Inspection on 25/04/05 for Woodcroft (Reigate)

This inspection was carried out on 25th April 2005.

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

The inspector 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

Woodcroft (Reigate) 12/06/09

Woodcroft (Reigate) 25/06/07

Woodcroft (Reigate) 24/11/05

Woodcroft (Reigate) 20/12/04

Woodcroft (Reigate) 14/07/04

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

CARE HOME ADULTS 18-65 Woodcroft 69 Lonesome Lane Reigate Surrey RH2 7QT Lead Inspector Damian Griffiths Unannounced 25 April 2005 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 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 Stationary 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. Woodcroft Version 1.10 Page 3 SERVICE INFORMATION Name of service Woodcroft Address 69 Lonesome Lane, Reigate, Surrey. RH2 7QT 01737 241821 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Millstead Care Ltd Mr Stuart Lomath CRH (PC) 6 Category(ies) of Learning Disability (LD) 6. registration, with number of places Learning Disability over 65 years of age (LD(E)) 1. Woodcroft Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Of the six residents accommodated in the home, one may fall within the category of LD(E). Date of last inspection 20 December 2004 Woodcroft Version 1.10 Page 5 Brief Description of the Service: Woodcroft is a home for life for 6 residents with learning and communication difficulties. The home is a small and comfortable detached bungalow situated in a quite rural lane on the outskirts of Reigate. It is close to the local town centre. The bungalow is enclosed within its own grounds and has a large rear garden. Residents are able to reach the garden by patio doors leading from the main living room area. There is parking available to accommodate 4 vehicles. All 6 rooms have their own washbasins and there are two large fully equipped communal bathrooms. The care staff at Woodcroft are qualified to NVQ level 2-4 and new staff are offered training and a full induction programme that includes supervision by senior members of the staff team. Residents and staff enjoy participating in local events of their choice and have a full programme of daily activities of their choice and staff. Woodcroft have a “Statement of Purpose”, which is available from the home for prospective residents. Woodcroft Version 1.10 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection for the year April 2005 to April 2006. It took place over 6 ½ hours. The lead inspector Damian Griffiths carried out this inspection and was assisted by staff members representing the Service throughout the inspection. Senior support worker Mandie Ford assisted in the morning and deputy manager Jacqueline Watson in the afternoon. Woodcroft is a small group home for residents with a learning disability. The care home was solely occupied by the homes maintenance man when I arrived. He kindly showed me around the premises that were seen to be clean, tidy and very homely. Two staff members and a resident arrived home shortly after I had arrived. The other residents and staff were attending various activities. I met 4 residents 2 of who were happy to talk to me. The Staff I met were courteous and sensitive to the residents needs and assisted me to communicate with some of the residents. What the service does well: What has improved since the last inspection? I was informed that the home has a program of maintenance that continues to improve the homes appearance. The window frames of the home were in need of attention when last inspected and have now been painted. Another requirement from the last inspection was for Woodcrofts’ business and finance plan to been submitted. This has been done and staff training in the Protection Of Vulnerable Adults training has been completed. Copies of staff Criminal Records Bureau (CRB) have been evidenced. Woodcroft Version 1.10 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodcroft Version 1.10 Page 8 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 Standards Statutory Requirements Identified During the Inspection Woodcroft Version 1.10 Page 9 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 standard(s) 1,2,3, and 4. The homes statement of purpose is presented in plain English that is easy to understand. The home has good methods of record keeping in place. The residents at Woodcroft receive a comprehensive assessment of their care needs that includes likes and dislikes. They are helped to visit health service professionals when needed. The care assessment received at Woodcroft is also able to highlight and manage potential risks for residents. EVIDENCE: Woodcroft staff are required to read the Statement of Purpose and to sign to confirm this. Residents have copies of Woodcroft Service Users Guide situated in a red folder within their bedroom. Staff are committed to helping each resident to understand their rights within the home and in the community. The residents red folder contains details of the cost of the accommodation, the way to make a complaint and access local amenities. A new resident to the home receives an assessment of their own care needs and Social Services may also provide a Care Mangers assessment, as was the case with the residents files inspected. New residents are given time to adjust to the idea of leaving home to stay at Woodcroft. This is achieved by visiting and staying for tea, weekend breaks, and then longer. Prospective residents are able to benefit by this approach and eventually achieve maximum independence from the parental home. Woodcroft Version 1.10 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 standard(s) 6, 7,and 9. Staff respect the residents right and ability to make decisions and act on them whenever reasonably possible. Risk factors have been identified and action plans are produced to reduce the risk. The inspection revealed there to be some care plans that required reviewing. EVIDENCE: New residents to Woodcroft have their own Individual Program Plan (IPP) compiled by a staff member assigned to them known as a “Key-Worker” and forms a part of their care