Care Home: Bury Metro - Woodbury

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What the care home does well People`s needs are assessed before a placement is agreed to ensure that support workers can meet their individual needs. People and their families are allocated a named key worker to promote good communication and relationships. They undertake annual home visits and telephone courtesy calls following a persons stay at the home. People using the short stay unit have a support plan and risk assessments in place that give direction to support workers as to how support is to be delivered. People appeared relaxed and content and there was a good rapport between them and their support workers. The staff team have a clear value base and promote opportunities for choice and independence where they can. People have access to an experienced staff team who have undertaken appropriate training and receive regular formal supervision from the management team. They have a good understanding of people`s needs. One returned survey stated that, "Staff are very helpful in helping me stick to my activity timetable and social life. Another stated that, "Our son enjoys socializing. Whilst at Woodbury the staff will take him to the local pub for a shandy. This is a highlight for our son. The management and staff must be congratulated on the approach they use." A competent and approachable management team, who work hard to maintain good standards, in the best interest of people using the service, leads, directs and supports an experienced staff team. What has improved since the last inspection? A consultation exercise has started to review the short stay provision and look at how the service could be improved The bathroom has been painted and a handwash basin has been fitted to improve control of infection practices. A second housekeeper has also been appointed. There is now a dedicated staff team for the short stay unit. Staffing levels have improved and there is only one vacancy for a night support worker. Over 50% of the support staff team now hold an NVQ Level 2 qualification or the equivalent. A number of people are qualified social workers or have undertaken NVQ Level 4 and NVQ Level 3. The established staff team have undertaken all the identified gaps in mandatory training to ensure the health and safety of people. This includes training in safeguarding procedures, fire safety and hoist training. All necessary training for new staff members is either ongoing or planned. CARE HOME ADULTS 18-65 Bury Metro - Woodbury Woodbury Wesley Street Tottington Bury Lancs BL8 3NN Lead Inspector Julie Bodell Unannounced Inspection 19 & 27th June 2008 07:30 th Bury Metro - Woodbury DS0000053090.V366357.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 Bury Metro - Woodbury DS0000053090.V366357.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. Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bury Metro - Woodbury Address 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) Woodbury Wesley Street Tottington Bury Lancs BL8 3NN 01204 887424 Bury M.B.C. Mr Peter Miller Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 30th July 2007 Date of last inspection Brief Description of the Service: Woodbury is a Local Authority home providing care and support for adults who have a learning disability. The home provides three different services within one building. The preindependence unit and the resettlement unit are registered as domiciliary care provision, and were not included in this inspection, which covered the four place short stay unit and the emergency place only. The short stay unit is on the ground floor. It is separate from the rest of the building and has its own entrance. The unit has exclusive use of a small lounge, dining kitchen, bathroom, and toilet. All bedrooms are single. Service users who are admitted in an emergency have use of a single bedroom on the first floor. They have use of the communal facilities used by those living in the resettlement unit. All service users are able to use the enclosed garden, and the relaxation room. The home is situated in the centre of Tottington, close to bus routes, shops, library, and other local amenities. Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The findings in this report refer only to the short stay service provided by Woodbury. A separate report is available covering the domiciliary service. This unannounced inspection was carried out over a day and a half day. Some shared information about the service was gathered at the domiciliary service inspection, which took place during the same period. We (the commission) spent time talking to two senior support workers and two support workers. We also spoke with four people using the service, looked round the building, watched what went on and looked at paperwork. We returned to speak with the registered manager to talk about the changes that are being considered and planned for the future of the short stay service. We requested quality assurance information (AQAA) from the service, which we received before the visit. We also received surveys from four people using the service and their relatives, six responses from support workers, two from social workers and one from a community nurse. What the service does well: People’s needs are assessed before a placement is agreed to ensure that support workers can meet their individual needs. People and their families are allocated a named key worker to promote good communication and relationships. They undertake annual home visits and telephone courtesy calls following a persons stay at the home. People using the short stay unit have a support plan and risk assessments in place that give direction to support workers as to how support is to be delivered. People appeared relaxed and content and there was a good rapport between them and their support workers. The staff team have a clear value base and promote opportunities for choice and independence where they can. People have access to an experienced staff team who have undertaken appropriate training and receive regular formal supervision from the management team. They have a good understanding of people’s needs. One returned survey stated that, “Staff are very helpful in helping me stick to my activity timetable and social life. Another stated that, “Our son enjoys socializing. Whilst at Woodbury the staff will take him to the local pub for a Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 6 shandy. This is a highlight for our son. The management and staff must be congratulated on the approach they use.” A competent and approachable management team, who work hard to maintain good standards, in the best interest of people using the service, leads, directs and supports an experienced staff team. 