Inspection on 19/12/05 for Woodwell House

This inspection was carried out on 19th December 2005.

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

Woodwell House 16/03/07

Woodwell House 25/08/05

Woodwell House 18/12/04

Woodwell House 24/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Woodwell House 227-229 Nibley Road Shirehampton Bristol BS11 9EQ Lead Inspector Helen Taylor Unannounced Inspection 19th December 2005 09:30 Woodwell House DS0000026588.V275143.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 Woodwell House DS0000026588.V275143.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. Woodwell House DS0000026588.V275143.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodwell House Address 227-229 Nibley Road Shirehampton Bristol BS11 9EQ 0117 9381942 0117 9382551 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) Avon Autistic Foundation Ms Ann Coleman Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Woodwell House DS0000026588.V275143.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 12 persons aged 18 - 64 years Date of last inspection 25th August 2005 Brief Description of the Service: Woodwell House is owned and operated by the Avon Autistic Foundation and is registered with the Commission for Social Care Inspection to provide accommodation and personal care for twelve persons aged between eighteen and sixty four years with a learning disability. Avon Autistic Foundation specialises in the care of persons who have a diagnosis of autism or asperger syndrome. The Foundation also operates a day centre providing a range of social and educational activities. Woodwell House is purpose built and consists of two properties linked by a corridor. The property is situated in a residential area close to local amenities and bus routes. At the time of the inspection there were five people accommodated, four persons in the upper house, and one person in the lower house. Woodwell House DS0000026588.V275143.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection programme to examine the care provided, and to review progress in relation to the requirement made during the last inspection conducted in August 2005. The inspection took place over five hours in the evening and all residents were present throughout. Evidence was gathered from a partial tour of the premises, observation, discussion with staff, residents, the manager, the provider and a review of records held. What the service does well: What has improved since the last inspection? What they could do better: The health and welfare of the residents would be improved if the medication records were properly maintained and indicated when an audit took place. Storing only necessary amounts of medication would reduce any potential risks to residents. Woodwell House DS0000026588.V275143.R01.S.doc Version 5.1 Page 6 Regular attendance at fire drills for all staff that work at the home, would improve the health and welfare of the residents and staff. Reviewing the residents personal goals according to achievement would promote greater independence for some residents. Developing the guidance in risk assessments relating to the use of the community would reduce any potential risks for residents and staff. 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. Woodwell House DS0000026588.V275143.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 Woodwell House DS0000026588.V275143.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): 1,2,3,4. There is information available to enable prospective residents and their supporters to make an informed choice about the facilities provided at the home. EVIDENCE: The home has in place a statement of purpose and resident guide that contains comprehensive information about the home and services offered. The resident guide has been developed with the use of pictorial information ensuring accessibility for those individuals with complex communication needs. Admissions to the home are through the care management approach, with local authority assessments and care plans used to develop a plan of care during the initial trial period. There have been no recent admissions to the home. The provider stated that recently an initial application had been received from a prospective resident. Family members have visited the home to view the facilities, and funding was being sought from the local authority involved. Woodwell House DS0000026588.V275143.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): 6,7,8,9,10. The assessment and care planning process ensure all aspects of personal, social and healthcare needs are met. Policies and procedures in place provide guidance on the promotion and protection of residents rights independence and choice. EVIDENCE: A review of the care file information indicated that each resident had in place information that informed staff of their assessed needs. The care plans had been reviewed regularly, and monthly summary reports gave a good overview of progress made and changes in support that may be required. There was individual development plans in place for each resident relating to personal goals. The records were comprehensive and provided examples of support in relation to the following: • Using money independently • Corresponding with family members • Developing a new communication system • Preparing meals Woodwell House DS0000026588.V275143.R01.S.doc Version 5.1 Page 10 The plans for each resident were developed according to assessed need. The aims and progress were consistently recorded and reviewed on a six monthly basis. It was evident from the records that in some cases minimal support was now required for the residents to fulfil some of the goals, and it was recommended the personal goals should be reviewed according to progress made, prior to the six-month review. This would enable residents to develop new skills according to individual achievement, and provide a progressive flavour to the personal development plans. There was good evidence of residents making choices within a risk management framework. Risk assessments were in place relating to all aspects of daily life. It was noted however in one risk assessment using the community the guidance for staff was centred on the home or the day centre. There was limited advice for staff on how to deal with a difficult situation whilst in the community, where other environmental issues may need to be addressed. It was recommended the risk assessments relating to the community be reviewed to ensure any risk to residents or staff is minimised. The behaviour management strategies seen were consistent with the assessed needs of the individual as detailed in the care plans. The care file information is stored securely, and staff members sign to acknowledge an understanding of the confidentiality policy. Woodwell House DS0000026588.V275143.