CARE HOME ADULTS 18-65
Woodcote Grove Road (100) 100 Woodcote Grove Road Coulsdon Surrey CR5 2AF Lead Inspector
James Pitts Unannounced Inspection 10th February 2009 11:58 Woodcote Grove Road (100) DS0000065438.V373615.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 Woodcote Grove Road (100) DS0000065438.V373615.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. Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Woodcote Grove Road (100) Address 100 Woodcote Grove Road Coulsdon Surrey CR5 2AF 020 8763 4256 020 8763 4257 NO EMAIL 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) CareTech Community Services (No.2) Ltd Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 8 18th February 2008 Date of last inspection Brief Description of the Service: Woodcote Grove Road (100) was registered in October 2003. The home offers eight single bedrooms; two of which are in flatlets in the home, there are two bedrooms with en-suite bathrooms. There are two bathrooms with toilets upstairs and one bathroom with a toilet downstairs. The home is registered to provide support to eight people with learning disabilities. Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means people who use this service experience good quality outcomes. Some of the people who use this service are not able to hold lengthy vocal conversations but all can make at least some of their needs known in other ways. Three of the people who live here and three members of the staff team, and the manager were present during the course of this inspection. This inspection involved a visit to the service, discussions with staff, one service user, and observation of interactions with other people who use the service and examination of specific records. Other information we may have received was also considered, for example social care professionals, contact with relatives, meetings attended by the Commission and other information received. Questionnaires were sent to us by four of the people who live here and each of their responses showed a high degree of trust and satisfaction with the service that is provided. What the service does well: What has improved since the last inspection? What they could do better:
For the two staff that were transferred to work for Caretech from another company that was purchased by this organisation it would be advisable to carry out renewed CRB checks for each of these people. Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Standards 1 & 2 were assessed at this inspection visit. The people who use this service, and others, are told what the home does and how it will do it. The people who use this service can continue to feel confident that the home will only care for people that the staff are trained and able to care for. EVIDENCE: The home’s statement of purpose was most recently updated in November 2008. A copy of this is readily available and a copy is also kept of the personal case record of each of the people who live here. The newly appointed manager, who was formally the deputy manager, has commenced work to update the service user guide using a picture and word format the more clearly reflects this service, its facilities and the people who provide the support. The work thus far carried out shows that once it is completed it should be a useful and relevant addition to the information that is currently provided. One person has left the home since the previous key standards inspection in February 2008. This person moved to a more appropriate placement nearer to their family. Two people moved into the service from another home that
Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 9 required extensive repair to the building. Although it is meant to be only until their original care home is refurbished it seems possible that these people may wish to remain at Woodcote permanently. It is positive to note that they are being consulted about their longer term preferences and in any case each of these people is appropriately placed at this home whatever they decide for their future. Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Standards 6, 7 & 9 were assessed at this inspection visit. The people who use this can remain confident that the staff know what they need. They can also be assured that the staff will try their best to make sure that each person who lives at the home is allowed to live the sort of life that they can meaningfully choose to. EVIDENCE: Three care plans were looked at in detail during this visit and these included those of the two newly placed people and another person who has lived at the home for some time. These are still written in a way that makes it look as though these are about what the service user thinks as they are written in the first person. An addition has been made to the care planning procedure. This is called “What have I planned to do this month” and states the aims, objectives and the achievements of each person. This is a positive development and along
Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 11 with the further changes that are being made to the way care plans are written and monitored this should hopefully provide a much greater degree of co – ordination and success in achieving care plan goals. The keyworker for each of the service users is expected to spend specific time with their respective key service user in order to assess their progress and to ascertain their thoughts, feelings and goals. There is once again good evidence that this is continuing to happen at regular intervals. The care plans also continue to include risk assessments that tell staff and other people about anything that may harm a service user and anything that the person might do that might hurt themselves. Copies of risk assessments are kept in the service users file and cover a variety of situations from accessing community activities to learning skills and activities within the home. Risk assessments are still being reviewed regularly, and most recently in January of this year. Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 15, 16 & 17 were assessed at this inspection visit. The people who use this service can remain confident that the staff of the home will provide continuing opportunities for everyone to develop their personal and social skills. This includes active support for each person to participate in the community and to develop and maintain personal and family relationships. EVIDENCE: The people who use this service continue to be supported to make use of a wide range of community based facilities. These can be anything from regular shopping trips, whether for food for the home or personal shopping, to attendance at local clubs run by particular organisations. The home has their own vehicle that is regularly used although this does not prevent the use of
Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 13 public transport where circumstances and the needs of individuals would allow. A part of the newly introduced “What have I planned and done this month” record is the inclusion of known leisure and activity preferences. Again this helps to plan and offer the support that is required to ensure that each person’s has as active and enjoyable activity, leisure and social life as they choose. The home’s staff group continue to encourage and support the maintenance of relationships with family members and virtually all of the people who live here do have at least some family contact. The daily routines of the home remain flexible within reason. The people who live here have the liberty to make their own choices about where they spend time in the home and whether they wished to be alone or in company. The home has all appropriate policies and practices on maintaining people’s dignity and rights. The home has a keypad entry system to the front door, the locks for which disengage automatically if the fire alarm is activated. Almost all of the people who live here would be at risk if the left the home without being accompanied by at least one member of staff. As reported at previous inspections, the reasons for the entry and exit door locking system are fully documented and the appropriate measures continue to be in place to secure everyone’s safety in using this, without undue limitations to each person’s liberty. Individual preferences for the food that people like to eat continue to be given due consideration. The menus show that appropriately varied and nutritious meals are available. Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 18, 19 & 20 were assessed at this inspection visit. The people who use this service can remain confident that they will get the right support to take care of their personal and healthcare needs. Anyone who needs to take medicine regularly to help them stay well will get the proper support from staff to make sure that this happens properly and safely. EVIDENCE: The methods of supporting each individual continue to be clearly written down in a way that focuses on the unique preferences and personality of each person. A revised health action plan format is currently being developed in line with the care planning changes that are being introduced. Each staff member is still required by the home to sign a confirmation that they have read the individual plan and will put it into practise. The people who use this service continue to make use of the range of community health services. Each person’s unique health care needs continues to be reflected in his or her care plan. A full medical profile is compiled which details the reason for prescription
Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 15 medicines and any risks that might arise about the use of the medication. The outcome of all medical appointments is also written down. All but one of the people who live here is registered with the same local GP. Risk assessments continue to indicate that none of those who live here are able to take their medication without the staff supporting them. The home has detailed written policy and procedure guidelines for the handling and administration of medication. All staff members responsible for administering medication have been trained to do so and all were re-assessed as the result of a complaint that was made earlier in 2008 about administration practices at the home. One error in medication administration was reported to the Commission in October of last year. Fortunately no harm resulted and the home implemented the organisational procedure to re –assess the staff member’s competence before allowing them to administer medication again. A monitored dosage system is used with all records being well and accurately kept. The home receives training and advice from a pharmacist employed by a well known national chemist. A system for daily auditing of medication administration was implemented prior to the previous key standards inspection and it is evident that this is successfully achieving the aim of quickly identifying any problems that may arise. . Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 22 & 23 were assessed at this inspection visit. The people who use this service can remain confident that the staff team at the home know what to do if there are complaints or concerns about abuse. EVIDENCE: One whistle blowing issue was raised with the line manager of the service in late 2007. This was reported in the previous key standards inspection report and subsequently a full report and action plan were submitted to the Commission as a result. It is note that the action taken appears to have achieved the required success as no further issues have since been raised. One complaint was made to the home just before this inspection visit took place. An initial response has been provided to the complainant as per the organisational procedures and a full response should follow once the service provider has looked at the complaint in detail. The Commission believes that this complaint should not require any involvement by the regulator, as it could be resolved locally. Two letters of compliment have also been received by the home since the previous inspection. Each of these highlights what the senders believe to be a good and effective service. Continuing updated training in the local authority protection of vulnerable adults procedures is occurring. No protection of vulnerable adults concerns has
Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 17 been raised since the previous inspection with any placing authority, the geographical authority, the service or the Commission. Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Standards 24 & 30 were assessed at this inspection. The people who use this service can feel confident that they are living in a maintained home although delays in repairs still occur. The home is kept clean and hygienic. EVIDENCE: The home has historically experienced delays in getting repairs actioned and with receiving items for use by people who live here. At the previous key inspection visit it was said that a restructuring of the maintenance within the organisation should result in more efficient action to resolve repairs and obtaining necessary equipment. Delays are, however, still occurring although less frequently. As the organisation, through regulation 26 visits, does know what needs to be achieved in terms of repairs and refurbishment the Commission will not make a statutory requirement about this on this occasion.
Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 19 However, it should be noted that if current maintenance and refurbishment is not achieved within the timeframes outlined in the plan that the Commission will consider enforcement action as this cannot be allowed to remain a perennial problem. Two of the people who use this service were kind enough to give a guided tour of their home. The personal and shared living space that is used by the people in residence generally remains comfortable and suitable to each person’s individual needs and preferences. The home was also found to be clean and hygienic. Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 32, 34 & 35 were assessed at this inspection. The people who use this service can remain confident that there are enough people working each day in order to take care of them. They can also be assured that the company that owns the home continues to ensure that there are sufficient numbers of staff that are properly qualified. EVIDENCE: The manager of the home recently appointed to the permanent position after the departure of the previous manager already has NVQ 3 and stated that they are soon to commence NVQ 4. All but 3 of the remaining 13 members of the staff team have either achieved NVQ level 2 or are currently undertaking this qualification. The home has enough staff available each day to offer support to the people who live here. With the exception of one senior staff position all other staff posts are filled. There is still a need to use agency staff to cover shifts on
Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 21 occasion but this is significantly reduced from the level it used to be. The home continues to place three or four staff on duty for each of the two waking day shifts. The decision about when more staff are needed on duty is made on the basis of the activities and events that the people who live here are planning to do. Most staff prefer to do longer day shifts, starting early in the morning and finishing late evening as it results in more rest days. The manager said that this also helps in terms of lessening interruptions to the activities of service users, as staff less frequently need to rush back to handover to the next waking day shift if they are working a long day. The managing organisation continues to carry out checks to make sure that the people who work here are safe people to work with the service users. These checks include things like asking the police if a new member of staff has ever been found guilty of a crime, and asking people who used to employ them if their work was good and if they are the right sort of person to work with the service users and to support them. The Commission accepts that as the home is run by a larger company that has a central personnel department that original copies of these checks can be kept there. The background checks confirmation, using a format suggested by the Commission, was seen for three staff that were employed since the previous key standards inspection and this visit, each showing that satisfactory checks have been completed. For the two staff that were transferred to work for Caretech from another company that was purchased by this organisation it would be advisable to carry out renewed CRB checks for these people. Training is now being far better organised at the home, building on previous improvements that were noted at the last inspection. Staff are placed on updates for standard areas of training and more specialised courses as these become available. The staff shift rota includes a list of which staff are attending a training day (or days) in each calendar month. This not only assists staff to remember what courses they are booked to do but also assists with planning for any shift cover that may be needed. Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 37, 39 & 42 were assessed at this inspection. The people who use this service can remain confident that they are living in a home that has effective internal and external management, is being run with their best interests at heart and that their rights are respected. EVIDENCE: As referred to in the staffing section of this report, the newly appointed permanent manager should be commencing their NVQ 4 shortly and does already hold NVQ 3. This person has also commenced the registration process with the Commission. Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 23 The law says that the owner of the home, or their representative, must visit the home at least once a month to check on how well the service users are being cared for and about how well the home is run. The home must then get a copy of the report that is written about the visit. These are known as Regulation 26 visits and the reports that were seen at this inspection show that this system is operating properly and is examining the home’s operation as diligently as would be expected. The Area Care Director was appointed in the latter part of 2007 and the dedicated time to service improvements is continuing to achieve a marked degree of success. The home’s manager has compiled a detailed business and development plan for the coming year. All of the necessary standards health and safety checks have been carried out within the last year and regular tests of the fire alarm, and fire drills, are also occurring. Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 24 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 x 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 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 25 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. Refer to Standard YA34 Good Practice Recommendations For the two staff that were transferred to work for Caretech from another company that was purchased by this organisation it would be advisable to carry out renewed CRB checks for each of these people. Woodcote Grove Road (100) DS0000065438.V373615.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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
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