Inspection on 11/04/05 for 17 Woodrows Lane

This inspection was carried out on 11th April 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

17 Woodrows Lane 17/09/09

17 Woodrows Lane 27/09/07

17 Woodrows Lane 17/10/06

17 Woodrows Lane 01/11/05

17 Woodrows Lane 05/10/04

17 Woodrows Lane 06/07/04

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Coopers Mill Ltd

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Paradise Lodge

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Upaya Ananda

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Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Woodrows Lane 17 Woodrows Lane Bockings Elm Clacton-on-Sea Essex Lead Inspector Pauline Dean Unannounced 11/04/05 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. Woodrows Lane Version 1.10 Page 3 SERVICE INFORMATION Name of service 17 Woodrows Lane Address 17 Woodrows Lane Bockings Elm Clacton on Sea Essex CO16 8DN 01255 433057 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) Mr Liyanage Lal Gunaratne Mrs Jennifer E Tubby Care Home 6 Category(ies) of Learning disability(6), Learning disability over registration, with number 65 years of age (2) of places Woodrows Lane Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 6 persons). 2. Two named service users, over the age of 65 years, who require care by reason of a learning disability. 3. Total number of service users accommodated not to exceed 6 persons Date of last inspection 05/10/04 Brief Description of the Service: 17 Woodrows Lane is a detached chalet bungalow offering care for six people with learning disabilities. The property is in keeping with the local community and is sited in a residential area. Accommodation is on the first and ground floor, with three single rooms on the first floor and one double and one single on the ground floor. Shower and bathing and toilet facilities are found on both floors. The ground floor single bedroom has an en-suite facility of a wash hand basin and toilet. Communal areas consist of a lounge, dining room and a small conservatory/lobby. There are gardens to the front, side and rear of the bungalow. There is a garage and a storage shed. The home is within walking distance of local shops, parks and schools. Public transport is close by and the home has their own transport. Woodrows Lane Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one day in April 2005. This was the first inspection of the inspection year – 2005 – 2006. Throughout the day there was discussion with the registered manager and the assistant manager and a third member of staff. All service users were met during this inspection and during the visit they were spoken to. No visitors or relatives were present during this inspection. A tour of the premises was conducted at this inspection and both care and staff records were sampled. In addition some policies and procedures were sampled and inspected. Twenty-eight of the forty-three standards were inspected, of these twenty-three were met with five almost met. What the service does well: What has improved since the last inspection? Since the last inspection the registered manager and the assistant manager have spent considerable time in the development of the Statement of Purpose and the Service Users’ Guide. The results are a great improvement. Staff recruitment practices and procedures have improved since the last inspection and all three care staff files sampled were found to meet requirements, namely sufficient references, Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks and copies of relevant identification documents such as birth certificate, passport and photographs. Woodrows Lane Version 1.10 Page 6 Care planning documentation has also undergone some revision since the last inspection with monthly reviews and six monthly reviews and revision now in place. Further ongoing review and revision are planned within this documentation and risk assessment documents to ensure ongoing appropriate care is given. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodrows Lane Version 1.10 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 Woodrows Lane Version 1.10 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) 1, 2 and 3. Clear detailed information is provided to prospective service users and their families to enable them to make a choice of whether they wish to be admitted to the home. A detailed and thorough pre-admission assessment is in place with care and attention given to ensuring that the home can meet the service users individual needs. EVIDENCE: Since the last inspection, amendments and changes have been made to the Statement of Purpose and this now meets requirements. Individual Service User Guides have been developed for all six service users. Four service users have an audio taped version with appropriate photographs and text and the remaining two service users have both a pictorial and written version of this document. These documents have gone a long way to ensuring that the home can demonstrate that they can meet the assessed needs of the individuals admitted into the home. There have been no new admissions to the home since 2003. Service users are admitted to the home via external Social Services’ referrals and they have a Community Care Assessment. In addition a needs assessment is undertaken by the home as detailed in the National Minimum Standards – Standard 2.3. Woodrows Lane Version 1.10 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, and 9. Service users assessed and changing needs and personal goals are detailed in their individual care plans to ensure their personal needs are met. Care planning records detail service users right to make decisions about what they wish to do. EVIDENCE: Four care plans and risk assessments for service users were sampled and inspected. These care plans were detailed covering all aspects of personal, social and healthcare needs. Care planning documents were reviewed regularly with service user involvement. One service user spoke of their awareness and understanding of their care plan. Risk assessments were seen on file, with guidelines for staff on action to be taken to minimise risk. One service user spoken to at this inspection highlighted an identified risk and the action taken by the home to manage this risk. The possibility of further risk assessments regarding accessing the rear garden was discussed with the assistant manager. See the section entitled – ’Environment’ for details. Woodrows Lane Version 1.10 Page 10 Effort has been taken to enable service users to participate in the day-to-day running of the home. Records of service users’ meetings were seen with service users discussing forthcoming holidays and activities in the home. In addition the introduction of individual Service User’s Guides has assisted with enabling all of the service user group to have some understanding of the policies and procedures, the activities and services on offer at Woodrows Lane. Further work on policies and procedures is detailed later in this report – see National Minimum Standard – Standard 40. Woodrows Lane Version 1.10 Page 11 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, and 17. Service users are supported and enabled to have opportunities for personal development through the provision and promotion of appropriate leisure and training activities in the community. Family contact and visiting arrangements are open and relaxed, with family links promoted and encouraged. The home offered a varied, planned menu, with consideration given to dietary requirements. EVIDENCE: Social activities within the home are limited and tend to be those followed by individuals, such as gardening, watching the television, washing up after meals and listening to music. Outside the home all of the service users are enabled to use the library, go shopping, going to the pub, going to car boot sales and using local bus transport. Each week four of the service users choose to attend a local social club and it was said that all enjoy walks and drives in the locality. Two service users access local educational colleges attending sessions on Mathematics, Computer Studies, Gardening. Flower Arranging and SelfAdvocacy sessions. The registered manager spoke of wishing to access other classes, but spaces were limited. Woodrows Lane Version 1.10 Page 12 Each year, residents of Woodrows Lane are given the opportunity of having a holiday. In the past service users have holidayed in United Kingdom and Europe. The registered manager spoke of current ongoing discussions and selection of centres for this year’s holidays, which will be selected to suit the individual service user’s wishes and needs. Service users spoken to confirmed that consideration was being given to venues for their holidays. Service users and records confirmed that contact with relatives is ongoing. Management and staff spoke of assisting service users to speak to relatives on the telephone and ensuring birthdays and Christmas cards are sent. The home operates a five-weekly rotational menu for five of the six service users with a two-week rotational menu for one service user to meet their diabetic needs. Care staff and service users assist with the preparation and cleaning away of meals. Food supplies are purchased from local supermarkets, normally twice a week, with one service user assisting with the supermarket shop trip. Woodrows Lane Version 1.10 Page 13 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 and 21. Service users personal and healthcare needs are met within the home and records evidenced that service users are supported to access healthcare professionals as needed. The administration of medication for service users was found to be detailed and recorded to ensure that service users’ health needs are met. EVIDENCE: Evidence reflected that the home ensured that service users receive personal care and support in the way that they prefer and require. This was detailed in care planning documents and confirmed by a service user. From consideration of records and discussion with management the home ensures that the healthcare needs of service users are met. Services of three GP surgeries are used and currently there is input from the occupational therapist service and community nurses. Medication storage, administration and disposal were inspected at this inspection. Records were sampled for three service users and they were in good order. Staff who administer medication have completed basic medication administration training. Woodrows Lane Version 1.10 Page 14 A new policy has been drafted on care management in the event of a death From speaking to and dying and the onset of ageing and dementia. management, staff and a service user it was evident that thought is given to