CARE HOME ADULTS 18-65
Woodview 58a Park Road West Birkenhead Wirral CH43 8SF Lead Inspector
Andrea Morris Unannounced Inspection 19th February 2006 10:30 Woodview DS0000018957.V284901.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 Woodview DS0000018957.V284901.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. Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Woodview Address 58a Park Road West Birkenhead Wirral CH43 8SF 0151 653 6566 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) Alternative Futures Limited Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One (1) named male service user over 65 years of age (LD/E) within an overall total of Four (4 )(LD) 18th August 2005 Date of last inspection Brief Description of the Service: Woodview is a two storey detached house which backs on to Birkenhead Park, with the back of the house and the large garden having attractive views across the park. It is on a busy main road, less than half a mile from Claughton Village where there are local shops and bus services. The home has its own minibus for the use of service users. The home has a large lounge and dining area on the ground floor. The kitchen adjoins the dining room and there is a very small lounge on the other side of the kitchen. There is a shower room, toilet and laundry on the ground floor. All service users have large single bedrooms on the first floor, which also houses an office, toilet and bathroom. Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took 3.5hours. During the inspection the inspector spoke with the manager and staff present. A tour was made of the home. A selection of documentation was examined, these included client care files, risk assessments, certificates relating to Health and Safety including fire documentation. Staff training files was also looked at. What the service does well: 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. Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 6 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 Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 7 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): 1, 2, 3, 4, 5, 6 All clients are assessed prior to admission, this assists in ensuring clients needs can be met fully. EVIDENCE: The home’s Statement of Purpose contains all the relevant information as requested in the National Minimum Standards. A copy is available upon request. All clients are admitted only after a detailed pre-admission assessment has been completed. The manager carries out an initial assessment, then over a period of time, the potential client is offered the opportunity to visit the home and staff members on several occasions so they can establish that they have made the right choice. All clients who move into the home are issued with a written contract that clearly determines their terms and conditions of residency. There have been no new clients admitted to the home since July 2005. Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 8 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, 8, 9, 10 Care plans are formulated well, this assists in providing the correct care and ensuring clients safety. EVIDENCE: Care files are formulated for each client. These on examination were found to be detailed and contained valuable information on each client. All care files are reviewed on a regular basis. All care files hold a sample of daily living, this information gives details on each client likes and dislikes. The information also details behaviours and what they indicate for staff and how the behaviour is best managed. Clients are encouraged to participate in all activities within the home. Evidence was seen that staff encouraged client participation but within their level of capability. Through discussions with staff it was noted that all staff had a good knowledge of each client and how best to care for them. Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 9 All activities are risk assessed. Risk assessments are reviewed on a regular basis. All care files are kept in a secure cupboard. The home has up to date policies and procedures these are available to all staff and are used as reference material as needed. Confidentiality is discussed initially at induction; staff meetings also address confidentiality as required. Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 10 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): 11, 12, 13, 14, 15, 16, 17 The meals in this home are good offering both choice and variety; special dietary needs are catered for. EVIDENCE: No clients attend work due to client’s individual capabilities. However, there are a variety of activities the clients are able to participate in. These include swimming, cinema, shopping and bowling. Any individual activities are recorded in the clients care files. They hold risk assessments as needed. The home operates an open visiting policy, most clients do have family support and are able to go home on a regular basis. Holidays are arranged for clients and staff attend, this allows clients to lead a fulfilling lifestyle. The home has access to a minibus, regular outings are provided, these include a drive round the area, and clients’ are able to choose outings as appropriate.
Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 11 Mealtimes are flexible and provide a variety of food, formal meals along with finger food options. Staff encourage clients to follow a health lifestyle as much as possible. The menu is on a three-week rota. Variations to the menu are available as needed. Clients are able to participate in meal preparation as their capabilities allow. Any participation from clients is risk assessed to promote safety. Menus were found to be well balanced and nutritious. Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 12 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, 20, 21 The medication is well managed and promotes safe practice. EVIDENCE: All clients have their own room. Risk assessments are documented in relation to clients care. Care plans are amended as needed and all care plans are reviewed on a regular basis. Medication for clients is held in the client’s own room in lockable cupboards. Medication documentation is recorded accurately and stock is well managed. Staff during the induction period receive training in medication administration, the manager is currently doing further drug administration via distant learning programme. There is a possibility of all staff being able to study the distant learning programme in the near future. All staff receive training in First Aid, this is re-newed every 3 years. Any client admitted to the home with specific medical need i.e. Epilepsy staff receive training in the condition prior to the client being admitted to the home. All accidents are recorded appropriately. The home has an adequate policy in relating to care of the dying client.
Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 13 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, 23 Staff receive training in Adult protection, this helps to protect clients from harm. EVIDENCE: All staff receive adult protection training during the induction period. Most staff have received further training in adult protection issues this helps to safeguard clients from harm, plans are in the future that all staff will receive the training on an annual basis. The home has a copy of the Wirral No Secrets Policy on Adult Protection. All staff are made aware of where it is kept and on how to use it. The home has an adequate complaints procedure. There is a copy available upon request from the office. The home documents all complaints received and the action taken. There has been recent discussions relating to plans for a service User Guide that will be provided in the relevant format for clients to be able to understand. The Commission for Social Care Inspection has not received any complaints since the last inspection. Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 14 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, 25, 26, 27, 28, 30 The home needs to be re-decorated so to create a pleasant and homely atmosphere. EVIDENCE: Each client has their own room, which is personalised with their own effects. Each room also has some specialist sensory equipment installed to promote a calm and relaxing environment. Clients are able to move about the home freely. Areas considered to pose a potential danger are supervised on the client entering. Clients are able to go to their room freely during the day. The bathrooms are in need of being re-decorated to ensure a good standard. Clients are able to have baths/showers on a daily basis if they choose. All clients were noted to be treated with respect. No staff member enters any room without knocking on the door first. The home is in need of re-decoration to bedrooms and to communal areas. Plans for a total refurbishment are set for May 2006. On the day of the inspection the home was found to be clean and free of any unpleasant odours.
Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 15 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): 31, 32, 33, 35, 36 The manager provides strong leadership; this assists with promoting safe practices of care. EVIDENCE: The staff rota was examined and found to be recorded accurately. No agency staff are used, as the home is fully staff. The majority of care staff hold an NVQ2 or above in care. The home manager is not yet registered with the Commission for Social Care Inspection; an application has been put forward and awaiting processing. The staff that spoke with the inspector stated they found the manager helpful, supportive and an active team player. Staff receive regular training in all mandatory subjects, these include First Aid, Fire, Moving and Handling, Challenging Behaviour and medication. Other training is sort as needed. It is recommended that the manager keeps a record in the home of all training staff have undertaken. All staff receive supervision on a 4-6 weekly basis. The manager maintains records of all supervision.
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The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40, 41, 42, 43 The home has clear policies and procedures relating to all practices; this assists in promoting safe practices in care. EVIDENCE: The home along with the Company regularly review the policies and procedures relating to care. This ensures all care practices are kept up to date and relevant to the client group. Copies of all policies and procedures are available for staff to access if required. The certificates relating to Health and Safety were examined and found to be in date and relevant. Fire safety records are also recorded accurately and staff receive regular fire training and drills to promote safety in the home. There is a clear management structure within the Company and in the home. This is detailed in the Statement of Purpose. The home operates a clear
Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 17 structure of responsibility, all staff are aware of their roles and responsibilities within the home. The Company also operates an on call system for out of hours, staff in all homes are able to access a senior member of staff for advise or support if required. The company has not as yet introduced a quality assurance system as required in the last inspection, this is necessary to obtain the view points of clients, their families and other professionals. Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 18 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 3 2 3 3 3 4 3 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 2 25 3 26 3 27 3 28 3 29 N/a 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 N/a 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 N/a N/a 2 3 3 3 3 Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 19 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 YA39 Regulation 24 Requirement Timescale for action The Registered Person must 30/03/06 ensure that an effective quality assurance and quality monitoring systems based on seeking the views of service users must be in place to measure success in achieving the aims, objectives and statement of purpose of the home. The Registered Person must ensure that the premises are kept in a good state of repair both internally and externally. The Registered Person must ensure that all parts of the home are kept reasonably decorated. 30/05/06 2. YA24 23(2b) 3. YA30 23(2d) 30/05/06 Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 20 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. Refer to Standard YA23 YA35 Good Practice Recommendations It is strongly recommended that all staff receive annual training in adult protection. It is strongly recommended that the manager maintains training records that are held in the home of all staff training undertaken. Woodview DS0000018957.V284901.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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