Inspection on 09/11/05 for 38a Woolifers Avenue

This inspection was carried out on 9th November 2005.

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 but made no statutory requirements on the home.

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 07/03/06

38a Woolifers Avenue 07/03/05

38a Woolifers Avenue 14/12/04

38a Woolifers Avenue 29/01/04

Similar services:

Coopers Mill Ltd

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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 Woolifers Ave. Corringham Essex SS17 9AU Lead Inspector Helen Laker Unannounced 9 November 2005 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. Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woolifers Avenue (38a) Address 38a Woolifers Ave Corringham Essex SS17 9AU 01375 640292 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) Mosaic Essex Ms Eufrocina Dysangco CRH Care Home 3 Category(ies) of LD Learning Disability registration, with number of places Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th March 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 HomesThe 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) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 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 two service users. The manager in charge and two members of staff were spoken with. Twenty seven National Minimum Standards were inspected on this occasion, nineteen overall outcomes were met and there were six requirements and two 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: Pre admission assessments must be carried out before admission. 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 had not been undertaken. The inspector was informed that the boiler has still to be attended to and replaced to ensure effective temperature control. The washing machine is still located in the kitchen and the tumble dryer in the office. The home must still consult the local Environmental Health Officer and obtain written clarification of agreement. This has been outstanding for the last two inspections and must be followed through. Examination of the most recently recruited / transferred staff files did not evidence that appropriate recruitment procedures are in place as information was missing. Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 Page 6 Training is overall up to date but this must be maintained for all new members of staff. The home needs to ensure all safety certificates are in date. 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) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 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 Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 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) 1,2,5 The admission procedure does generally include an adequate assessment which ensures that service users needs can be met. On this occasion it could not be verified or found 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 last admission evidenced that a full assessment had been carried out before admission by the social worker but not to which the staff of the home had been party. The home has an admission policy which includes pre-admission procedures. 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 was not dated or signed. These also still need to include the total weekly cost. Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 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) 6,7,9 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. 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, 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. Clear risk assessments are detailed in each service users support plan. However one risk assessment concerning a service user travelling in cars detailed that she was to be accompanied by a second member of staff had not always being followed at the last inspection, and it was noted that regular reviews had not been undertaken. Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 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) 12,13,15,16,17 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: The service users like going out and enjoy walks and shopping. One likes to go for rides in the car and to charity shops. Service users are enabled to access various community facilities including, visits to local pubs, restaurants and cinemas. The home operates an open visitors policy whereby service users can receive their family, friends and representatives at any time. Staff encourage service users to maintain contact with their relatives wherever possible. Service users are able to personalise their own rooms and have access to all parts of the home. The home’s front door is kept locked in line with a risk assessment and is recorded as an infringement of rights. Service users are involved in the planning of the home’s menu and with the preparation of meals and have specialist diets. Menus seen were varied and Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 Page 11 nutritious and the staff informed mealtimes are flexible. Comprehensive nutrition records were seen to be maintained. Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 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 Arrangements are in place to ensure that the health care needs of service users are identified and met. Medication administration and recording is being addressed appropriately. EVIDENCE: The manager advised that service users are able to choose when they go to bed and when they rise, although this depends on the daytime activities. Service users are encouraged to manage their own personal care as far as possible. Service users are supported by staff in choosing their own clothes. Service users have access to the G.P. dentist, chiropodist as well as a psychiatrist. All healthcare visits are recorded in each individual service users care plan. No service user has been assessed as able to manage their own medication. Agreement for staff to manage medication is recorded in the care plans. The home uses a pre-dispensed system for the administration of tablet medication. Medication administration records (MAR) were seen to be completed appropriately. Staff administering medication have received appropriate training. Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 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 home has an appropriate complaints policy which informs complainants of their rights and assures them their complaint will be taken seriously. Staff are aware of the issues relating to the protection of vulnerable adults. EVIDENCE: The home has an appropriate complaints procedure and recording system. The home has appropriate adult protection and whistle blowing policies and procedures. A copy of the Thurrock Council’s Adult protection policy and procedure was available. All staff read and sign the policies. Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 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) 24,25,26,27,28,29,30 38A Woolifers Avenue was clean and bright and provided the service users with homely and comfortable surroundings. Some internal maintenance and environmental health issues are still to be addressed. 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 available however the inspector was informed that the boiler has still to be attended to and replaced to ensure effective temperature control. Service users bedrooms meet individual space requirements. All the bedrooms were seen to be well decorated, furnished and personalised to each individual service users taste. The home provides one bathroom and one shower, both with toilets. Communal space includes a large well furnished lounge/diner and a modern kitchen. Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 Page 15 The home has a wide range of equipment and aids to meet the needs of the service user including handrails adapted shower and ceiling hoist. One service user who has a visual impairment uses objects of reference and fragrance sachets to identify the different rooms in the house. The home has an infection control policy however the washing machine is still located in the kitchen and the tumble dryer in the office. The home must still consult the local Environmental Health Officer and obtain written clarification regarding their agreement. This has been outstanding for the last two inspections and must be followed through. Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 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) 34,35 Generally adequate recruitment policies and practices are in place but on this occasion not for a transferred member of staff. Overall the home has an effective and competent staff team who receive training to the required standard. EVIDENCE: 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 procedures apply and documentation should be in place and CRB checks were not available to inspect. The inspector was advised that the home has access to the proprietor’s corporate training budget. Staff spoken with said they have access to a wide range of training. A number of staff are working towards NVQ. Mandatory training is overall up to date but again not for the newest member of staff. Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 Page 17 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) 39,42 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 certificates are in date. EVIDENCE: 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 out of date such as PAT testing. Staff spoken with previously said they have attended fire training and regular safety checks are made and recorded. UP to date employers liability insurance was seen. Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 Page 18 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 3 2 x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woolifers Avenue (38a) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 Page 19 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 2 Regulation 14 (1) & (2) Requirement 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. The registered person must 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 with immediate effect not met.) The registered provider must ensure that the home’s laundry facilities are reviewed and relocated to avoid cross infection. (Previous timescale of with immediate effect not met.) Recruitment records required by regulation for the protection of service users and for the effective and efficient running of the business must be maintained, up-to-date and Timescale for action 20th December 2005 2. 9 13 (4) (b) 20th December 2005 3. 30 13(1), (4) & (6) 20th December 2005 4. 34 17 (3) (a) & (b) 20th December 2005 Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 Page 20 5. 35 16 (1) (a) 6. 42 12 (1) (a) 13 (4) accurate. (Previous timescale of with immediate effect not met.) 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. 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 of up to date maintenance certificates being produced. 20th December 2005 20th December 2005 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 5 24 Good Practice Recommendations The total weekly cost of residency should be included in each service user’s terms and conditions The homes premises are safe and well maintained. This refers to renewing the boiler Woolifers Avenue (38a) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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) I56 I06 S18119 Woolifers V242120 091105 Stage 4.doc Version 1.40 Page 22 - 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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