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. Bury Metro - Woodbury DS0000053090.V366357.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 Bury Metro - Woodbury DS0000053090.V366357.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): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective users of the short stay service have their needs assessed prior to a placement being agreed to ensure that there needs can be met. Ways of improving the present service are being considered. EVIDENCE: Woodbury provides care and support for up to four service users at any one time. There are currently thirty-eight people accessing the service, twenty on a regular basis. People have a diverse range of needs from profound and complex needs requiring a high level of personal care to minimal support. Two people’s care files were looked at. They show that community care assessments had been carried out by a qualified social worker and obtained before a short stay place was offered to ensure that the service was able to meet the needs of the person. The person using the emergency bed has used the short stay facility for many years and is well known to the staff team. Their care plan is currently being updated to reflect recent changes. Following completion of an application form to use the service, a support worker from the home carries out a more detailed assessment, in conjunction Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 9 with the person and their relatives, to ensure suitability and compatibility for all concerned, and to make sure that the admission criteria is met. The assessments are written from the person’s perspective, and included their likes and dislikes, how they liked to spend their time, and how they would like support workers to assist them. A senior support worker oversees the day-today running of the respite unit. People using the service and their families have an allocated key worker, who carries out an annual home visit. A newsletter was sent out to people using the service and their families in October 2007. A cheese and wine evening was held in December 2007. Eight families and staff members attended. It is planned that there will be an annual newsletter and social event. The short stay facility is now used to capacity most of the time. Arrangements are made on the basis of levels of need and compatibility. There is a range of arrangements, with a small number of people receiving one to one support during their stay. It has been recognised by adult care services that the arrangements for the short stay need to improve to make it accessible to more people and have a more spacious environment. One staff member stated in a returned survey under what could the agency do better, “Provide a larger respite facility. We feel that there is a shortage of respite beds within the building, so many times we have had families in desperate need of respite and unable to offer a bed due to limited spaces and compatibility of individuals.” A social worker stated that, “They do not have enough capacity to meet the demand.” We talked to the registered manager about the future of the short stay service provided at Woodbury. We were informed that a review of the service started in January 2008. It is being led by the director of operations and is in the early stages of consultation. The registered manager is currently involved in updating the trade union. This will be followed by consultation with people who use the service and their relatives and the staff team. Plans are in place to look at services in other areas to compare and contrast different arrangements. The registered manager and a social worker are undertaking this work and will feedback their findings to the local authority in the autumn. There have been concerns about the use of the emergency bed, which has been blocked now for some time. This bed is now the only emergency bed in the local authority. One staff member stated in a returned survey under what could the agency do better, “Provide more emergency beds, due to having only one within the borough, this has proven to be very difficult trying to manage situations, when at times we have had 2/3 individuals needing emergency care.” The arrangements for emergency admissions will also be considered through the consultation exercise. We will be monitoring the consultation exercise to ensure that plans to improve the short stay provision progress. Bury Metro - Woodbury DS0000053090.V366357.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): 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. People have a support plan that is updated to reflect any changes in their needs. People are given choices and are encouraged to be as independent as possible. EVIDENCE: People who use the respite unit or emergency place live at Woodbury for short periods only. Any major decisions about their lives would therefore tend to be made with their families or other representatives. We looked at the care records for a person using the respite service which contained a detailed care plan that gave guidance to support workers about how the person was to be supported. The care plan had been developed from the information gathered during the assessment and covered areas such as communication, healthcare issues including, epilepsy and diabetes, personal Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 11 care, dressing and undressing, personal hygiene, mobility, road safety, night routine, and attendance of a day service. The people using the service or their relatives, are encouraged to sign their agreement to the care plan. Records showed that the care plans were reviewed annually. Potential risks had been assessed, and balanced against the person’s right to choice and independence. Risk assessments covered areas such as use of the kitchen, bathing, maintaining health, moving and handling, epilepsy, and general health and safety. Daily report records were completed for each person. They included details of meals eaten, activities undertaken, and other general information related to the person’s needs. Bury Metro - Woodbury DS0000053090.V366357.