CARE HOME ADULTS 18-65
Woodcote Road (75) 75 Woodcote Road Wallington Surrey SM6 0PU Lead Inspector
David Pennells Unannounced Inspection 22nd February 2006 3:25pm Woodcote Road (75) DS0000019134.V283032.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 Road (75) DS0000019134.V283032.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 Road (75) DS0000019134.V283032.R01.S.doc Version 5.1 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.V283032.R01.S.doc Version 5.1 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. 15th November 2005 Date of last inspection Brief Description of the Service: The home is registered with the Commission to provide personal & 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, including a railway station, allowing quick access to the major towns of Croydon & Sutton. The property comprises two large lounge areas and a separate dining room. There are 12 single bedrooms situated on the ground and first floors. All bedrooms are provided with wash-hand basins. There are 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 contemporary feel. 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.V283032.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection visit was conducted during the late afternoon / early evening of an ordinary weekday. The Acting Manager, Mary Colquhoun, was available to assist the inspector in reviewing previous requirements & recommendations set at the last inspection, and staff and service users were happy to chat with the inspector about life and work at the home. The inspector is grateful to the service users, manager and staff for their welcome, hospitality and cooperation. What the service does well: What has improved since the last inspection?
Requirements relating to the guidance around ‘prn’ (‘when required’) medication have been fully responded to, with the home having created clear guidance and documentation relating to each service user’s medication, as applicable. The third requirement - though kept in this document - has been ‘semi’-met - by the manager ensuring that books on best practice regarding injections are available to nursing staff - this whilst awaiting the publication of the Hexagon approved policy document. The requirement is kept in to ensure that the document does, in fact, appear. Staff members have now completed their NVQ training in care in sufficient numbers to achieve the target of 50 of care staff being qualified. Woodcote Road (75) DS0000019134.V283032.R01.S.doc Version 5.1 Page 6 Recommendations relating to ensuring that health & safety checks are undertaken in the handyperson’s absence have been heeded and the recording of checks of fire door holders is now in place. 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.V283032.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 Road (75) DS0000019134.V283032.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): none inspected fully this time. 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: Due to the longevity of stays at the house (over two thirds of the population having been at the home for more than five years - the most recent having been in the home for nearly three), the occasion for introduction of new service users has not arisen more recently. The home was inspected against the key standard and also Nos 1,3 & 5 - all were found ‘met’. No standards were inspected this time; from knowledge of the home and its practices, the remaining standard would almost certainly be met - and for the information of readers of this current report, the judgement statements from the previous inspection report are reiterated above. Woodcote Road (75) DS0000019134.V283032.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): none inspected fully this time. 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: All three key standards - and standard 10 - were inspected at the last inspection visit and all found ‘met’. For the benefit of readers of this report, the judgement statements are reiterated from the previous inspection report covering these principal areas.
Woodcote Road (75) DS0000019134.V283032.R01.S.doc Version 5.1 Page 10 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): 15. 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 will be encouraged to maintain and are supported to make appropriate relationships. 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: All standards - except key standard 15 - were inspected at the last visit, and found ‘met’. The above judgement statements, excepting the second one, are reiterated from the previous report. Standard 15 is also, now found ‘met’. Woodcote Road (75) DS0000019134.V283032.R01.S.doc Version 5.1 Page 11 In regard to Standard 15, the home makes every effort to ensure that service user relationships with families and friends / contacts are maintained and enabled in the most appropriate and satisfying way. Some service users regularly have friends or family visit the home, and a number go away to stay with their friends / loved ones. Social events are seen as a way of encouraging engagement. Family members are invited to be involved in reviews, and the service user’s opinions are respected if they prefer a ‘distance’ to be maintained, or not to engage with them at all. Friendships are also encouraged outside the house; a number of service users attend activities where they have external ‘sets’ of friends / acquaintances. A service user’s sexuality / orientation is accepted by the house, with appropriate encouragement / guidance being provided to support such issues. Access to psychology / counselling is available for relationship issues. Woodcote Road (75) DS0000019134.V283032.R01.S.doc Version 5.1 Page 12 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): 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. EVIDENCE: Standard 20 is marked as ‘met’ by the inspector - this intentionally being done, despite the requirement still being quoted at the back of this report. The house now just awaits the advent of a written procedure and guidance for the administration of injections - which must be held alongside the medications policy and procedure - to acknowledge nursing staffs’ responsibility for injections to some service users. Books on ‘best practice’ are now in place at the home - as an interim measure; the acting manager accessed these, pending the central policy document is being published. The requirement has therefore been met ‘in spirit’ - the document ‘closing the circle’. The remaining previous concerns regarding ‘prn’ (‘when required’) medication have now been fully addressed. All other standards were previously found to be ‘met’.
Woodcote Road (75) DS0000019134.V283032.R01.S.doc Version 5.1 Page 13 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): neither inspected fully this time. 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. The standard was found fully ‘met’ at the last inspection visit. 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 standard was also found fully ‘met’ at the last inspection visit, and the inspector had no reason to change the assessment of these standards at this visit. Woodcote Road (75) DS0000019134.V283032.R01.S.doc Version 5.1 Page 14 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. 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: 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 - and are the subject of a recommendation brought forward from the previous report. The only other issue raised at this visit is the recommendation that the principal staircase carpet be reviewed with a view to replacement in the foreseeable future. Woodcote Road (75) DS0000019134.V283032.R01.S.doc Version 5.1 Page 15 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): none inspected fully this time. 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: 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. About eighteen staff members are currently working at the home. Of these staff, seven are registered nurses currently and 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 ‘Rehab Cook’ post has now been recruited to; the new incumbent was interviewed and found to be positive about the new workplace and the opportunities for the future. Sufficient staff members have now completed their NVQ - at level 2 or above -to ensure that the house has met its standard target of at least 50 of the care staff being qualified in care practices. All standards were found ‘met’ at the last inspection and clearly continue so.
Woodcote Road (75) DS0000019134.V283032.R01.S.doc Version 5.1 Page 16 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): none inspected fully this time. 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. 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 Woodcote Road (75) DS0000019134.V283032.R01.S.doc Version 5.1 Page 17 NVQ, Level 5, in Management and has worked as Deputy previously in the home for some four 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 will be 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. Statutory records and documentation relating to the conduct of the home was examined at the time of the inspection visit and all was found kept satisfactorily. All but two standards were found ‘met’ at the previous inspection, and the inspector is confident that all elements of the remaining two (which are not key standards) would also be met. The above judgement statements reflect the inspector’s general contentment with the conduct of the home, and the ongoing support given by the home’s management to staff and service users - and by senior management to the manager and the home itself. Woodcote Road (75) DS0000019134.V283032.R01.S.doc Version 5.1 Page 18 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X X X X X X X X Woodcote Road (75) DS0000019134.V283032.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES 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 acknowledge nursing staffs’ responsibility for injections to some service users.
Timescale of 30/12/05 not met - though books on ‘best practice’ are now in place, and the central policy document is undergoing revision. Timescale for action 30/04/06 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 deteriorating - with potholes 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, creating a greater hazard that it potentially already is. The principal staircase carpet must be reviewed for safety and possible replacement in the near future.
DS0000019134.V283032.R01.S.doc Version 5.1 Page 20 2. YA24 Woodcote Road (75) 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
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