Care Home: Woodley House Care Home

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What the care home does well The staff team at Woodley House have a good understanding of the needs of the people they support. This includes individual`s communication methods; this ensures that each person`s needs are met in a way they prefer. Information such as care plans and person centred plans were detailed and regularly reviewed, which ensures the staff team have accurate information on each person`s abilities, interests and areas where they required support to ensure their needs were met. This promoted autonomy and enabled people to live their lives as independently as possible. What has improved since the last inspection? As stated above care plans are more comprehensive with changing needs reflected throughout. Risk assessments were in place to keep people safe, whilst still allowing them to stay as independent as possible. The medication practices were assessed and demonstrated that medicines were managed appropriately. The necessary recruitment information such as POVA first checks and a satisfactory CRB disclosure were in place within the staff files looked at. This indicates that the staff are suitable to work with the people living at the home A sample of health and safety certificates and records were examined all records seen were up to date and demonstrated that the health and safety of those using the service, the staff team and visitors was protected. What the care home could do better: Employment histories were in place within the staff files seen, however there were some gaps in these records that had not been explored. This doesn`t provide a clear audit trail of the person`s employment. Key inspection report CARE HOME ADULTS 18-65 Woodley House Care Home Woodley Street Ruddington Nottingham NG11 6EP Lead Inspector Angela Kennedy Unannounced Inspection 30th March 2009 10.30 Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodley House Care Home Address Woodley Street Ruddington Nottingham NG11 6EP 0115 984 8069 0115 945 6020 rachael.stevenson@btconnect.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Woodley House Ltd Rachel Ashton Care Home 21 Category(ies) of Learning disability (21) registration, with number of places Woodley House Care Home DS0000008768.V374819.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 to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 21 14th August 2007 Date of last inspection Brief Description of the Service: Woodley House is an adapted period property that sits in its own grounds close to the centre of the village of Ruddington, which has a range of shops, churches and public houses. Woodley House currently has 7 single and 3 double bedrooms; 1 room has an ensuite. There are three floors in the house without a vertical lift so any potential service users would have to be fully mobile. Directly next to the care home in the same grounds is a detached cottage and next to Woodley House is a detached bungalow, which has its own access and garden. Both the cottage and bungalow have been adapted and furnished to provide two four bedroom independent living units for people requiring personal care and accommodation, who have a learning disability. The two units come under the registration of Woodley House care home. Information about Woodley House is available in the statement of purpose and service user guide. The fees for living at the home at the time of the inspection range from £800 to £1300. These are fees agreed with different local authorities and are dependent on the needs of individuals. Woodley House Care Home DS0000008768.V374819.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 star. This means the people who use this service experience good quality outcomes. This key inspection was unannounced. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with the people using the service. The focus of inspections undertaken is upon outcomes for service users and their views on the service provided. This process considers the provider’s and registered manager’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. At this inspection people were resident in the main house and the cottage. The bungalow did not have anybody living in it. At this inspection visit two people were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the individual. One person case tracked was able to verbally express their views of the service and the support it provided. Other people at the home were spoken with, some due to their disability were unable to verbally express their views of the service. However observations of staff with people using the service were made throughout the day. Three members of staff were spoken with at some length. Their views and opinions of the care provided, the support and training given to them is included within this report. The registered manager was on duty on the day of this inspection and provided the relevant information requested. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 7 taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 8 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 Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident that the service can support them. This is because there is an accurate assessment of needs that they, or the people close to them have been involved in. EVIDENCE: One person case tracked had been living at Woodley House for a significant period of time, so there was no assessment information prior to their admissions available. There was evidence in place to demonstrate that the appropriate health and social care professionals were involved in the care of this individual in ensuring that the home continued to meet their needs. The other person case tracked had been recently admitted and a comprehensive needs assessment was in place that formed the basis of their care plans. Information had been obtained from this person’s former residential home to further develop their care plans and provide a profile of this person. This profile informed staff of their interests and things they enjoyed doing, and their personal and health care needs. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 10 Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual’s needs and personal goals are reflected in their care plans. Staff promote rights and choices and people are supported to take risks to enable them to stay independent. EVIDENCE: Both of the people case tracked had care plans that covered their social, emotional, health and personal care needs. The care plans seen were detailed and clearly instructed the staff team on the level and type of support needed. This included the communication needs of the individual and their preferences on how support was provided. The care plans for one of the people case tracked had not been reviewed, as they had recently moved to Woodley House and therefore at the time of this inspection a review was not needed. The other person’s care plans had been reviewed every three months, this ensured any Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 12 changes in their support needs were identified. Records demonstrated that the individuals had been consulted in the development of their care plans. Risk management forms were seen in the records of both people case tracked. The risk management forms identified the risks and the strategies that were in place to enable the staff to support individuals, whilst enabling them to stay as independent as possible. All of the risk management forms were up to date. This ensures that the measures for keeping the people safe remain appropriate. The staff spoken with were able to demonstrate a good understanding of individual’s needs, including their communication needs, which reflected what is written in care plans. Both of the people case tracked had a key worker who was responsible for ensuring their care plans were kept up to date. Evidence was seen to demonstrate this. Information in the care plans informed staff on how individual’s expressed their preferences and communicated their needs or concerns. Records demonstrated that individuals made choices and preferences. Preferred daily routines were recorded, these were known as ‘daily life plans’. The communication methods used varied and staff spoken with were able to confirm how individuals were able to make choices and decisions about what they wanted to do. Some people were shown items while others use picture boards and photographs and some signs and symbols. Some of the people living at the Woodley House were not able to verbally express their opinion of the service. However some of the people spoken with were able to indicate that they liked living at the home. One person case tracked was able to verbally express their opinion of the service and said that they were very happy with their new home, they said that the staff team supported them well. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 13 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): This is what people staying in this care home experience: 12,13,15,16 and17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are treated as individuals’ and the staff team are responsive to their needs, preferences and personal development. EVIDENCE: All of the people living at the home accessed day services during the week, some on a full time and some on a part time basis. As stated earlier in this report individual’s preferences were recorded in their care plans. Weekly timetables were included in care files, which demonstrated a variety of activities undertaken with individuals including day care, shopping, walks at local parks and activities within the home. Staff spoken with also confirmed this. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 14 Information in care plans showed that the service supported individuals to maintain relationships with their family, either by relatives coming to see them or individuals going to visit their relative. Care plans seen demonstrated that people were supported to maintain their faith and religion. This included attending services of their choice and practicing their faith within the home. One person case tracked was supported to say a prayer of thanks before meals and worship in private if they wanted to. Care plans also provided information regarding individuals goals for the future and clear information was in place to demonstrate how these goals were to be achieved with support as required. Staff interaction with the people living at the home was observed. They demonstrated a friendly and respectful manner towards the people they were supporting. For people with limited verbal communication, visual aids such as photographs were provided to enable people to make choices regarding their preferred choice of meal. Evidence was seen in care plans to demonstrate that specific dietary requirements were followed; this was done in consultation with relevant professionals as needed. Menu plans were in place both within the main building and the cottage to demonstrate that people had been consulted about their preferred choices. Menu records evidenced that people were offered a varied and a healthy diet. One person case tracked confirmed that they purchased their own food with staff support. They confirmed that this was one of their goals that had been agreed with staff and said they enjoyed going shopping. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal support from staff in a way they prefer and want. The staff team support people to take medication safely. EVIDENCE: The care plans seen informed the staff of the individual’s preferred method of support in their personal care needs. Evidence was seen within care plans that demonstrated that healthcare needs were met. This included a Health Record book, where appointments were recorded, such as appointments to see doctors, dentist, podiatrist and opticians and well-man and well-woman clinics. Records seen showed that specialist professionals were accessed as necessary. Within the ‘my health booklet’ information was given regarding each persons communication methods and identified how individuals would show their Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 16 consent to treatment. This demonstrated that individuals’ choices were respected and their ability to consent was not merely determined by their ability to verbally communicate. The manager confirmed that the service liaised with their local community learning disability team in supporting individual’s health care needs as required. The medication practices were looked at and the record of administration was seen for the people case tracked. The storage of medicines was organised and the instructions for administration were clear and records show that medicines were administered as prescribed. All medicines