plan. The IPP enables all staff at Woodcroft to be aware of the resident’s particular care needs and interests. Residents without family were able to have their own advocate from outside of the home. The IPP is reviewed annually and is a part of the plan of care. Residents of Woodcroft have access to the local GP and are in contact with their local area Social Services Department. Residents are supported to attend professional health care services and hospitals. One resident at Woodcroft has a hospital appointment and will be taken there by the staff. A resident was observed being taken out on two occasions. Staff informed me of the assessed risks that had been identified and were confident in managing the situation. The staff later admitted that they had not actually read the care plan. The resident enjoyed his walk. Woodcroft Version 1.10 Page 11 Each resident receives a risk assessment that helps him or her to achieve a relatively safe outcome. The manger at Woodcroft is required to ensure a review of all care plans and risk assessments that are overdue some of the care plans inspected were in need of review. One resident is required to have a risk assessment due to being taken to the A&E department of the local hospital for a complaint that may reoccur . Woodcroft Version 1.10 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 standard(s) 13 and 17. Residents at Woodcroft are helped to visit local amenities of their choice and gain access to local community events. Staff actively promote healthy diets when helping them to chose a variety of low fat foodstuffs for the daily menu. EVIDENCE: Residents are able to visit the local shops and day centres and some attend the local colleges. The inspector was informed that residents also visit two local pubs and several restaurants. All the residents are able to attend the local Church of England service on Sundays if they wish. Staff assist residents to stay in touch with old friends. Residents are taken to see them every week. Residents with girlfriends are able to spend time together in the privacy of their room. Later on this month, residents will be able to exercise their right to vote in the general election. Samples of daily menus were inspected and residents have a reasonable and varied choice of meals. Special dietary requirements are also noted on the menu along with individual likes and dislikes. Woodcroft Version 1.10 Page 13 Staff at Woodcroft informed the Inspector of their intent to allow greater individual choice and also to promote a low fat diet whenever possible. Residents are free to choose different foods and staff record food that is disliked for future reference. A bowl of fruit is always available for residents to help themselves. Woodcroft Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20. Residents have access to all relevant Health Care services within the local community and all prescribed medication in the home is recorded and administered safely. EVIDENCE: One resident has needed to be taken to the Accident and Emergency unit at the local hospital since the last inspection. The resident (and family) have been supported to attend and to see a specialist by the staff at Woodcroft. The accident book was inspected and contained details of the incident. A risk assessment is required to ensure that if there is a repeat of this incident the resident is able to see either the consultant that is familiar with this case or the consultant has identified staff at the hospital that are able to manage the residents particular needs. All residents have access to the usual health practitioners; GP, Community Nurse and Chiropody services and they also enjoy visits from an aromatherapist. Prescribed medication, is kept locked and within a metal cabinet as required by regulation. Only trained staff are allowed to distribute medication to the residents. The inspector was able to confirm that all prescribed medication was dated correctly. The Medical Administration Sheet was correct and up to date and the returns book completed and stamped by the local pharmacy. Woodcroft Version 1.10 Page 15 Woodcroft Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 . Residents at Woodcroft are able to make their needs known to staff, however there is no evidence to confirm how the complaints system works for the residents, there are no examples in the policy or in the residents “Service Users guide”. Woodcroft needs to ensure that new staff employed have all their appropriate documentation kept in staff files within the home and available for inspection. EVIDENCE: There have been no complaints registered at Woodcroft since the last inspection. Staff are required to read the complaints policy and procedures and sign that they have read them. At the time of the inspection there was evidence to show that some staff had not complied with this procedure. The residents have details of how to complain in their own “Service Users Guide” kept in red folders in their rooms, and details of CSCI are included. The residents spoken to by the Inspector did not know how to make a complaint despite the information being provided. A staff member or advocate would need to help them to make a complaint. The key-worker system used at the home involves a dedicated member of staff who is assigned to work with a resident to identify issues for personal development. One key worker informed the inspector of her intent to provide a pictorial account to help assist a resident understand the complaints process. I have, therefore, made a recommendation that a suitable format for residents to be explored and if successful be included in the service users guide to provide an example of how a resident can make a complaint. The statement of Purpose informs residents of the opportunity to express views and ideas at house meetings. Details of the meetings were not seen during this inspection. Woodcroft Version 1.10 Page 17 The new guidelines for the Surrey Multi-Agency Procedures for Vulnerable Adults were available and in place. Woodcroft Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,26,27 and 28. Woodcroft is a homely