Inspection on 06/09/05 for Woodbury

This inspection was carried out on 6th September 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

Woodbury 20/02/07

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 Community Care Services 8 Kingsdowne Road Surbiton, Surrey KT6 6JZ Lead Inspector Diane Thackrah Unannounced 6 September 2005 th 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. Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodbury Address Royal Borough Of Kingston, Community Care Services, 8 Kingsdowne Road, Surbiton, Surrey KT6 6JZ 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 83909441 020 83997653 @rbk.kingston.gov.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 G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 12 April 2005. Brief Description of the Service: Woodbury is a service for adults who have a learning disability. It forms the forcal point of the Woodbury Community Housing Project. The property itself offers both long and short stay residentail 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 G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on 6th September 2005 between 11.25 and 14.30. A partial tour of the premises took place. Care records were examined. The Registered Manager, one service user and three staff members were spoken with. Four service users were present during the inspection. What the service does well: What has improved since the last inspection? One Requirement was made following the last inspection of the home. Whilst this issue was not addressed within agreed timescales, the Requirement was found to have been met at this inspection. Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 6 There have been good efforts to recruit permanent staff members in recognition that service users will benefit from continuity in care from staff members they know. The home is now largely staff by a permanent staff team. 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. Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 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 Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 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) None of these Standards were examined during this inspection. EVIDENCE: Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 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 standard(s) 6, 8, 9 and 10. 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 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. One staff member said that they consulted with service users when care plans are changed. Care plans examined had been produced in written and pictorial formats. Photographs Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 10 were also included. The home is currently in the process of devising new formats for care planning, with a view to assisting service users to be involved further in the care planning process. Progress on this matter will be assessed at the next inspection. 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. There were records detailing that service users are currently being consulted about their views on new meals being served. Service users are supported to take reasonable risks in order for them to develop and maintain independent lifestyles. Risk assessments were documented in the personal files examined. These had been discussed with the service user and their care manager and had been incorporated in care plans. One service user has been diagnosed as having epilepsy. An assessment of the risks associated with this individual having a seizure, including the action to be taken by staff in the event has been undertaken. The home has a policies and procedures regarding confidentiality. One staff member spoken with 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 G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 11 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) 12, 14, 16 and 17. 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. Dietary needs are well catered for, nutritionally balanced, and clearly based on personal preferences and choice. EVIDENCE: The majority of service users were attending day centres at the time of this inspection. Two service users were involved in ‘home days’. 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 Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 12 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 planned for this year including trips to Centre Parks and Middleton on Sea. 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 users 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. Two service users were going out for lunch. Other service users were provided with a healthy and well-presented 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. 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 and new furniture for this room was being planned for at the time of this inspection. Meals are currently served in two sittings. The Registered Manager said that this arrangement meets the current requirements of service users. It is recommended however, that consideration be given to increasing the space in the dining area so as to allow service users to eat together if this is their wish. Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 13 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 and 19. Suitable arrangements are in place to ensure that the physical and emotional health care needs of service users are identified, planned for and met. EVIDENCE: A new employee was spoken with and they confirmed that they were undergoing an induction programme that covered 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. One service user was still in bed at the time of this inspection and a staff member reported that this was the service users choice. 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. A spech and language specialist was visiting one service user at the time of this inspection. Consistency and continuity of care is provided by the use of key workers and by detailing individual preferences in care plans. 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. Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 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 standard(s) 22 and 23. 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: The home has a detailed complaints procedure. A pictorial format of this procedure has been developed and provided to service users. The Registered Manager said that no complaints have been made to the home since the last inspection. Minutes of recent 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. The home has comprehensive policies and procedures for responding to allegations or suspicions of abuse. The Registered Manager said that no such incidents have been reported since the last inspection. Written protocols are also in place for dealing with verbal and physical aggression. Staff members spoken with said that training in adult abuse is provided. One staff member said that they were currently undertaking NVQ Level 3 in Care training, and that part of this training covers the protection of vulnerable adults. A newly appointed staff member said that they had received information about adult abuse and the homes whistle blowing policy on the first day of their employment in the home. Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 15 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 G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 16 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, 27 and 30. 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. There is a very large, well kept garden to the rear of the home. The home is in keeping with premised 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, those in wheelchairs have access only to the ground floor. There is a planned maintenance and renew programme. All the dining room furniture is scheduled to be replaced. Bathrooms and toilets provide sufficient privacy and are close to communal areas and private rooms. One bathroom had a sink with exposed pipes at the time of the last inspection and a Requirement was made that these must be Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 17 covered in the interests of safety. These pipes had been partly covered at the time of this inspection. The Registered Manager reported that this was a mistake on the part of the company contracted to cover the pipes. These pipes had been boxed in adequately by the end of this inspection. Toilets and bathrooms are lockable, but can be opened with an override devise in an emergency. 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 G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 18 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) 33, 35 and 36. 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 a Permanente staff team now largely staffs the home. 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. One member of staff said that the home’s policies and procedures are discussed at team meetings, along with staff’s key working responsibilities. A training and development plan for the home has recently been updated. One staff member said that they were currently undertaking training at NVQ Level 3 in Care. Other staff members reported that staff training has been on going. Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 19 All staff members receive a structured induction programme. A revised induction programme has been developed and a new member of staff said that they were receiving a comprehensive induction, which had begun on their first day of employment. This staff member confirmed that their induction had so far covered Confidentiality, Whistle Blowing, Safe Working Practice and Recording. This staff member also confirmed that they had received good support and guidance from management and other, more experienced staff members since commencing post and it was clear that they 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. Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 20 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) 37 and 38. The Registered Manager is suitably experienced and competent to carry out her duties effectively and the service users benefit from her open and inclusive style of management. 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 and prior to being manager, worked in the home has a care worker and in senior posts. She is suitably qualified to run the home and to meet it’s 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 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 Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 21 in the home. Staff members and service users were observed to share positive relationships with the Registered Manager. Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 22 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 x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 x 3 x 3 x 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodbury Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x x x G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 23 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. Refer to Standard 17 Good Practice Recommendations The Registered Provider should give consideration to increasing the size of the dining area in order to allow all service users to dine together if this is their wish. Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 24 Commission for Social Care Inspection CSCI 8th Floor Grosvenor House 125 High Street, Croydon CR0 9XP 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 Woodbury G53-G53 S34367 Woodbury V213757 050905 stage 0.doc Version 1.40 Page 25 - 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!