Inspection on 14/06/05 for Woodbourne Avenue, 31

This inspection was carried out on 14th June 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 Avenue, 31 09/03/07

Woodbourne Avenue, 31 06/12/05

Woodbourne Avenue, 31 24/01/05

Woodbourne Avenue, 31 16/08/04

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 31 Woodbourne Avenue Streatham London SW16 1UP Lead Inspector Mary Magee Unannounced 14th &15th June 2005 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. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 31 Woodbourne Avenue, Address Streatham, London SW16 1UP 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) 020 8769 1865 020 8769 1865 The Frances Taylor Foundation Sister Mary Hogan CRH Care Home 8 Category(ies) of PC Care home only registration, with number of places 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 to include one service user aged 65 years or above Date of last inspection 24th January 2005 Brief Description of the Service: 31 Woodbourne Avenue is one of a number of care homes owned and managed by the Frances Taylor Foundation. This is a registered charity providing social, health and pastoral care services. This care home is registered to provide care and accommodation for eight adults with a learning disability. It is a threestorey semi-detached house located in a pleasant quiet residential street and just a short walk away from the busy shopping area of Streatham. The locality provides a variety of recreational and leisure facilities and is conveniently located for rail and bus links. The premises provide a pleasant and homely environment. Bedrooms are single occupancy. There is a large well-kept garden to the rear of the home. There is one vacancy at the home. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection.2005-06This unannounced inspection was undertaken over two days. On the first day the registered manager was unavailable so the inspector followed up with a short visit the following day. The inspection lasted for five hours overall. Two service users and three staff were spoken to as well as the registered manager. The inspector viewed two service users personnel files. An allocated social worker from the local authority was spoken to by telephone. A tour of the building was conducted with three bedrooms inspected. What the service does well: What has improved since the last inspection? What they could do better: The home continues to provide a high quality of care to service users. Areas for improvement could concentrate on developing services further for older people as one of the residents is of retirement age. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 6 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. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 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 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 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) 2 Service users assessed needs are understood and met by a skilled and experienced staff team EVIDENCE: The inspector found evidence that assessments had been completed for service users. Two service users spoke to the inspector. They said that staff understood their needs and that they enjoyed life at the home. Records of care planning as well delivery of care demonstrated that their assessed needs were met. One young lady has experienced serious medical problems recently. She had consulted with a neurologist regarding frequent seizures that had affected her mobility. As a result she experiences great difficulties with mobilising and is unable to use the bathroom upstairs. The registered manager had made referrals to the MDT and to the social worker about the changes. Risk assessments reflected the recent changes and the support required by staff. The home has made appropriate arrangements for the short term to met her needs safely. The inspector spoke to the social worker about the concerns. A suitable placement had been found before the issue of the draft report. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 9 Staff are experienced and have developed the skills and knowledge to meet the needs of people with learning disabilities. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 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 standard(s) 6 7 Care arrangements in place ensure that the current and changing needs of service users are assessed and met. EVIDENCE: Service user’s needs are assessed and reflected in written care plans. Two of these were examined. The information recorded reflected the service user’s needs, aspirations and goals. Changes to service user’s lifestyle and circumstances were also reflected on the records. On one of the care plans there were several recently updated risk assessments. These placed necessary restrictions on one service user to prevent falls on the stairs and also reduce the risk of staff sustaining injury.. The home is working on the new person centre planning recommended by the local authority. Two service users told the inspector that they were consulted on decisions that affect them. A written record was viewed of the management of individual finances. Receipts were available for all purchases Four service users attend activities independently outside the home. Two service users attending college returned to the home with the support of staff. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 11 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 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 standard(s) 11 12 17 Service users are valued and supported to lead fulfilling lifestyles. EVIDENCE: One service user was celebrating her birthday. She showed the inspector a number of gifts that she received from staff and service users. She spoke of how much she was looking forward to the evening celebration at a local restaurant. Staff and service users were invited and attending. Service users are valued and respected with celebrations for those with birthdays or achievements at college. Four service users attend college regularly. One service user has voluntary employment at a local charity shop. Two service users were observed preparing vegetables for supper on the first day of inspection. Menus were viewed of meals served 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 13 and of the meals planned. Two of the service users did not appear to contribute to the meal planning. A member of staff said that all service users were consulted regarding choice. It is recommended that service users are fully involved in meal planning. Service users help themselves to the contents of the fridge. This has caused difficulties in dating and labelling open items. A pate recently purchased was not labelled. Service users should be encouraged to label food items that are perishable. The mealtime was relaxed and family like with good exchange of conversation between service users. Service users took responsibility for washing up afterwards. