Care Home: Woodlands Care Home

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What the care home does well Information tells people what the service can provide to help people and their families to make decisions about their future care needs. People can visit and have short stays to help with these decisions. People are given help and support to make choices in their daily lives. Lots of different activities are provided and people can choose to take part if they want to. Staff help people to do things they like to do and to try new activities. Woodlands looks after people well and the help people need is written down so staff know what to do. Staff help people with their medical appointments. Staff work with other professionals and agencies to help people keep well. Staff are trained to help them understand how to meet the needs of people who use the service and give them the support they want. Woodlands makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Woodlands. People are helped to keep in touch with their families and friends. Visitors are made welcome in the relaxed and friendly home. People can choose what they want to eat from the healthy menu. Alternative options to the main menu are provided, and people can have snacks and drinks at all times. Surveys say that people are happy with the care that is given by staff at Woodlands. What has improved since the last inspection? Coseley Systems Ltd now owns Woodlands care home. The change to the running of the home has been well managed. Care plans are being updated using a computer. This makes it easier to make changes to care plans when needed and keep them up to date. Everyone who lives at Woodlands has been given a new contract from the new owners. The building is being redecorated and updated when people are away on holiday. What the care home could do better: Make sure that risk assessments are dated. Medication Information sheets should be dated so the reader can be confident that information is accurate and up to date. Review the fire risk assessment each time a new person moves in to Woodlands. Out of date fire records should be archived so that it is easier for staff find current records. CARE HOME ADULTS 18-65 Woodlands Care Home 164/165 Chester Road North Kidderminister Worcestershire DY10 1TP Lead Inspector Dianne Thompson Unannounced Inspection 11th August 2008 09:30 Woodlands Care Home DS0000070092.V369453.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 Woodlands Care Home DS0000070092.V369453.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. Woodlands Care Home DS0000070092.V369453.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Care Home Address 164/165 Chester Road North Kidderminister Worcestershire DY10 1TP 01562 755787 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) Coseley Systems Limited Mrs Josephine Mary Gaud Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Woodlands Care Home DS0000070092.V369453.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) the service users of the following gender: Either Whose Primary care needs on admission to the home are within the following categories: 2. Learning Disabilities (LD) 12 The maximum number of service users to be accommodated is 12. Date of last inspection Not applicable Brief Description of the Service: Woodlands is situated on a main road in a residential area of Kidderminster approximately one mile from the town centre. There are limited car parking facilities at the front of the premises and an enclosed garden at the rear. Woodlands consists of two town houses that are connected by a covered walkway on the ground floor at the rear of the premises. People who live at Woodlands are accommodated on three floors in six single bedrooms and three double bedrooms. The building does not have a stair lift or a passenger lift. Two of the single bedrooms have an en suite facility. Coseley Systems Limited is now the registered provider having purchased Woodlands earlier this year. Woodlands provides a residential care service for a maximum of twelve people with learning disabilities. Details of fees for living at Woodlands are agreed on an individual basis as stated in the Service User Guide. The reader may wish to contact the service for up to date fee information. Woodlands Care Home DS0000070092.V369453.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. This was an unannounced inspection visit to see what the service was like for the people who live at Woodlands. Time was spent talking to some of the people who live at Woodlands and some of the staff working there. We looked at some of the records, policies and procedures in the office. We talked to other people to get their views about the service. The manager completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). The AQAA is where the manager tells us about the service provided at Woodlands and the ways they plan to make the service better. We looked at parts of the premises. Information gathered from other sources, such as surveys, monthly visit reports and information sent to the CSCI has been included in this report. What the service does well: Information tells people what the service can provide to help people and their families to make decisions about their future care needs. People can visit and have short stays to help with these decisions. People are given help and support to make choices in their daily lives. Lots of different activities are provided and people can choose to take part if they want to. Staff help people to do things they like to do and to try new activities. Woodlands looks after people well and the help people need is written down so staff know what to do. Staff help people with their medical appointments. Staff work with other professionals and agencies to help people keep well. Staff are trained to help them understand how to meet the needs of people who use the service and give them the support they want. Woodlands makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Woodlands. Woodlands Care Home DS0000070092.V369453.R01.S.doc Version 5.2 Page 6 People are helped to keep in touch with their families and friends. Visitors are made welcome in the relaxed and friendly home. People can choose what they want to eat from the healthy menu. Alternative options to the main menu are provided, and people can have snacks and drinks at all times. Surveys say that people are happy with the care that is given by staff at Woodlands. 