Inspection on 15/11/05 for Woodcote Road (75)

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodcote Road (75) 30/04/07

Woodcote Road (75) 22/02/06

Woodcote Road (75) 03/02/05

Woodcote Road (75) 18/11/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Woodcote Road (75) 75 Woodcote Road Wallington Surrey SM6 0PU Lead Inspector David Pennells Unannounced Inspection 15th November 2005 13:55 Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 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 Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 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 Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodcote Road (75) Address 75 Woodcote Road Wallington Surrey SM6 0PU 020 8647 8452 020 8647 2113 woodcote-road@hexagon.org.uk www.hexagon.org.uk Hexagon Housing Association Limited 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) Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow two specified service users over the age of 65 to be accommodated for as long as the service can adequately meet their needs. 3rd February 2005 Date of last inspection Brief Description of the Service: The home is registered with the Commission to provide personal and nursing care for up to twelve people with enduring mental health needs. 75 Woodcote Road is a substantial traditional mid-Victorian brick-built, detached family-style property situated just South of the centre of Wallington, and therefore close to the town’s facilities including shops, entertainment and good transport links. The property comprises two large lounge areas and a separate dining room. There are 12 single bedrooms situated on the ground and first floors. No bedrooms have en-suite facilities, other than wash-hand basins. There are, however, toilets and bathrooms conveniently situated throughout the home. Although the ‘shell’ of the home is Victorian, much of the interior impresses by its clean lines and modernity. There is a substantial garden area to the rear of the premises and off-street parking to the side of the property, this being shared with the Health Authority property next door. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was conducted across the afternoon and early evening of a weekday. On his arrival, the staff members were just commencing their shift handover meeting – the inspector joined in with this exchange of information and then spent time speaking to service users before the arrival back in the home of Mary Colquhoun, the Acting Manager. Following time spent with the Acting Manager discussing the current progress of the home - and reviewing the requirements and recommendation set at the last inspection visit, the inspector finally spent more time with staff members and some time speaking with service users, some of whom had not been in the house earlier that afternoon. The inspector left the home following suppertime at about 7.05pm. What the service does well: What has improved since the last inspection? Little was required to improve at the last inspection visit; a couple of health and safety monitoring issues have now been addressed and policy / procedure documentation has been accessed. The home continues to run well and efficiently providing a well run and managed service. The exterior of the house has been decorated and a number of internal rooms are soon to be painted. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 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 Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 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 Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 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): 1, 2, 3 & 5. The home provides service users & other interested parties with full details to enable them to make an informed choice about choosing to live at the home. Prospective service users can be confident that they will – through adequate assessment and consultation, acknowledging the candidate’s own preferences be assured that the home can meet their needs prior to making a firm decision to stay. Service users can be assured that they will be provided with suitable written contracts / terms and conditions – in the form of a licence from the registered provider - to make clear the conditions relating to living at the home. EVIDENCE: The population at the home has remained consistent – with no changes throughout the past twelve months. The standards in this section, therefore, were not ‘actively’ inspected at this visit, save for staff confirming that the assessment and administrative process would be similar. The judgement above is based on the previous inspection reports – where all standards were fully assessed as ‘met’. An extract from previous reports reveal: “The home has provided each service user with a folder which contains all aspects of information concerning the house - including the Statement of Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 9 Purpose, Complaints Procedure, Resident’s Charter, Activities Programme, a copy of the most recent Inspection Report (if requested) the Licence agreement and the Care Contract, and documentation about the house and the local area - as a compact and complete Service User Guide.” Service user files contained the care manager’s comprehensive assessment and the mental health “Care Programme Approach” assessment and reviews for those service users receiving this form of after-care. After an initial referral, the prospective service user is visited by an allocated keyworker and cokeyworker to assess their suitability for the home and refer their finding back to the home. All service users have a formal Licence agreement - relating to life at the home - held with Hexagon Housing Association, as well as a three-way contract (‘Agreement for the purchased of a care service’ between the service user / the home / and the funder) issued by their care manager representing their placing or funding authority. Case files checked during the inspection confirmed elements of this standard to be met, and spare copies of the contracts / agreements are held in the office for reference. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10. The home maintains care plans and assessment documents designed to ensure that the needs of service users are met in a focused and individual way, with their rights to individuality and self-expression being protected. The wishes and aspirations of each service user are taken into account, including the plan indicating where staff assistance may be needed, to create a fulfilling lifestyle. Service users can be assured that risk-taking will be an integral part of the support / protection plans put in place by the homes. Service users and relatives / friends can be assured that information about service users is kept in line with best practice and data protection legislation. EVIDENCE: Thorough care plans were in place; the usual ‘day-to-day’ notes concerning the service user’s wellbeing were well reported, with specific care plan goals regularly reflected on as well. The service user’s files held risk assessments; identified short and long term goals and a few simple and clear action plans. The plans are drawn up in consultation with the service user, social workers and the mental health team. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 11 Each service user’s care plan and associated risk assessments makes clear the varying levels of risk and how service users are to be supported in their programme; it is clear that for some, ‘rehabilitation’ is a very low-key concept - indeed, for some, ‘level’ maintenance - keeping an ‘even keel’ - is a significant achievement / milestone in itself. Staff members were evidently very familiar with service users and their needs and keyworkers in particular assist service users through the ‘confusions’ of life. Information is held securely in the home’s offices - in locked filing cupboards. Similar security is afforded to staff files by the management in a separate office. The manager confirmed that the issue of access to personal records was covered in the ‘Confidential Reporting’ policy of the registered provider. Access to staff records is covered in the Staff Handbook. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 16 & 17. Service users can be assured that the service provides opportunities for them to engage in activities both within and outside the home, and to adopt a lifestyle best suited to the individual. Relatives / friends can expect a positive welcome from the home, within the context of respect for a service user’s own choices and decision-making. Service users can expect to be provided with a good standard of nutritious and wholesome food – meeting dietary needs and ensuring that mealtimes are a pleasant and enjoyable time. EVIDENCE: The home sees as its central role the need to help service users stabilise their mental health and to work with the psychiatric health services in doing so. Beyond or alongside this, service users are encouraged to build new friendships and to improve communication skills both within the home and outside in the wider community. It is clear that many service users in the home require a great deal of support to overcome their lack of motivation on Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 13 occasions; this is where close relationships established through the staff ‘keyworking’ come into play. Staff members working with service users were again very evidently ‘attuned’ to service user’s individual needs. Engagements between staff and service users - where the supportive intervention of a staff member demonstrated a positive regard and clear knowledge of the service user’s characteristics and specific needs – were again noted. As well as providing a range of recreational activities, the home has weekly schedules for domestic tasks for the service users to undertake, such as laundry, washing-up, helping in the kitchen, shopping and tidying their rooms. Each service user in the house is quite different; having differing needs and levels of capacity to engage in a fulfilling lifestyle. For the majority of the present service users, most of whom have more limited aspirations, they enjoy living in a pleasant and relatively stress-free environment. For them ‘progress’ is sometimes just maintaining a reasonable state of mental health. Most service users make regular use of community facilities such as the local shopping centres, cinemas, pubs etc. The home supports service users in obtaining “Freedom Passes” for accessing London-wide public transport without further payment - and indeed, every service user has one, though not all use the opportunity it affords. The home has a people carrier (suitably insured), which is driven by a number of staff and very popular with service users. Staff will escort service users and support them within the community to encourage greater participation in community life and to broaden service user’s skills in using public services. Service users are encouraged to take part in leisure pursuits including shopping expeditions, visits to cinemas, pubs and to participate in leisure outings (such as trips down the Thames, to the seaside, Hampton Court Palace, and entertainment venues such as the Fairfield Halls in Croydon). Some need encouragement to participate in more significant opportunities such as annual holidays (three service users went to Cornwall with staff this year) - because with limited motivation, and possible levels of anxiety, they are often more keen / content to keep to the ‘certainty’ of the routine life at home. The staff - the keyworkers especially, negotiate the ‘fine line’ of encouraging, whilst not forcing, service users into activity. Questionnaires returned from eight relatives / family members of service users indicated that all felt welcomed at the home and equally staff were variously described as ‘wonderful’ and ‘welcoming’ and the service was by one stated to be ‘exemplary’. All indicated they were kept well-informed about issues which affected their loved ones, and none were dissatisfied with the overall care provided at the home. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 14 The previous person who provided the principal catering input to the home (as a ‘rehabilitation worker’) has moved onto a new post working more directly with service users. A new recruit had been identified for the post, and was just awaiting the return of their CRB check prior to commencing work. The food provided on the evening of the visit was of excellent quality and quantity. There is little danger of any service user going hungry; the culture of eating well is set in the home. The lasagne, fresh cabbage and chips appeared most appetising. Service users clearly enjoyed their meal; fruit trifle and ice cream topped off a substantial meal. One service user undertakes his own catering in the back kitchen area – where many service users also make their own drinks during the day. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 15 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 be assured that their personal, health care and emotional / mental health care needs will be recognised and met by the home’s daily service input - and through longer-term assessment and care planning programme jointly constructed with mental health care specialists. The systems adopted by the home regarding medication generally ensure the safety and consistent treatment and support for each service user, though this would be entirely so if closer attention was given to the detail around providing guidance and recording details concerning ‘prn’ (when required) medication. EVIDENCE: Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 16 The home’s staff members were clearly aware of the need to respect the privacy & dignity of individual service users, who require a varying range of support, though no one required ongoing direct personal care assistance. Some service users needed encouragement with personal hygiene, and others just guidance on the use of money, etc. Each service user has an appointed keyworker and co-keyworker. Observations against specific care plan goals were recorded - and at least two observational reports were logged per day covering areas other than the specific individual care plan goals. 75, Woodcote Road is a care home with nursing - and each shift is provided with a qualified nurse (Registered Mental Nurse) available to monitor the health of service users. Standard ‘observations’ were noted, as well as mental nursing insight being used for the service user’s assessment and care. Service user records showed that staff members ensure all service users keep in touch with their GP and any specialist health professionals - such as Community Psychiatric Nurses and Consultant Psychiatrists. Specialist agency input has also been found useful in the past. For general health issues, two local GP practices are used, one in Carshalton and one in Wallington. Chiropody is generally provided at the local Shotfield Health Centre. Dental and ophthalmic services are accessed locally in Wallington, or to the service user’s preference. Two service users self-administer medication handed out to them on a weekly basis; some others have staff involvement generally, but self-manage medication when they go away on home / holiday visits. One service user has a long-term history of refusing to accept medication. One service user self-admits themselves to hospital – via Accident & Emergency - when they feel they require such attention; such a route is now recognised by both the home and the hospital. The system generally used is a monitored dose (‘blister pack’) system provided by Boots the Chemist. Team leaders have a responsibility for auditing the medication records and stocks from time to time. The most recent audit had been conducted six days before the inspection visit. The previous requirement concerning the introduction of a clearer criteria sheet for any ‘prn’ (when required’) drug was still clearly not in place; in conversation with senior staff, it was recognised that a ‘checklist’ of steps to address prior to this ‘discretionary’ administration would be beneficial and supportive to these professionals. Such information would also support agency staff covering the senior role when they are not so familiar with the individual service users. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 17 Hexagon’s own policy speaks of “prescribers must give… clear unambiguous written direction to the nursing staff describing in what circumstances the medication should be given – including the maximum number of doses over a set period” As examples, the following were instructions found on the MAR sheets for two service users: “Take one or two tablets eight-hourly if required for anxiety or stress” and (relating to a 5 mg tablet): “Take one when required up to 20 mg total when agitated or restless”. It was clear – and agreed with staff that greater clarity would be appreciated. The inspector also noted that records on the reverse of the administration record sheets were not consistently being kept in regard to the ‘prn’ (‘when required’) medication. This record is vitally important – as the fullest description of such ‘discretionary’ administration is needed. Staff members must be required to follow the same procedure so that full justification / ‘reference back’ / review is possible. A previous requirement regarding the consistent monitoring of the medication refrigerator temperatures had been met; the fridge was currently empty so the records had reduced to weekly monitoring. The inspector was told that such records would be restored to daily checks if any specific medication were stored within it. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 18 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. Service users can be confident that their comments and complaints are responded to, with appropriate action taken. The home provides adequate support to service users to ensure that they are protected from harm and any form of abuse. EVIDENCE: The home has a clear Complaints Procedure in place; information for service users and their representatives is available both in the Statement of Purpose and the Service User Guide, and it is posted in locations around the home. A record for the logging of complaints is in place. No complaints have been formally received concerning the home in the past twelve months; most issues are dealt with immediately they arise to save issues getting ‘out of proportion’. The home has a positive approach to service user’s airing their grievances and seeks to address them fairly and methodically. It is evident that some service users “complain” not because of a poor service but because they have other opinions about the running of the house, or situations which affect them. The inspector remains satisfied that service users’ views are actively listened to and acted upon, as this standard requires. The home has its own procedures for dealing with allegations of abuse. These refer to the local authority’s guidance on the Protection of Vulnerable Adults and the need to refer any allegations to the care management team with delay before any internal investigations commence. The home and the registered provider have ensured that all staff members have been checked under the Criminal Records Bureau; the inspector noted all new CRB documentation. Checks on agency staff are also rigorous to ensure the safety of service users. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 19 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. Service users can expect to live in a clean, warm and comfortable environment designed to meet their individual needs and providing adequate services and domestic facilities. Service users can be assured that the home is maintained and run as a safe environment in which they may live, without unnecessary risk. EVIDENCE: The house is located within the local community of Wallington - centrally located, not far from the shops on a principal main road. Access to local community facilities are therefore close by, and transport - with bus stops opposite and the railway station not that far away - are excellent. The premises are generally spacious and maintained to a high standard. The home remains comfortable and homely. The home has recently (27th October) had a revisit from a Fire Safety Officer of the London Fire and Emergency Planning Authority, confirming that the home met the necessary Fire Precautions (Workplace) Regulations 1997 (as amended). Risk assessments are in place and all equipment and the integrated fire alarm system was fully serviced and operational. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 20 All bedrooms in the house are singly occupied and of various sizes. The bedrooms that are below 10 square metres (as an ‘existing home’ these rooms are allowed to continue to be) are not ideal, but the home does strive to provide service users with alternate communal space for their private use, if they so wish. This home does not accommodate wheelchair users. The bedrooms are reasonably decorated, warm and comfortable and are laid out to the individual service user’s preference. Although a number of service user stated they would ‘like a bigger room’, they were resigned to the reality of if they wished to continue to use the service this was the one element that they had to ‘give way’ on. Each bedroom has a wash-hand basin facility. There are 4 ‘communal’ toilets for service users, and bathing facilities include baths and showers - one has a bidet, which has been installed and is identified as an asset to the house. One shower-room has a ‘standard’ cubicle, whilst the other is a more open floordraining shower / wet room, which enables staff assistance - and also avoids steps and problems with shower doors. This will be of greater benefit as the population at the home continues to age. All the bathing and toilet facilities seen were clean and tidy and at a comfortable temperature - a domestic ensures the thorough cleaning of such areas. The home has a range of “communal spaces” including a vast lounge and a second equally large lounge / dining area, that can be divided to provide a private communal space, if needed. There is also small kitchenette and dining space to the rear of the premises, which is used by service users for making drinks during the day and also by the service user who self-caters. There is also a small office / meeting room on the top floor. The range of communal spaces provides flexibility for staff and service users so they may choose where, and with whom. they spend their time. Few adaptations are required at this time for the current service user group, but service users are