Inspection on 10/07/07 for Woodham 2

This inspection was carried out on 10th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodham 2 09/07/08

Woodham 2 24/01/07

Woodham 2 16/01/06

Woodham 2 20/07/05

Woodham 2 21/01/05

Woodham 2 08/09/04

Woodham 2 04/02/04

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 Woodham 2 33 Newlands Park London SE26 5PN Lead Inspector David Lacey Unannounced Inspection 10th July 2007 10:00 Woodham 2 DS0000044288.V339045.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 Woodham 2 DS0000044288.V339045.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. Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodham 2 Address 33 Newlands Park London SE26 5PN 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) 020 8778 1850 F/P 020 8778 1850 woodhamltd@aol.com Woodham ENT Ltd Pamela Ruffles Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2007 Brief Description of the Service: Woodham 2 is a detached Victorian residence on a main road in Sydenham, within a short walk from shops and rail or bus transport. The building has been converted to a home providing care for up to nine residents with mental illness and forensic histories. The care home aims to support people who are aged 1865 and have been discharged from psychiatric in-patient facilities, mediumsecure units or special hospitals. People resident at the home are encouraged towards independent living in the community. The fees for Woodham 2 are a minimum of £1,000.00 per week (information provided to CSCI in July 2007). Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced visit to the home, when I spoke with residents, members of staff, and the registered manager. I looked at some of the documentation in the home and toured the premises. Residents at the home were invited to complete and return postal questionnaires to the commission, and their responses have been summarised in the report. The home has recently provided a self-assessment of the quality of its services, which also informed the inspection. What the service does well: What has improved since the last inspection? What they could do better: Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 6 Make sure that all elements of residents’ care plans are implemented so their assessed needs may be met. Where residents are choosing not to follow their planned therapeutic programmes, the home needs to make it evident this has been reviewed with the resident and the appropriate care manager. As previously required, specific training needs to be made available for all care staff in the rehabilitation of people with mental health problems, as the statement of purpose shows this is the main focus for the home. The recruitment records for all staff based at the home need to be available for inspection, so it can be determined that the operation of the home’s recruitment and selection procedures is protecting residents. It needs to be evident that all staff members have regular supervision sessions, because this helps to ensure they are competent and confident to give residents the care they need. Make sure the provider’s policy and procedure have been followed in managing any complaints received. This will ensure that complainants have their concerns investigated promptly and receive a response within a reasonable timescale. The home needs to have in place a detailed building/environment risk assessment and an up to date certificate for the home’s electrical wiring installation. 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. Woodham 2 DS0000044288.V339045.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 Woodham 2 DS0000044288.V339045.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): 1, 2, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ needs are assessed, to ensure the home can meet them. People and their representatives can visit the home before deciding whether to move in. Residents are provided with written terms and conditions for their placement at Woodham 2. EVIDENCE: Before a resident is offered admission to the home, a full needs assessment is undertaken. When I arrived for the unannounced visit the registered manager was out of the home carrying out a pre-admission assessment of a newly referred client to see whether the home could meet his needs. In the residents’ plans I sampled for inspection, there was evidence that their needs had been fully assessed before they moved in. There were Care Programme Approach (CPA) reports and hospital discharge reports, as well as evidence that the home had carried out its own assessment. On each file there was a copy of the letter sent by the home to the resident confirming that, following assessment, the home can meet their needs. Of the six residents who returned completed comment cards to the commission, four stated they had received enough information about Woodham 2 before they moved in so they could decide if it was the right place Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 9 for them. Two residents stated they had not received enough information. Five residents had been asked if they wanted to move to this home, and one stated that he had not been asked about this. The manager confirmed the home’s normal practice is to offer prospective residents the opportunity to visit the home before being offered a place. There is then a trial period to enable all parties time to assess if the placement is the right one for the resident. Residents are provided with a contract detailing the terms and conditions of their stay in the home, and copies of these were in residents’ plans I sampled for inspection. Woodham 2 DS0000044288.V339045.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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to make decisions about their life in the home, and to maintain their independence. It was evident that residents are involved in planning and reviewing their care. All residents have care plans that offer guidance to staff on how to meet their needs but some therapeutic activity plans were not being carried out in full. EVIDENCE: I looked at three residents’ care plans, which addressed their assessed needs. There were risk assessment and risk management plans in place, which covered each resident’s mental health needs, giving information and guidance about signs and symptoms that are likely to indicate recurrence or deterioration of their mental health problems. The home had addressed a previous recommendation to improve care planning. Care plans had been reviewed regularly and residents had been invited to sign, confirming their involvement in planning their care and their agreement with the plans. Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 11 It was evident from care documentation, from observation during the visit and from discussions that residents’ choices sometimes conflict with the therapeutic programmes they have signed up to. Planned therapeutic activities to develop residents’ independent living skills and abilities to manage aspects of their behaviour were not always taking place. For example, a resident who was due to attend a college course on the day of the inspection decided not to do so, although he was said to have received prompting from staff. Staff could have attempted to engage him in other activities that he might have preferred but did not take the opportunity to do this. Other residents remained in bed for much of the day, thus did not carry out the activities on their plans. Staff members commented that, although they offered therapeutic activities, residents often did not wish to undertake them. Staff members stated they inform care managers when residents are not following their planned programmes but there was not enough evidence of this or of strategies used by staff to try to increase residents’ engagement with their planned therapeutic programmes (see requirements). Each resident is allocated a key worker, a strategy which is intended to enhance the level of service provided by holding key worker sessions that consider various aspects of residents’ support and care needs. Residents’ plans had monthly key worker summaries on file. Generally, it was evident that residents had received regular key work sessions, although one of the residents had refused this service and this had been noted on the monthly summary. Of the residents who returned completed comment cards to the commission, two stated they always make decisions about what they do each day, and four stated this was usually the case. Residents decide how they spend their time although, as noted above, their choices sometimes conflict with their therapeutic programmes. I saw notes of residents’ forum meetings, which showed that residents were involved in making choices and decisions, and enabled to contribute their views and ideas about the running of the home. The most recent forum had been held on 10 June. The meeting had an agenda and had been chaired by a resident. The home provides information about local independent advocacy services, and this is displayed prominently on the notice board in the hallway. Woodham 2 DS0000044288.V339045.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): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to engage in meaningful activities although they are not always taking up the therapeutic programmes offered to them. An annual holiday for all the residents had just taken place, and most had chosen to go. Residents are supported to maintain links with their families and friends, but space in the home to see visitors privately is limited at the present time. Residents have a varied diet, and may contribute to decisions about changing menus. EVIDENCE: The home offers a therapeutic programme that aims to support residents to develop independent living skills. Examination of care plans and discussion with residents showed they are encouraged to explore and take up educational and employment opportunities, and to engage in fulfilling activities. For example, one resident had gone to the gym on the morning of the inspection and another said he also goes to the local gym sometimes. However, as mentioned earlier in this report, some planned therapeutic activities had not Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 13 been carried out and this needs to be addressed. It had appeared that service users were spending their day as they wished to do so, not necessarily engaging regularly in appropriate rehabilitation activities. Residents had been on holiday again this year to Butlins. This had been offered to all residents, within the contract price, but two had chosen not to go and had stayed behind in the home. It was evident that residents are supported to maintain links with family and friends. For example, one of the residents was out of the home at the time of the inspection visit as he was spending a few days with a parent. Another resident told me about going on a holiday abroad recently with his family, which he had enjoyed very much. The home has some restrictions, for example, there is a curfew time. Prospective residents are made aware of these restrictions before they decide to move in, and they are included in the written terms and conditions that they receive and sign. ‘House rules’ mean, for example, that residents are expected to take responsibility for doing their own laundry and tidying their rooms. Five residents who returned completed comment cards to the commission stated they could do what they wanted during the day and the weekend. Four stated they could do what they wanted in the evenings but one said he could not. It was said meeting with a visitor in the lounge is possible but lacks privacy as other residents are around, and that smoking is permitted only in the lounge or outside. I raised these matters with the manager who said the house rules are always explained to each prospective resident before they make a decision to move into the home. Residents have keys to their rooms and, during my visit, I noticed that residents were coming and going from the house freely. The present menus had been drawn up in January 2007, following discussion with residents. The menus, which are due for review in July 2007, indicated that residents are offered a varied diet. Food stocks in the home seemed low on the day of my visit, with little food in the kitchen fridge and freezer and stocks in the basement freezer needing replenishment. The person in charge explained that a shopping trip was taking place today, now that five of the residents had returned from their annual holiday. There was a bowl of fruit on the dining room table, from which residents could help themselves. Residents make their own breakfast and lunch, and each of them has a ‘cooking day’ when they help staff to plan and prepare the evening meal. Residents said they have enough to eat and drink, and daily records of food served are kept and were available for inspection. These records indicated that residents were usually provided with a diet that was nutritious and healthy. Feedback from residents about the food was mainly positive. Woodham 2 DS0000044288.V339045.