audited had the correct quantities of medication as stated on the medication administration record (MAR). Care plans relating to medication were in place within the records seen. These records were detailed and provided staff with good quality information. The cabinet used to store controlled drugs (C.D’S) complied with new legislation that is now in place for residential care homes. No C.D register was in place, although at the time of this visit no controlled drugs were in use or stored at the home. The manager confirmed that all staff had undertaken medication training from a suitably qualified person. Records were seen to demonstrate this. This training was enhanced by competency assessments that were undertaken in house. Additional training had been provided to named staff from suitably qualified personnel to enable staff to undertake invasive procedures such as administering rectal diazepam as a first aid measure. Certificates were in place to demonstrate that this training was undertaken and this training was valid for two years when refresher training would be provided as required. Named staff had also been trained in the administration of insulin. This administration did not involve the drawing up of insulin and was carefully monitored by the district nursing team. Extensive records and clear labelling and instructions enabled staff to undertake this practice in a safe way. Staff signatures, their job title, their initials and their name were recorded in the medication administration file. This ensured all staff administering medication could be identified at medication audits. A medication policy was in place and this included instructions to staff on what action to take in the event of an overdose or when administering homely remedies. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 17 Each person had a medication information sheet, to inform staff and ensure best practice was maintained. This provided information on all prescribed medication and reasons for administration and the side effects of each medication. None of the people living at Woodley House were able to administer or store their medication independently. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Concerns are looked into and actions are taken to put thing right. The practices and policies in place ensure people are safeguarded from abuse. EVIDENCE: There is a satisfactory complaints procedure, which is included in the service user guide and available in a suitable format for the people using the service. Complaints records looked at are well maintained and showed that there has been three complaints made since the last inspection. Staff spoken to demonstrated a good understanding of the complaints procedure, in ensuring expressed concerns are acted on. They confirmed that they would raise any concerns they had regarding the service. This included any issues or concerns they had for and on behalf of the people living at the home. Two of the complaints recorded had been raised by the manager on behalf of people using the service to their prospective day opportunity placements. The records demonstrated that all complaints had been addressed appropriately and effectively. We have received no complaints since the last inspection. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 19 The homes policies and procedures for responding to suspicion or evidence of abuse, or neglect, are satisfactory. Since the last inspection there have been no safeguarding adults investigations. Training records seen demonstrated that staff had received training on safeguarding adults. Suitable accounting procedures were in place for monies held for people living at the home. The money for the two people case tracked was checked against the records held and was correct. This demonstrates that the practices in place safeguard people from financial abuse. It was noted that not all transactions had two signatures; this is a good practice measure to further protect individuals from financial abuse. Behaviour management guidelines were in place in the records of the people case tracked. These records provided good detail and demonstrated that proactive and positive interventions were in place to support individuals and maintain their safety. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People stay in a safe, clean and comfortable environment that suits their needs and lifestyle. EVIDENCE: Since the last inspection the service has increased its registration to accommodate up to 21 people. On one side of Woodley House in the same grounds is a detached cottage and on the other side next to Woodley House is a detached bungalow, which has its own access and garden. Both the cottage and bungalow have been adapted and furnished to provide two four bedroom independent living units. At the time of this inspection visit no one was living in the bungalow, therefore it was not viewed. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 21 However the cottage was in use and therefore this was viewed. The accommodation was furnished to a very high and modern standard and provided a very comfortable attractive and homely environment for the person living there. Equipment needed to enable safe practices to be maintained, such as a medication cabinet, was stored unobtrusively to ensure the cottage remained domestic in style. All of the bedrooms had ensuite facilities, such as a toilet, wash hand basin, bath or shower. The communal living room/ diner was attractive, spacious and provided a music centre and television, comfortable furniture and dining furniture. The person living at the cottage had been encouraged and supported to add their own personal effects and this included an aquarium with tropical fish. Discussions with this person confirmed that they were very pleased with the furnishings and décor of their home. They said that they were supported by staff to maintain their home and shop, prepare and cook their own meals. In the main house all work identified at the last inspection visit has been addressed, however refurbishment remains ongoing, as due to the needs of individuals this is continuously required. Examples of this included toilet seats that had been removed by individuals using the service and furniture that had been ripped. The manager was able to confirm that furniture that had been ripped has been re-ordered and plans were in place to refurbish one bathroom. With regard to the missing toilet seat it was confirmed that this was the preference of the person that used this toilet and the continuous replacement of this toilet seat had resulted in this person becoming agitated and removing it. The manager did confirm that a raised toilet seat was used over this toilet when accepted. One bedroom carpet in the main house that was seen was stained and needed cleaning. This was done before the end of this inspection visit. The home is not suitable for people with mobility problems as there is no lift to the first floor. The laundry facilities are appropriate for the needs of the people using the service. The communal areas of the main house, which provided televisions and music centres were viewed and appeared clean and tidy. The kitchen area was seen but not inspected, as an environmental health visit was also undertaken on the same day. The manager confirmed that no requirements had been left. