Inspection on 15/02/06 for Winray Care Home

This inspection was carried out on 15th February 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Winray Care Home 09/05/08

Winray Care Home 10/12/07

Winray Care Home 18/05/06

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Winray Care Home 17 Clarendon Road Leytonstone London E11 1BZ Lead Inspector Kristen Judd Unannounced Inspection 15 February 2006 10:00 th Winray Care Home DS0000061891.V283440.R02.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 Winray Care Home DS0000061891.V283440.R02.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. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Winray Care Home Address 17 Clarendon Road Leytonstone London E11 1BZ 020 8279 7884 020 8279 6812 info@winraycare.com www.winraycare.com Winray Care Home 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) Mrs Denise Lewis Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th August 2005 Brief Description of the Service: The homes Statement of Purpose states that the aim is to provide a home for four young adults who are affected by Autistic Spectrum Disorders, Severe Learning Disability and behaviour that can challenge the service. The house is a semi detached property located in a residential area in the London Borough of Waltham Forest and is well situated for access to public transport. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 15th February 2006. No service users currently live at the home, and indeed, there have been no service users residing at the home since its registration in March 2005. As such many of the key standards have been unable to be assessed. This inspection followed up the requirements made at the additional visit held on 11th August 2005 where twelve requirements. Three requirements and one recommendation have been made following this inspection. Verbal feedback was given at the end of the inspection. The inspector wishes to thank the management for facilitating this unannounced inspection. What the service does well: 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. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 6 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 Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 7 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 The Statement of Purpose must accurately reflect the service provision to ensure that purchases of care can make informed choices. EVIDENCE: The Statement of Purpose states that the home will admit young adults who are affected by Austic Spectrum Disorder, Severe Learning Disability, and behaviour that can challenge the service. The description of the home states ‘Winray Care Home is a semi–detached building which covers three floors to give plenty of space to move around or spend time on their own’. This however is not the case as there is limited space in the communal areas and the corridors are extremely narrow. This needs to be taken into account when assessing prospective service users. The inspector also noted that there are many discrepancies within the document such as ‘Therapies’ referrers to a sensory room at Winray, however at the time of inspection there was none in place. The description of the garden area is also deemed not accurate. These are considered important issues given the service user group that the home aims to accommodate and if such facilities are not in place this needs to be clear on the documentation with guidance as to when these facilities will be implemented. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 8 The registered manager must amend the Statement of Purpose to ensure that it accurately reflects the service provision to ensure that purchases of care can make informed choices. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 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 the following standard(s): The standards in this section were not tested on this occasion, but will be tested as part of the next inspection. EVIDENCE: The standards in this section were not tested on this occasion, but will be tested as part of the next inspection. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 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 the following standard(s): The standards in this section were not tested on this occasion, but will be tested as part of the next inspection. EVIDENCE: The standards in this section were not tested on this occasion, but will be tested as part of the next inspection. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 11 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): The standards in this section were not tested on this occasion, but will be tested as part of the next inspection. EVIDENCE: The standards in this section were not tested on this occasion, but will be tested as part of the next inspection. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 12 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): 22 The homes documentation must be accurate and in a suitable format to ensure that service user are well informed. EVIDENCE: The complaints policy was seen, which provides information about the different stages of the complain process and provides timescales for response. However it is recommended that such policies be developed into a more suitable format for younger adults with Learning Disabilities. Additionally the policy must be amended to clearly indicate that complaints can be made directly to the Commission for Social Care Inspection. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 13 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 There remain some concerns with regard to the environment and this needs to be taken into account when assessing service users prior to admission to ensure their needs can be met. EVIDENCE: The communal space and corridors were plain and drab, and inspired an air of gloominess not conducive to a homely environment. On discussion with management the inspector was informed that work would be done to make the environment ‘homley’ once service users are admitted and hopefully they would be involved in the process. The inspector acknowledges that the bedrooms have been improved. There is a communal lounge and a kitchen diner but there are no other communal areas. The corridors are very small and two people could not pass at some points. It continues to be of concern how service users with challenging behaviour would cope in this environment and how staff would deal with any incidents in these restricted areas. The bathrooms and toilets look ‘tired’ and are very small and would be difficult to accommodate any specialist equipment if required by service users. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 14 The inspector acknowledges that the environmental issues raised in the previous report have been addressed. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 15 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): The standards in this section were not tested on this occasion, but will be tested as part of the next inspection. EVIDENCE: The standards in this section were not tested on this occasion, but will be tested as part of the next inspection. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 16 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): 41 &42 There must be accurate service specific policies and procedures in place for staff to follow to ensure that service users needs are met. EVIDENCE: A small sample of the homes policies and procedures was seen at the time of inspection. Further work is needed to ensure that they are service specific and accurate. For example The Adult Protection procedure makes reference to the Domiciliary Care Regulations. The procedure also makes reference to the NCSC on the flow chart, which should be amended, to the Commission for Social Care Inspection. The medication policy needs amendment as it informs staff that there can administer ‘homely remedies’ such a anal suppositories however this would be considered an evasive procedure. Additionally it was noted that there is no recruitment policy in place. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 17 The following health and safety checks have been evidenced: Emergency lighting checked 28/04/05 Gas certificates were seen dated 10/04 valid for one year. This is outstanding The electric certificate 01/05 valid for 2 years. Portable Appliance Test had not been completed. This is outstanding Fire extinguishers were last checked 30/06/04. This is outstanding Insurance certificate valid until 21/02/06. This is near renewal. Fire alarm was last serviced 28/04/05. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 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 Standard No Score 1 2 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 x ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x x x x x 2 x 2 x Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 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 YA1 Regulation 23.1(a) Requirement The registered manager must ensure that the Statement of Purpose accurately reflects the services and facilities. (Timescale of 30/09/05 not met) The registered manager must ensure that all relevant policies and procedures as stated in Appendix 2 of the National Minimum Standards are in place and that they are service specific. The registered manager must ensure that all Health and Safety checks are update and copies of all the certificates must be forwarded to the Commission for Social Care Inspection. Timescale for action 30/04/06 2 YA40 12.1 30/04/06 3 YA42 13.4 31/03/06 Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 20 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 YA41 Good Practice Recommendations It is recommended that procedures such as complaints be presented in a format suitable for adult with learning disabilities. Winray Care Home DS0000061891.V283440.R02.S.doc Version 5.1 Page 21 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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. 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