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 good. This judgement has been made using available evidence including a visit to this service. Residents were generally satisfied with the support they receive from staff. Generally, their physical and mental health needs are met, and they have good access to services, with health and social care professionals visiting them in the home or seeing them at clinics. The home must ensure that care is always delivered as planned. Medicines are administered safely and residents who are assessed as able to self-medicate are supported to do so by the home’s staff. EVIDENCE: None of the people living at the home at the present time need support with personal care although, when necessary, staff members offer prompting and encouragement. The home operates a key-worker system to ensure consistency of support, and residents I spoke with were generally satisfied with the support they receive. Residents felt staff generally respect their privacy and dignity, for example, they knock on bedroom doors before entering. I saw and heard friendly and informal interaction between staff and residents during my visit. Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 15 It was evident from discussion and from relevant documentation that residents’ physical and mental health care needs are addressed. Health care services, such as optical and dental services, are readily available and all residents are registered with a local GP. Residents also have regular Care Programme Approach (CPA) reviews and attend psychiatric outpatient clinics. Mental health professionals, such as community psychiatric nurses, visit individual residents at the home. It was noted that for some residents it had been included within their care plans that they should be tested for illegal substances. However, records indicated this had not always occurred as frequently as it had been specified. The home has a ‘no drugs’ policy and one resident commented, “In the past I have been in hostels where there were people smoking drugs but this place is drug free which helps a lot”. From this, it can be seen it is important for residents that testing is carried out at the prescribed interval. Similarly, the care review of a resident in April 2007 had identified specific inputs to be provided by Woodham staff. These included monitoring the resident’s weight and encouraging healthy eating options, but records showed he had not been weighed since 27/4/07. Monitoring of vital signs and giving feedback to the assertive community team was part of the plan but it was not evident this had been carried out. Staff were tasked to encourage self-care, such as looking after his room, but his room was very untidy and it was not evident during my visit that staff were encouraging him to address this (see requirements). Medication procedures had not changed since the last inspection. Medication is stored in locked cabinets in the office, plus there are storage cabinets in each resident’s room to allow for self-medication. A senior support worker gave medicines on the morning of my visit, and I observed her doing this safely and in accordance with the home’s procedures. She explained the home’s procedures for receiving, administering and disposing of medication, and showed me the relevant records. Discussion and later scrutiny of her personnel file confirmed she had completed training to prepare her to administer medication. She holds a Certificate in the Safe Handling of Medicines (NCFE level 2), which she obtained in November 2006. It was evident all staff based at Woodham 2 had completed medication training. Staff members’ had completed a signature and initial list, to assist medication auditing. Community psychiatric nurses visit the home to give depot medication to any residents who are prescribed this treatment. One medicine administration record I saw had two alterations made with correction fluid (e.g. ‘Tippex’) where a dose had been recorded in the wrong place. This was raised with the manager who agreed to remind staff to handwrite any alterations (see requirements). Two residents were self-medicating, following a process of risk assessment. Staff members had followed the home’s self-medication procedures when supporting residents to administer their own medicines. Their medicines are decanted into dossette boxes, one week’s supply at a time. Only staff who Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 16 have been trained carry out the secondary dispensing into the dossettes. The home keeps a ‘decanting book’, which showed that two staff sign. The residents confirm verbally to staff that they have taken their medication, and staff had signed to this effect. Staff had carried out regular spot checks to make sure medication is being taken and had recorded when they have done this. Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents know how to make a complaint should the need arise and who to speak to if they are not happy. It was not evident that a recorded complaint had been managed in line with the home’s complaints procedure. Staff know that residents must be protected from abuse, and staff based at the home have completed adult protection training. EVIDENCE: Since the last inspection, the commission has not received any complaints, concerns or allegations about this home, and is not aware that any adult protection investigations have been carried out in relation to residents living at Woodham 2. All six residents who returned completed comment cards to the commission stated they knew who to speak to if they were not happy. One commented he would speak with “a member of staff”. All six residents stated they knew how to make a complaint. One commented, “I have complained once or twice to staff, would not know anyone higher to complain to”. The home has an appropriate complaints procedure, which is made accessible to residents and visitors by being displayed on a notice board in the hallway. A resident said if he was worried or wanted to complain about something he would talk to his key-worker or to the home’s manager. Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 18 The information supplied by the home to the CSCI before the inspection stated no complaints had been received in the preceding twelve months. However, the home’s complaints book had one recorded complaint since the previous inspection. This was a written complaint from a resident about the delay in getting a new clothes rail he had been requesting. The entry in the book referred to the letter from the resident being filed elsewhere but this letter could not be found. There were no records to show how the complaint had been managed in line with the home’s procedure (see requirements). The home has appropriate procedures in place to safeguard adults. Discussion with the manager and inspection of training records showed that the three staff members based at the home had completed adult protection training. Other staff members on the duty rota are based at a different Woodham Enterprises care home. The manager said they had received adult protection training but it was not possible to see their training records, as these are kept at the other home. Care staff were aware that residents must be protected from abuse and knew about their reporting responsibilities if they witnessed or suspected abuse. Information supplied by the home to the CSCI before the inspection confirmed there is a policy and procedure for managing residents’ money, valuables and financial affairs. Most of the residents manage their own finances. One said he had been pleased to have some help with managing his money. Three residents’ plans I saw included financial records referring to a ‘fund’ into which residents pay money, which they withdraw as needed. The records specified amounts and dates of transactions, and were up to date and signed. One resident had paid in and withdrawn substantial sums from the fund. The other two had paid in and withdrawn much smaller amounts. I raised this with the registered manager and asked her to clarify this arrangement. She said it had been an arrangement set up to help residents who had difficulty in managing their finances. The aim was to support these residents to become financially independent. She was aware of the care homes’ regulations in this respect, and confirmed the monies were neither payment for care home fees nor for use in connection with the running of the home. She stated the money had been held in the home’s safe on behalf of the individual residents and not paid into a bank account. Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have an environment to live in which is generally suitable for its stated purpose. The house is clean, comfortable and safe. The provider is considering how to provide designated space that residents can use to meet privately with visitors. EVIDENCE: The home appeared clean and free from unpleasant odours, with its communal areas reasonably tidy. Three residents who returned completed comment cards to the commission stated the home is always fresh and clean, and two stated this is usually the case. Eight of the bedrooms have an en-suite facility, including a shower. One resident has sole use of a bathroom near his room, which has a bath with shower over it. He told me he is happy with this arrangement and enjoys using the bath. Two other residents told me their rooms were comfortable and had what they needed. Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 20 Residents are offered a key to their room and staff can open rooms in an emergency. One resident had lost his key and said until a replacement is obtained he is happy to ask staff to use their master key to lock his room. The music centre in the communal lounge was not in full working order. This had been raised at the previous inspection, when it was understood the centre would be repaired or replaced. A resident was listening to music but could only listen to the radio, as some of the music centre’s features were not working (see recommendations). It was suggested at the last inspection that the provider consider what formal arrangements could be made to designate a private area within the home for visitors, consultations or treatment. The manager said they were considering erecting a small outbuilding for this purpose, as had been done recently at another Woodham Enterprises care home. She was not sure whether planning permission would be needed, and I strongly suggested she seek specific advice about planning permission and building control from the local authority (Bromley). The laundry room is outside in a separate, small building near the back door of the house. The laundry facilities are adequate for the home and are away from food preparation areas. The dryer had been replaced since the previous inspection. A resident said he could get his clothes washed and dried, and he was happy with the laundry arrangements. Each resident has a day allocated to do his laundry, supported by staff. A specialist contractor had carried out legionella testing in March 2007, and the certificate showed that the results had been satisfactory. Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. The home’s recruitment practices protect residents but recruitment information for all staff at the home must be made available for inspection. Staffing levels are satisfactory and working time is monitored to ensure staff do not work excessive hours. Members of staff are offered training opportunities but as previously required there must be specific training for all care staff in the rehabilitation of residents with mental health problems. Most staff had achieved NVQ in care at level 2 or above. It was not evident that all staff had received regular supervision. EVIDENCE: Of the six residents who returned completed comment cards to the commission, four stated the staff always treat them well, one that this was usually the case. One resident did not respond to this question. Three stated the care staff always listen and act on what they [the residents] say and three that this is usually the case. One resident did not respond to this question. The personnel files for two of the three staff based at Woodham 2 were examined and each was found to contain the recruitment information required. The file for the third member of staff was not on the premises. The manager Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 22 said it was at another of the company’s homes, as she had taken it there during a CSCI inspection as the staff member had been working shifts at that home also. The home must ensure the required information regarding staff based at the home is available for inspection (see requirements). It was understood that certain staff members who work shifts at Woodham 2 are based at one of the other Woodham care homes. This means their records are still available for inspection by the commission, even though they were not available at Woodham 2 for my inspection on this occasion. I saw the worked staff rota for June and early July 2007. It showed two staff on each shift, including