responding appropriately to service users changing needs as they grow older. This is particularly relevant as the current age range of service users is a mixture of 40s to over 65 years old. A third service user will be 65 years old in July 2005 and notification is required to enable a condition of registration for this named service user to be added to the home’s registration to enable the home to continue to care for them. Woodrows Lane Version 1.10 Page 15 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 and 23. Appropriate practices were in place to ensure that service users views are listened to and acted upon and the protection of service users is promoted. Staff training, the awareness of the manager, policies and staff recruitment practices promotes this. EVIDENCE: The home’s complaints procedure has been reviewed and revised following the last inspection and it now met requirements. In addition a new adult protection policy has been developed, this gives details of the procedure to be followed in the event of suspicion of abuse and to reflect the need to make a referral of other agencies such as the police, social services and the Commission for Social Care Inspection (CSCI). Both the manager and the assistant manager had attended adult protection training from an external training resource. Details of Protection of Vulnerable Adults (POVA) training as offered by Essex County Council was left with the home for them to pursue. Copies of the local authority POVA guidance are now given to staff members. Since the last inspection, allegations of physical abuse have been made. Management and staff have co-operated and assisted fully in the Police investigations. The registered manager said that the home had been informed that there are no charges and the investigations are concluded. Woodrows Lane Version 1.10 Page 16 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 and 30. The home provides a safe, homely and pleasant environment, which was clean and comfortable. EVIDENCE: Records relating to premises issues were not inspected on this inspection. A tour of the premises was undertaken at this inspection and the accommodation was found to be clean, tidy, bright and free from offensive odours. One service user was keen to show me their room and spoke of being involved in the planning and arrangement of their furnishings and fittings. Within the rear garden there was evidence of staff enabling and encouraging service users to access the garden and follow gardening pursues should they wish to do so. With the outset of the warmer weather, consideration is to be given to the concrete paving area outside the lounge patio doors. Detailed risk assessments are to be implemented with particular regard to one service user and varying levels in this area. The possibility of the installation of soft matting in this area and future repair/building work may need to be considered following these considerations. Woodrows Lane Version 1.10 Page 17 In-house laundry facilities of a washer and dryer domestic in character are found on the ground floor. New flooring has been fitted to the laundry. This was impermeable and as with the wall surfaces easily cleaned. Woodrows Lane Version 1.10 Page 18 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) 33, 34 and 35. Staffing levels and skills are appropriate to the needs of service users. Staff recruitment requirements as highlighted at the last inspection have been met and recruitment practices followed appropriate procedures. An induction and basic staff training programme has been introduced to ensure that training and skills requirements are met. EVIDENCE: From discussion with management and reviewing staff rotas, staffing levels as recommended by the Department of Health guidance – Residential Forum were found to be met. The registered manager said that staffing levels continue to be reviewed to ensure that service users needs are met at all times. A service user confirmed that staffing levels are sufficient to enable them to access local social clubs and activities and attend collage courses. The files of three care staff files were sampled and inspected. These contained evidence that all the required checks (including references and Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks had been satisfactory carried out and copies of relevant identification documents had been obtained e.g. birth certificate, passport and photograph. Staff contracts and the General Social Care Council (GSCC) code of conduct and practice were not considered at this inspection. Woodrows Lane Version 1.10 Page 19 The training file of the most recent staff member was inspected. This evidenced that induction training, which meets the Sector Skills Council specifications, had been commenced. Individual staff training and development assessment and profiles were not considered at this inspection, although it was noted that basic training needs such as basic food hygiene, moving and handling and fire safety training are planned in forthcoming months. Woodrows Lane Version 1.10 Page 20 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, 39, 40, 41 and 42. Staff and service users are well supported by the home’s manager, who is hands-on and part of the care team of the home. An effective quality assurance and quality monitoring system is still required, for analyses of completed questionnaires