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. Woodlands Care Home DS0000070092.V369453.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 Woodlands Care Home DS0000070092.V369453.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 good This judgement has been made using available evidence including a visit to this service. Information is available about the service, and what can be provided to help people and their families making decisions about their future care needs. People are given opportunities to visit and assessments are completed before people move in to make sure their individual needs can be met. EVIDENCE: Policies and procedures are in place for assessing potential people to live at Woodlands. Information about the service included in a Statement of Purpose and Service User guide that is available for all enquirers and residents. The Statement of Purpose has been updated to reflect the change of provider. The admissions procedure states that full community care assessments are required and in addition Woodlands complete their own assessments. We saw that community care assessments and service assessments had been completed for the files examined. Care plans are written from the information gathered during assessments, visits and discussions with families and other interested parties. The manager says in the service’s AQAA that ‘depending on the needs of the prospective residents we will bring in professionals’ such as ‘occupational therapist or physiotherapist to ensure we can meet the needs of the individuals’. Woodlands Care Home DS0000070092.V369453.R01.S.doc Version 5.2 Page 9 Surveys confirm that families and carers have been consulted and included in the assessment process. The statement of purpose and service user guide has been updated to reflect the new ownership of Woodlands. This information is available in alternative formats to make it more accessible, such as symbols. The manager says in the service AQAA that a website for Woodlands is being developed and this will give interested parties more information about the service and the company Coseley Systems Limited. Surveys confirm that information is shared about the service to help people contribute to decisions that involve their relatives. Woodlands Care Home DS0000070092.V369453.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, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans provide staff with relevant information about individual assessed needs to make sure people receive up to date and consistent support. People who use the service are supported in making decisions about their lives and are provided with opportunities to participate in various aspects of life in the home. Risk assessments show how risks are to be reduced and how independence is promoted and maintained. EVIDENCE: Care plans for three people were checked and both contained appropriate information about individual needs and how they are to be met. Care plans set out in detail the action to be taken by care staff. Care plans show that reviews are taking place on a regular basis. A review of the care plans examined had been completed during October 2007 and July 2008. A joint Woodlands Care Home DS0000070092.V369453.R01.S.doc Version 5.2 Page 11 care plan review had been held in January 2008 with Worcestershire County Council to confirm a person’s move to Woodlands. Information in care plans cover all aspects of each person including their daily living needs, health and personal care, physical well-being, social interests and relationships, religious and cultural needs and any other specific areas. We saw examples of preferred personal care routines such as support to get up, to get dressed, and support to eat meals. People communicate in different ways and a Speech and Language therapist helps to make sure the service develops their communication skills to meet the needs of the people living at Woodlands. Care plans are available in a range of formats that includes symbols and pictures. Staff complete records with people who use the service to make sure everyone is involved as much as possible in their everyday lives and choices, including the running of the home. Each person is allocated a key worker to oversee his or her care. Key workers support people on a one-to-one basis and contribute to the care planning process. Risk assessments are completed to keep people safe and include additional support guidelines for staff to follow where this is needed. We saw detailed risk assessments that had been completed. These risk assessments work to promote everyday living skills for people who live at Woodlands, such as how people are able to use the kitchen to make their own drinks. Risk assessments are currently being updated together with care plans. The deputy was advised to make sure that risk assessments are dated, show dates for planned reviews and continue to explore ways to make sure that people can be as independent as possible. The deputy manager said that risk assessments and care plans are now completed on the computer, which makes updating information much easier. Surveys confirm that care given is what is expected or agreed with the service. Woodlands Care Home DS0000070092.V369453.