two waking staff at night. There were some instances where a staff member had worked an early and late shift on the same day, which means from 08.00 – 22.00. There continue to be instances where a staff member works a late shift and the following night shift, and the manager stated that she is monitoring staff members’ working hours to ensure they have adequate time off duty. She stated the company is considering the introduction of permanent night staff, rather than having staff rotate through all day/night shifts. Supervision sessions had been recorded but were not taking place for all staff at the appropriate intervals. For example, one staff member had last had supervision in January 2007. The next session had been due in March but had not taken place and there had been no further supervision sessions since for this staff member (see requirements). Information provided to the commission by the home before the inspection showed that 80 of care staff were in the process of completing NVQ at level 2 or above. On discussing this with the manager, it became evident this percentage referred to the total number of care staff working in the Woodham care homes, rather than only those based at Woodham 2. More than 50 of staff based at Woodham 2 have achieved NVQ2 or above. The external NVQ assessor was in the home when I arrived, carrying out an assessment of a member of staff. She said all staff are encouraged to undertake training, and that all have either completed NVQ’s or are working towards them. The assessor also facilitates medication training for staff, through Ruskin College. A previous requirement to ensure specific training is arranged for all care staff in the rehabilitation of people with mental health problems had not been met (see requirements). It was understood arrangements had been made for some staff to attend future training to raise their understanding of the Mental Capacity Act, which the manager had identified as relevant to carrying out rehabilitation work with the residents. Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 23 Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that the commission has assessed the manager as fit to run the home. Feedback about the quality of services has been sought from residents, relatives and professionals as part of self- monitoring. Regulation 26 reports are being supplied. Staff receive training in relation to safe working practices. A requirement made by the fire authority has been met. EVIDENCE: The home’s manager has been registered with the commission following a process of assessment. She has the necessary skills and experience to run the home effectively. She is also the Responsible Individual for another of the company’s homes but assured me that she has enough time to fulfil both functions without compromising her management of Woodham 2. Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 25 It was evident that the home continues to have vacancies and I raised this with the manager. She assured me of the home’s continuing financial viability, and said that the home had been getting referrals but so far local authority funding to support the proposed placements had not been available. The manager said the home’s fee levels had been reviewed and changed, and the provider was now able to provide sponsoring authorities with a breakdown of the fees charged. The appropriate liability insurance cover was in place. The provider had been meeting a previous requirement to ensure the care home is visited unannounced at least once a month and a copy of the visit report supplied to the CSCI. In relation to quality assurance, a report of a satisfaction survey conducted by the home in January 2007 was displayed on the notice board in the hallway. Views had been obtained from residents, relatives, and professionals involved in the residents’ care. Another survey had been scheduled for later in July. A sample of health and safety documentation was examined. The home had a current gas safety certificate, dated September 2006. A specialist contractor had carried out Legionella testing in March 2007. A staff member was aware of the fire points and the evacuation procedure. The LFEPA (fire authority) had inspected the home in April 2007 and issued a requirement to install fire resistant board to the stairwell leading to the basement storage area. This work had been completed. It was not possible to locate an up to date certificate for the electrical wiring installation or a detailed building/environment risk assessment (see requirements). Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 2 X Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 27 Yes 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 YA6 Regulation 12 Requirement The registered person must ensure that where residents are choosing not to follow their planned therapeutic programmes, it is evident this has been reviewed with the resident and the appropriate care manager. The registered person must ensure that all parts of residents’ care plans are implemented so their assessed needs may be met. The registered person must ensure that correction fluid (e.g. ‘Tippex’) is not used to correct errors on medicine administration charts. The registered person must ensure it is always evident that the provider’s policy and procedure have been followed in managing any complaints received. The registered person must ensure that the required DS0000044288.V339045.R01.S.doc Timescale for action 31/08/07 2 YA19 12 31/08/07 3 YA20 13 31/08/07 4 YA22 22 31/08/07 5 YA34 19 31/08/07 Woodham 2 Version 5.2 Page 28 recruitment records for staff are available in the home. 6 YA35 18 The registered person must ensure specific training is arranged for all care staff in the rehabilitation of residents with mental health problems, as this will benefit residents. Previous requirement. The registered person must ensure it is evident that all staff members have regular supervision sessions. The registered person must ensure there is an up to date certificate for the electrical wiring installation. The registered person must ensure there is a detailed building/environment risk assessment in place. 30/09/07 7 YA36 18 30/09/07 8 YA42 23 30/09/07 9 YA42 13 30/09/07 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 registered person should ensure the music centre in the lounge is either repaired, so that all its features work, or replaced. Woodham 2 DS0000044288.V339045.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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