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): 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. Whilst staying at Woodbury, people are able to carry on with their usual weekday routines and have the opportunity to participate in activities outside the home. EVIDENCE: People who use Woodbury generally maintain their day-to-day commitments. Two people had been at the day centre during the day and another had been at college and one person at their job where they work in the kitchen and serve in a café. Two people said that they like to book into Woodbury at the same time as friends and enjoy a “girlie” weekend and have a glass of wine and a party. They were going out to Gateway for the evening. Support workers helped them Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 13 to get ready to go out, with their makeup and getting dressed up. They were going out on Ring and Ride, a community transport service. Another person was looking forward to watching football on television with the support worker. Before the match they were going out to the shop to get a drink and some sweets. The person and the support worker were picking opposite teams by their colours and were looking forward to seeing who would win. The fourth person had a relaxing evening planned. We received two surveys from people who use the service supported by their relatives to complete. One survey stated that, “Staff are very helpful in helping me stick to my activity timetable and social life.” Another stated that, “Our son enjoys socializing. Whilst at Woodbury the staff will take him to the local pub for a shandy. This is a highlight for our son. The management and staff must be congratulated on the approach they use.” Support workers said that they felt that the staffing arrangements had improved and they were able to take people out more during their stay. A good rapport was observed between the support workers and people using the service and the atmosphere was relaxed and friendly. People said that they liked all the staff team at Woodbury. Relatives and friends are able to visit people during their stay at Woodbury. Some people like to maintain contact by telephone. People have there own small kitchen/dining room. There are facilities to make drinks and small meals like breakfast and snacks. The main meal of the day is prepared in the main kitchen. The inspector joined people for the main meal of the day, which was a choice of salad and jacket potato or fish chips and peas. Everything was eaten and everybody appeared to enjoy the meal. The support worker was very polite and offered lots of choice throughout the meal and encouraged people to interact with each other. People said that they enjoyed their meals and that they got enough to eat. There is a list of dietary needs for people that identifies allergies, problems, dislikes and how the person is to be supported. The main kitchen has been repainted recently. Bury Metro - Woodbury DS0000053090.V366357.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): 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 liaises with relatives to ensure that people’s health needs are appropriately met. The medication system and procedures are satisfactory. EVIDENCE: Support workers were observed to assist people in a discreet manner, e.g. ensuring that doors were kept closed. Disposable gloves and aprons are available as necessary. In one person’s file there was an epilepsy care plan and risk assessments around maintaining good health and administering medication. Families generally take responsibility for making and attending health care appointments. Support workers monitor people’s health during their stay. If there was a cause for concern then the person’s family would be contacted, or support workers contact the GP, BARDOC, NHS Direct or go to hospital, if necessary. Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 15 All support workers currently working on the respite unit have received medication training. The medication system was generally in good order. Relatives usually dossette the medication that people bring in with them and support workers record them on receipt. Medication is stored in a lockable cabinet in the small short stay office. There are plans to introduce small lockable cabinets into each bedroom. Photographs identifying people are kept on their medication records to ensure that medication is administered to the correct person. Bury Metro - Woodbury DS0000053090.V366357.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): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most of the staff team have undertaken safeguarding vulnerable adults procedure training to ensure the protection of people through best practice. EVIDENCE: The home has a written complaints procedure. The complaints procedure includes the contact details of CSCI and the local authority complaints officer. There have been no complaints received by the CSCI in respect of this service. There have been no internal complaints about the service. The agency has written procedures covering Safeguarding Vulnerable Adults and Whistle Blowing. The subject is part of the Learning Disability Qualification training. We were informed that the majority of the staff team have attended a safeguarding awareness course and plans are in place for new support workers to attend in the near future. Staff members not providing care also need to attend this training. Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 17 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): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Ongoing efforts have been made by support workers to make the short stay unit safe, homely and comfortable for those people who use the service. EVIDENCE: The home is situated in the centre of Tottington, close to bus routes, shops, and other local amenities. The short stay unit is on the ground floor. It is separate from the rest of the building, and has its own entrance. The unit has exclusive use of a lounge, dining kitchen, bathroom and toilet. The shared lounge and kitchen/dining room areas are small for the numbers of people using the service, particularly if people are wheelchair users. All bedrooms are single. Any person admitted in an emergency has use of a single bedroom on the first floor. The enclosed garden provides a pleasant setting where people can sit out in nice weather. Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 18 Bedrooms are individually decorated in different colour schemes, and people bring in a few of their own possessions to make their rooms more homely. The bedrooms were refurbished last year and wardrobes, drawers and vanity units, were replaced. Since our last visit the bathroom has been painted. A hand washbasin has also been fitted in the bathroom to improve control of infection arrangements for people. The hydraulic bath was out of action when we made our first visit to the home and people had to use the bath on the other side of the building and this had been the situation for a number of weeks. The bath had been repaired by our second visit. The home is fitted with adaptations and equipment suited to the needs of the people. These included grab rails, portable hoists, assisted bath, shower, ramps and assistance call system. Keypads were placed at entrances to the short stay unit to aid security. Bedroom doors were fitted with alarms. A relative stated in a returned survey that, “We are particularly happy with the security that is in situ, our son can wander off so this is very important.” There is no passenger lift, so anyone using the emergency bedroom would need to be able to use the stairs. Standards of cleanliness in the short stay unit were good. Liquid soap and paper towels were provided for hand washing in communal areas. Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 19 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): 32 33 34 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support workers have access to mandatory training to ensure the health and safety of people through good practice. EVIDENCE: The staffing arrangements at Woodbury have improved and there is currently only one vacancy for a night support worker. Woodbury uses care pool support workers from the local authority who work there regularly and know people well. Support workers from outside agencies are rarely used to ensure consistency. Out of the thirty two combined manager and care support staff team seventeen now hold an NVQ Level 2 or above. This includes three staff members who have a social work qualification (DipSW), five who have undertaken NVQ Level 4 and five who hold NVQ Level 3. Two staff members are currently undertaking a social work qualification at this time. Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 20 Mandatory training includes basic food hygiene, health and safety, control of infection, first aid, moving and handling and medication training. We previously noted some gaps in staff training amongst the established staff team. This has now been addressed. New support workers undertake the Learning Disability Qualification as part of their induction programme. In a returned survey a staff member stated that, “My induction was very comprehensive and covered all the information I required. I had a two week spell where I shadowed an experienced staff member before working independently. I had regular meetings with my line manager to see how I was progressing.” Another stated that, “My only criticism is that there seems to be very little training on the various disabilities of service users.” The local authority carries out the required range of background checks on all staff including a Criminal Records Bureau (CRB) check. We have previously inspected employment files at Bury Adult Care Services human resources section and found the recruitment process to be robust, safe and promote equality and diversity. A new support worker stated that, “Everyone I’ve met seems friendly and willing to help and support you.” Another stated, “I personally have a very supportive manager.” Support workers confirmed that they received regular six weekly supervision sessions, which are planned in advance. On the day of the inspection the senior support worker had come in early to hold a supervision session with a night support worker. A support worker stated in a returned survey that, “ I feel Woodbury is doing a brilliant job with a wonderful staff team. Each person brings their own strength of character. I am very proud to be working among people I admire and care for very much. This also includes the clients.” Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 21 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): 37 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and approachable management team, who work hard to maintain good standards in the best interest of people using the service, leads, directs and supports an experienced staff team. EVIDENCE: The manager is registered with the CSCI. He has been manager of Woodbury since 1992. He holds the Certificate in Social Service qualification and the Registered Manager’s Award NVQ Level 4 and has undertaken updated mandatory health and safety training since the last inspection. Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 22 An experienced deputy manager and three competent and capable senior support workers support the registered manager in the running of the agency. Support workers spoken with were complimentary about the management team. In response to what the agency does well one support worker stated, “Approachable management team who are prepared to listen and advise.” The senior support workers have delegated responsibility for the three areas of service, pre-independence, resettlement and respite. The senior support workers explained the weekly and monthly checks that they undertake to ensure that standards are maintained. Quality Assurance checks are carried out with a record of visit and comments being requested from people about whether they enjoyed their stay at Woodbury. Monthly visits by the registered provider to ensure that good standards are being maintained need to be undertaken in line with legal requirements. We were provided with a detailed AQAA by the registered manager, which gives us quality assurance information about the service. People using the service and their relatives will be included in the consultation exercise about the changes and future arrangements about the short stay service. Maintenance and service checks were examined and found to be in order. We were told that an NEICIC inspection of the home’s electrical fittings and fitments had been undertaken and that the architects department currently had the certificate. It was agreed that a copy of the certificate would be forwarded to us. We raised a number of concerns at the last inspection about fire safety, which in the main have been addressed. The majority of the staff team have now received fire safety training and the fire risk assessment has been reviewed. Old information in the fire book still needs to be to be archived to make it more user friendly by having up-to-date information readily available for staff to use. COSHH practices were seen to have improved around the building and we were informed that all members of the staff team have been trained in how to use a hoist including care pool support workers. In line with good practice there is a bath thermometer in the bathroom and a record of water temperatures is maintained. Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 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 3 X 4 X 1 X X 2 X Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 26 Requirement That the registered provider or representative visits the home in accordance with this regulation. (Outstanding 30/09/07) Timescale for action 30/09/08 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. Refer to Standard YA42 Good Practice Recommendations The fire record book needs to be checked, and out of date or no longer relevant information needs to be archived to make it more user friendly. Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Bury Metro - Woodbury DS0000053090.V366357.R01.S.doc Version 5.2 Page 26 - 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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