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): 11,12,13,14,15,16,17. Opportunities for personal development and links with the local community are an integral part of the care provided at this home. The health and well being of the residents is maintained through the supply of a varied, nutritious diet. EVIDENCE: Individual activity plans are developed for each resident to encourage the pursuit of interests at the day centre and in the wider community. The Inspector had the opportunity to speak with one resident in the privacy of his own room, and he was able to show his weekly planner displayed on the wall. The activity planner had been developed with the use of symbols and pictorial information. The resident was able to read the planner and explain what activities he would be doing, where they would take place, and on what day. Woodwell House DS0000026588.V275143.R01.S.doc Version 5.1 Page 12 Written handovers and achievement records detailing time spent at the day centre, and involvement in organised activities including any behavioural concerns was noted each day. Records noted recent trips to the American Museum and a local seaside resort. The day centre offers over forty activities including art and music therapy, computer technology and cooking skills. There was evidence of family involvement in the development of care plans, and the provider explained that two residents would be spending some time at home during the Christmas period. A varied menu was displayed on the notice board, and the staff member explained residents would be shown the food or packaging to enable choices to be made. Observations confirmed choice being offered, and the residents were able to help with meal preparations. The kitchen was clean, tidy and well organised. The food storage areas were clean, and opened food was appropriately labelled. All records held in relation to food preparation were up to date and in order. Woodwell House DS0000026588.V275143.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): 18,19.20,21. The personal and health care needs of the residents are monitored effectively and action is taken promptly when concerns arise, so that residents can be confident their needs will be met. Improvements to the administration and storage of medication would reduce potential risks to the residents. EVIDENCE: There was good evidence in the care files that personal support is provided with each residents preferences recorded as an integral part of the care provision. Advice is sought appropriately from health professionals when concerns arise. There was evidence of preventative health measures for example: visits to optician, dentist and GP where necessary. Staff members support the residents attending any health appointment. Those staff members spoken with were able to demonstrate a good understanding of individual need, and observed interactions were sensitive and respectful. Woodwell House DS0000026588.V275143.R01.S.doc Version 5.1 Page 14 The care plans reviewed contain adequate information about end of life plans. Details of family members are noted in the file, and legal appointees in the event of death. A review of the storage and administration of medication revealed three errors. Individual medication is dispensed in monitored dosage cassettes. The dosette boxes for each resident are colour coded and contain a picture of the resident, a list of medication and guidance for staff. The storage and records for this medication were up to date and in good order. Homely remedies are kept to a minimum in this home, however the records reviewed did not correspond with the medication held. Similarly the balance of medication stored for use as required was found to be incorrect in relation to the medication held. The last entry in this record was March 2005. There was little indication in the records of when an internal audit had been completed. Medication for use as required must be kept to a minimum, and any excess medication returned to the pharmacist. One packet of medication dated June 2003 was found in the medication cabinet, and no records to indicate its presence. Medication no longer used must be appropriately disposed of and records held. The home must ensure records of all medication are up to date and in order. Internal audits of medication must be recorded with a date in the records reviewed. Woodwell House DS0000026588.V275143.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): 22,23. The complaints process in the home is good and there was evidence that the residents views are listened to and acted upon. The risk of residents suffering any form of abuse or neglect is appropriately minimised. EVIDENCE: A detailed complaints procedure is in place. The resident guide contains pictorial and symbol information to encourage residents to raise any concerns or communicate any problems on a day-to-day basis. The care files contained records of monthly concerns and suggestions meetings between residents and key workers. Various communication methods are used depending on the needs of the individual. One staff member present was able to explain that a new communication system was being developed with one of the residents to prompt the resident in making choices. The staff member demonstrated an enthusiastic approach to the development of this system. Policies and procedures are in place to ensure residents are protected from any form of abuse. The provider is aware of his responsibility to implement local authority protocols in relation to any allegation of abuse, and of his duty to inform the Commission of any incident. The provider stated that staff receive abuse awareness training delivered by the local authority as part of the induction programme. No staff training records were reviewed on this occasion but this will be a focus of the next inspection. Woodwell House DS0000026588.V275143.