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, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are supported and encouraged to take an active part in their choice of activities. Everyone is encouraged and supported to maintain links with their families and to develop friendships. Dietary needs are well catered for with a varied and healthy menu provided. EVIDENCE: People living at Woodlands are encouraged and supported to make choices about activities and daily living with as much control over their lives as they are able. People make choices about how to spend their day and examples of this were observed throughout the inspection visit. Five people were out for the day and people at home were involved in a variety of activities. One person was watching the Olympics on television; another person was doing their laundry and in between trips to the washing machine was making a jigsaw puzzle in their room. One person returned from a shopping trip and another person from their place of work. Woodlands Care Home DS0000070092.V369453.R01.S.doc Version 5.2 Page 13 The range of activities provided includes Kidderminster College, swimming, pubs for meals, shopping in town, and the Nite Out club. Some people choose to attend the Baptist church every Sunday. One person talked about his day ‘in the forest’ working for Beacon Employment. He said he had ‘enjoyed the day, but it was hard work in the forest’. We saw certificates and diplomas for courses completed proudly displayed on bedrooms walls. People choose the household tasks they prefer to do such as laying tables, cleaning the kitchen after use, and emptying the bin. One person said she had ‘cleaned the kitchen and dining room after lunch and now the tables are ready for tonight’. In house activities include music and movement sessions, computer sessions, hair dressing, massage, reflexology, listening to music, DVD’s, jigsaws, going out for meals. There is a vegetable plot in the garden that is managed by the people who live at Woodlands. The household timetable includes cookery, budgeting and shopping which is done on Thursdays. Surveys confirmed that people are able to choose what they want to do and include comments ‘I enjoy helping to keep the garden tidy and grow my own fruit and veg’; ‘I choose to work because I like to work. I choose to do what I want on my days off. Sometimes I change plans if we are going out on a daytrip’. People are supported to have a holiday each year and a holiday to Butlins in Minehead is planned for early September 2008. People went to Borth in Wales last year. Care records show that regular contact with friends and family is supported. People who use the service are able to see their visitors in private, and surveys confirm that they are made welcome. The service provides meals that are varied and nutritious, with different choices available where preferred. Snacks and drinks are available throughout the day. People are consulted about their choice of food and diets, and support is given for people who find it difficult to eat and need help. Eating and Drinking Guidelines to support people are developed with the Speech and Language Therapist. Discussion around the dining table focussed on the menu for this evening’s meal of homemade cottage pie with fresh vegetables. People discussed this and everyone seemed to be happy with the choice. One person asked if they were happy with the choice of vegetables and said that he ‘looks after the others’. Woodlands Care Home DS0000070092.V369453.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, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individual health and personal care needs are being well met by the staff at Woodlands. Care plans are completed and reviewed regularly. This makes sure that staff have all the information they need to provide consistent support. Woodlands has a medication policy and procedure for staff to follow to ensure that all medication is administered and stored safely for the protection of everyone who uses the service. EVIDENCE: People who live at Woodlands have care plans that include their health action plan. These plans give information about personal care needs and the ways people prefer to be supported. Health action plans give detailed information about each person’s health needs and how they are to be met. Additional information is made available to help staff have a greater understanding or basic awareness about specific conditions such as Microcephaly. Woodlands Care Home DS0000070092.V369453.R01.S.doc Version 5.2 Page 15 Records show that all physical checks are completed where people have particular health related issues such as weight and physical functions. Routine health checks are completed, such as well woman, dementia screening and psychiatry. People have good access to medical support through their Primary Health Care Team (PCT) as required, such as a speech and language therapist, physiotherapist, dietician, dentist and doctors. A record of visits to the doctors or other medical professionals is kept. We saw staff engage with people in a respectful way, making sure that dignity and self-esteem was important for each person. Although communication with some people who use the service for visitors may be difficult, people appeared to be comfortable and at ease in their surroundings. Surveys confirm that staff are ‘very good at doing what they do’ and ‘look after people well’. People living