Inspection on 08/05/06 for Woodcote Grove Road (100)

This inspection was carried out on 8th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodcote Grove Road (100) 10/02/09

Woodcote Grove Road (100) 18/02/08

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 8th May 2006 13:25 Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 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.V289958.R01.S.doc Version 5.1 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.V289958.R01.S.doc Version 5.1 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.V289958.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2005 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 whom have been recognised as having Autistic Spectrum Disorder. The home is situated on a quiet main road in Coulsdon. Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection focused on the remaining requirements from the previous inspection and some of the core standards that the Commission inspects in every inspection year. It should be noted that the home has made some continuing improvements, although further efforts are still required. The manager was not able to be present as she was not on duty. However, two of the five service users made some comments during this visit and the staff who were on duty also talked about their work at the home and the care of the service users. There are five people living at the home, all of whom were at home during this visit. Most of the people who live here find it very difficult to have conversations with staff or other people to let them know in detail how they are and what they need. These people can let staff know in their own individual ways that they might want something and the staff have to get to know the service users very well to recognise the ways in which each person does this. What the service does well: What has improved since the last inspection? The home has improved its response to situations where service users show signs of increasingly doing things that harm themselves or others. The managing organisation has also improved the provision of the number of staff who can drive the people carrier. The staff team have improved the diligence with which they adhere to the policy on administering medicines and ensuring that service users are not placed at risk of harm by failures of diligence in providing good care. Monthly visits that must be carried out by a representative of the managing organisation have improved, as too has the managerial oversight of the home. Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 Page 6 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. Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 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.V289958.R01.S.doc Version 5.1 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 the following standard(s): 2&5 The service users can remain confident that the home will only care for people that the home is registered to care for. The service users are told about how much it costs to live at the home and whenever this amount changes all of the people who need to know are told. EVIDENCE: There have been no new service user come to live at the home since the previous inspection visit. The file for the person who was admitted prior to the previous unannounced inspection was seen at that visit in December 2005. There was sufficient information in place at that time to show that the decision on this service user’s placement had been taken in light of suitable information about their care and support needs. There is a comprehensive contract in place that outlines the service that is provided and what this costs. Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 The service users can now feel more confident that enough is being done to address situations that result in service users behaving in ways that might hurt themselves or others. However, the staff team still need to develop the methods of communication with service users to maximise their involvement in their own lives and the care that they receive. EVIDENCE: Two service user 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 inspection was that two of the service users were showing regular signs of distress and are either hurting themselves or becoming angry and might hit out at other people. When things like this occur the staff write an incident report although it is previously unclear whether these then lead to the proper assessment and response to why and how to support service users to remain safe. It is positive to note that further Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 Page 10 developments have been made to both the plans and the risk assessments to show how staff should support these service users at time when they feel distressed. Aside from the home’s manager no other staff had been trained in methods of working with people who display these types of behaviours at the time of the previous unannounced inspection. The number of staff who have since had this training could not be verified at this visit. The manager is required to write to the Commission in response to this report to indicate how many more staff have been trained and to outline the programme to ensure that this will include the whole team. 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 some evidence that this is happening at regular intervals. However, as a result of the findings at the previous inspection staff were seen to require more training particularly when considering the needs of any service user who may have limited verbal, signing or written communication abilities. It could not be verified at this visit whether this has occurred and so in response to this report the manager must outline how this has been, or will be, achieved. 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 reviewed very often, and most recently in March of this year. There was also a concern at the previous inspection that although risk assessments are very detailed; the staff did not know how to properly carry out safety checks of the hot water temperatures in the showers. Please see the comment made under the section “Environment”. The home continues to have very clear procedures for staff about making sure that service users personal information remains confidential. These procedures are designed to ensure that information is not shared with anyone who does not have a right to know. Each member of the staff team signs a record to confirm that they have read, understood and will abide by the confidentiality policy. Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15, & 16 The service users can feel confident that they are offered choices in how to live their lives. This could, however, be expanded upon further so that service users can have increasing opportunities to be involved in community based activities and leisure pursuits. EVIDENCE: Some of the service users go to day centres or to other activities. However these activities were noted at the previous inspection as being very limited and the activity sheets indicate that most of the activities that occur are at home. As a result of that finding the home were told that there needs to be a lot more work done to ensure that service users are offered increased opportunities not only for fulfilling weekday activities but also to pursue social and leisure interests. Since that time there has been some small indication of more community based activities, however these events are still largely as a group when they occur and further improvement is still required. The home has its own vehicle that service users are transported in although there were difficulties with the home not having many staff that can drive. Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 Page 12 There are now six staff that can drive the home’s people carrier, which is an improvement on the number who could do so at the time of the previous inspection. The staff continue to support each service user to keep in contact with their families and friends. Family and Friends are made very welcome when they visit the home and many of the service users go to visit their families, often staying for a whole day or even longer at times. There are still not many rules at this home. The most important one is that no one is allowed to smoke in the house, although none of the service users smoke in any case. All of the people who live here are allowed to use the entire house, except other people’s bedrooms or the office if a meeting is happening. All of the service users are registered to vote, however it remains unlikely that any would take a particular interest in doing so. Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 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 the following standard(s): 18, 19 & 20 Service users can feel more confident that all of the staff will make sure that they are always supported in the way that each of the people who live at the home really needs. There has been an improvement to the way in which the staff team adhere to the policy and guidelines of the organisation that are designed to prevent service users from being placed at unacceptable risk. EVIDENCE: At the time of the inspection in September of last year it was questioned whether a service user who was scolded whilst having a shower was being properly supported at the time. The managing organisation has now dealt with this particular occurrence, however it was also questionable whether there was sufficient diligence in keeping service users safe and appropriately supported. A further incident occurred in between that inspection and the one that took place in December last year when a service users was given the incorrect medication, which was in fact supposed to be given to a different service user. Both of these concerns about care practices at the home were responded to at the time by the Commission and it is noted that no serious concerns about care have arisen since. The staff team were informed that they must adhere to the policy and procedures for administering medication at all times and this Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 Page 14 must be properly overseen by the management of the home. The managing organisation outlined what further response and retraining was to be provided to both of the staff involved and how the home will ensure that proper and diligent care practices are observed from here on. This was looked into again at this inspection visit and it was see that the proper procedures were being followed when medication was seen to be given to certain users at lunch time and that the recording was completed and checked properly. Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home has clear information about how people who either live at the home or others can make a complaint. Service users can feel confident that the staff team are now better at making sure that no-one does anything to deliberately harm them. EVIDENCE: The service users are given clear information about how to complain and what happens when they make a complaint. No comments were received from relatives, advocates or other people prior to this inspection. No complaints have been made to either the home or to the Commission since the previous unannounced inspection. The two concerns that were raised about service users suffering harm prior to the inspections of last year were fully investigated at the time and conclusions were reached. Although there was no indication of any deliberate intent to harm service users the home were told that they must remember that a failure to apply good care practice could also be classed as abusive. The managing organisation were told that they must outline to the Commission how it intended to ensure that service users are not placed at risk of harm by failures of diligence in providing good care. It is noted that there have been no further failures to date. Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 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 the following standard(s): 24 & 30 The service users can now be assured that the showers in the home have been made safe to use. Other safety checks still appear to be carried out properly and the home is kept clean and is comfortable place in which to live. EVIDENCE: During the previous key standards inspection in 2005 the override to the shower control temperature settings were looked at as this had been said to be the reason that a service user had become injured when using the shower. These controls were replaced. Please refer to the section of this report entitled “Conduct and management of the home” for further comment about the apparent confusion that appeared to previously exist about how hot water temperature checks should be carried out. The home continues to be well decorated, comfortable and is kept clean and hygienic. Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Service users can feel confident that there are enough people working each day in order to take care of them. The can now 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 unannounced inspection. Her progress on completing this could not be verified at this inspection visit, as she was not on duty at the home. The deputy manager continues to do the NVQ level3, one care and support worker is doing NVQ level 2 and another achieved the NVQ level 2 qualification last year. The manager previously said that the remainder of the staff team would start their NVQ qualification course in October of last year. The managing organisation has since written to the Commission to outline how it intends to ensure that there are sufficient numbers of appropriately qualified staff working at the home. The home has enough staff available each day to offer support to service users. At present there is still a regular need to use agency staff this has decreased due to three new staff having commenced in post so far this year. Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 Page 18 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. As the manager could not be present during this visit the confirmation of these checks could not be seen, however, these will be checked for new staff at the next visit. Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The service users can feel confident that they are living in a home that is showing continuing improvement in the way that it is managed and that health and safety checks are properly carried out. EVIDENCE: At the previous unannounced inspection it was noted that the manager has yet to complete the NVQ level 4 qualification. The manager was informed at that time that she must endeavour to complete this without undue delay. As the manager could not be present during this visit she will need to respond to this report to outline what progress she has made. 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. This was not seen to be happening at the time of the unannounced inspection in December 2005, Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 Page 20 although there has been much improvement since. A new area care director has been appointed recently and has he responsibility to carry out these visits. A copy of each monthly report is also now being sent to the Commission as required. The lack of diligence in both internal and external oversight in the management of this home was of serious concern, which was underlined by the serious incidents that have happened in the last year. The managing organisation has previously provided the Commission with assurances that these failures have been, and will continue to be addressed. There are continuing signs of positive improvements taking place and the Commission will continue to monitor these areas. The information that is held in service user’s case files is well kept and is easy to read. Personal information that is written about each service user is kept confidential by the home. Hot water temperature checks are occurring regularly and at times when hot water is seen to be dangerously high the home are now taking urgent remedial action to respond to any problems. Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 Page 21 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 X 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 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 1 X 3 3 LIFESTYLES Standard No Score 11 X 12 1 13 1 14 x 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 1 X 3 X X 3 x Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 Page 22 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 YA7 Regulation 24 (3) Requirement The staff team require more training particularly when considering the needs of any service user who may have limited verbal or written communication abilities. There must be more work done to ensure that service users are offered increased opportunities not only for fulfilling weekday activities but also to pursue social and leisure interests. There must be more work done to ensure that service users are offered increased opportunities not only for fulfilling weekday activities but also to pursue social and leisure interests. The manager must endeavour to complete the NVQ level 4 qualification without undue delay. Timescale for action 08/05/06 2. YA12 16 (20 (m) & (n) 08/05/06 3. YA13 16 (20 (m) & (n) 08/05/06 4. YA37 9 (2) (b) (i) 08/05/06 Woodcote Grove Road (100) DS0000065438.V289958.R01.S.doc Version 5.1 Page 23 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.V289958.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 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. 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