environment safely run and is reasonably well maintained. It is located within it’s own extensive grounds and is suitable for it’s stated purpose. EVIDENCE: The premises are in good order. The window frames were raised in the last inspection report, however they have been painted and the inspector was informed that the home has a planned maintenance programme. The inspector was unable to see this during the inspection. The rear garden is well maintained and accessible from the communal area of the living room. Residents have full access to all rooms that were upon inspection, clean and airy. The living room however was in need of redecoration and the curtains and curtain rail were hanging off the wall and wallpaper was torn. The radiator in this room was without a suitable cover and a resident had been injured in the past. The accident had been recorded but it was not apparent how it had been rectified. In the interests of health and safety the inspector requires this to be rectified. Woodcroft Version 1.10 Page 19 All residents were able to personalise their rooms and all had access to their own TV and audio equipment. Staff are trained and understand the fire policy and procedure. Equipment is regularly maintained and inspected by the Fire Safety Officer. Residents expressed satisfaction with their home. The Inspector was able to speak with two residents about the home and they confirmed this with smiles of approval. Both were sitting comfortable and relaxed in the communal area. Woodcroft Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 The manager has direct responsibility to recruit staff that are able to show the necessary skills and qualifications to support the residents at Woodcroft and that all safety checks have been carried out as required. At the time of the inspection the home was not able to provide the appropriate documentation to confirm the safety checks for staff had been carried out. EVIDENCE: All staff receive a full programme of training including first aid and support to acquire NVQ levels 2 –3. Staff are encouraged to participate with distance learning packages that are made available. New staff members receive induction training and are supervised before they are allowed to work on their own with residents. Woodcroft Version 1.10 Page 21 The Inspector spoke to five members of staff, including the Deputy Manager, and all were helpful and enthusiastic and enjoyed being at Woodcroft. Woodcroft states that Residents are encouraged to participate with staff recruitment and prospective staff members are expected to spend supervised time with the residents. Staff were all very attentive and able to show their skill, patience and understanding towards the residents. The atmosphere at Woodcroft was homely and relaxed even when residents that I had not met arrived home from the Day Centre they were attending. A new staff member who reported that she was very excited about her new role at Woodcroft was however unfamiliar with the residents Care Plan and had not signed the Policy and Procedure schedules. The Inspector discussed the relevant Protection of Vulnerable Adults procedure with the Deputy Manager. Eight enhanced (completed) CRB checks were recorded however two new staff members had not received the completed CRB certificate. The Inspector was unable to record details that would clarify the requirements of the Care Standards Act (2001) as they were with the Registered Manager who was absent. The details relate to references and ID. Access to staff records were also an issue at the previous inspection. The Deputy Manager assured the Inspector that new staff members are not allowed to work alone with the residents until certificates in place. An immediate requirement for the production of the required documents was therefore issued. A CRB check is also required for all therapists/Volunteers visiting the home. There is a need to comply with the procedures identified by the Care Homes Regulations (2001) and the “Protection Of Vulnerable Adult Scheme, A Practical Guide” lists individuals to be checked, e.g., chiropodists and, this would include the aromatherapist. To ensue that staff members are safe to work with the residents at Woodcroft. The inspector has made this an immediate requirement. Woodcroft Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not inspected EVIDENCE: Woodcroft Version 1.10 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 3 3 x x Standard No 11 12 13 14 15 Woodcroft x x 3 x x Standard No 31 32 33 34 35 36 Score x x x 1 x x Version 1.10 Page 24 16 17 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x Woodcroft Version 1.10 Page 25 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 34.1-3 Regulation 19(1) (b) (4)(b) Requirement The registered person shall not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraphs 1-9 of schedule 2. The registered manger will ensure residents care plans are reviewed and appropriate risk assessments are in place. The registered person must ensure that all parts of the care home are reasonably decorated, e.g., living room area. The registered manager shall ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazard to their safety, i.e., The radiator in the living room area must be covered or pre-set on a low surface temperature. Timescale for action 25/4/05 2 6 and 9 15 (1) (2) (b) 23 (2) (d) 18/07/05 3 24 04/07/05 4 24 4 (a) 18/07/05 Woodcroft Version 1.10 Page 26 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 22.5/7.2/7. 4 Good Practice Recommendations It is recommended that the home follow up and develop a pictorial method of “how to make a complaint” with the residents and if successful, show this as an example in the service users guide. It is recommended that a copy of maintenance schedule be sent to the lead inspector at CSCI on receipt of this report. 3 24 Woodcroft Version 1.10 Page 27 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. Extracts may not be used or reproduced without the express permission of CSCI Woodcroft Version 1.10 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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