Inspection on 08/06/09 for Woodham 2

This is the latest available inspection report for this service, carried out on 8th June 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodham 2 10/07/07

Woodham 2 24/01/07

Woodham 2 16/01/06

Woodham 2 20/07/05

Woodham 2 21/01/05

Woodham 2 08/09/04

Woodham 2 04/02/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOME ADULTS 18-65 Woodham 2 33 Newlands Park London SE26 5PN Lead Inspector David Lacey Unannounced Inspection 8th June 2009 10:00 Woodham 2 DS0000044288.V375782.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. Woodham 2 DS0000044288.V375782.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 Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodham 2 Address 33 Newlands Park London SE26 5PN 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) 020 8778 1850 F/P 020 8778 1850 woodhamltd@aol.com Woodham ENT Ltd Jackson Adetola Adebambo Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Woodham 2 DS0000044288.V375782.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 (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 9 Date of last inspection Brief Description of the Service: Woodham 2 is a detached Victorian house on a main road in Sydenham, within a short walk from shops and rail or bus transport. The building has been converted to a home providing care for up to nine residents with mental illness and forensic histories. The care home aims to support people aged 18-65 who have been discharged from psychiatric in-patient facilities, medium-secure units or special hospitals. People resident at the home are encouraged towards independent living in the community. The fees for Woodham 2 range from £850-£1200 per week (this information given to CQC June 2009). Woodham 2 DS0000044288.V375782.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 two stars, which means that people using the service receive a good service. This key inspection included an unannounced visit to the home, when five of the nine residents, the registered manager and members of staff on duty were spoken with. All communal areas of the premises and two of the bedrooms were inspected. Documentation such as care plans and records of care provided, staff recruitment files, and policies and procedures were sampled. At our request, the care home provided us with its annual quality assurance assessment (AQAA), which also informed the inspection. This self-assessment document focuses on how outcomes are being met for residents and also gives us some numerical information. What the service does well: The home offers its residents a comfortable environment to live in, including single bedrooms that they can choose to personalise, and en-suite bathing and toilet facilities. Staff are good at introducing newly referred people to the home, by giving them information and opportunities to visit before making a decision to move in. The home’s manager and staff liaise with and support the appropriate care professionals to make sure residents’ physical and mental health needs are met. Each resident is supported by a key worker, who meets with them regularly to discuss any issues about their care and rehabilitation. Residents are encouraged and supported to maintain contact with their families and friends, if this is their choice. Any concerns raised by residents are dealt with and staff members have training about safeguarding adults. Residents are encouraged to contribute to the running of the home and to give their views about the home’s services. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Either repair or replace the torn stair carpet, as it is a potential trip hazard for people walking up or down the stairs. Draw up an action plan outlining when and how aims and outcomes identified through surveys of residents’ views will be addressed. This is an important component of the self-monitoring process. Make sure there is strong evidence of residents’ engagement with therapeutic/rehabilitative activities offered within the care home. This will enable the outcomes of these activities to be assessed more effectively and help to identify any changes needed. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is 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. Woodham 2 DS0000044288.V375782.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 Woodham 2 DS0000044288.V375782.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, 3, 4, 5 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. Before they move into the home, people’s needs and risks are assessed, to ensure the home is suitable. Prospective residents’ and their representatives are enabled to visit the home before making a decision whether to move in. Residents are provided with written terms and conditions for their placement at the home. EVIDENCE: Three people had moved into the home since our last key inspection. It was evident from documentation on file that full assessments of their needs and risks had been undertaken before they had been offered admission to the home. The new residents had community treatment orders and their assessments regarded enhanced care programme approach (CPA). It was evident that Woodham 2 staff had completed the home’s intake assessment form. The provider writes to newly referred residents confirming that Woodham 2 can meet their needs, and copies of these letters are kept on file. The home’s normal practice is to offer prospective residents and their representatives opportunities to visit the home before being offered a place. Two residents confirmed they had visited the home before they moved in, and Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 10 it was evident the outcomes of residents’ pre-admission visits to the home and overnight stays had been recorded in their care documentation. Once a resident moves into the home, there is then a trial period to enable all parties time to assess if the placement is the right one for that person. A resident said he had been living in the home for six months and felt he had settled in well. Each resident is provided with a contract detailing the terms and conditions of their stay in the home. Copies of these were seen in those residents’ plans sampled for inspection. Woodham 2 DS0000044288.V375782.