at Woodlands said that ‘staff help to keep me well’ and ‘they look after me and take me to the doctors’. A policy and procedure is in place for the administration of medication. All staff who are involved in the administration of medication receive accredited training. The manager states in the service’s AQAA that ‘All staff are trained on an on-going basis and take part in a medication training course each year. Staff also have an in-depth induction before they administer medication’. Consent to medication forms are included in care plans and these are signed by the person using the service or their representative. Each person has a medication information sheet that provides information about the prescribed medication, the reasons for taking this and the list of times medication is to be taken. This information sheet should be dated so the reader can be confident information is accurate and up to date. Medication is stored securely and given to people at the right time and full records are kept which show this. Woodlands Care Home DS0000070092.V369453.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, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People have access to easy to understand information about how to complain and staff support people to express their views and any concerns they may have. There are suitable procedures in place for the management of complaints and to make sure that people who use the service are protected from abuse. EVIDENCE: Woodlands has a complaints policy and procedure in place which is accessible to people who live at the home and their relatives. A symbolised complaints procedure was seen on the wall. The manager says in the service AQAA that people are ‘supported and encouraged to raise any concerns or worries they may have. They know who to talk to about their concerns. They can speak to any of the senior staff also to their key-worker’. People who use the service said they would ‘tell staff if they are not happy’. Staff use the complaints procedure to support people should they wish to make a complaint. Survey responses show that people are aware of the complaints procedure and that no complaints have been made. The manager confirms in the service’s AQAA that no complaints have been made to the service. We have not received any complaints or safeguarding concerns about Woodlands. The service has a complaints book that records both compliments and any complaints that are made. Woodlands Care Home DS0000070092.V369453.R01.S.doc Version 5.2 Page 17 There are specific policies and procedures in place to guide staff on the protection of vulnerable adults from abuse and on ‘whistle blowing’ for staff. Staff receive training in abuse awareness. Staff confirmed they are aware of the procedures and understand the implications of concerns, complaints and protection issues. Financial policies and procedures are in place. For some people family members are their appointees and manage their finances. Staff support people with weekly budgeting and information is recorded on the finance record sheet. Woodlands Care Home DS0000070092.V369453.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): 24, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at Woodlands enjoy a safe and homely living environment although they will benefit from the redecoration and refurbishment of the home. The building is spacious and kept clean. EVIDENCE: Woodlands is situated in a residential area of Kidderminster with access to shops, leisure centre and doctors surgery locally. Woodlands provide a service to a maximum of twelve adults who have learning disabilities and some people who may have a physical disability. Woodlands consists of two town houses that are connected by a covered walkway on the ground floor at the rear of the properties. People who live at Woodlands are accommodated on three floors in six single bedrooms and three double bedrooms. The home does not have a stair lift or a passenger lift. Two of the single bedrooms have an en suite facility. Woodlands Care Home DS0000070092.V369453.R01.S.doc Version 5.2 Page 19 We looked at all parts of the premises. Some of the people who use the service were happy to show their bedrooms. All rooms are clean, tidy and well presented. The bedrooms are a good size, suitably furnished and personalised by people living at the home. Woodlands is clean and tidy throughout. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. All cleaning materials are locked in the laundry room. The large tree in the rear garden has been removed and the borders have been made more attractive. There is now a larger lawn area that people can use with garden seats, tables and chairs available. Work is due to take place in two weeks time (while everyone is on holiday) to refurbish the home and redecorate some areas. This will include the hall way into the main house that needs plastering and redecoration. New light fittings are to be fitted throughout the main house and an extension to the existing office is planned. Woodlands Care Home DS0000070092.V369453.