Inspection on 20/02/07 for Woodbury

This inspection was carried out on 20th February 2007.

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

Woodbury 06/09/05

Woodbury 12/04/05

Woodbury 01/10/04

Woodbury 14/04/04

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 Woodbury Royal Borough of Kingston Community Care Services 8 Kingsdowne Road Surbiton Surrey KT6 6JZ Lead Inspector Michael Stapley Key Unannounced Inspection 20th February 2007 09:30 Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 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 Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 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. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodbury Address 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) Royal Borough of Kingston Community Care Services 8 Kingsdowne Road Surbiton Surrey KT6 6JZ 020 8390 9441 020 8399 7653 jane.wells@rbk.kingston.co.uk Royal Borough Of Kingston Upon Thames Jane Elizabeth Wells Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. A minimum of four staff must be on duty at any one time. A minimum of two members of staff, one waking and one sleeping, must be on duty at night times. At least two senior staff should be employed at Woodbury in addition to the designated senior responsible for managing Chamberlain Way. The Registered Manager is also registered to manage Chamberlain Way, a care home for 2 adults with learning disability. The organisation must ensure that the above minimum staffing levels remain under review and that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health and welfare of service users. 6th September 2005 Date of last inspection Brief Description of the Service: Woodbury is a service for adults who have a learning disability. It forms the focal point of the Woodbury Community Housing Project. The property itself offers both long and short stay residential care. The service is managed and owned by the Royal Borough of Kingston. The home is a large detached property in a residential area in Surbiton. Accommodation is provided over three floors. There is a large rear garden and parts of the building benefit from views of the local area. The building is decorated tastefully and in keeping with the service users wishes and tastes. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. • This home was inspected under the National Minimum Standards Care Homes for Younger Adults. The inspection took place over one day on 20th February 2007 The registered manager, Ms Jane Wells was present throughout the inspection. The inspector also spoke to a number of support workers and service user’s during the course of the inspection. Records examined included service user plans; care manager needs assessments and risk assessments, medication records, complaints, staffing records, health and safety and fire records. All of the requirements from the two inspections during 2005/06 and the one requirement made at a recent ‘random’ inspection have been complied with within laid down timescales and there were no requirements made at this inspection. Overall the home continues to provide a high standard of care. • • • • What the service does well: • The staff team are able to critically evaluate the service and look at areas that can be improved through the homes “action for quality initiative” The ethos of the initiative is to create opportunities for discussion, changes to practice and cross fertilisation of ideas. Action for Quality includes questionnaires and audits for service user’s and staff (to be extended to other stakeholders) and an organisational health checklist. Questionnaires are designed to facilitate open and honest feedback. Through this ongoing live process the team at DS0000034367.V330743.R01.S.doc Version 5.2 Page 6 • Woodbury Woodbury are able to reflect and focus upon choices and outcomes. The development of Action for Quality will drive a person centred model of service delivery. • The staff team at the home are also examining equality issues specific to the homes service area in line with the Council’s duty under antidiscriminatory legislation, the home will seek to ensure that it will incorporate equality issues into its every day work. Training and development continues to support good standards of professional knowledge, LDAF induction has been completed by all new staff. NVQ Level 3 Promoting Independence is an ongoing rolling programme offered and undertaken by all staff who have completed LDAF induction. NVQ Assessor training is also being undertaken by all senior staff. The support and investment into training is exceptional in this Borough, there is also opportunity to undertake professional social work qualification. The service has been able to provide information and support plans in accessible formats which are comprehensive and well considered - these plans have also been replicated in other services within the Royal Borough of Kingston including voluntary organisations. Woodbury maintains very good professional links with the wider organisation, carers, health care specialists, befrienders, buddies and advocates. • • What has improved since the last inspection? • • RECRUITMENT – new permanent staff have been successfully recruited, reducing the need for temporary staff. ENVIRONMENT – new laundry equipment in line with appropriate infection control measures has been installed. The equipment will ensure that C-DIFF and MRSA are not present in linen and laundry. The laundry system ensures safety in this area whilst being able to wash clothes on lower temperatures efficiently. OFFICE MOVE – The office space has been relocated to the top floor thus giving the service users more privacy and affording a more homely environment. The