assessed if they need aids or adaptations; for example one service has a flashing light fire alarm in addition to the sounder. There is no lift in this home - but it is not registered to provide care for people with physical disability / mobility problems. The home has been assessed regarding its suitability by both the staff on site and by the Health & Safety Executive. The home was found to be clean, odour-free, tidy and well maintained. Staff and the maintenance / gardening person monitor all areas to ensure such aspects are being well kept, decorated and maintained. Quotes have been obtained to decorate the main sitting room (which gets very nicotine stained) and three bedrooms – hopefully before Christmas. The home provides adequate laundering facilities to deal with all types of linen including a sluicing cycle, with high-temperature washing of any soiled linen. A new washing machine has just been provided. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 21 The exterior of the home has been recently redecorated; all appeared well. Concerns about the growing potholes in the car park outside (shared with the Primary Care Trust building next door) are an issue for the registered provider and the PCT jointly. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 22 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): 31, 32, 33, 34 & 35. Service users can rely on the home providing adequate staff in sufficient numbers and duly competent and well trained to provide a service that seeks to effectively meet their individually identified needs. Service users can be assured that the home’s recruitment and staff support mechanisms – including induction and training processes - are organised so as to ensure the safety, protection and wellbeing of service users. EVIDENCE: Eighteen staff members are currently working at the home (with a further staff member on maternity leave and another on a career break). Of these twenty staff in total, seven are registered nurses currently (with registration pin numbers confirmed) and apart from the Acting Manager hold the post of Senior Team Leader. Eleven Support Workers are employed alongside the nurses, with a handyman and a cleaner completing the complement of staff. The Cook’s post is presently being recruited to. Staff members are clear about their roles and responsibilities and have full job descriptions and contracts of employment. The home continues to have a wellestablished and stable staff team, who are familiar to the service users. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 23 Three care staff members have NVQ at Level 3 and another staff member is undertaking Level 2 training, with two staff indicated as on the waiting list for Levels 2 & 3. The figure of six staff against a total of eleven support workers indicates that the home is currently ‘on target’ but not by the end of 2005 to achieve the national minimum standard by that deadline. The home benefits from having the ‘background’ support of a Personnel Section at Hexagon Housing. The inspector checked a sample of the staff records with the manager (all documentation is held on limited access) and was able to again confirm that a thorough and rigorous recruitment process is undertaken; a new staff member’s staff file was examined and all appeared to be in order with two references, a Criminal Records Bureau check and other appropriate documentation in place. Criminal records Bureau checks were also seen for other ‘new starters’. A new starter senior confirmed that her induction had been helpful – not only spending days at the home but also visiting ‘head office’ for a training day during her first week of employment. This staff member was concentrating now on getting to know the service users; the most vital element for all working in this, at times, challenging environment. Staff training is a high priority for the manager and the staff training matrix evidenced almost 100 scores for the staff team in regard to Fire training, Food hygiene, manual; handling, personal safety, Health & safety and first aid training. Nine staff members currently hold the ‘Appointed Persons’ First Aid level of training – a commendable level, ensuring that a First Aid qualified member of staff covers all shifts within the home. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 24 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, 40, 42 & 43. The registered provider ensures that the home operates competent local management systems to ensure that service users benefit from a well-run, and safe environment. Service users can be assured that generally their rights and interests are well served and protected through the home’s approach to record keeping, policies & procedures, and the day-to-day conduct of the home - including the taking note of their expressed opinions or those of their advocates. Service users can be assured that their welfare, health and safety is, in general, safeguarded through the home’s rigorous adherence to appropriate guidance and regulations concerning best safety practice. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 25 EVIDENCE: Mary Colquhoun the present Acting Manager (previously the Deputy) is well qualified to manage the home – and has been doing so since August 2004. Mary Colquhoun is a qualified RMN, has a Certificate in Counselling, has an NVQ, Level 5 in Management and has worked as Deputy previously in the home for three and a half years. The vacancy for a Registered Manager continues, as the offer to the person identified to take over the post has been withdrawn. It is hoped that the situation is resolved soon. Fortunately, the situation concerning continuity at the home has not been an issue, as staff members within the organisation have ‘stepped up’ to fill posts – thus ensuring familiarity for service users and ensuring that prior knowledge informs the conduct / running of the home. The management structure encourages a shared management responsibility, with tasks delegated concerning key tasks such as Health & Safety and Risk Assessments. Senior staff members share the supervision responsibilities for staff – and also for Staff Appraisals. Staff were open and straight forward in their responses to the inspector. Staff meetings are held regularly, and each member of staff has supervision both informally on a day-to-day basis and more. A representaive of the Housing Association conducts the ‘monthy visits’ to meet staff and service users and to fulfil the obligation of the registered provider under the 2001 Care Homes Regulation number 26. The Acting Manager confirmed to the inspector that Hexagon undertake quality surveys of service users and other stakeholders; the results feed into the planning for the future of the home. Major reviews also enable the service user to express their opinions about their placement to an outside advocate - and to bring these opinions ‘to the table’ of the review meeting. ‘Cue forms’ are used to prompt comments, which provide useful pointers. Service user meetings are also held at the home, and they are additionally included / invited to attend Tenant Participation Meetings. One service user has an independent advocate. Policies and procedures are well maintained and feature in a number of separate manuals as well as the staff handbook; this division of subject area enables staff to access policies all that more easily. Woodcote Road uses standardised ‘Hexagon’ formats for records, and the Association’s policies and procedures are in place (authenticated by name and creation / review date) and were created to ensure they meet the National Minimum Standards. Staff members acknowledge policies and procedures drawn to their attention by signing a document indicating their seeing and understanding such policies. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 26 Maintenance, servicing and health and safety checks to equipment within the home were all up to date and indicated satisfactory outcomes. Fire alarm check records were in order, as were fire drill records – evidencing the drilling of staff in a minimally annual routine. The recording of the weekly checks of the ‘Dorgard’ fire door holding devices used in the home should be recorded as a matter of routine alongside the other records. A requirement of the two previous visits had now been met – in that the handyman is consistently monitoring and keeping records of hot water maximum temperature outflows. It was noted, however, that the checks were missed when the handyman was recently on leave. It is strongly recommended that another staff member is delegated the responsibility to undertake these checks during any of the handyman’s absences. The household budgets for this home are controlled by the manager, who has cost-centre control over all domestic and staffing expenditure. Effective financial management systems are clearly in place. The manager is involved in planning budgets, and this involvement in financial projections allows her to run the home effectively and smoothly. The home is run as part of the Hexagon Housing Association - a registered charity and housing provider; financing and the effective running of the organisation are therefore monitored and regulated by both the Charity Commissioners and the Housing Corporation. Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodcote Road (75) Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 X 3 3 DS0000019134.V259283.R01.S.doc Version 5.0 Page 28 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 YA20 Regulation 13(2) & 17 Requirement A written procedure and guidance for the administration of injections must be held alongside the medications policy and procedure - to reflect the regular need for nursing staff to undertake the administration of injections to some service users. Timescale for action 30/12/05 2 YA20 13(2) & 17 Each ‘PRN’ medication must have 15/12/05 clear, individual criteria for administration - for the benefit and review of fulltime staff members - and especially to support agency nursing staff when they are expected to administer such items. (Timescales of 30.12.04 & 30.05.05 not met.) Records of ‘PRN’ medication must be consistently kept on the medication administration record sheets. Staff members must be required to follow the procedure consistently so that full justification / ‘reference back’ / review is possible. 15/12/05 3 YA20 13(2) & 17 Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 29 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 YA24 Good Practice Recommendations The shared car parking area is slowly deteriorating and potholes are developing; the registered provider and the PCT should agree a strategy to address this safety issue before the surface deteriorates to a more significant level. A minimum of 50 of care staff should be trained to NVQ Level 2 in Care - or above - by 2005. It is strongly recommended that another staff member is delegated the responsibility to undertake the hot water maximum temperature outflow checks during any of the handyman’s absences. The visual checks that the ‘Dorgard’ fire door holders are releasing should be consistently – but separately - recoded alongside the fire alarm testing records. 2 3 YA32 YA42 4 YA42 Woodcote Road (75) DS0000019134.V259283.R01.S.doc Version 5.0 Page 30 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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