Inspection on 18/02/08 for Woodcote Grove Road (100)

This inspection was carried out on 18th February 2008.

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

Woodcote Grove Road (100) 10/02/09

Woodcote Grove Road (100) 08/05/06

Woodcote Grove Road (100) 12/12/05

Woodcote Grove Road (100) 06/09/05

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 Woodcote Grove Road (100) 100 Woodcote Grove Road Coulsdon Surrey CR5 2AF Lead Inspector James Pitts Key Unannounced Inspection 18th February 2008 11:55 Woodcote Grove Road (100) DS0000065438.V352546.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.V352546.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.V352546.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 Mrs Lesley Ann Lush Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 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. At present the home offers support to five service users, all of who have been recognised as having Autistic Spectrum Disorder. The home is situated on a quiet main road in Coulsdon. Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Most 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 four members of the staff team were present during the course of this inspection. . This inspection involved a visit to the service, discussions with staff, and observation of interactions with the people who use the service and examination of specific records. The previous key standards report and two intervening random inspections were also taken into consideration as too was information from other sources, for example social care professionals, contact with relatives, meetings attended by the Commission and other information received. What the service does well: What has improved since the last inspection? What they could do better: For the first time since the home was registered there have been no areas identified that necessitate any statutory requirements to be made. This improvement to the service is noteworthy and every support and encouragement should continue to be provided to enable this to continue. Woodcote Grove Road (100) DS0000065438.V352546.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.V352546.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.V352546.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, and the guide for service users is presented in a clear way so that people can understand 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 December 2007. 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. Two people have left the home since the previous key standards inspection in May 2006. One person moved to a more appropriate placement and the other to live somewhere closer to their family. As there have been no su8bsequent new admissions to the home key standard 2 does not necessitate any further comment at this stage. This standard will be assessed again at such time as anyone new is admitted to the home. Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 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. 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 feel 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: All four care plans, which are known as “ Individual Support Requirements “, were looked at in detail during this visit. These are still written in a way that makes it look as though these are about what the service user thinks as the words that are used are things like “how staff assist me with personal care” and “how staff treat me and my communication needs”. One thing that was of concern at the previous key standards inspection was that two of the service Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 10 users at that time were showing regular signs of distress and are either hurting themselves or becoming angry and might hit out at other people. The manager was then required to write to the Commission to indicate how many more staff have been trained and to outline the programme to ensure that this would include the whole team. By the time of the random inspection in November 2006 this had been achieved and no subsequent areas of concern have come to light. 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 evidence that this is continuing to happen at regular intervals. The care plans also 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 August of last year. The deputy manager said that these were just about to be reviewed again in line with the policy to do so at least every six months, or sooner if the need arises. Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 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. 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 feel confident that the staff of the home will provide opportunities for everyone to develop their personal and social skills. This includes increasingly active support for each person to participate in the community both in terms of the activities of daily life and leisure interests. The opportunity for each person to develop and maintain personal and family relations is also offered and is supported by the staff team. 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 Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 12 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 public transport where circumstances and the needs of individuals would allow. An individual social activities diary is completed for each person who lives here to show which activities each engage in and to provide details of the range and frequency of these activities. This is a marked improvement on what was seen at the previous key standards inspection. The staff team are able to demonstrate a clear understanding of the cultural and religious practise preference that each person who uses this service chooses to adhere to. 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 are 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. 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. Individual preferences for the food that people like to eat are given due consideration. The menus show that appropriately varied and nutritious meals are available. Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 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. 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. 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 medicines and any risks that might arise about the use of the medication. The outcome of all medical appointments is also written down. Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 14 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. A monitored dosage system is used with all records being well and accurately kept. The home receives training and advice from their local chemist in regards to all medication. The home has improved the way in which medication is handled and administered as previous inspections had highlighted recurring problems. A system for daily auditing of medication administration has been implemented, which helps to quickly identify if any problems have arisen. Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 15 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 feel confident that the staff team at the home know what to do if there are complaints or concerns about abuse. The home has clear guidance for staff about the procedures to be followed in either of these circumstances, and continued staff training is maintaining the awareness across the whole staff team. EVIDENCE: One whistle blowing issue was raised with the Commission and the registered provider in late 2007. This was investigated under the provider’s whistle blowing procedures. The outcome was that although no serious concerns were substantiated there were areas of improvement to the quality of the service that were identified. The Commission is satisfied that the registered provider examined these concerns properly and are taking steps to appropriately address the quality service improvements that were recommended. One other complaint was made by a relative about their son not being at home when they visited. This was responded to locally. The registered provider in reply to the annual quality of service audit received two responses in late 2007. These were from relatives of two people who live at the home and each of these replies showed that they are very satisfied with the service that is provided. Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 16 Continuing updated training in the local authority protection of vulnerable adults procedures is occurring. Due to the limited number of places available on this course, which is run on a cyclical basis, it will take time to achieve training for 100 of the staff team. One protection of vulnerable adults concerns was raised late last year with the geographical and placing authorities as well as the Commission. This was not progressed further as the concern was as the result of a miss understanding rather than any actual harm having occurred. Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. 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 an increasingly and efficiently well maintained home. The home is also 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. During this key inspection visit the deputy manager said that a restructuring of the maintenance within the organisation should result in more efficient action to resolve repairs and obtaining necessary equipment. The local maintenance contractor actually visited on the day of this inspection to address some minor repairs. Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 18 One of the people who use this service was kind enough to give a guided tour of the ground floor of the 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.V352546.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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 feel confident that there are enough people working each day in order to take care of them. The can also be assured that the company that owns the home are doing what they can to make sure that there are sufficient numbers of staff who are properly qualified. EVIDENCE: The manager of the home was still doing the NVQ level 4 qualification at the time of the previous key standards inspection although this was successfully completed in October 2006. The deputy manager has completed the NVQ level3, and all but one of the remaining team have either achieved NVQ level 2 or are currently undertaking this qualification. Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 20 The home has enough staff available each day to offer support to the people who live here. With the exception of one permanent position all other staff positions have been filled. There is still a regular need to use agency staff to cover one long term staff post due to illness, however the need to use agency or bank staff aside from this has decreased significantly. The home places 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. The managing organisation carries 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 was seen for two staff that were employed in the time between the previous key standards inspection and this visit, each showing that satisfactory checks have been completed. Training is now being far better organised at the home. Staff are placed on updates for standard areas of training and more specialised courses as these become available. The staff shift rota now 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.V352546.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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 feel increasingly confident that they are living in a home that has 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 registered manager successfully completed the NVQ level 4 qualification in October 2006. 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. The lack of diligence in both Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 22 internal and external oversight in the management of this home was of serious concern at previous inspections, and it is noted that significant improvements have since been achieved. A new Area Care Director was appointed in the latter part of 2007 and is able to dedicate more time to service improvements than was previously the case. The registered provider operates a large number of services over a wide geographical area. Organisational restructuring and dedication of resources more locally based is obviously having a positive impact for this service. The following health and safety checks have been carried out within the last year: Fire Alarm System: 03/07/07 Fire extinguishers: 12/10/07 Gas Safety Check: 30/07/07 Portable appliance check: 07/11/07 Legionellosis: 26/10/07 Regular tests of the fire alarm system and fire drills are also occurring, as too are hot water temperature checks to ensure that this is not excessively high. London Borough of Croydon Environmental Services Department carried out a food safety inspection on 27/06/07. Two requirements for repairs in the kitchen were identified and each of these was subsequently attended to. Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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.V352546.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 25 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 Woodcote Grove Road (100) DS0000065438.V352546.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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