CARE HOME ADULTS 18-65
Woodham 2 33 Newlands Park London SE26 5PN Lead Inspector
Lorraine Pumford Unannounced Inspection 16th January 2006 14:00 Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 1 Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 2 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.V282480.R01.S.doc Version 5.1 Page 3 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.V282480.R01.S.doc Version 5.1 Page 4 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 woodhamltd@aol.com Woodham ENT Ltd ** Post Vacant *** Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 5 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th July 2005 Brief Description of the Service: Woodham 2 is a large, detached Victorian residence on a main road in Sydenham, within a short walk from shops and rail or bus transport. It provides care, board and accommodation for up to eight service users with mental illness and forensic histories. The care home aims to support service users who are aged 18-65 and have been discharged from psychiatric inpatient facilities, medium-secure units or special hospitals. Service users may be resident at the home for up to three years, during which time they are encouraged towards independent living in the community. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This report contains information obtained from an unannounced inspection, during that time staff and service users were spoken with, a number of polices and procedures examined and parts of the premises inspected. As it was not possible to examine records pertaining to staff recruitment or training at the time of either this or the last unannounced inspections a third announced inspection was arranged with the manager to focus on these issues. All Registered Care Homes receive a minimum of two inspections within a 12 months period as this inspection may not have covered all the “National Minimum Standards” on this occasion if further information is required it is recommended that a copy of the last inspection report also be obtained. What the service does well: What has improved since the last inspection?
Since the last inspection the provider has updated the Statement of Purpose and a copy of this has been forwarded to the CSCI. The provider now sends a letter to prospective service users prior to admission confirming that following their initial assessment, the home will be able to meet their assessed needs. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 7 Whilst it was not possible to specifically designate a room in the home for service users to use for private conversation, the provider has arranged for the dining room to be used for this purpose, and A procedure around the dining rooms use for this purpose has been implemented. Since the last inspection additional dinning and lounge furniture has been provided to reflect the number of service uses the home is registered to accommodate. The manager working in the home at the time of the last inspection has now submitted an application to the CSCI to become the registered manager. In addition to routine visits, the provider or his representative now officially visit the home once a month for the purpose of completing an audit regarding the care and service being provided to service users. A copy of these findings are now submitted to the CSCI. 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. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: The key standards were inspected during the previous inspection and therefore not inspected again on this occasion. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The key standards were inspected during the previous inspection and therefore not inspected again on this occasion. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,15,17 Service users are provided with opportunities to develop social, emotional, communication and independent living skills. EVIDENCE: The key standards were inspected during the previous inspection and therefore not inspected again on this occasion. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 Service users receive personal support from care staff working in the home and appropriate professional health care and support. Procedures for those service users who self-medicate must be improved to protect the service users. EVIDENCE: None of the current service users group require practical assistance with personal care. Service users are able to make personal choices regarding clothing, preferred appearance etc. Service users were seen to move around the premises freely and come and go from the home as they pleased. Staff appropriately asked service users of their planned destination and the time they intended to return. From discussion with staff service users receive regular input from community psychiatric nurses. Medication was inspected in detail at the time of the last inspection and a number of issues raised, the manager stated action was still ongoing regarding some of the issues and was confident these would soon be addressed fully. Discussion took place specifically regarding service users who self medicate. At present staff are signing the MAR on verbal information from service users that
Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 13 medication has been taken; as this has not been witnessed by staff this information should be entered in the service users personal care plan. There is additional space on the MAR sheet to record the medication and the quantity given to the service user to manage, staff must sign and date this record at the time the medication is issued. Mechanisms must be in place for monitoring that service users who self medicate are managing medication responsibly. Staff need to carry out regular written audits with service users to ensure the medication is being managed safely. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 There is a policy regarding Whistle blowing. Staff need to update their adult protection training to maintain the safety, protection and well being of service users in the home. EVIDENCE: Staff spoken with stated they understood the term whistle blowing and felt they could go to the homeowner or manager if they had any particular concerns. The issue is also covered in the homes induction programme. The manager stated she was aware of the need for staff to have regular updates regarding the local authoritys adult protection policy and procedures. The manager was advised to contact the London Borough of Bromleys Adult Protection co-coordinator to obtain a copy of the joint working Adult Protection document and to obtain places for staff on relevant training courses. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 There is adequate furniture in community areas for the number of service users accommodated. EVIDENCE: On the day of the inspection communal areas seen were warm, clean, comfortable and appropriately furnished. Since the last inspection additional dining and lounge furniture has been provided for the service users accommodated. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35, 36 Staff are provided with appropriate training to meet the needs of the service users accommodated. EVIDENCE: On the day of the inspection the staff rota displayed was an accurate reflection of the staff on duty working in the home. During the course of the inspection two members of staff were spoken with privately and two staff files were examined in relation to recruitment and training. Staff stated that they had received a period of induction when they commenced employment in the home. Staff felt that they had been given appropriate training opportunities, one member of staff has attained an NVQ3 in care and is currently undertaking the registered managers award, another member of staff spoken is due to commence an NVQ 3 in the near future. Both members of staff had received training in relation to working with service users with additional mental health needs. Both members of staff had provided references and information for CRB checks, the last CRB check for one member of staff took place three years ago it is recommended that providers have a system in place to regularly update CRB and POVA checks.
Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 17 Staff stated they had been provided with a job description and contract stating their terms and conditions of employment. The format seen required the signature of the homeowner or deputy; the manager was advised the format should also be signed by the employee. Both staff spoken with stated they receive supervision on a regular basis. A member of staff spoken with stated he is also responsible for the formal supervision of other care staff working in the home and he had been provided with appropriate training to enable him to undertake this task. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The manager has taken steps to promote and protect the health, safety and welfare of service users in the home. EVIDENCE: Records seen by the inspector indicate that regular tests to the fire alarm system take place. Maintenance checks to fire extinguishers have also been carried out. Staff spoken with stated they had received health and safety training, a member of staff stated he was the designated health and safety representative for the home. Some members of staff hold a current first aid and food hygiene certificate, and letters seen indicate the manager is currently arranging training for all staff in relation to these issues. The manager has arranged for all staff to attend training in relation to safe administration of medication at a local college in the near future. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 19 Documentation seen indicates that a record is kept of any accident or incident, which affects the health and well being of service users and staff working in the home. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 x 2 x 3 x 4 x 5 x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x x x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 x 15 3 16 x 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x 2 x x x x x x 3 x Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 21 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 YA17YA17 Regulation 17(2) Sch.4 13 Requirement Timescale for action 30/03/06 2. YA20YA20 13(2) 3. YA23YA23 13(6) Records of food provided to the service users in sufficient detail to enable any person inspecting the records to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets provided for individual service users. The registered person shall make 30/03/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The Registered Person shall 30/05/06 make arrangements, by training staff or by other measures, to prevent the service users being harmed or suffering abuse or of being placed at risk of harm or abuse. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 22 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. 2. Refer to Standard YA35YA35 YA34YA34 Good Practice Recommendations It is recommended that both the employer and employee sign the contract of employment. It is recommended that POVA checks be taken up on all staff working in the home. Woodham 2 DS0000044288.V282480.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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