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, 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. Each resident has a care plan that addresses personal goals and changing needs, and residents are encouraged to be involved in planning and reviewing their care. Residents are supported and given assistance as needed to make decisions about their lives, and are supported within a risk assessment framework to maintain independence. EVIDENCE: Three residents’ care plans were sampled for inspection. Care plans had been drawn up from the assessments of each resident’s needs, with their involvement wherever possible. Risk assessment and risk management plans were in place, covering each resident’s mental health needs, including guidance to address any recurrence or deterioration of their mental health problems. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 12 Each resident is allocated a key worker, with the aim of enhancing the level of service provided. Key workers provide support, for example, by holding regular one-to-one sessions with residents. Monthly key-worker summaries that reviewed the care provided were seen on the care files sampled. Residents’ meetings had taken place each month, most recently in May 2009. Meeting notes showed residents chair the meetings in turn, are involved in making choices and decisions, and contribute their views and ideas about how the home is run. During our last inspection, a resident spoke with the inspector about how he was following a care plan to prepare him to realise his choice to move to a more independent living situation. At this present visit, the inspector was told that person had now moved out from the home to live more independently, in the way that he had wanted. Details of local independent advocacy groups are available and staff members help residents, if they wish, to contact and find support from a group. Information leaflets about safeguarding adults, deprivation of liberty safeguards, mental capacity legislation, and the care programme approach were available for residents to pick up and read. The company’s Charter of Residents’ Rights was seen on each of the residents’ files that were sampled for inspection. The Charter includes a commitment to values such as independence, choice, privacy, and dignity for residents. It covers residents’ access to community facilities and services, and respect for residents’ cultural, religious, emotional and sexual needs. It makes a stated commitment to high standards of care and safety. Woodham 2 DS0000044288.V375782.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: 11, 12, 13, 15, 16, 17 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 living at the home are supported to access training and employment opportunities and to engage in other meaningful activities, though the evidence for people’s completion of in-house activities is not strong. An annual holiday is offered to all residents as part of the contract price. Residents are part of the local community, and their rights and responsibilities are recognised. Residents generally eat well and have a varied diet. Residents are supported to maintain links with their families and friends, and more space has been made available to see visitors privately. EVIDENCE: It was evident from discussion that people working in the home are aware of its role in supporting residents to develop their independent living skills. The home’s AQAA confirmed residents attend in-house therapeutic groups and activities. The manager explained these include cooking, cleaning, shopping, Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 14 budgeting, assertive group, film nights, and football in the nearby park for physical activity. An activities plan for each resident was on display in the office. Residents were either out of the home or spending most of the time in their bedrooms during the inspection visit. There is now a garden building with facilities such as a snooker table and dart board but no residents were using it at the time of inspection. The only in-house activity seen was one or two residents watching television in the lounge for short periods. The manager said there are normally brief sessions with residents earlier in the mornings. The staff on duty for the morning shift spent much of the time in the lounge even when there were no residents present, and it was suggested more effort could have been made to actively engage with residents as part of their rehabilitation. Residents are allocated specific days for laundry, cleaning and cooking as part of their contribution to the running of the home and their development of independent living skills. Two residents were seen at different times of the day preparing food for themselves, but no cleaning or laundry activity was observed (see recommendations). There was more evidence of activities carried out outside the home than those undertaken within it. It was evident from care plans and key work sessions that people at the home had been supported by staff to take up opportunities for training/education and to engage in fulfilling activities. For example, one resident was working in catering in a voluntary capacity and two other residents were attending a local college on one day each week. Residents confirmed they make use of local facilities and are encouraged to take up opportunities for personal development. People living at the home have ‘freedom passes’ to enable them to use public transport without charge and it was evident that they make use of this for travel both locally and throughout London. Residents were about to go on their annual holiday, which is offered to all people living at Woodham 2. Two residents were also being supported to go on holiday with their families during the summer, with one having enrolled on a course to begin learning the language of the country his family