Duty office is now on the ground floor making it possible for all service users to now access it. ARCHITECTS PLANS – plans have been completed for an extension to the building on the ground floor to provide a larger dining area. A DS0000034367.V330743.R01.S.doc Version 5.2 Page 7 • • Woodbury feasibility study with costings has also been undertaken for the provision of a lift to all floors. This has been passed by fire inspection. • ACTION FOR QUALITY – following the launch of Action for Quality the service have achieved ◊better menu choices ◊smaller groups on service user holidays ◊more choices on social activities in the community with new venues identified ◊revised transport arrangements ◊revised service user grouping managing two groups by team leaders to increase focus on individual needs and wishes. ◊risk assessments updated and are now more comprehensive ◊rolling programme for person centred plans to include all service users ◊better partnership working with day centre staff as part of the day centre modernisation agenda that will directly benefit the service user at the home and increase the scope of activities undertaken. What they could do better: • The service need to look at how they communicate information gathered at service user reviews and how it is fed back to the rest of the team to ensure that all are aware of changing goals and objectives. The service will endeavour to look at individuals morning routines and see how much of this is choice orientated as opposed to service dictated. • Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 8 • • The service will look more closely at equality issues reflecting on both home life and community access. The service is planning to develop closer working links with non disabled services in the wider community i.e. Devon Way (Community Centre for over 55’s), local recreation and leisure centres. 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. The summary of this inspection report can be made available in other formats on request. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 9 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 Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good information and introduction opportunities for prospective service users, their families and representatives to make an informed choice about moving to the home. Service users are only admitted to the home following a full assessment that ensures the home can meet the needs of any service user residing at the home. EVIDENCE: Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 11 The home has a Service User Guide that contains all elements of Standard 1.2 it provides clear and accessible information in a written and pictorial format. Service users are consulted about the Service User Guide when any changes or amendments are made to it. Staff spoken to demonstrated a good understanding of the needs and abilities of service users who live in, or may wish to live in the home. Individual records are kept for each service user. Full assessment information was available for the most recent service user to move into the home. This had been obtained from the Community Learning Disability Team. The manager advised the inspector that staff at the home liaise with the Care Manager of each new service user, prior to them moving into the home. This is to ensure that the home is able to fully meet service user’s needs. In discussion with the manager and staff it was evident that assessment is on going and is seen as very much part of the care plan. Personal Care plans are based on the home’s individual system which is an in depth assessment of all aspects of service users personal care, social, recreational and emotional needs. The home carries out regular reviews where information is up dated and care plans changed as appropriate. There are also yearly reviews carried out with the service users, their families and other professionals as appropriate. The manager advised that all service users have access to an advocate. Contracts inspected contained all the information as required under standard 5.2; thus ensuring service user’s rights. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 12 Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to make decisions about their own lives and to express their views and preferences, this enables them to achieve independence. Confidentiality is respected; therefore service users know that their best interests are protected. Service users are also supported to take ‘responsible’ risks and precautionary measures are in place to, so far as reasonable practicable, minimise any identified risks and/or hazards. Suitable arrangements have been set up to ensure the service users can participate in all aspects of life in the home. Staff members are skilled in helping service users to express their views and preferences, in addition to helping them make decisions about their own lives. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 14 EVIDENCE: Care plans examined had been generated from Care Management needs assessments. Plans included information about the service user’s individual personal, social and health care needs. Records detailed that care plans had been reviewed regularly, and updated to reflect changing needs. Key workers are responsible for the updating of care plans. Staff spoken to informed the inspector that they consulted with service users when care plans are changed. Care plans examined had been produced in written and pictorial formats. Photographs were also included. Minutes of a recent service user’s meeting were available. These detailed that service users had been consulted about a number of aspects of life in the home, including food and activities. Support Plans and details about how to make a complaint are provided in a clear accessible format. Service users are offered opportunities to participate in the day-to-day running of the home both on an informal basis, and in service user’s meetings. The minutes of the most recent meeting were examined and these detailed that service users had been involved in choosing menus, holidays and activities. Service users are supported to take reasonable risks in order for them to develop and maintain independent lifestyles. Risk assessments on all service users were found to be up to date and the inspector noted there was a comprehensive risk assessment checklist. These had been discussed with the service user and their care manager and had been incorporated in care plans. There were ‘moving and handling’ care plans that included details of ‘transfers’ There were also instructions for staff on ‘hoisting’ service users. The manager advised that service users would be assessed as to how many staff would be needed to use the hoist on an individual basis. The home has a policies and procedures regarding confidentiality. Staff spoken to was clear about their responsibilities in relation to confidentiality. Records in relation to service users were found to be accurate and stored securely at the time of this inspection. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 16 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The opportunities the service users have to engage in social, leisure and recreational activities, both at home and in the wider community, appear to be varied and stimulating. Service users are enabled to maintain fulfilling lifestyles outside of the home and to engage in leisure activities. Service users maintain family relationships. The home provides meals that are varied and enjoyable. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 17 EVIDENCE: The majority of service users were attending day centres at the time of this inspection. One service user was involved in a ‘home day’. Home days involve individual service users spending one-to-one time with a staff member and engaging in activities such as shopping, going for a meal, or completing washing or the upkeep of their bedroom. Another two service users were spending the day in the home and were observed to spend time in the communal lounge watching television and chatting with staff members. Staff members spoken with said that service users are involved in a variety of activities and most have active social lives. Group and individual trips occur. There are music facilities, a TV and video in the communal lounge and a number of service users also have these facilities in their bedrooms. Service users also have access to a large garden. There have been three holidays last summer including trips to Centre Parks., Butlins and Disneyland. Service users were observed to enjoy freedom of movement within the home and restrictions about going outside were recorded in care plans. Staff members knock before entering service user’s bedrooms and bathroom doors have locks with an override device. The preferred form of address for service users was recorded in personal files examined. The majority of service users were eating lunch at day centres at the time of this inspection. Other service users were provided with a healthy and wellpresented meal. A staff member said that menus are based on the likes and dislikes of service users and there were records detailing that service users have been consulted about what should be on the menu. Dietary needs are well catered for, nutritionally balanced, and clearly based on personal preferences and choice. The registered manager advised the inspector that the home had recently introduced a pictorial chart for service users to indicate ‘Food I like’ and ‘Food I don’t like’. These cards are particularly useful for bank staff as they clearly indicate what service like to eat. Records are kept of food actually eaten to ensure that service users have a healthy and balanced diet. The home has a chef from Monday to Friday who has a basic food hygiene certificate. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 18 There were ample stocks of fresh fruit, salad and vegetables stored in the kitchen. Food taken out of its original packaging was correctly stored and labelled in accordance with basic food hygiene standards. One service user’s care plan detailed that cultural meals would be provided. There is a pleasant dining area although meals are currently served in two sittings. The Registered Manager said that this arrangement meets the current requirements of service users. It was recommended at the last inspection that consideration be given to increasing the size of the dining room so as to allow service users to eat together if this is their wish. This recommendation is currently under consideration and is repeated following this inspection. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements are in place to ensure that the physical and emotional health care needs of service users are identified, planned for and met. Residents’ medication is well managed to ensure good health. EVIDENCE: Individual plans of care are available. These provide detailed information about service users preferences about how they are guided and supported. Support Plans aid staff members to provide consistency and continuity of support by detailing preferred routines, likes and dislikes. Preferred times for getting up and going to bed are recorded. Staff spoken to advised the inspector that these times are flexible. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 20 Health records are maintained for each service user. One record examined detailed that the service user had access to routine health checks and specialist health care. Significant events and accidents are recorded and monitored. Case records are maintained and entries detail that staff members monitor service user’s health. A requirement was made at the last inspection that “The Registered Provider must ensure that all medicines received, administered and leaving the home or disposed of are recorded to ensure that there is no mishandling” This requirement has now been met as the registered manager has introduced a monthly medication form to monitor all aspects of medication as suggested by the inspector. In addition medication is checked at each staff handover. The last pharmacy inspection was on 19th February although the report was not available for inspection. Detailed records are kept of all health care appointments attended by service users. One service user’s personal records detailed visits from the GP, psychiatric nurse and dentist. All newly appointed staff complete the Skills for Care programme of induction. These include the six common induction standards. They cover the principles of dignity, privacy and promoting independence. Care plans examined detailed service user’s preferences about how they should be supported by staff members and how personal support should be provided. Service users use a number of technical aids and equipment. A professional assessment was noted to be in place regarding a hoist used by one service user. Consistency and continuity of care is provided by the use of key workers and by detailing individual preferences in care plans. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a system in place for the effective handling of complaints and service users and their relatives are encouraged to raise any concerns they have. Service users therefore know that their concerns will be acted upon. Arrangements are in place for handling allegations and instances of abuse. This ensures that service users will be protected from harm. EVIDENCE: There had been no complaints about the home since the last key inspection. Evidence was noted that issues regarding complaints are being effectively managed. Complaints are monitored by a senior member of staff and are inspected on a monthly basis during the course of Regulation 26 visits. The complaints procedure is detailed in the Service Users Guide. It is in plain English and in pictorial form. Signs and symbols are used for ease of reference and there are telephone numbers of agencies, including the commission that service users may contact in the event of a complaint. Minutes of service user meetings held in the home detailed that staff members have explained to service users how they can make a complaint. In addition to the home’s complaints procedure, service users and their family members are provided with information about how to make a complaint directly to the Royal Borough of Kingston upon Thames. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 22 There had been one Adult Protection Investigation since the last key inspection. This was thoroughly investigated and managed effectively within local authority guidelines and legislation. All notifications made under regulation 37 had been appropriately recorded at the time of the inspection. All staff at the home has undertaken Adult Protection training and has a clear understanding of the underpinning procedures. There are policies and procedures in place in relation to service user’s money and financial affairs. Service user’s money is largely dealt with via the Royal Borough of Kingston upon Thames finance department. Some money is handled on behalf of service users, in the home. A safe is available for the safe storage of money, and records of all transactions are maintained. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The size and layout of the home, which is furnished and decorated to a good standard, ensures the service users live in a comfortable, clean and homely environment. EVIDENCE: The home is situated on a residential road in Surbiton. Accommodation is provided over three floors. There are staircases leading to the upper floors. There is no lift at present although this is currently under consideration. There is a very large, well kept garden to the rear of the home. The home is in keeping with premises in the local area. The premises were found to be safe and comfortable and to provide suitable lighting, heat and ventilation. Staff members have clearly made good efforts to ensure that the home is bright and cheerful. Some service users have access to all areas of the home; however, Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 24 those in wheelchairs have access only to the ground floor. There is a planned programme of maintenance and renewal. Bathrooms and toilets provide sufficient privacy and are close to communal areas and private rooms. Toilets and bathrooms are lockable, but can be opened with an override devise in an emergency. Bedrooms viewed provided sufficient and suitable furniture. There were restrictors on windows. All areas of the home were clean, hygienic and free from offensive odours. Cleaners are employed in the home on a daily basis. Laundry facilities are adequate, and situated away from the kitchen. All relevant policies and procedures are in place regarding the control of infection. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitably experienced staff members are employed in sufficient numbers to meet the health and welfare needs of the service users. Staff members receive support and guidance which ensures that they are able to provide good support to service users. EVIDENCE: Staffing levels, evidenced in staff rotas, and in numbers on shift at the time of this inspection were found to be appropriate and safe, in accordance with the care and social needs of the service users. Three new staff members have been recruited following a successful recruitment campaign, and one agency member of staff is in the process of transferring to the permanent staff. Staffing at the home now consists mainly of permanent staff although there is one job share vacancy at present. The staff team, in general reflects the cultural and gender composition of current service users. The staff members on duty at the time of this inspection were all observed interacting with the service users in a caring and respectful manner. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 26 Staff spoken to confirmed that the home’s policies and procedures are discussed at team meetings, along with staff’s key working responsibilities. The home has a training and development plan which is updated annually. Staff have the opportunity to undertake NVQ level 2 and 3 following completion of their induction programme. Two staff are currently completing the A1 assessor’s course and the registered manager advised the inspector that staff have the opportunity to undertake professional social work training. Staff members spoken to confirmed that staff training is on going. All staff members receive a structured induction programme. As stated earlier in this report the induction programme has been revised. The ‘skills for care’ programme of induction is comprehensive and staff usually commence this on their first day of employment. The programme of induction includes topics such as Confidentiality, Whistle Blowing, Safe Working Practice and Recording. Staff spoken during the course of the two inspections for 2006/07 confirmed that they receive good support and guidance from management and other, more experienced staff members. It was evident that newly appointed staff were not expected to carryout care tasks until they were fully trained to do so. Staff members confirmed that they received formal supervision. Records are maintained of supervision sessions. Yearly appraisals also occur as evidenced during the course of this inspection. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 27 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is suitably experienced and competent to carry out her duties effectively and the service user’s benefit from her open and inclusive style of management. Staff members follow safe working practices in the home, which ensure that the health, safety and welfare of service users are promoted and protected. EVIDENCE: The Registered Manager has been in operational day-to-day control of the home for a number of years. She has many years experience in social care Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 28 and prior to being manager, worked in the home as a care worker and in senior posts. She is suitably qualified to run the home and to meet its stated aims and objectives. There are clear lines of accountability within the Royal Borough of Kingston upon Thames and the Registered Manager stated that her line manager is always on hand to offer advice and support as and when required. Unannounced visits to the home continue to be undertaken by the senior management of the local authority in accordance with the Care Homes Regulations (2001). Minutes of staff and service users meetings detail that staff members and service user are encouraged to be creative, innovative and involved in changes in the home. Staff members and service users were observed to share positive relationships with the Registered Manager. There is a detailed risk assessment in relation to fire and records indicate that the fire alarm, fire equipment and emergency lighting are tested on a regular basis. Staff members report that regular fire drills occur and there were records to confirm this. The last fire drill took place on 19th February 2007. Documentation was in place detailing that up to date safety checks have been made on the gas, electricity and the water system. Certificates were available for hoist and wheelchair checks. Staff members confirmed that they carry out monthly health, maintenance and safety checks of the premises. Records of these were examined. As part of the inspection process. Records of accidents and injuries were available, as were individual risk assessments for service users. The system for consultation with service users, families, stakeholders and other interested parties is positive. The quality assurance system includes a programme of ‘Action for Quality’ This comprises of Institutional Questionnaires, Service User Questionnaires and an Organizational Health Check. When all the results are collated the registered manager advised that ‘Outcomes’ would be drawn up for the benefit of service users. The home is shortly to complete a survey for care managers, families and other stakeholders. The home will need to collate the results of these surveys and ensure the outcomes of the surveys are addressed and acted on for the benefit and wellbeing of the service users at the home. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 29 Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 30 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? NO 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 YA24 YA29 Good Practice Recommendations The Registered Provider should give consideration to the size of the dining area in order to allow all service users to dine together if this is their wish. The registered provider should consider installing a lift in the home so allow those service users in wheel chairs unrestricted access to the home. Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Woodbury DS0000034367.V330743.R01.S.doc Version 5.2 Page 33 - 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. 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