Inspection on 06/12/05 for Woodbourne Avenue, 31

This inspection was carried out on 6th December 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 14/06/05

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 Woodbourne Avenue, 31 Streatham London SW16 1UP Lead Inspector Mary Magee Unannounced Inspection 6th December 2005 15:00 Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 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 Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 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. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodbourne Avenue, 31 Address Streatham London SW16 1UP 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) 020 8769 1865 0208 769 1865 The Frances Taylor Foundation Sister Mary Hogan Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (0) of places Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. to include one service user aged 65 years or above Date of last inspection 14th June 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. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken in the afternoon. It lasted over three hours. The manager and two members of staff were present. All five service users met with the inspector, their comments are included in the report. A selection of service user records was viewed as well as maintenance records for the premises. The inspector conducted a tour of the premises, all the communal areas as well as three bedrooms were viewed. 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. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 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 Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 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): 1235 A caring supportive environment is fostered at the home. People are valued and included in all aspects of the home. EVIDENCE: The home has developed a service users’ guide and a statement of purpose. It gives a good description of what is available to anyone requiring information about the home and the range of services offered. No new service users have been recently admitted. The service user group have all lived together for some time. The majority lived together at a large establishment for some years before relocating to this smaller home. Service users feel valued and well cared for. Five service users were spoken to They spoke of the fulfilling lifestyle offered and of how well staff understood their needs and aspirations. Service users spoke of the caring ethos fostered by staff and of the benefits they got from living in a mutually supportive environment. Some of these pleasant practices were seen in the way service users offered hot drinks as service users returned from college. They discussed freely their plans for the festive period and considered those that were not due to visit relatives. Service users have dependent a variety of skills to enable them to be independent. Service users have been enabled to develop at their own pace. In the past six months a service user’s physical condition deteriorated to the point where the home was no longer suitable and able to meet her needs. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 8 Appropriate referrals were made to professionals to find suitable accommodation. Relatives were also involved in the consultation process. The manager also supported the service user to visit homes that were better equipped to meet the needs of those with physical disabilities. The home fosters a spirit of inclusiveness. There is a strong bond between all service users; many have lived in the same establishment for numerous years. All five service users spoken with said how much they were looking forward to the festivities at Christmas. Contact has been maintained with a former service user, staff have supported service users to visit a former service user at her new home. Contracts are developed with service users. Some of the information regarding charges and costs is not accurate and should be updated. Examples of this are the holiday contributions made by service users. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 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): 6789 The arrangements for delivering care and support are set clearly out in care plans. Service users have allocated key workers that are knowledgeable and committed and know how to meet individual needs. EVIDENCE: Service users’ care plans are person centred and reflected the service user’s needs, aspirations and goals. Any changes that arise in service user’s lifestyle and circumstances are recorded. In addition to care and support plans individual books are held for service users. These are used as daily diaries for individuals to record all notable events and give a good indication of the services provided from other bodies such as hospitals and colleges. Risk assessments are kept up to date for service users. These indicated that risks were assessed and that necessary actions were taken to minimise risks without imposing too many restrictions. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 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): 13 14 16 17 Service users enjoy having responsibilities in their lives and the opportunities to lead fulfilling lifestyles. EVIDENCE: Service users are very much part of the local community. They are close to the main shopping area and frequent shops and restaurants nearby. At weekends the majority of service users like to worship and attend weekly mass at the local Catholic Church. Four service users attend college regularly. One service user has voluntary employment at a local charity shop. Service users that were not attending college were involved in the preparation of evening supper. After the meal another service user was busy washing up. She said “service users enjoyed doing tasks and took turns with housekeeping chores in the kitchen”. She spoke of how much she as well other service users enjoyed taking responsibilities in the home. All service users were spoken to. Feedback was that the home had given all service users an opportunity to grow and develop as individuals. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 11 A service user also showed her college reports to the inspector. It demonstrated that that the individual was supported and encouraged by staff to pursue what she enjoyed. Staff at the home retain an important role in and attend open evenings at the college. Service users are encouraged to build and develop friendships and to invite friends to the home. Service users or staff do not enter another’s bedroom unless they are invited to enter by the occupant. There is a strong sense of belonging evident. Service users have lived together for some time and consider the needs of fellow service users. The caring ethos is fostered throughout with the welfare of all service users paramount. A service user with deteriorating health moved recently to another home. Members of staff have supported service users to sustain the links by visiting her when possible. Mealtimes are pleasurable and relaxed. The majority of meals are prepared from basic ingredients. Service users are involved in deciding what meals are served. New menus are planned each week. Due to small numbers last minute changes to meal times can be easily accommodated. Service users are fully involved and assist with the weekly shopping at the local supermarket. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 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 the following standard(s): 18 19 21 Service users receive personal support that is good, flexible and reliable and that responds promptly to their changing needs. The systems in place to monitor the emotional and physical healthcare needs of service users are reliable. EVIDENCE: Service users are supported to manage their personal care by staff of the same gender. Each service user has an allocated key worker. Two service users spoken to said that the workers “knew and understood their ways”. Interaction observed between service users and staff was positive. The home has ensured that the healthcare needs of service users are met by the implementing of suitable systems. Health action plans suggested by the local authority have been completed. Records views showed that that service users were supported to attend appointments with doctors and consultants as well as attend well woman clinics. The conditions of service users are closely monitored. Potential complications or problems in emotional or physical health are identified early and prompt referrals are made to appropriate specialists. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 13 Service users are treated with dignity and respect. One service user is of retirement age and wishes to remain at the home and be with the people she is familiar with. Consultation should take place to decide on plans to meet her needs if the service user agrees. The home is meeting the needs of all service users but they need to ensure that the ageing of service users be given more consideration. It is recommended that staff receive training on looking after older people. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Service users benefit from a staff team that are reliable and consistent and that are knowledgeable on procedures to safeguard people from abuse or neglect. EVIDENCE: Service users are confident and continue to develop self-esteem. The approach of staff enables service users to grow and develop as individuals. The service is very much service user driven. Views of service users are listened to carefully and taken on board. Service users said that they felt free to express their opinions openly and found all staff approachable. Two service users spoken to said that “ the staff were reliable and that did everything in the best interest of those living at the home”. The organisation promotes and encourages developments that safeguard service users from neglect, abuse or self-harm. An example of this work relates to books used for individuals that cannot verbalise easily. A user-friendly workbook is used; words such as bullying and complaint are demonstrated in an easily understood format and are easily communicated by service users to staff. All the staff team had received training the previous month on the protection of vulnerable adults. Service users hold individual bank accounts. Interest is paid on these accounts. The registered manager is the appointee for service users. Records of financial transactions were viewed. Small quantities of money are withdrawn and held at the home in a safe to allow service users ease of access. Signatures are retained for all financial transactions that occur. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 27 30 Service users are offered a comfortable family style environment that is beautifully maintained. Service users have single bedrooms that are spacious and extremely well decorated. EVIDENCE: The premises are a semi-detached house with eight single bedrooms. Three of these have been vacant for some time. Three bedrooms were viewed. The house is beautifully maintained throughout and has a very homely feel. Several communal areas are available. There is a spacious well-furnished lounge as well as a conservatory and a dining room/kitchen. Redecoration takes place regularly and as needed. A handyman is employed by the organisation to complete all the light maintenance work. Service users were happy as he had set up the Christmas decorations. The home appeared very festive. Attention is given to maintaining a high standard of hygiene at the home. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35 36 The home has a stable and experienced staff team that are supervised and supported. They have the necessary skills and attributes and receive ongoing training appropriate to their role. EVIDENCE: The staff team has experienced little change in staffing personnel. No new members of staff have been appointed for some time. Service users spoke of the confidence that they had developed in the staff team. It was also evident from the rapport and interaction between service users and members of staff that service users were secure in the knowledge that staff knew how to support them. One service user spoke about her allocated key worker, she said, “the lady allocated to her care was special and so kind”. Feedback received from all service users indicated that the home had good support mechanisms in place. Service users found the staff team to be supportive and encouraging. Instances were quoted by a number of those spoken to of the success achieved by individuals due to the praise and encouragement from staff. A clear message was received from service users that staff had all the necessary qualities and attributes, they are good listeners approachable and sympathetic, also that staff quickly recognise when a service user is unhappy. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 17 Five full time and four bank support staff are employed at the home. The manager discussed the progress in terms of training. All members of staff have achieved a minimum NVQ Level 2 in care. The organisation has a training and development programme for the staff team and a dedicated budget to achieve this. The home has an induction and foundation training programme that meets Sector Skills Councils specifications. Records of training given included evidence that mandatory training was provided to the staff team. Future training planned for staff included the needs of the learning disabled, as well as teamwork. It was also acknowledged that individual staff members had requested specific training and that the plans had been made to respond to these requests. At the previous inspection it was identified that staff require training on meeting the needs of older people. The manager had requested training in this field and was awaiting confirmation of the programme. It is restated as a recommendation. There have been no changes to staffing personnel for the past two years. Personnel files relating to these staff were viewed at a previous inspection and found to be thorough. Regular monthly group meetings are held for the staff team. Staff receive regular one to one supervision. Rotas showed that there are always appropriate numbers of suitably trained staff on duty at all times. During the day there is a minimum of two support workers, at night there is one sleeping night staff available. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 41 42 Service users enjoy living in a home that is run in their best interests. An open caring inclusive approach is fostered. This practice leaves service users and members of staff feeling valued and appreciated. EVIDENCE: The registered manager has been employed by the organisation for a number of years. The majority of service users knew her when they lived at another home. She has supported and provided stability to them through times of great change. She is well regarded by service users and staff. Her dedication and commitment has given strong leadership as well as stability. The organisation has developed a quality assurance system for the home to measure how successful the home is in achieving its aims and objectives. The organisation has recently updated the policies and procedures for the home. Record keeping is of a high standard. Individual records are held securely. The office on the ground floor is also the sleepover room. There are plans to use a vacant room upstairs as an office in the future. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 19 A selection of maintenance records was examined. The following were found to be in order, a current gas certificate for the heating and hot water system was available, and the chlorination of water had recently taken place. All fire fighting equipment had been serviced in the previous month, these included fire extinguishers and fire alarms. Regular fire drills are conducted at the home. Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 x 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 4 4 x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 3 14 3 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodbourne Avenue, 31 Score 3 3 x 3 Standard No 37 38 39 40 41 42 43 Score 4 x 3 x 3 3 x DS0000022773.V271762.R01.S.doc Version 5.0 Page 21 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. 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 Refer to Standard YA5 YA21 Good Practice Recommendations The registered person should ensure that the information available in the contracts issued is updated and includes costs and charges and the services not covered by fees. The registered person should ensure that the needs of older service users are considered, consultation to take place with service users and outcomes to be reflected in planning for growing older. The registered manager should ensure that staff receive training on issues and conditions that affect older people. 3 YA32 Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Woodbourne Avenue, 31 DS0000022773.V271762.R01.S.doc Version 5.0 Page 23 - 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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