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 22 Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Woodley House recruitment practices do not fully protect the people using the service. Trained and competent staff meets individual’s needs. EVIDENCE: At the time of this inspection visit there was 14 people using the service. The rotas demonstrated that there was sufficient staff on duty to meet the needs of the people using the service. The records demonstrated that all but two members of staff had achieved a National Vocational Qualification (NVQ) at level 2. Four staff had an NVQ at level 3 and four were working towards this qualification. Two staff were working towards NVQ 4. Evidence was also seen to demonstrate that staff undertook a learning disability qualification as part of their induction training. This demonstrates that people are supported by a staff team that have received the right training to ensure their needs can be met. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 24 Checks are undertaken to ensure the staff are suitable to work with the people living at the home. Two staff files were looked at and contained two written references and evidence of a satisfactory criminal record bureau check and Protection Of Vulnerable Adults (POVA) first check, which were obtained before both staff members commenced their employment. Evidence was seen to demonstrate that people are supported by a staff team who understand and do what is expected of them. Staff training records demonstrated that mandatory training and training specific to the needs of the people at the home was kept up to date. This training included, fire safety, safeguarding adults, food hygiene, prevention of spread of infection, first aid, health and safety, mental capacity act training and medication training. Staff spoken with confirmed that the training provided was good and comments included, “ the training includes areas specific to service users and is very good” Staff also reported that the teamwork at the service was very good. Staff members spoken with demonstrated a good understanding of their roles and responsibilities and insight into the needs of the needs of the people they supported. There was evidence that staff receive supervision on a regular basis and staff members did confirm this during discussions. As stated earlier in this report, one person using the service said that the staff team supported them well. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 25 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and safety of the people living at the home is safeguarded by an effective management system. The service aims to ensure it is run in the best interest of the people living there. EVIDENCE: The registered manager at Woodley House has NVQ 4 and the registered managers award. She has been working at the home for a number of years. Staff spoken with were complimentary about the managers ability to run the service. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 26 The service continues to develop and review their practice to enable them to improve and promote their quality assurance measures. The Nottinghamshire initiative “quality tree” is used at the service. This provides tools that involve people with a learning disability in reviewing and monitoring the quality of the service they receive. Feedback seen from a sample of recently completed surveys was positive. Comments from relatives included, “I find the staff friendly and cooperative” and “the atmosphere in the home is calm, people are given an opportunity to follow their own interests” and “ they are very prompt to note changes of behaviour or health and keep us informed”. Staff used informal methods to gather the views of the people using the service; these included ‘sit and talk’ sessions, which were informal chats, with a cup of tea after the evening meal with the people that used the service and service user meetings where held monthly, where talking mats were used to support people in completing satisfaction questionnaires. A sample of service certificates was seen and all were up to date; this included the gas safety certificate and electrical installation certificate, portable electrical appliance test records and fire safety checks. Food probing temperatures were taken daily to ensure that food was served at the correct temperature. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 27 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 2 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 3 X Version 5.2 Page 28 Woodley House Care Home DS0000008768.V374819.R01.S.doc 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 YA34 Regulation 19 Requirement Full employment histories and a satisfactory written explanation of any gaps in employment must be in place for all staff working at the home. This is to ensure that people living at the home are protected by the homes recruitment policy and practices Timescale for action 30/06/09 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 YA20 YA23 Good Practice Recommendations A CD register should be purchased to ensure this is available if needed in the future. Two signatures should be provided on individuals financial transaction records to further promote and safeguard people from financial abuse. Woodley House Care Home DS0000008768.V374819.R01.S.doc Version 5.2 Page 29 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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