Inspection on 30/04/07 for Woodcote Road (75)

This inspection was carried out on 30th April 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodcote Road (75) 22/02/06

Woodcote Road (75) 15/11/05

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 Key Unannounced Inspection 30th April 2007 13:55p Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 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) Olaposi Olalowo Folaju Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three (3) specified service users over the age of 65 can be accommodated for as long as the service can adequately meet their needs. 22nd February 2006 Date of last inspection Brief Description of the Service: This home is registered with the Commission to provide personal & nursing care for up to twelve people with enduring mental health needs. The weekly charge, confirmed in April 2007 by the manager, was £1,200 per week per resident. 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 busses and a railway station, allowing quick access to the towns of Croydon, Sutton & into central London. The property comprises two large lounge areas and a separate dining room. An additional, principally self-catering, area is available in the newer part of the house to the rear. 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 open, ‘contemporary’ feel. There is a substantial, pleasantly sheltered 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.V337931.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit - which was unannounced - extended across the afternoon and into the early evening of a working day, the inspector being assisted in his work by both the deputy manager - Mary Colquhoun (previously the acting manager), and one of the team leaders - Sylvester Amuh. Sadly, the newly appointed manager, Ola Folaju, had just gone on leave earlier that very day, so the inspector was not able to meet with him. The follow-up of previous requirements and recommendations was conducted with the deputy manager, and the team leader generally facilitated the inspection of current administration, and discussed care practices. During the visit, the inspector was able to meet a number of care staff from two shifts; including his being involved in the afternoon handover meeting which was just commencing at the point of the inspector’s arrival. The inspector was able to speak with the majority of the residents - both jointly and on a one-to-one basis, in the main lounge, in the smaller selfcatering unit, and also over the supper meal, which the inspector took part in. Surveys returned to the CSCI, giving feedback about the home were provided from six relatives, and a GP and a Psychiatrist - with six residents also providing written feedback to questionnaires, which were subsequently provided and then returned to the Commission. What the service does well: The home provides a good service to the twelve service users, who mostly suffer from chronic mental health conditions, and who have been resident at the home for a minimum of about four years, and a maximum of nearer thirteen years. Two-thirds of these have been resident at the home since prior to 2000 - the earliest since 1994. The house is well maintained and provides private bedroom space of various sizes for each service user, as well as a variety of pleasant communal areas for their use. Individuals are encouraged to be independent as is possible / they wish to be, and to engage with community opportunities as much as possible though many find this engagement difficult - and need significant support. Residents and their families / advocates indicated - in their responses to the Commission’s questionnaires - contentment with the service provided: “Both my [relative] and myself are very happy with the arrangements at Hexagon House” - “All the staff I come in contact with are extremely helpful - and cheerful!!”………. - “The house always looks clean and tidy.” Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 6 Feedback from relatives and residents about the actual care service provided also speaks for itself: ”My [relative] receives very good care & support at Hexagon… happy within the limitations of his illness…this is something that has taken years to achieve…the staff do a great job” - “I am invited to the review of my [relative’s] progress and am given a copy of the review….” - “…staff are easy to talk to…” The home is well supported by the registered provider, Hexagon Housing, who provide the infrastructure of line management, documentation and estates support for the house - staffing is to a good level, and the resultant service is personalised and sensitive to each residents needs. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can be confident that they will – through adequate assessment and consultation, and 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: No resident at the home had been admitted through a full admission process since the National Minimum Standards and Care Homes Regulations 2002 were fully enforced - this requiring a Statement of Purpose and Service User Guide to be provided. Three residents at the home are over the age of 65 and a variation to the home’s registration recognises this fact. All three older residents are considered to be able to continue to receive an appropriate service in this service location; the management are clear about continuing assessment of needs to check this issue out. Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 9 Two residents have left the home since the last inspection - one due to their sad death (in hospital), and one due to their removal to a new care setting. Residents’ files contained their 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 would be visited by an allocated keyworker and co-keyworker to assess their suitability for the home itself, and refer their findings back to the home. All residents have a formal Licence agreement - relating to life at the home, including respecting the individuality / diversity of each worker / resident at the home - held with Hexagon Housing Association, as well as a three-way contract / agreement for the purchase of a care service between the service user / the home / and the funding authority. Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home maintains care plans and assessment documents designed to ensure that the expressed 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: Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 11 The inspector attended the handover between the six rostered staff, morning and afternoon shifts - and all of the residents were thoroughly, individually discussed, this ensuring that there was a continuity of approach and of the agreed care plan. 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, care manager / social workers and the community mental health team. 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. 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. 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 home now has a Rehabilitation & Activity Worker in post. Activities within the home include: Computer ‘classes’ / keep fit / Book Club / Karaoke & Disco / Relaxation / letter writing and current affairs sessions. Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11 - 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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: Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 13 Resident’s lifestyle in the local community is specific to each individual attendance at the local Leisure Centre, Cinema, and Pubs being matched by more ‘educational’ opportunities such as visiting libraries / museums and art galleries - as well as some residents taking part in local adult education activities at the local Scola. One resident regularly attends a Folk Club in a pub in Croydon town centre - and has an avid interest in music. 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 is very (if not too) popular with service users. According to expressed need, residents attend Church Services of their own choice, with two residents clearly having affiliations and active engagement with the local Roman Catholic and Anglican churches, respectively. One issue of concern raised in a relative’s questionnaire on behalf of their relative had been raised, coincidentally, in the recent residents’ meeting, discussed and a way forward agreed and minuted. It was heartening to see such active addressing of issues pertinent to the lifestyles of the residents, individually and corporately. 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. Holidays are arranged to meet individual needs; staff assist residents to chose an appropriate location and focus - and support their participation - depending on realistic assessment of the individual. The staff - the keyworkers especially, negotiate the ‘fine line’ of encouraging, whilst not forcing, service users into activity. Residents and staff’s cultural backgrounds are subtly promoted - for instance, in the dining area, which is a pleasant location that is furnished in a ‘smart’, but homely way, where there is a computer and also other leisure activity equipment - and interesting multi-cultural artefacts on display in a cabinet and on other surfaces. Poetry - written by the residents themselves - was afforded the respect and honour of being displayed in frames on the walls. There was a real sense of active work being undertaken and respect for achievement. One service user undertakes his catering in the back kitchen area – where many service users also make their own drinks during the day. Service users are used to assisting in the kitchen and there is a relaxed feeling to mealtimes and food in general. One resident stated in their questionnaire that they’d like more bacon - and more steak & kidney pudding. Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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 ensure the safety and consistent treatment and support for each service user, with specific measures being taken to encourage self-medication and familiarity with dealing with their prescriptions. EVIDENCE: Residents are respected for their preferences - for instance some females prefer the care of a female worker - including female company on holidays. Some females (the minority of the resident group) however, are quite content to have a male keyworker and work just as well with ‘opposite sex’ staff. Eight of the twenty staff team, in its entirety, are male. Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 15 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. Residents’ records showed that staff members ensure all service users keep in touch with their GP and any specialist health professionals - such as the Sutton Community Mental Health Team - based at Cheviot House, Sutton Hospital, which supports all residents in mental health issues. Feedback from this team was positive in regard to aspects of contact and support. Advocacy is available to individuals through the ‘allocated’ advocacy co-ordinator from the Sutton Advocacy for Mental Health scheme. The sole requirement set at the last inspection, concerning having a procedure and guidance concerning nursing staff’s responsibility for giving injections, has been fully met. It is further recommended that a second signature - to evidence the identity of the required witness to ‘depo’ injections - be recorded alongside the administrator’s signature. Two excellent examples of the home working with individual residents in regard to medication issues and ‘taking control’ were cited: In one example, a resident has been provided with a chart to explain ‘what, where and when’ is involved in their own medication regime - this allays their present anxiety and its consequences - as well as providing a mechanism for the home to work towards handing back the chance to self-medicate as soon as is practicable. Another example was given where the care planning of interventionist 1:1s for a resident, when they were feeling they were becoming needful of extra ‘prn’ medication, meant that this ventilation of feelings avoided the need for extra medication and de-escalated a potentially difficult situation. Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their comments and complaints are responded to, with appropriate action taken, within the context of the corporate complaints system run by the Housing Association. The home provides adequate support to service users to ensure that they are protected from harm and any form of abuse, neglect or self-harm. 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 home declared seven complaints as received in the past twelve months at the time of the inspection, with one yet to be concluded; of these only one was substantiated - concerning food issues. All complaints have been dealt with within the organisations stated timescales for resolution. Subsequent to the inspection visit, a significant but anonymous complaint has been received by the Commission, which the registered providers have handled in an exemplary way - through involving investigators at ‘arm’s length’ from the service provision to ensure impartiality and fairness to the investigation. Subsequent to the outcomes of this investigation being fed back to the Commission, the registered provider has shown due diligence by correcting the Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 17 (inadvertent) wrongs which had been revealed, and by revising policy, procedure and practice - to ensure that such circumstances could not rise again. All respondents to the CSCI residents’ questionnaire stated they were familiar with the procedure of how to make a complaint: one service user made it plain that if he has a complaint, they would “complain to my MP Tom Brake MP” - or would alternatively “speak to my social worker”. Another mentioned that they would approach their keyworker at the home. 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. Advocacy is also available to individuals through the ‘allocated’ advocacy coordinator from the Sutton Advocacy for Mental Health scheme. With regard to the gender balance of staff at the home, a concern raised by a resident about the presence of two female staff on at nighttime was thoroughly discussed at a staff meeting, and it was recognised that this would only happen if there was a clear emergency situation (perhaps a staff member going sick at the last minute). 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 without delay before any internal investigations commence. The registered provider has ensured that all staff members have been checked under the Criminal Records Bureau; the inspector noted CRB documentation for newer staff recruited since the last visit. Checks on any agency staff used are also rigorous, to ensure the ongoing safety of service users. Seven of the current ten service users were declared as being in control of their own financial affairs - though some have the over-arching support of their local authority. One resident is subject to Court of Protection oversight, and one is subject to legal Guardianship. Individual personal allowance amounts are kept in separate ‘wallets’ in the home’s safe for a couple of residents and moneys deposited for safekeeping for any resident is carefully recorded. The manager declared in the pre-inspection questionnaire that additional charges only come into play when ‘a service user requests more than one holiday per annum’ - the cost of this depending on the location, staffing input, and the duration of the holiday itself. Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 is comfortable and homely. Fire Risk assessments are in place and all equipment and the integrated fire alarm system was fully serviced and Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 19 operational. All maintenance records were found to be in order; only portable appliance testing appeared to be delayed in its annual cycle; the inspector received confirmation of these tests being done within a week of his visit. All bedrooms in the house are singly occupied and of various sizes. Three bedrooms have been repainted since the last inspection visit in February 2006. 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. Bedrooms are well decorated, warm and comfortable, and are laid out to the individual service user’s preference. Each bedroom has a wash-hand basin facility. There are four ‘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 an open floor-draining wet room, which enables staff assistance where necessary - and also avoids steps and problems with shower doors. This will be of growing benefit as the population at the home continues to age. Mindful of the developing age profile of the residents living at the home, the provision of radiator covers should be now considered in bathrooms, toilets and other such high-risk areas of the home; this is mentioned under standard 42. All bathing / toilet facilities seen were clean, tidy and at a comfortable temperature - staff ensure the thorough cleaning of such areas. The home has a range of “communal spaces” including a large lounge and a second equally large activities / lounge / dining area, that can be divided to provide a private communal space, if needed. There is also a 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. The home was clean, odour-free, tidy and well maintained on the day of this unannounced inspection. Staff and the maintenance / gardening person monitor all areas to ensure such aspects are being well kept, decorated and maintained. The staircase carpet has been replaced since the issue featured as a recommendation for action in the last inspection report. The large car park, which serves the home and the adjacent PCT building, has been recently tarmac’d - providing better and safer access to the home from both the main road and also the car park itself. A more substantial ‘security’ fence has been provided at the side of the building where it is ‘open’ to the car park - and added security for night times has been provided. Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can rely on the home providing adequate staff in sufficient numbers, and being duly competent and well trained, to provide a service that seeks to meet their individually identified needs effectively. Service users can be assured that the home’s recruitment and staff support mechanisms – including checks, induction and training processes - are organised so as to ensure the safety, protection and wellbeing of service users. EVIDENCE: Six team leaders, the deputy manager, and the manager are all currently registered nurses, who work alongside seven support workers, the rehabilitation cook and the activities officer. An administrator, half-time cleaner and gardener handyperson complete the staffing complement. Three of the care staff have competed their level 2 NVQ in care - as well as the activities worker having her level 3 qualification - this leading to the 50 figure of care staff qualified alongside the nursing staff being exceeded. Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 21 Some agency cover had been used by the home - to the extent of about ten shifts over an eight-week period. Occasional cover for the domestic worker and cook had also been used. Staffing is constant and reliable; only one staff member was recruited in 2006 - and two in 2005. The staff file of the new staff member was checked by the inspector and was in full accord with the regulatory requirements - including the Criminal Records Bureau check / appropriate references / induction record / supervision record and the training record, which was developing. The home benefits from having the ‘background’ support of a Personnel Section at Hexagon Housing. Hexagon Housing has a clear approach to diversity issues in its broadest terms - providing a 2/3-day course on diversity for its entire staff and promoting diversity in its newsletters and other publications. Dealing with discrimination - particularly racism at times in the home - is dealt with by strong reinforcement of the rights of all to coexist together, with inappropriate / offensive remarks being actively challenged. Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 & 43. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The registered provider ensures that the home operates well with competent local management systems to ensure that service users benefit from a wellrun, and safe environment. Service users can be assured that their rights and interests are well served and protected through the home’s approach to quality assurance, 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: Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 23 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, and on a structured basis. The management of the home is clearly well ordered; the house diary evidences attention to detail and shows that items are taken up and doublechecked to ensure full completion of tasks. Health & safety issues have been well managed within the home, with records seen for essential safety checks. The inspector recommends that audits between Fire Drill attendance and attendance at Fire Training seminars should be cross-referenced and maintained - to ensure that staff members continue to be actively involved in active drills on a regular basis. Advocacy is available to individuals through the ‘allocated’ advocacy coordinator from the Sutton Advocacy for Mental Health scheme. Monitoring meetings for the home are attended by such an advocate - providing an ‘armslength’ view of the home and its service provision. Quality assurance within the service is provided through various routes: - An independent freelance visitor conducts the unannounced Regulation 26 visits on behalf of the registered provider, Hexagon Housing. - The home actively involves of families / friends/ advocates in resident review meetings; this was confirmed by relatives. - Through questionnaires to residents and the circulation of information magazines on a quarterly basis, seeking their feedback and opinions. - Residents are invited to the organisation’s ‘User forums’ twice a year including being invited to inform the agenda for those meetings. Regular Residents meetings are also held at the home, these being minuted. 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 Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 24 members acknowledge policies and procedures drawn to their attention by signing a document indicating both reading & understanding of such policies. 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 the running of the home both 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.V337931.R01.S.doc Version 5.2 Page 25 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 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 X 3 X 4 X 3 3 3 Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations That a second signature - to evidence the identity of the witness to ‘depo’ injections be recorded alongside the administrator’s signature. An audit of participation in Fire Drills by staff should be undertaken to ensure that they are regularly attended, as well as attendance at the Fire Training seminars. Mindful of the developing ageing profile of the residents living at the home, the provision of radiator covers should be now considered in bathrooms, toilets and other such high-risk areas of the home. 2. YA42 3. YA42 Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodcote Road (75) DS0000019134.V337931.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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