Inspection on 07/03/06 for 38a Woolifers Avenue

This inspection was carried out on 7th March 2006.

CSCI 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 CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

38a Woolifers Avenue 24/07/08

38a Woolifers Avenue 31/07/07

38a Woolifers Avenue 06/06/06

38a Woolifers Avenue 09/11/05

38a Woolifers Avenue 07/03/05

38a Woolifers Avenue 14/12/04

38a Woolifers Avenue 29/01/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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 Woolifers Avenue (38a) 38a Wollifers Ave Corringham Essex SS17 9AU Lead Inspector Helen Laker Unannounced Inspection 7th March 2006 10:00 Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woolifers Avenue (38a) Address 38a Wollifers Ave Corringham Essex SS17 9AU 01375 640292 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) Mosaic Essex Ms Eufrocina Dysangco Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9th November 2005 Brief Description of the Service: The home provides residential accommodation for three adults with learning disabilities. The proprietors have recently changed their name from New Essex Housing Association, which was a subsidiary housing association of New Islington and Hackney Housing Association, to Mosaic Homes. The home facilities include one large living/dining area, three single bedrooms, one shower room and one bathroom. Service users access a range of formal day care placements within the local community. In addition service users are encouraged to access leisure interests and community facilities. The home is situated a short car journey from Corringham Town and Lakeside shopping Centre. Service users have access to a lease car and there are bus and train links to the area. The home has a garden to the rear. Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection, which took place with one inspector in the home. There was a tour of the premises and grounds and an inspection of records and documentation. Time was spent discussing the care of the three service users. The manager in charge and one member of staff were spoken with. Twenty four National Minimum Standards were inspected on this occasion, eighteen overall outcomes were met and there were six requirements and four recommendations detailed in the full report. Discussion of the inspection findings took place with the manager in charge at the end and throughout the inspection and guidance was given. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose and service users guide needs to be more service user friendly. Pre admission assessments must be carried out before admission and trial visits undertaken and recorded. Contracts must detail the contributions to be paid by each service user and be dated or signed. These still need to include the total weekly cost. Regular reviews of risk assessments are still top be addressed and undertaken. Examination of the most recently recruited / transferred and core staff files did not evidence that appropriate recruitment procedures are in place as information was missing. Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 6 Training is overall up to date but this must be maintained for all new members of staff. The manager should complete her NVQ level 4 qualification. The home needs to ensure all safety inspections have taken place and are in date and that fire drills are undertaken. These issues were all discussed at the time of the inspection and the intended outcomes of each. 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. Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 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 the following standard(s): 1,2,3,4,5 Prospective service users have the information available to make informed choices. The admission procedure does not include an adequate assessment, which ensures that service users needs can be met. On this occasion it could not be verified, as it had not been done for the homes most recent admission the home provides a caring environment where visitors are made welcome. EVIDENCE: The home’s statement of purpose and service user guide required minor amendments and further development to ensure it is user friendly. The support plan for the homes most recent admission did not evidence that an assessment had been carried out before admission to which the staff of the home had been party. The home has an admission policy, which includes preadmission procedures. Staff have received training in sensory impairment in learning disabilities and staff have introduced systems of communication with the service users this has resulted in aggressive behaviour problems previously experienced having now ceased. Risk assessments have been carried out for lone working and a protocol produced for night staff to follow. The home is adequately equipped to facilitate the needs of current service users. Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 9 Generally prospective service users are invited to visit the home as often as they wish before admission. This did not happen in the case of the most recent service user admitted who did not visit at all. The staff did not also make visits to the service user before agreeing placement. Individual service user contracts were seen to be on each individual service users file. Each contract detailed the contributions to be paid by each service user but although signed was not dated on this occasion. These also still need to include the total weekly cost payable. Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,8,9,10 Each service user has an individual plan and service users are supported to take risks as part of an independent lifestyle via a process of assessment. Risk assessments require attention regarding reviews. Due to service users learning disabilities they are only able to make limited decisions but staff facilitate this as much as possible. EVIDENCE: Two support plans examined were seen to be comprehensive, generally regularly reviewed and evidenced service user involvement. Staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. Although risk assessments are detailed in each service users support plan these had not been reviewed regularly. However one risk assessment, highlighted at the homes last inspection, concerning a service user travelling in cars, details now that she was to be accompanied by a second member of staff and it was noted still that regular reviews had not been undertaken. Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 11 Staff are aware of the home’s policy on confidentiality service users records were seen to be kept up to date and held securely. Two service users are under the Court of Protection. Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 – 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,14 Social activities take place and service users are generally happy with the choices in routine available to them. Visitors are made welcome and overall the service users rights and responsibilities are recognised in their daily lives. EVIDENCE: Service users are encouraged to maintain and develop independent living skills by being involved in household chores and with their own personal care as far as they are able, however one service user has a greater level of needs and requires more staff support. Service users are encouraged to pursue their own personal interests: these include listening to music, watching TV, videos, collecting items and one service user has opportunities to attend a weekly evening club. Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 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 the following standard(s): 21 Good arrangements are in place to ensure that the ageing, illness and death of service users and their needs are identified and met should the occasion arise. EVIDENCE: Service users wishes on death and dying are sensitively obtained as appropriate, and recorded in individual support plans. As the home is a learning disability home deaths in the home are very few and none have happened recently. The Manager stated that dying and death are handled sensitively and professionally at the home. Policies were seen and are in place within the home to meet this standard Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 14 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 the following standard(s): NOT INSPECTED EVIDENCE: NOT INSPECTED Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 24, 30 38A Woolifers Avenue was clean and bright and provided the service users with homely and comfortable surroundings. Internal maintenance and environmental health issues highlighted at the homes last inspection have now been attended to. EVIDENCE: The home was clean and tidy throughout and provided a comfortable and homely environment for the service users. It is located in a residential area of Corringham close to bus routes and local shops. It has a good sized accessible garden. The home’s maintenance programme was seen previously and the inspector was informed that the boiler has now been attended to and replaced to ensure effective temperature control. The home has an infection control policy and the washing machine is located in the kitchen and the tumble dryer in the office. The home has sought written clarification from the local Environmental Health Officer and obtained their agreement regarding best working practices. Environmental risk assessments were seen for this and staff are adhering to their advice. Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Adequate recruitment procedures were not demonstrated on this occasion and policies are in place. Overall the home has an effective and competent staff team who receive training to the required standard. Updates need addressing. EVIDENCE: The inspector was informed that each member of staff has an appropriate job description and have been issued with the general social care council’s code of practice. This could not be evidenced on the day of inspection. Staff spoken with evidenced a sound knowledge of the service users care needs. Staff ratios continue as set by the previous registering authority, two staff on each shift during the day and one working night staff. However staff rotas indicated that on every Bank staff cover sickness, holidays and vacancies. The manager works hands on for 3 shifts per week. The home has a core staff team, which is supplemented very rarely by agency workers. None are used at present. Examination of the most recently recruited / transferred staff files did not evidence that appropriate recruitment procedures are in place as information was missing. The manager was advised that even if a staff member is transferred from another home in the group the mandatory recruitment Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 17 procedures apply and documentation should be in place and CRB checks were not available to inspect. This was highlighted at the homes last inspection also. The inspector was advised that the home has access to the proprietor’s corporate training budget. Staff have access to a wide range of training. Two members of staff have achieved NVQ 3, and another two are currently undertaking NVQ 3. One new member of staff required some mandatory training and updates for all staff are either planned or in progress. Staff receive comprehensive supervision on a monthly basis and appraisals annually Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,40,41,42,43 There is guidance and direction to staff and the home has in place practices that will promote and safeguard the health, safety and welfare of the people using the service. The home needs to ensure all safety inspections and fire drills are undertaken and up to date. EVIDENCE: Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 19 The manager is a qualified enrolled nurse and attends regular training to keep up to date with her registration. Some updates were noted to be required. She is undertaking training at NVQ level 4 which she indicated is taking longer than she expected. The manager is allocated 10 hours per week supernumerary to the rota to carry out her management duties. Staff spoken with said the manager is approachable and easy to talk to. The homes last minuted staff meeting was held on 11th February 2006 The home uses the proprietor’s policies and procedures. Those seen were to a good standard and regularly reviewed. Records seen were found to be accessible, in good order and securely stored in the office. The manager was aware of her responsibilities for Health and Safety within the home. Regular regulation 26 reports are received by the commission. Safety certificates for electricity, gas and emergency lighting were available for inspection but some were noted to be due such as PAT electrical installation periodic testing. Staff spoken with previously said they have attended fire training and regular safety checks are made and recorded. On inspection it was noted that fire drills had not been undertaken since 18th July 2005. The manager was advised that this must be addressed. Up to date employers liability insurance was seen. Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 2 3 3 4 2 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 2 32 3 33 3 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 2 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X 3 3 3 x 3 3 2 3 Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES 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 YA2 Regulation 14 (1) & (2) Requirement Timescale for action 21/04/06 2 YA4 12 (1) & (2) 3. YA9 13 (4) (b) 4. YA34 17 (3) (a) & (b) New service users must be admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives, (if any), and relevant professionals have been party including the home staff. (Previous timescale of 20th December 2005 not met.) The registered person invites 21/04/06 prospective service users to visit the home on an introductory basis before making a decision to move in The registered person must 21/04/06 ensure that comprehensive risk assessments are carried out and reviewed regularly for all service users, including specific details within individualised plans of care. (Previous timescale of 20th December 2005 not met.) Recruitment records required by 21/04/06 regulation for the protection of service users and for the effective and efficient running of the business must be maintained, up-to-date and accurate. (Previous timescale of DS0000018119.V277317.R01.S.doc Version 5.1 Woolifers Avenue (38a) Page 22 20th December 2005 not met.) 5. YA35 16 (1) (a) The registered person must ensure that all staff employed at the home receive training for the work undertaken. It is recommended this meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. This needs to be kept up to date. (Previous timescale of 20th December 2005 not met.) Arrangements must be in place to ensure that all parts of the home to which service users have access are, so far as is reasonably practicable, free from hazards to their safety. This with particular reference to production up to date safety inspections and ensuring fire drills are undertaken. (Previous timescale of 20th December 2005 not met.) 21/04/06 6. YA42 12 (1) (a) 13 (4) 21/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3 4 Refer to Standard YA1 YA5 YA31 YA37 Good Practice Recommendations The service users guide and statement of purpose need to be more service user friendly. The total weekly cost of residency should be included in each service users terms and conditions It is recommended that job descriptions be included in all staff files The manager should complete her NVQ level four qualification. Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Woolifers Avenue (38a) DS0000018119.V277317.R01.S.doc Version 5.1 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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