would be visiting. One resident said he had decided not to go on the annual holiday on this occasion. He had been before with residents from the home and had enjoyed it but preferred to stay at the home this time, as he had other things he wanted to do. His choice had been respected and the home was making sure he could do this. The same resident spoke about his life in the home. He said he is happy here and that staff members are supportive. He likes the location of the home, as it is near to shops and good public transport links that make it easy for him to get around. It was evident that residents are supported to maintain links with family and friends. For example, one spends each weekend with his partner away from the home, which is incorporated into his care plan and risk assessment. The relative of another resident visited him on the day of inspection, and he Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 15 confirmed she visits regularly. It was evident she is made welcome at the home and had a good rapport with the manager and staff. The home uses a four-week rotating menu, which was available for inspection and indicated that residents are offered a varied diet. It was understood the menu was not strictly adhered to but was used more by support workers for ideas of meals to cook. Usually, people would be asked on the day what they would like to eat. Residents choose when and where they eat, and whether they eat alone or with others. Staff make sure that the food provided to residents is recorded each day. These records were seen during the visit, were up to date and showed overall the meals were sufficiently varied and nutritious. Residents make their own breakfast and lunch, and each of them has a ‘cooking day’ when they help staff to plan and prepare the evening meal. Residents spoken with said they have enough to eat and drink, and that the food is usually good. One said he had asked recently for more food appropriate to his culture and preferences, and sometimes this was now being provided. Food stocks in the home were adequate, with some food in the kitchen fridge and freezer and further stocks in the basement storage room. It was understood from the manager that a shopping trip was due. There was a bowl of fresh fruit on the dining room table, from which residents helped themselves during the day. Restrictions such as the curfew time are always explained to each prospective resident before they make a decision to move into the home, and they are included in the written terms and conditions that they receive and sign. ‘House rules’ mean, for example, that residents are expected to take responsibility for doing their own laundry and tidying their rooms, with staff support as necessary. Residents have keys to their rooms and were seen coming and going from the house freely throughout the day of the inspection visit. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 16 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. Residents receive support from staff flexibly and in ways they prefer. Residents are satisfied with the support they receive from staff, and that their physical and mental health needs are met. Residents who are assessed as able to self-medicate are supported to do so by staff. The home’s medication system is being managed effectively. Should the home’s staff need to store any controlled drugs on behalf of residents, the provider would first need to upgrade the home’s storage facilities to meet the relevant legislation. EVIDENCE: None of the people living at the home at the time of this inspection required support with personal care but staff were providing prompting and encouragement as required. Issues about supporting individuals with their personal care had been addressed within their care plans. All the residents were independently mobile. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 17 It was evident from discussion and from examining relevant documentation that people’s physical and mental health care needs were being met. The home’s manager had made sure that each of the recently admitted residents are registered with a local GP. This was confirmed by copies of correspondence with the local Primary Care Trust and records of medical support to the residents. Health care services, such as optical and dental services, are readily available and there was evidence of residents’ contacts with primary health care services. Care records sampled showed that those residents had community treatment orders in place. Their treatment and support was being coordinated by relevant health care professionals, through a combination of attendance at outpatient clinics and visits to individual residents at the home. Regular care programme approach (CPA) reviews of residents’ mental health needs and risk factors had been held. The residents case-tracked by the inspector had care plans for substance misuse. Urine screening to test for this had been carried out and the results recorded in their care files. Residents’ weights had been taken each month and recorded. Information leaflets about heat-wave protection were available in the home for residents to pick up and read. The home’s medication policy had last been reviewed in September 2008 and a handwritten amendment had been made in line with our previous recommendation that when any medicine is disposed of a complete record is kept. The amendment needed strengthening to make sure staff members have clear and unambiguous guidance about disposal of unwanted medicines. This was discussed with the registered manager who undertook to make the necessary changes to the policy. The home’s records of receipt and disposal of medicines were in satisfactory order. The medicine administration records (MAR) of three residents were inspected. There were no unexplained gaps in administration and the medicines in storage tallied with the records on the MARs. The administration of a variable dose prescription for one resident was being recorded so that the dose given each time was written. The manager’s monthly medication audit for one resident’s medication was seen on file. The home’s list of staff members’ signatures and initials was up to date. The registered manager stated that all staff working at the home who administer medication had received appropriate training to ensure their competence in this regard. A support worker on duty was undertaking a course in managing and safe handling of medicines, and was spending some time during the shift to study course materials. Our previous requirement to ensure the home’s policy is always followed with regards to the safety and security of the medicine cabinet keys was being met. The registered manager was in charge of the home on the day of inspection and was carrying out the home’s normal practice that the shift leader keeps the drug keys. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 18 There were no controlled drugs (CD) being stored in the home, which had also been the case at our last inspection. The home’s AQAA confirmed that no CDs had been administered or stored at the home in the past year. The home’s existing medicines storage cupboards are screwed to a stud and partition wall in the office and the home does not have a CD cupboard that complies with present legislation in this respect. The registered manager confirmed he was aware that, should the home need to store any CDs in the future, they would need to meet the relevant legislation by obtaining a CD cupboard in which to store the drugs and installing it correctly. There were two residents self-administering their medication, as part of their rehabilitation programmes and following risk assessments. Residents benefit from the support to self-medicate, as medication compliance to help prevent relapse is an important part of their rehabilitation. Each resident who selfmedicates is given a week’s supply of their medication at a time in a dossette box, which they keep in lockable storage in their bedrooms. Staff members monitor compliance according to the care plan and sign when they carry out checks. This arrangement means that staff have to carry out secondary dispensing (which the home refers to as ‘decanting’) from the medicines supplied for those residents to ensure they have a supply in a separate sevenday dossette. The registered manager was aware of the potential risks involved in secondary dispensing by staff, and showed evidence that two staff members plus the resident always do this and sign to confirm. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 19 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, 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. People living at the home know who to speak to if they are not happy, and have ready access to the home’s complaints procedure. Measures are taken to protect people from abuse. Staff members complete safeguarding training, and the home has safeguarding policies and procedures for the protection of residents. EVIDENCE: The home’s complaints procedure was displayed in the hallway so that residents and visitors could see it easily. Copies were also being kept in each resident’s file. The contact details for the commission needed changing, both to reflect the change to the Care Quality Commission (CQC) and our move to a different office address. The home’s complaints book showed three complaints since our last inspection, and recorded that each had been resolved. One complaint had been about a blocked sink in a resident’s en-suite, which had been fixed promptly. Another complaint was from a neighbour who had complained to the home about loud music at night. Action had been taken to reduce this and no further complaint had been received. A resident had complained about the condition of his mattress. To address this, the manager had carried out an audit and had replaced four residents’ mattresses. The resident who had raised this issue told the inspector his concern had been dealt with quickly and his new mattress was very comfortable. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 20 Interaction observed between staff and residents was friendly and respectful. A resident said he considered he and the other people living in the home were supported well. A resident said if he was worried or wanted to complain about something he would talk straight away to the home’s manager or another staff member. It was evident from records of key worker sessions and notes of house meetings that residents also have more formal opportunities to raise any concerns they may have. The local (Bromley) safeguarding guidance was available in the home, and copies of a council leaflet about protecting vulnerable adults were available in the lounge so that residents and visitors could read it and take a copy if they wished. The home’s policy on adult protection was seen on file. It had last been reviewed in September 2008 and was due for review again in September 2009. The policy was satisfactory in part but our previous recommendation for some specific amendments to ensure clarity and accuracy had been only met in part. These recommended changes were discussed in detail with the registered manager during the inspection visit, and he undertook to make the changes. Support workers had completed adult protection training, so they have a working knowledge about the different types of abuse and what action to take if they witness or suspect abuse of residents. As noted under standard 7, details of local independent advocacy groups are available and staff members help residents, if they wish, to contact and find support from a group. Information leaflets about safeguarding adults, deprivation of liberty safeguards, and mental capacity legislation were available freely in the home. In-house training for staff about mental capacity legislation and deprivation of liberty safeguards was understood to be available, and it is advised that all the home’s support workers should complete this. The home’s AQAA stated that in the past twelve months, no restraints had been used, and there had not been any safeguarding referrals or investigations. Since