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 14 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 20 Systems are in place that ensure the healthcare needs of service users are monitored and that any areas of concern are identified and responded to promptly. EVIDENCE: One service user requires support with personal careThe registered manager informed the inspector of the all the necessary actions that had been taken recently. Referrals have been made to appropriate professionals but no special equipment was identified to respond to her needs. Staff at the home were aware of the concerns for the service user and of the actions required to address these until an appropriate placement was found. Service users have allocated key workers. Two service users spoken to said that the workers “knew and understood what they did or did not like”. Interaction observed between service users and staff was positive. For a non verbal service user facial expressions and body language used was understood by staff. Service users are supported to access all NHS health care facilities as well as the GP facilities and specialist clinics. The home has worked on the Health 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 15 Action Plans for service users issued by the local authority. These plans are completed in conjunction with the local doctor and nurse. The healthcare needs of service users are monitored closely. Medical folders are held for service users. Both records viewed contained records of appointments and investigations ongoing at hospitals. There are clear medication policies and procedures. The dispensing pharmacist has been directly involved in checking the procedures. Staff at the home also complete these. No errors were observed on the MAR sheets. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 16 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 Service users are in safe hands with a staff team that is competent and committed. The views of service users are listened to and taken seriously. EVIDENCE: Discussions were held with two service users. Both said that staff were approachable and listened to their views. No complaints were recorded in the complaints log. The inspector saw written correspondence from the manager to the relatives of one service user. The manager spoke of the importance of keeping family informed of any changes in a service user’s condition and of the involvement of family in assisting with future decision making. Great efforts have been made in safeguarding service users from neglect, abuse or self harm and that particularly relates to individuals that cannot verbalise easily. A user-friendly workbook for service users where words such as bullying and complaint are demonstrated in an easily understood format and communicated by current service users to staff. Two members of staff spoken to were knowledgeable about Adult Protection Policies and Procedures. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 17 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 30 Service users live in a comfortable family style environment. Service users have personalised their bedrooms which are spacious and beautifully decorated. EVIDENCE: The premises are a semi-detached house with eight single bedrooms. It is beautifully maintained throughout and has a very homely feel. Several communal areas are available for service users. There is one well-furnished lounge as well as a conservatory and a dining room/kitchen. Two bedrooms were viewed. These had an abundance of natural light and were decorated brightly. Both service users that invited the inspector to view their bedrooms were proud of them and had many treasured items on display. They have both lived at the home for a number of years and said “that it has a family feel”. The home is unsuitable for more than one person with mobility difficulties. There are no bathrooms at ground level and there is no lift. There is one toilet located on the ground floor. The standard of hygiene is good at the home. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 18 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 19 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) 32 35 Service users benefit from a caring experienced and well trained staff team. EVIDENCE: During the day there are two support workers. At night there is one waking night worker. In response to the change in needs of one service user an additional staff member has been employed at night. The home has already fulfilled the 2005 qualification standard for staff as four of the five current care workers have NVQ level 2 or above. Two of the staff spoken to have worked with the service users for several years. They told the inspector that they know and understand the needs of individuals. They said they have learned from experience of the importance of encouraging and praising service users for achievements. The key worker for one service user was involved in supporting her with arrangements for the birthday celebrations. The service user told the inspector how well her key worker understood her. She gave examples of occasions when she experienced anxiety but on talking through events with her key person it had helped her to restore calm. The inspector observed the key worker take a great interest in her supporting role and praised the service user on her choice of new outfit. The young woman responded confidently by accepting gracefully the praise. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 20 Staff have received a range of mandatory training. Staff told the inspector of the refreshers received in health and safety, challenging behaviour and learning disability issues. As one service user is over retirement age it was recommended that staff receive training on diseases and conditions that affect older people. This recommendation has been restated. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 21 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) 38 42 Service users benefit from living in a home that is well managed. EVIDENCE: From discussions with two service users and two members of staff evidence was provided that the home was well run. Comments from both groups were that the management style was open and inclusive. Service users and staff feel valued and appreciated. The staff team has remained stable with retention figures high. Staff and service users were observed to communicate and interact easily with the manager. The manager was responsive in return. Regular meetings take place at the home with staff and management. Minutes of these were produced. The health and safety of service users and staff are promoted. The manager had notified CSCI as well as the social worker regarding the change in needs of a service user. Suitable temporary measures were in place. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 22 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 23 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 x 3 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 x x x 3 3 Standard No 31 32 33 34 35 36 Score x 3 x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 31 Woodbourne Avenue Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 3 x G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 24 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard 17 17 32 Good Practice Recommendations The registered person should ensure that service users are consulted on and fully involved in planning meals at the home The registered person should ensure that staff support and encourage service users to label food items The registered manager should ensure that staff receive training on issues and conditions that affect older people. 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 -EH 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 31 Woodbourne Avenue G52-G02 S22773 Woodbourne Ave V233890 140605 stage 4.doc Version 1.30 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!