Inspection on 11/04/05 for Woodbourne

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

Other inspections for this house

Woodbourne 21/05/07

Woodbourne 28/11/05

Woodbourne 09/11/04

Woodbourne 25/05/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOMES FOR OLDER PEOPLE Woodbourne 1 Oakwood Road Horley Surrey RH6 7BZ Lead Inspector Cathy Clarke Unannounced 11 April 2005 9.00 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 Older People. 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. Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodbourne Address 1 Oakwood Road Horley Surrey RH6 7BZ 01293 822829 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 Rohana Silva Mr Rohana Silva Care Home 6 Category(ies) of MD Mental Disorder (2) registration, with number MD(E) Mental Disorder - over 65 (4) of places Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9 November 2004 Brief Description of the Service: Woodbourne is a detached property set in a residential area close to Horley town centre. Services and accommodation are available for six men and women with mental illness. The service users are relatively independent in terms of personal care needs but require support and monitoring to maintain active lives in the community. Bedrooms are provided on the ground and first floor, all are single and half have en-suite facilities. The communal areas comprise of two lounges (one of which is a designated smoking area) and a kitchen/dining room. There are good staff facilities available including two sleeping rooms. Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. Cathy Clarke, Lead Inspector for the service, carried out this inspection. Mr and Mrs Silva were present as representatives for the establishment. A full tour of the premises took place and documents inspected included were care plans, menu plans, staff records and various policies and procedures. Four service users were spoken to during the inspection, two of them in their rooms in private. This was a positive inspection. The inspector would like to thank the directors, staff and service users for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? What they could do better: The policy and procedure for the protection of vulnerable adults needs to be further developed to ensure clarity for staff following the current and most up to date version of the Surrey Multi Agency procedures. The Manager and Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 6 Deputy Manager are to attend the updated Surrey Multi Agency protection from abuse training and cascade information down to care staff. An external medication training programme must be accessed for all staff and MAR charts completed as required. The storage of items within the medication cupboard must be regularly checked to ensure that they are within the allocated expiry date. Ventilation must be improved in the activities/smoking room. It was stated that staff hold nursing qualifications, however their registration is not up to date and therefore brings currency and continuous professional development into question. Management are advised to seek advice regarding the current situation on nurses holding qualifications without an up to date registration and whether these qualifications act therefore as an equivalent to the relevant NVQ. 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. Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3,4,5, 6. The homes Statement of Purpose and Service User Guide provide service users and prospective service users with details of the services the home provides. This enables service users to make an informed decision about admission and the ongoing care to be received within the home. EVIDENCE: A number of service user files were seen during this visit and it was apparent that all received assessments prior to moving in. Each service user is issued with a contract, which clearly states all areas of occupancy. Prospective service users, family and representatives are invited to make a visit to the home prior to admission and a trial period of up to three months is offered. Care plans were found to be comprehensive detailing the health and social care needs of the service users. Intermediate care is not provided within this home. Service users spoken to during the inspection said that they liked living in the home and that staff understood their needs. Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10, Care plans had been compiled for all service users and were found to be comprehensive. The home provides access to a range of health care professionals who both provide care in the home and are accessed in the community. Problems were found with the storage and administration of medication. EVIDENCE: Each service user is issued with a comprehensive care plan outlining their health, and social care needs. A community psychiatric nurse visits the home every three weeks and service users are visited by the local General Practitioner every quarter. A chiropodist visits the home every 4-6 weeks as well as the Optician and community dentist. Health care services visit the home but service users also have the opportunity to access local services out in the community should they wish. None of the service users self medicate. The medication cabinet was found to contain some dressings, which were out of date and the service was advised to dispose of them. There was one signature missing from one of the medication administration records and this was pointed out to the registered manager. All other records were complete and recorded accurately. Medication training Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 10 must be accessed for all staff working at the home. Records sampled during the visit demonstrated that the cook who is not employed to care for service users had signed as a witness for medication given by a member of care staff. All service users are independent and require no assistance with personal care. During the visit it was observed that staff knock on doors before entering rooms and one service user who likes to stay in his room was not disturbed. When health care professionals visit they see the service users in their own rooms. There are no shared rooms within the service. There is a coin-operated phone in the lobby for service users use. Service users were called by their preferred names or titles during the visit. The home has a “home for life philosophy” and would look after service users who become ill with the aid of health professionals where necessary. Please refer to the requirements and recommendations section of this report. Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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 The staff have a good understanding of the service users’ support needs. This is evident from the positive relationships, which have been formed between the staff and service users. Menus sampled showed that they are changed weekly and offer choice and variety. EVIDENCE: One service user likes to go out to the local pub, betting shops, market, and restaurants. Activities are available and take place within the community and home. The service users like to do picture framing and supplies of materials and equipment for this were seen on display within the home. Service users keep in contact with their family and there are no restrictions on visiting the home. Religious interests have been met with Holy Communion received every two weeks. Guardianship orders are in place for three service users, one service user manages his own money and another service user’s family oversees his finances. Service users spoken to on the day of inspection said that they like the facilities within the home and are free to make their own decisions about daily living. Meals were not sampled during this inspection however the menu plan showed that the menu is changed weekly with a varied diet available. No special diets are required however one of the service users has a high carbohydrate diet to ensure weight gain. The owners of the home are fully aware of the likes and Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 12 dislikes of the service users with regard to food and drink. The kitchen and dining room were clean and tidy with fridge and freezer temperatures recorded as required. Staff have obtained the Basic Food Hygiene certificate and this is renewed every three years. Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The complaints process is clear and information is available to all service users within the home on how to make a complaint. The homes Vulnerable Adults policy and procedure needs further development to ensure clarity for staff. EVIDENCE: The complaints procedures are clear and service users spoken to acknowledged that they knew who to complain to and felt that management and staff would listen to any concerns. The Vulnerable Adults policy and procedure is currently held within the reporting actions/incidents of concern policy and it was felt that this should be separated into a stand-alone policy and procedure to give clarity to staff. The owners have agreed to attend the Surrey Multi Agency Approach updatetraining programme and will cascade information to staff. The owners were advised to use the new updated version of the Surrey Multi Agency procedures to formulate the policy and procedure document. Please see recommendations section of this report. Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,21,22,23,24,25,26 The standard of the environment within this home is good providing service users with an attractive, comfortable and homely place to live. Many of the homes original features have been kept and this enhances the ambiance. EVIDENCE: The communal rooms within the service are well decorated. Fire checks have been carried out every 6 months and there are no environmental health officer requirements. The carpet in the smoker’s room needs to be changed and an extractor fan is to be fitted. It was felt that paper stored in this room should be moved to a more suitable storage area in case of fire. One of the bedrooms on the ground floor requires replacement flooring in the bathroom. There are four bedrooms with en-suite bathrooms and there are a further two shower rooms and one bathroom situated within the home. Each service user has a toilet within close proximity to their rooms. Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 15 Equipment has not been necessary within the home for mobility or disability because of the independence of the service users living there. Every room has a radio control system in place. One of the service users has a hospital bed and when questioned said that he had had this for some time and preferred it to a normal divan. All the rooms are large and there are no shared rooms within the home. There are wash hand basins in all rooms and locks on all of the doors. One service user has a key to her bedroom the others prefer not to use them. The home is warm and windows above ground floor level have window restrictors in place. The pipes to the downstairs toilet are to be boxed in. The water is on direct supply with no tanks necessary. Ventilation in the smokers/activities room must be improved. Overall the premises were found to be very clean and hygienic and laundry facilities included a washing machine and dryer. Sluicing facilities are not required. See the requirements section of this report. Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28, The staffing levels within the home meet the requirements of the service users presently living within the home and their levels of independence. EVIDENCE: The home is managed and run by the owners five days per week with the assistance of a cook and handyman. Staff on nights are employed as sleeping night staff. There are no staff employed under the age of 18 years and no assistance with personal care is presently required within the home. The registered manager has registered on the NVQ Level 4 Registered Managers Award programme together with his wife/co-owner who has also attended the NVQ assessor’s award update with the Surrey Training Consortium. One member of staff is RMN/RGN qualified although registration of his qualification is not live. Advice regarding the validity of nurse qualifications without an up to date registration should be sought in order to ensure that the homes staff are complying with the minimum ratio of 50 trained members of care staff (NVQ 2 or equivalent) being achieved by 2005. Please see recommendations section of this report. Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36, The management approach within the home creates an open, positive and inclusive atmosphere between management, staff and service users. The home reviews its performance by seeking the views of service users through a consultation process undertaken via an annual survey and regular service user and staff feedback. EVIDENCE: The home is committed to providing a quality service and the annual survey is distributed to service users to gain feedback on the care provided. The manager has 20years experience of working with people with mental health issues. Service users confirmed that they could tell the manager if they are not happy with the level and quality of the service. Policies and procedures within the service are regularly reviewed and updated. Accounts are managed by the deputy manager who is a qualified Chartered Management Accountant and audited by an external accountant. Business insurance is in place. No Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 18 money is kept on behalf of service users any expenditure is receipted and reimbursements are claimed accordingly. Supervision is undertaken and 1-1 records sampled covered all aspects of staff performance and care. Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x 3 N/A 3 3 2 3 STAFFING Standard No Score 27 2 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 3 3 3 x x Woodbourne H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. 6. Standard 19 9.7 19 19 19 25 Regulation 13 (2) 13 (2) 23 (l)) 23 (2) (b) 23 (2) (b) 23 (p) Requirement Medication administration records must accurately reflect medication given. Medication training must be provided for all staff within the home. Paper stored in the smoking room must be moved to a more suitable storage area. The flooring in the downstairs bedroom ensuite must be replaced. Pipes in the downstairs toilet must be boxed in. Ventilation must be improved in the smokers/activities room Timescale for action 12/04/05 30/06/05 31/5/05 30/06/05 30/06/05 30/06/05 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. 2. Refer to Standard 9.7 18 Good Practice Recommendations It is recommended that only those staff who are employed to deliver care are to witness the giving of medication where necessary. It is recommended that the vulnerable adults policy and procedure is a stand alone document and should reflect H58-H09 s41738 Woodbourne v222355 110405 Stage 4.doc Version 1.30 Page 21 Woodbourne 3. 27 the most current Surrey Multi Agency Vulnerable Adults procedures. It is recommended that management seek advice on the validity of qualifications without live registration for those nurses in employment against the required government qualifications for care staff. 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