the last inspection, the commission has not received any complaints, concerns or allegations about this home, and is not aware that any safeguarding investigations have been carried out in relation to residents living at Woodham 2. Some of the people living in the home at present manage their own finances and some need support with managing money. The home has a policy and procedure for helping residents to manage their valuables and financial affairs. The registered manager explained the form the home uses to record the home’s support to residents with their finances refers only to money held in the home for these residents, not to any external account. He said the home holds small amounts for residents who need assistance with budgeting and they withdraw money for day to day expenses, which they sign for and is recorded. These records were available for inspection. The manager stated if a Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 21 resident has a larger amount of money, he is encouraged to open a bank account in his own name where this money can be deposited. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 22 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, 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. Residents have a comfortable environment in which to live and are satisfied with their accommodation. EVIDENCE: The home’s communal areas were clean, tidy and free from unpleasant odours. New sofas had been provided in the lounge and dining room. The stair carpet was torn on the lower landing, which was drawn to the manager’s attention as a possible trip hazard, and worn on some of the stair treads (see requirement). Two bedrooms were inspected, with the permission of their occupants. Both bedrooms were assessed against the standards and found to meet them. The bedroom of a recently admitted resident had with few personal items, whereas the bedroom of a resident who had been living in the home for some years was Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 23 full of his possessions, mostly his music and video collection. Residents are offered a key to their room and staff can open rooms in an emergency. Our two previous requirements regarding items in the bathroom on the first floor had been met. A lightweight, plastic framed mirror had been provided so residents using this bathroom can safely use a mirror in this room. The cold tap in the bath was now working effectively following repair. The laundry facilities were working effectively on the day of the visit. The laundry is in a small building near the back door of the house, is adequate for the home and is away from food preparation areas. The kitchen was clean and tidy, with all cooking equipment working. Our two previous requirements regarding kitchen facilities had been met. A new fridge/freezer had been obtained, which addressed the problem with the door seal of the old refrigerator that had been in use. The wash hand-basin in the kitchen had both liquid soap and towels, to enable effective hand washing to improve hygiene and control of infection. The provider had constructed an additional temporary building in the back garden to provide a more private place for residents to meet with their visitors and carry out various recreational activities such as snooker and darts. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 24 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, 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. An accurate rota was in place indicating the levels and mix of staff working at the home are sufficient to meet the residents’ needs. Staff members are offered training opportunities relevant to the work they do, and either hold or are in the process of studying for a relevant qualification. The home’s recruitment procedures are designed and carried out to support and protect residents. EVIDENCE: There were nine people in residence at the time of this inspection, all males. Thus, the home was full with no vacancies. The registered manager and a support worker, who were both male, were on duty when the inspector arrived for the site visit. This staffing arrangement matched that shown on the staff rota for the day. Information given in the AQAA, discussion with the manager and staff, and examination of rotas showed there are at least two staff members on each shift. The support worker on duty said he had worked in all the company’s homes but is now based at Woodham 2, working full-time and across all shifts including at night. He confirmed there are always at least two Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 25 staff on duty on each shift, including two waking staff at night. The manager stated in the AQAA that one of the home’s plans for improvement over the next year is to continue to monitor staff members’ working hours to make sure they are not overworked. This follows our concern at the last inspection that staff members have adequate time off duty and do not become over-tired, as this might compromise the standard of care they deliver. The registered manager stated in the AQAA that the home has a staff development programme that meets the relevant standards. The AQAA also stated all permanent staff have at least NVQ at level 2, which was confirmed at the site visit by the manager who said that staff have gone on to attain NVQ at level 3. A support worker on duty said he had completed NVQ at level 3 and was currently enrolled on a course to further develop his skills and experience in administration of medicines. There was documentary evidence of a completed NVQ3 on two of the four staff members’ files inspected. Discussion and examination of staff files showed that staff members have regular supervision and that annual appraisals are undertaken when their personal development and individual training needs are considered. Notes of staff meetings were available for inspection. They had been held each month, with the most recent taking place in May 2009. Four staff members’ recruitment files were sampled at this inspection. These were staff based permanently at Woodham 2. Some staff members who work shifts at Woodham 2 are based at other Woodham care homes. This means their records are still available for inspection by the commission, even though they were not available at Woodham 2 for inspection on this occasion. The staff files seen were generally in good order and contained the information required. No new staff had been appointed since our last inspection, which meant our previous requirement and recommendation about recruitment practice could only be assessed with regard to existing staff members. From the files sampled, it was evident the requirement had been met. The manager has signalled in the AQAA that the home aims to involve residents more in the selection of new staff members. This plan is to be encouraged. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 26 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, 41, 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. Residents can be assured that the commission has judged the manager as fit to run the home. The provider is monitoring the quality of services, seeking views of residents and staff. The commission has been notified promptly of events concerning residents’ health and welfare. Residents’ health and safety is promoted. Feedback about the home has been sought from residents, as part of self-monitoring and an updated action plan to address issues raised needs to be formulated. EVIDENCE: Since our previous inspection, the home’s manager has become registered with the commission following a process of assessment by our regional registration Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 27 team. He was formerly the deputy manager of Woodham 2 and has worked at the home for some years. The home’s Annual Quality Assurance Assessment (AQAA) was completed adequately, giving us information required. It had been handwritten and the inspector suggested future AQAAs could be prepared and sent to the commission electronically, thus making the document easier to update. The manager said this is his intention in the future. There was a quality assurance report, dated January 2009, for Woodham 2 on the residents’ notice board, showing that views had been obtained from residents. These are understood to be carried out every six months, with the next one due in July 2009. An updated action/development plan needs to be drawn up to show how issues would be addressed (see requirements). There was a specific report on residents’ food satisfaction and preferences, with a ‘food policy’ stated to be effective until October 2009. This report was identical to the one seen at the previous inspection, confirming changes in menus to meet residents’ cultural preferences expressed at the 2008 survey. Reports of the provider’s monthly monitoring visits were on file. The content of the reports had been informed in part by the views of residents and staff members and covered the topics of environment, residents, records, health and safety, staff and issues for or about the commission. The most recent report was dated May 2009. Since our last inspection, one resident had been admitted to hospital. The home notified us promptly. In this way, the home had demonstrated compliance with our previous requirement to notify the commission about any occasions when a resident needs hospital treatment. A sample of health and safety documentation was examined, and showed that the home promotes the health and safety of its residents, staff and visitors. Maintenance certificates seen were up to date and within the appropriate timeframes. For example, the home had a current gas safety certificate, dated May 2009. There was an up to date certificate for the electrical wiring installation and portable appliances had been tested in March 2009. A specialist contractor had carried out legionella testing in June 2008, and the certificate showed the results had been satisfactory. The registered manager stated he is the recognised first aider for the home. The home’s fire procedure and fire risk assessment were on file, and records of fire alarm tests and fire drills had been kept. Five fire drills had been held since the last inspection, all taking place after 21.00 hrs. A staff member was aware of the home’s fire points and evacuation procedure. There were certificates from a specialist contractor of fire safety equipment and emergency lighting inspection, dated January and May 2009. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 28 A valid certificate of liability insurance cover was on display in the home. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 29 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 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 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 2 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 2 X 3 3 X Version 5.2 Page 30 Woodham 2 DS0000044288.V375782.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 YA24 Regulation 13 Requirement The registered person must ensure that the torn stair carpet is repaired or the carpet replaced. This is a potential trip hazard. The registered person must ensure that an action plan is drawn up outlining when and how aims and outcomes identified through surveys of residents’ views will be addressed. This is an important part of the self-monitoring process. Timescale for action 31/07/09 2 YA39 24 31/08/09 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 Refer to Standard YA11 Good Practice Recommendations The registered person should ensure there is strong evidence of residents’ engagement with therapeutic/rehabilitative activities that are offered within the care home. This will enable the outcomes of these activities to be assessed more effectively and help to DS0000044288.V375782.R01.S.doc Version 5.2 Page 31 Woodham 2 identify any changes needed. Woodham 2 DS0000044288.V375782.R01.S.doc Version 5.2 Page 32 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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). 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