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): 24,25,26,27,30. The residents live in a safe, comfortable, homely environment, which promotes individual choice and is regularly maintained. EVIDENCE: Woodwell House provides a bright, well-furnished home for those accommodated. The communal space consists of a lounge, dining room, spacious kitchen and a visitors room. Individual accommodation is in single rooms. There is a well-kept garden area with seating and activity equipment for use outside. External contractors maintain the garden area ensuring it is safe for use by the residents. A rolling programme of internal re-decoration, repair and replacement of furniture, fixtures and fittings, ensures the home is maintained to a high standard. Although a full environmental check was not undertaken, the Inspector had the opportunity to view three bedrooms accompanied by the residents. The rooms were all furnished to a high standard, and reflected individual taste. One resident was an avid collector of memorabilia, and eagerly showed off his different collections, displayed neatly in his room. Woodwell House DS0000026588.V275143.R01.S.doc Version 5.1 Page 17 Another resident displayed his own artwork on the walls in his room, and was very proud of his achievements. Those residents spoken with conveyed to the Inspector they were happy in the home, and their needs were being met. The care file information provided evidence that residents are encouraged to take part in the daily functioning of the home. Personal development plans included support with the following: ironing, meal planning, cooking and cleanliness in bedrooms and communal space. The home was clean and tidy on the day of inspection. Woodwell House DS0000026588.V275143.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): 31,33. The residents benefit from a staff team who are clear about their role within the home. EVIDENCE: Staffing information was not viewed on this occasion. However, the personnel files of the two staff present have been examined during a recent inspection at the Ann Coleman Day Centre, also owned and operated by the Avon Autistic Foundation, and where the organisations administrator is located. Those records indicated that a robust recruitment procedure is in place. The staff present conveyed to the inspector that they were clear about their role and responsibility within the home. Observations of interactions between the staff and residents provided evidence of a high standard of sensitive care delivery. A requirement to incorporate the learning disability award framework into the induction programme has been complied with. Evidence of LDAF induction packs has previously been seen, although the inspector was unable to review progress due to the timescales involved. The LDAF induction is a lengthy programme and will be a focus of the next inspection to ensure all staff are involved. Woodwell House DS0000026588.V275143.R01.S.doc Version 5.1 Page 19 A review of essential training as part of the foundation programme will also be undertaken at the next inspection. This will allow new staff to be slotted into organised training events. Woodwell House DS0000026588.V275143.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): 37,39,42,43. The home is well managed and progress continues to be made in the development of a formal training programme for all staff. There are effective polices and procedures in place to ensure the health and welfare of the residents, however this could be improved. EVIDENCE: The registered manager is Mrs Ann Coleman who was not present during the inspection. Mr Andrew Coleman, the registered manager at the Ann Coleman Centre, and Mr John Coleman, the registered provider were both present. There are clear lines of responsibility at the home, and the staffing rota indicated a high level of management support is available on a regular basis. Throughout the inspection process the provider conveyed a positive attitude to meeting any requirements or recommendations discussed. Woodwell House DS0000026588.V275143.R01.S.doc Version 5.1 Page 21 As previously noted, the home has recently introduced the learning disability award induction programme and is developing a formal foundation programme to ensure all staff receives essential training in conjunction with the induction. Staff shift guidelines seen provided evidence of the residents being included in the day-to-day functioning of the home. Records reviewed in relation to fire safety indicated regular fire drills, and checks of essential fire safety equipment. The records were detailed and included in-house fire instruction for all staff. There was evidence of all electrical appliances being checked, and certificates from the local fire safety officer were in place. Although regular fire drills had been held, in two cases staff members had not attended a fire drill at appropriate intervals. The provider explained that often staff attend a fire drill at another establishment. It is required that all staff who work in the home must attend fire drills at appropriate intervals in the establishment in which they work, and records held. The commission receives copies of monthly monitoring visits carried out by the registered provider. A valid certificate of insurance was displayed in the home. Woodwell House DS0000026588.V275143.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 3 2 3 3 3 4 3 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 4 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 1 3 3 X 3 X X 2 3 Woodwell House DS0000026588.V275143.R01.S.doc Version 5.1 Page 23 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 Medication records must be properly maintained, with a date and signature of any audits noted in the records. Only necessary amounts of medication must be held in the home, old or unwanted stack must be disposed of appropriately. All staff must attend fire drills at appropriate intervals and records kept. Timescale for action 14/02/06 2. YA20 13.2 14/02/06 3. YA42 23.4 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA9 Good Practice Recommendations IPP goals should be reviewed according to individual progression. Review the risk assessments relating to the use of the community, ensuring potential risks to residents and staff are minimised. Woodwell House DS0000026588.V275143.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Woodwell House DS0000026588.V275143.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!