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): 32, 34, 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty with the right skills and knowledge to meet the needs of people who live at Woodlands. Staff are well supported and work together to provide consistent and good quality care. Staff receive relevant training to help them meet the needs of people who use the service. Recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to make sure that everyone living at Woodlands is kept safe. EVIDENCE: Woodlands has a committed and stable staff team. People commented in surveys that they were generally satisfied with the service and the staff. Staff appeared to be enthusiastic and well motivated. Recruitment policies and procedures have been reviewed and updated to reflect the new ownership of the service. Staff have been given new contracts of employment. The revised recruitment policy and procedure makes sure that everyone completes an appropriate application form and that suitable Woodlands Care Home DS0000070092.V369453.R01.S.doc Version 5.2 Page 21 references are obtained including one from most recent employers. Appropriate criminal records and other checks are undertaken before appointments are confirmed. Staff records were examined for three people. All required information was seen and included confirmation of identity, security checks and suitable references. All staff are required to work a probationary period. The manager confirms that all new staff complete an induction that takes place over a three-month period. Staff work to the service’s handbook ‘and each subject is signed off individually by senior staff’. Mandatory training is completed and each member of staff has a training programme based on their individual training and development assessments. Six staff are currently NVQ qualified. Training provided includes alcohol awareness and dementia. Regular staff team meetings are held and minutes of these meetings were made available during the inspection visit. Supervision of care staff covers all aspects of care practice and records show that staff appraisals are completed annually. We saw that all staff received supervision between 13/06/08 and 07/07/08. Survey comments include ‘staff always treat us well’, ‘most of the staff listen well and help me’ and ‘they are kind to me’. Woodlands Care Home DS0000070092.V369453.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): 37, 39, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service is well managed and staff receive the leadership and support they need. Woodlands is monitored in various ways to make sure that the health and welfare of people using the service is protected. EVIDENCE: The manager was on annual leave at the time of the inspection, but staff on duty and the deputy manager were able to assist fully with the inspection process. The manager Mrs Jo Gaud has many years experience working with people with learning disabilities and regularly completes training relevant to her position as registered manager of Woodlands. Management responsibilities are Woodlands Care Home DS0000070092.V369453.R01.S.doc Version 5.2 Page 23 shared with a deputy manager. They are involved in organising day-to-day activities, health and safety promotion, staff supervision and induction. The Annual Quality Assurance Assessment (AQAA) was well completed and submitted to the CSCI prior to the inspection visit. The AQAA is where the manager tells us about the service provided at Woodlands and the ways they plan to improve the service. The manager states in the AQAA that the service ‘is managed in an open and positive manner. Staff and residents are involved in the day-to-day choices and needs of the home’. Coseley Systems Limited currently employs a consultant to conduct monthly visits to monitor the service and how it is being run. These visits include interviews with staff and people living in the home. We saw from the reports that an audit of relevant parts of the service, including records, environment, complaints received, finance and safety is completed. Any actions that may be needed to address shortfalls are specified. The manager states in the service’s AQAA that the consultant ‘offers support and advice on any issue he finds. The proprietors visit three to four times each week’. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Staff are to complete mandatory health and safety training topics. Individual and generic risk assessments are in place. Fire records show that all checks are completed regularly and information is well documented. The deputy manager was advised that information would be easier to access if the out of date information were archived. The fire risk assessment should be reviewed as the current one is dated 2005. The deputy manager was advised to review the fire risk assessment and complete a fire drill each time a new person is admitted to live at Woodlands. The manager states in the service’s AQAA that there are plans to produce periodic newsletters for people who use the service, families and staff. Surveys confirm that the manager and staff are approachable and include comments such as ‘I like living here and I am very happy’. Woodlands Care Home DS0000070092.V369453.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 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 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 3 X 3 X 3 X X 2 X Woodlands Care Home DS0000070092.V369453.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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. 3. 4. Refer to Standard YA9 YA20 YA42 YA42 Good Practice Recommendations Risk assessments to promote independent lifestyles should be dated, with dates for planned reviews. Medication Information sheets should be dated so the reader can be confident that information is accurate and up to date. Out of date fire records should be archived so that access to current records is easier. The fire risk assessment should be reviewed regularly and updated if necessary. Additionally a review should be completed when a new person is admitted to live at Woodlands. Woodlands Care Home DS0000070092.V369453.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Woodlands Care Home DS0000070092.V369453.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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