need to be completed. Omissions were found in policies and procedures required to safeguard service users rights and interests. Overall the records required to protect service users needs were found to be in place and some safety certifications held were found to meet requirements. EVIDENCE: It was evident from talking with staff that they feel they receive guidance and direction from the manager. Whilst it is acknowledged that the current registered manager has a wealth of experience in care and management, Mrs Tubby said that she is not prepared to undertake training to meet the required level 4 National Vocational Qualifications (NVQ) in both management and care. The assistant manager confirmed that they were considering taking on the role Woodrows Lane Version 1.10 Page 21 of registered manager and an application for registration is required. They also confirmed that they were prepared to undertake the required training. It is understood that these changes have been discussed with the registered provider. The registered manager has already given out questionnaires to service users, relatives and the community nursing team who visit service users. It was recognised that there is a need to disseminate these questionnaires to develop an annual development plan based on a systematic cycle of planning-actionreview. The introduction of further questionnaires detailing specific care issues is to be considered. Policies and procedures were sampled and reviewed and omissions were noted. Policies and procedure in place and meeting requirements were the home’s fire procedure and the procedure regarding access to files and record keeping. Omissions found were a policy regarding the maintaining of contact with and visits by family and friends and a policy on smoking and the use of alcohol and substances by service users, visitors and staff. It was noted however, that a new policy on smoking in the home by both service users and staff had been introduced. Overall records required by regulation for the protection of service users were seen to be in order, with the exception of the Regulation 26 visit by the registered provider. Sample formats for completion by the registered provider have been sent to the care home for immediate use. This is outstanding from previous inspections. Safe working practices are ensured through the introduction of basic training opportunities. These were as detailed earlier in this report. A more detailed review of staff training will be conducted at future inspections. Safety certifications were sampled and inspected. A electrical inspection had been completed in January 2005 and electrical portable appliance testing was to take place in May 2005. A gas safety and performance service checklist had been completed in January 2005, but there was no gas safety certification such as a Gas Landlords Certificate. In addition the home needs to introduce the regulation and recording of hot water temperatures to control the risk of Legionella and risk from hot water/surfaces based on the capabilities and needs of service users i.e. temperature close to 43 degrees centigrade. Woodrows Lane Version 1.10 Page 22 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 3 x x 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 3 x x x x x 3 Standard No 11 12 13 14 15 Woodrows Lane x 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 3 3 x Version 1.10 Page 23 16 17 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 2 x 2 2 2 2 2 Woodrows Lane Version 1.10 Page 24 Yes 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 37 Regulation 18 Requirement The registered person must ensure that the registered manager is competent, qualified and experienced to run the home and meet its stated purpose, aims and objectives. This is with regard to obtaining a qualification in level 4 NVQ in both management and care. This was a repeat requirement. [ The registered person must ensure that there is an effective quality assurance and quality monitoring systems in place to measure success in achieving the aims, objectives and statement of purpose of the home. (This is a repeat requirement. Previous timescale of 01/12/04 not met.) The registered manager must ensuere that the homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in National Minimum Standards Care Homes for Adults (18-65) - Appendix 2. (This is a repeat requirement. Previous timescale of 01/12/04 not met.) Version 1.10 Timescale for action Action plan required by 27/06/05 2. 39 24 Implement aion of a Q A system by 27/08/05 3. 40 17, 24 27/06/05 Woodrows Lane Page 25 4. 41 26 5. 42 23 The registered provider must ensure that they conduct a visit and supply a copy of the visit report in accordance with Regulation 26 The registered manager must ensure that the health, safety and welfare of service users is safeguarded through the completion of appropriate safety certification. (This is a repeat requirement. Previous timescale of 01/12/04 not met.) 27/06/05 27/06/05 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 Good Practice Recommendations Woodrows Lane Version 1.10 Page 26 Commission for Social Care Inspection 1st Floor Fairfax House Causton Road Colchester, CO1 1RJ 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 Woodrows Lane Version 1.10 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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