Inspection on 12/05/05 for 1 Wood Close

This inspection was carried out on 12th May 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

1 Wood Close 16/06/09

1 Wood Close 20/06/07

1 Wood Close 01/08/05

1 Wood Close 30/11/04

1 Wood Close 29/06/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 1 Wood Close Salfords Surrey RH1 5EE Lead Inspector Mavis Clahar Unannounced 12 May 2005 @ 08:15am th 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 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 Stationary 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. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 1 Wood Close Address Salfords Surrey RH1 5EE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01293 430685 Ashcroft Care Services Limited Miss Helen Jane Lavers CRH - Care Home 6 Category(ies) of LD - Learning Disability (6) registration, with number of places 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 - The age/age range of the persons to be accommodated will be 18 - 65 years. Date of last inspection 30 November 2004 Brief Description of the Service: 1 Woodclose is a home within the Ashcroft Care Services providing care and accommodation to six male and female service users with profound learning disabilities. Woodclose is situated on the outskirts of the market town of Horley in the village of Salfords, in a quiet residential area, with a nature reserve duck pond within a few minutes walk. The home comprise of six single bedrooms with ensuite facilities situated on all three floors. The home has a large garden laid mainly to lawn with a wide variety of garden furnitureand recreational facilities for the enjoyment of the service users. The home has its own transport which is used to transport service users to various to their various activities, shopping and holidays. Service users are encouraged and enabled to participate in the activities and amenities offerred in the nearby town of Horley and within the village. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This was an unannounced inspection and the inspector arrived at 08.15 hours. Only one service user was up and dressed, having had his breakfast earlier. None of the service users in this home have verbal skills, so it was very good for the inspector to be able to spend uninterrupted time with this service user. The first part of the inspection was spent with one service user, who responded with a smile and a stroke of the inspector’s hand when he was in agreement; and a groan and hands clasped to his body when he was not in agreement. From the groans, the smiles and hand stroking, it was apparent that the service user felt comfortable with a stranger in his home, that he was happy, liked his food and did not like to go to bed early. On occasions whilst the inspector was making notes the service user would get up from the kitchen table wonder out into the hall and lounge and then returned to the kitchen table. The inspector formed the opinion that the service user was comfortable in his surroundings, was free to move around the house and liked the one to one attention he was receiving. The next part of the inspection was spent talking to care workers and other service users as they came down to breakfast, which was different for each service user. This was followed by case tracking, which provided a high level of information about each individual. Care was delivered based on good assessment of health and social care needs. A tour of the home and gardens; followed, although none of the service users wanted to come on the tour. Full discussion with the home manager followed by feedback and discussions with senior management and the home manager completed the inspection. What the service does well: Each service user is assessed on a yearly basis using the Social Training Achievement Programme. From comparisons of achievements from 2004 to 2005 it was evident that care workers are dedicated to the service users who are in their care; it was also evident that although every effort was being made to develop each service users’ social achievement, there was no pressure on the service user to achieve and most importantly service users had choices in areas they want to develop or discontinue. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 6 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. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 3 4 5 The home was found to be operating effectively in respect of these standards. The inspector was impressed by the quality and availability of information about the running of the home. This was seen as a positive approach to enabling new service users to make a decision about the home. EVIDENCE: From the random sample of service users files reviewed, and time spent with service users and staff, it was evident that full assessments of service users needs are undertaken, documented and care plans made from this assessment. What was particularly good for the inspector to see was that the assessment was continuous and changes were made to the care plans to reflect these assessments. A prospective new service user to the home was visiting with his personal key worker on the day of inspection. This service user along with the support of his parents, key worker and care manager was able to choose the colours for the bedroom to be painted. This home has demonstrated that service users are encouraged and enabled to make choices. It was evident from the service users files that each service user is issued with a contract of residency within this home. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 7 8 9 The home continues to support, encourage and enable service users to live active and full lives. EVIDENCE: The care plans and daily work sheets documented activities of daily living such as laying and clearing the table, personal care doing the laundry vacuuming taking showers and baths doing the house shopping and personal shopping are all activities in which service users partake. Discussions with service users and care workers provided evidence that service users are encouraged to take risks and to be as independent and in control of their lives as is possible. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 13 14 15 17 Service users are encouraged and supported to choose lifestyles suitable to their needs. Service users had wide and differing social contacts that enhances self worth and promote their lifestyles. EVIDENCE: The observed relationship between care workers and service users was relaxed and friendly creating a warm and friendly homely feeling. None of the service users in this home are capable of verbal communication. The effort care workers put into communicating with service users is to be commended. Each service users has their own key worker who documents modes of communication the service user likes and understands. Service users care plans and activity sheet demonstrated that they are truly involved in their community. Service users go out to the restaurants, bowling, pubs, shopping both for the house and for personal items and they also go out for walks as observed on the day of inspection. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 11 Service users all have at least two weeks holidays per year. Some visit Lourdes on a yearly basis; while others like foreign holidays and some like to be away for short periods only. On the day of inspection one service user was packed and ready to go away for the weekend. There was good family and friends contact with service users at this home. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 19 20 The home continues to offer good individualised care to service users, to ensure their assessed needs are met. EVIDENCE: The care plans reviewed offered clear directions on any intervention of support each service user required with personal care. The care plan also contained information regarding physical and medical and emotional needs of the service users. Daily care, including visits to the dentist, chiropodist and dietician were all recorded, dated and signed. Evidence gathered from care workers and to lesser degree service users had all supported these findings. None of the service users at this home were risk assessed as capable of selfadministering medicines. Review of service users medication records and observation of medicines being administered by care worker, resulted in the inspector forming the opinion that medicines were being administered within the home’s policy and procedure on administration of medicines. Evidence gathered from discussions with service users and care workers, and from reviewing documentation at the home indicated that the home worked hard to ensure service users’ health and personal care needs are consistently met. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 23 The service users were appropriately protected and their views were important and were acted upon. EVIDENCE: Review of the home’s complaints folder showed that the home had not received any complaints since the last inspection. The home’s complaints policy was written in a form that was acceptable to the service users. They were able to bring to care workers attention areas of their lives that they were uncomfortable with. This was dealt with and documented in the care plans, and if applicable was also documented in their passports. This was a personal book of information service users take with them whenever they leave their home. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 25 26 28 30 The home needs refurbishing inside and outside to bring it back to the homely, comfortable and safe environment it used to be. EVIDENCE: Two service users bedrooms were in need of redecorating. One in particular with the low ceiling needs preventative work carried out on the ceiling as a precaution to avoid accidents to the service user of this bedroom. Requirements were issued on this standard. All the bedrooms in this home were decorated to the wishes of the service user, who further individualise their rooms with personal effects. The use of the large lounge, dinning room and large garden complement and supplement the enjoyment of service users plus the inclusiveness of their individual bedrooms. Generally, the home was clean and tidy and free from any odour. The inspector was informed that staff with the help of service user keeps the home clean. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 15 The company had recently relocated their head office from next door to Woodclose, leaving an office, which was originally Woodclose garage free. It is the intention of the current manager to move the home’s office from the attic to this ground floor office. This he feels will make him more accessible to staff, service users and their relatives. Also with the move of the head office, the Service users will loose garden space in length, but will gain garden space in width. The outside of the building needs repainting. A requirement was issued on this standard. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 32 34 35 36 From evidence gathered during the inspection it is apparent that all the standards excepting standard 34 are adequately met. Staff appeared to be enthusiastic and committed to supporting service users, with training and development given high priority. EVIDENCE: Review of service users care plans, passports and daily records revealed each service user is allocated a key worker and a supporter of the key worker. Discussions with care workers and service users who were able to either point to their key worker or go to their key worker supported the documentation. The inspector further observed key care worker supporting and enabling service users to maximise their potentials. Staff files reviewed does not comply with the homes recruitment policy. The home must obtain a copy of the amended version of The Care Homes Regulations 2001 and comply with the requirements of Schedule 2. A requirement was issued on this standard. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 17 Discussions with care workers and review of care workers files and the training matrix demonstrated a good level of consistent training of staff. Care workers spoken to seem knowledgeable about the needs of the service users. The inspector formed the opinion that these care workers are dedicated and are willing to stretch and support services users to enjoy whatever they choose to do. Care workers files demonstrated consistent supervision, and care workers supported this in discussions. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 38 40 41 42 The home is without a registered manager for four months. A manager is in post since 1st April but has not proffered an application to CSCI for registration. However, the management of the home is effective, with service users receiving a person centred approach to care. EVIDENCE: The new manager is in post since 1st April 2005 and has not made application to CSCI for registration. A requirement has been issued on this standard. From evidence gathered during this inspection confirmed that service users benefit from the leadership and management approach to the home, which is adequately run. Training records of staff revealed that service users rights and interests are been considered. However, the home fails to comply with its own policy and procedure on recruitment of staff as reflected in staff files. A requirement was issued on this standard. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 19 Good record keeping is demonstrated in the service users care plans, daily records, and medication records. The key worker system and the person centred approach to care all demonstrated that service users safety and welfare are prominent in the care of service uses. However, the state of the low ceiling in one service user’s bedroom was a cause for worry. A requirement was issued on this standard. Discussions with senior management about the necessity of keeping all information about the home at the home under secure conditions ensued. Also the need for managers to have access to up to date information regarding new changes made by legislation CRB and CSI. The inspector was informed that these issues would be discussed at senior management meeting, and outcomes would be sent to CSCI. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 x 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 x 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1 Wood Close Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 2 x 2 2 2 x H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 21 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. 2. 3. Standard 24 24 34 Regulation 23 (2) (b) (d) 23 (2) (b) (d) 19 (4)(b) (i) (c); (5) (d) Requirement Repair the ceiling of the Attic bedroom Decorate the upstairs bedroom which had been damaged Two satisfactory written references are required for each care worker prior to been employed at the home. The registered individual must ensure Schedule 2, paragraphs 1 to 9 of The Amended care Homes Regulation 2001 are fulfilled. The registerd individual must forward to CSCI an application for registered manager of the home. The registered individual must ensure that the home operates within its recruitment policy and guidelines to protect service users. The registered individual must ensure that all records of staff including job application and CRBs are kept securely in the home. The outside of the building should be repainted Timescale for action 12.08.05 12.08.05 12.08.05 4. 38 8 (1) 12.06.05 5. 40 12 (1) (a) 12.06.05 6. 41 17 (2) 12.06.05 7. 42 23 (2) (b) 12.08.05 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 22 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 40 37 Good Practice Recommendations The home should obtain the amended copy of The Care homes regulations 2001. The address of the company should be changed to show the new address on all documentation.. 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 1 Wood Close H58 H09 S13442 Wood Close V225905 190405 Stage 4.doc Version 1.30 Page 24 - 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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