE: Care plans contain details of the personal care support people need and how they prefer to receive it. Three people who live in the home completed a comment card; all three said staff always treat them well. Three relatives completed a comment card; all three said the home always gives the support and care that they expect. People are supported to attend a range of health services, including GP, nurse, dentist and specialist hospital appointments. Since the last inspection everyone has been supported to have an optician appointment. Details of consultations are recorded, including any advice given by the practitioner. Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 15 Staff reported that all of the people living in the home need support to administer any medication they are prescribed. Medication is securely stored in a locked cupboard and most tablets are supplied in a monitored dosage system. A record is kept of medication coming into the home and returned to the pharmacist for disposal. All staff administering medication have received training. One person is prescribed a medication that has a variable dosage, between one and three tablets. Staff administering this medication had recorded the number of tablets given for the four days before the inspection, but not for any other time it was administered. There were no guidelines in place for staff to determine how many of these tablets should be taken each day. The regional manager said he would ensure this work was completed and clear information provided for staff. There were no medication administration records available for the four people who were away on holiday, as staff had taken all the records with them. It was therefore not possible to assess whether these administration records had been fully completed. The company’s quality assurance manager said she would develop a system that ensures records are available in the home, whilst also keeping a record of medication administered to people when they are out of the home. Woodrow Cottage DS0000064287.V352693.R01.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. There are good systems for dealing with complaints and protecting people from abuse. This gives people confidence any complaints will be taken seriously and responded to. EVIDENCE: Three people living in the home completed a CSCI comment card; two said they know how to make a complaint and staff always listen to and act on what they say, one did not answer these questions. Three relatives completed a CSCI comment card; all three said they know how to make a complaint and that the home has responded appropriately to any concerns that have been raised. The home has a complaints procedure, which is provided to all people living at the home and has been made more accessible in a pictorial format. The manager reported in the annual quality assurance assessment that the home has not received any complaints in the last year. CSCI has not received any complaints about the home, but did receive an anonymous complaint about changes in the company and the actions of some senior staff. This was passed to the company and was investigated by the managing director. The complaint was not upheld. Staff have completed training in safeguarding adults. Staff spoken with demonstrated a good understanding of the action they should take if abuse is witnessed, reported or suspected. There is a policy and procedure on safeguarding adults and the prevention of abuse. The home looks after money for all the people who live there. This is individually stored in a locked Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 17 cupboard and records are kept of expenditure. The records of two people’s money were checked and the cash held matched the balance recorded. Woodrow Cottage DS0000064287.V352693.R01.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. The home is well maintained and provides a clean, comfortable and safe environment for people. EVIDENCE: All of the home’s communal areas were viewed during the visit. The home is maintained to a high standard, with good quality, domestic furniture and fittings. People living in the home have access to a lounge, dining room, quiet lounge and kitchen. The manager reported in the annual quality assurance assessment for CSCI that it was planned to change the quiet lounge into a ‘chill out room’, to be used for relaxation and sensory activities. There is a planned maintenance and renewal programme and staff reported that the maintenance team responds quickly to requests. Since the last inspection, hand rails have been fitted on the raised patio area in the garden to help people who are unsteady on their feet. 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 Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 19 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. Three people who live in the home completed a comment card; all said the home was always clean and fresh. Woodrow Cottage DS0000064287.V352693.R01.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, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures and a well-trained staff team help to ensure people are protected and their needs are met. EVIDENCE: The manager reported in the annual quality assurance assessment for CSCI that two of the staff have achieved the National Vocational Qualification (NVQ) at level 2 or above and five are currently completing either level 2 or 3. The manager reported in the annual quality assurance assessment for CSCI that all staff who have worked in the home over the last twelve months have had satisfactory pre-employment checks. The files of four members of staff who have been employed since the last inspection were checked. All four had a Criminal Records Bureau enhanced disclosure or Protection of Vulnerable Adults list check. Three had two written references, although these could not be found for one member of staff. The manager was not present during the inspection, but found the references in the safe on the day following the inspection. Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 21 The home has an on-going training programme and staff reported that they receive good training, which helps them meet people’s needs. Staff training records indicated they had completed an induction and courses in medication administration, first aid, safeguarding adults, food hygiene, responding to aggressive behaviour, moving and handling and fire safety. The manager completes a weekly analysis of training, which is used by the company to plan courses that are needed. These records indicated that people had been booked onto training courses where gaps had been identified. Woodrow Cottage DS0000064287.V352693.R01.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 adequate. This judgement has been made using available evidence including a visit to this service. There are good systems in place to support staff in the absence of the manager, however, the lack of quality assurance systems does not ensure that shortfalls in the service are identified and improvements planned. EVIDENCE: The manager is currently on a period of leave from the service. CSCI were informed that a manager from one of the company’s other homes was overseeing the service in the manager’s absence. A senior member of the care staff is taking the lead in the home to ensure that the service operates effectively. Staff spoken with said they thought the arrangements were working well and felt they had the support they need. The regional manager reported that he had just taken over responsibility for this service and would visit regularly to ensure the home was running well in the manager’s absence. Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 23 A regional manager visits the home every month to assess the quality of the service that is being provided. Reports of these visits are made and sent to the manager, including any actions that are required. The most recent report was seen and did not contain any information about the medication issues that are highlighted in this report. The company has recently employed a quality assurance manager, who is currently completing a ‘health check’ of all their services. The results of these audits will be used to develop an improvement plan. The manager reported in the annual quality assurance assessment that there is currently not a system for formally surveying people who live in the home, their relatives and other stakeholders about the quality of the service that is provided. The lack of quality assurance systems was highlighted at the last inspection. The manager reported in the annual quality assurance assessment for CSCI that the electrical system, portable electrical equipment, fire detection and fighting equipment and heating system are regularly serviced and maintained. These records were inspected during the visit and while most were in place, there was no record that the fire fighting equipment and emergency lighting was being tested and checked by staff each month. The regional manager said he would ensure that these tests were carried out. Woodrow Cottage DS0000064287.V352693.R01.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 3 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 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement The registered person must ensure that medication is safely administered: • There must be clear guidance for staff covering how many tablets people need when the prescribed dose is variable. The guidance must cover who should make the decision and what criteria should be used. • There must be a record in the home of medication administered to people who use the service. Timescale for action 31/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Woodrow Cottage DS0000064287.V352693.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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