Inspection on 24/01/07 for Woodham 2

This inspection was carried out on 24th January 2007.

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 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 3 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 10/07/07

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 24 January / 21 February 2007 10.00 Woodham 2 DS0000044288.V325924.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.V325924.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.V325924.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.V325924.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2006 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 nine 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 resident at the home are encouraged towards independent living in the community. Woodham 2 DS0000044288.V325924.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. I spoke with service users, members of staff, and the person in charge. I looked at some of the documentation in the home and inspected parts of the premises. It was not possible to examine either staff recruitment records or some health and safety documentation at the unannounced visit, so a second visit was carried out by appointment with the home’s manager. Mention is made in this report of an unannounced random inspection of the home, undertaken in July 2006. The fees for Woodham 2 are a minimum of £1,200.00 per week. What the service does well: What has improved since the last inspection? There are always two waking staff members rostered to work at night. Recruitment practices have improved, with all required information obtained and references followed up. All care staff have completed adult protection training. The satisfaction survey undertaken previously had been repeated. Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodham 2 DS0000044288.V325924.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.V325924.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New service users’ needs are assessed, to ensure the home can meet these needs. Prospective service users can visit the home before deciding whether to move in. A contract is provided to service users. EVIDENCE: Discussions with service users and staff, and scrutiny of relevant documentation showed that a full needs assessment is undertaken before a service user is offered admission to the home. On each service user plan I sampled for inspection, there was a copy of the letter sent by the home to the service user confirming that, following assessment, the home can meet their needs. Any prospective service users are given 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 right for the service user. Service users are provided with a contract detailing the terms and conditions of their stay in the home, and copies of these were in all service user plans I sampled for inspection. Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to make decisions about their life in the home, and to maintain their independence. Care plans have sufficient detail to guide staff on how to meet service users’ needs. There should be clearer evidence of care planning by the home’s staff. EVIDENCE: I examined a sample of service users’ plans. The plans identified service users’ needs and the actions required to meet them. Individual risk assessments were included. Care plans had been kept under review. A key worker is allocated to each service user, which is intended to enhance the level of service provided. Service use plans had monthly key worker summaries on file. At the previous inspection, it was apparent that the home was reliant on care plans devised by mental health teams. I recommended that the home had clear evidence of care planning by the home’s staff. This recommendation had Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 10 been addressed in an action plan but discussions and examination of service users’ plans showed evidence of care planning by staff could be strengthened further. A health care professional surveyed by the commission commented that the home should take a more pro-active role in care planning rather than relying on community mental health teams to do this. (Recommendation 1). ‘Contingency plans’ on file for each service user included contact details of the next of kin and of supporting professionals, ‘early warning signs’, risks, actions for staff to take in the event of relapse, medications, legal status under the Mental Health Act, diagnosis and date of birth. Those I saw had been prepared in November 2006 and were due for review in February 2007. Both discussions and records showed that service users are involved in decisions about how they spend their time. I saw notes of residents’ forum meetings, which showed that service users 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 15 January, and five service users and two staff had attended. The meeting had an agenda and had been chaired by a service user. Written comments were received from two health care professionals who responded to a CSCI survey. One stated the home usually supports service users to live the life they choose, giving an example of a service user placed at Woodham 2 who is encouraged to self-cater, socialise, see his family, go to parties, and play music. The other health care professional responding to the survey stated that the home sometimes supports service users to choose their lifestyle but only with support from the local community mental health teams. Two service users told me (separately) that they could come and go from the home as they pleased, though they always told staff where they were going and have to be back at the latest by 22.00 hrs. Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are encouraged and supported to maintain links with their families and friends, but can only see visitors privately in their own rooms. The provision of rehabilitative activities within the home is being developed further. Service users are provided with a varied diet, and may contribute to decisions about changing menus. EVIDENCE: Discussion with service users and staff, and examination of records showed that educational and employment opportunities are explored and encouraged. At the previous inspection, it had not been evident that service users undertook activities in accordance with the activities plan on display. It had appeared that service users were spending their day as they wished to do so, not necessarily engaging regularly in appropriate rehabilitation activities. I recommended that the home kept clear evidence of activities undertaken by service users. The manager outlined activities that have been made available Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 12 and future initiatives planned. A new ‘residents daily activity’ form has been introduced which evidences input but not how service users may have benefited. This was discussed as an area for development. One service user told me he did not do much in the home and there was nothing provided in the way of activities that appealed to him. During my visit, he listened to music and read a newspaper that a staff member gave him. A professional who provided comments stated that the home’s staff support the service users to carry out activities outside the home. The professional was not aware of the activities provision within the home but would expect service users to be encouraged to take part. Service users said they could have visitors in the home but one pointed out there was no room other than his bedroom where he could meet privately with a visitor. Meeting with a visitor in the lounge was possible but lacked privacy as other service users were around (see recommendation under standard 28). Menus indicated that service users are offered a varied and nutritious diet. Service users said they could not always agree about menu content, for example, one service user would like more Caribbean food to be provided whereas another was not so keen. The manager stated that she tries to take all expressed preferences into account when buying food and planning menus. The present menus had been drawn up in January 2007, following discussion with all service users. The menus are due for review in July 2007 and it is recommended this be recorded, to evidence that service users have contributed to the review in relation to their individual food preferences (Recommendation 2). Food stocks in the home were adequate on the day of my visit, and it was understood a shopping trip was about to take place. Daily records of food served are kept and were available for inspection. A health care professional commented that a service user placed in the home is vegetarian and is always offered vegetarian options. Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 13 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. Service users have access to health and social care as they need, and supporting professionals visit them in the home. Medicines are administered safely and service users who are assessed as able to self-medicate are supported to do so by the home’s staff. EVIDENCE: These standards were assessed by discussions with service users and staff, by examining relevant documentation and by taking other professionals’ comments into account. I was able to meet with a health care professional who was visiting a service user in the home. The professional is a member of a multidisciplinary team, which supports the service user and has responsibility for his treatment. The professional said the home’s staff communicate well with him and the service user’s care is reviewed regularly. Comments were received from two health care professionals who responded to the CSCI survey. One stated the home always meets service users’ health care needs, the other that they sometimes did this. One stated the care home usually seeks advice and acts upon it to Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 14 manage and improve individuals’ health care needs, the other that the home sometimes did this. A specific comment was that the home liaises with the community mental health team straight away when there are significant issues but there could be more informal liaison even when there are no significant problems. This will help to maintain good working relationships, which should in turn benefit service users. Medication is stored in locked cabinets in the office, plus there are storage cabinets in each service user’s room. The person in charge said that medicines are supplied from the community pharmacist or, in the case of some psychotropic medication, brought to the home by the mental health teams. The receipt of medicines is recorded in a book kept in the home. MAR charts are kept on computer and printed off as hard copies to be kept in the file. The home had a staff members’ signature and initial list, to assist medication auditing. Community psychiatric nurses visit the home to give depot medication to any service users who are prescribed this treatment. Three service users were self-medicating at the time of this inspection. Their medicines were being decanted into dossette boxes, one week’s supply at a time. The home keeps a ‘decanting book’, which two staff sign. The service users confirm verbally to staff that they have taken their medication, and staff sign a ‘self-medication MAR’. The person in charge said that staff carry out regular spot checks to make sure medication is being taken and showed records to that effect. Staff who administer medication have received specific training. A support worker told me he was not involved in medication administration, as he had not yet completed the necessary training. Thus, only staff who have been trained carry out the secondary dispensing into the dossettes. This is important, in line with RPS guidance that service users have a right to expect that the same standard of skill and care will be applied by staff in dispensing into a compliance aid as would be applied if the service user were receiving the medication from a pharmacist. It was understood that secondary dispensing in the home was needed, as it was not always possible for the medicine supplier to fill these dossettes. The manager confirmed the home has a suitable written policy, which staff members follow when supporting service users to administer their own medicines. Service users’ privacy and dignity is respected, for example, by staff members knocking on bedroom doors before entering. There was friendly and informal interaction between staff and service users during my visit. Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. Service users concerns will be taken seriously. Staff are aware that service users must be protected from abuse, and there has been progress in arranging formal adult protection training for staff. EVIDENCE: The commission has not received any complaints, concerns or allegations about this home since the previous inspection. One health care professional who replied to the CSCI survey stated the home had not responded well to concern raised about care. Another stated that s/he had not needed to raise any concerns about care. Neither respondent offered any specific examples of care concerns. A service user said if he was worried or wanted to complain about something he would talk to his key-worker or to the home’s manager. Adult protection training for all staff was required from the previous inspection, when it had been evident that staff members had not been able to attend the alerter training session in June 2006 but would be attending the next event in October 2006. At the present inspection, the manager confirmed the completion of the home’s action plan that all staff had completed adult protection training, and showed evidence to that effect. The previous Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 16 requirement about adult protection training that had not been addressed within timescales has now been met. Care staff spoken with were aware of the term whistle blowing and knew what they should do if they witnessed poor practice. They were aware that service users must be protected from abuse. Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have an environment to live in which is generally suitable for its stated purpose but lacks a designated room for service users to meet privately with visitors. The home should ensure it is complying with relevant water regulations. EVIDENCE: I toured the home with the person in charge, who confirmed there had not been any changes to the premises since the previous inspection. I did not inspect all the rooms but the home appeared clean, reasonably tidy and free from unpleasant odours. Each service user except one has a single bedroom, with an en-suite facility including a shower. One service user has sole use of a bathroom near his room, which has a bath with shower over it. Two service users told me their rooms were comfortable and had what they needed. Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 18 Service users are able to have the key to their room and staff can open rooms in an emergency. A service user told me his lock was broken. He said he had mentioned this at the residents’ forum (when I checked this had been recorded in the minutes), someone had come to look at it the day before and it will now be fixed. As noted above, there is no designated visitors’ room. This has not precluded registration of the home but the provider should consider what arrangements could be made (Recommendation 3). A service user said meeting with a visitor in the lounge was possible but lacked privacy as other service users were around. The dining room can be partitioned off as there is a built-in partition but the route to the kitchen is through the dining room, which means this room lacks privacy also. The laundry room is outside in a separate, small building near the back door of the house. The manager stated she would be contacting the local water authority shortly to ensure the home is complying with relevant water regulations, and this action is recommended (Recommendation 4). The laundry contained one washing machine and one dryer, and a service user was using this facility during my visit. He said the machines worked as they should and he could get his clothes washed and dried quite quickly. Each service user has a day allocated to do his laundry, supported by staff. The music centre in the communal lounge was not in full working order. A service user said he enjoyed listening to music but was restricted to listening to the radio, as some music centre facilities were not working. The manager agreed to ensure the centre was repaired or replaced. Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the home’s recruitment practices. Service users benefit from continuity of staff, but working time should continue to be monitored to ensure staff do not work excessive hours. Members of staff are offered training opportunities and have regular supervision. There must be specific training for all care staff in the rehabilitation of service users with mental health problems. EVIDENCE: At the previous inspection, it had been evident from scrutiny of a sample of files that improvement was still needed to recruitment practices, as some of the information and documentation required by legislation was not present on each file. To follow up the home’s submitted action plan, a sample of three staff files was examined on this occasion and each was found to contain the recruitment information required. Thus, the previous requirement in this respect had been met. One file did not contain a CRB disclosure but the manager stated that this newly appointed staff member had not yet started work in the home, and would not do so until the disclosure was received and assessed as satisfactory. Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 20 The manager had met a previous recommendation by ensuring employment references are followed up by telephone, if the source of the reference is not clear (for example, no letterhead or official stamp). She had also drafted a schedule of knowledge-based interview questions for selecting applicants and invited my comment about these. I suggested she might wish to add some questions that invite applicants to give examples from their previous experience, to demonstrate specific competencies. A support worker confirmed he had completed an induction programme and had been assessed by the manager and senior staff at the start of his employment. He had found this helpful, as he had not worked with this client group before. He stated he had submitted an application form, had been interviewed and had references taken up, and had received an enhanced CRB disclosure through his employer. At the previous inspection, it was found that the arrangements for night staffing were not consistent with an agreement made with the Central Registration Team in April 2006. I made it clear at the previous inspection that any change to the agreed night staffing arrangements must be set out in a written proposal to the CSCI, which would be considered once it has been received. In the meantime, the home must have two waking staff at night members on duty in the home each night. The CSCI has not received any such proposal since that time. On this occasion, I saw the worked staff rota for January 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 were at least 12 instances where a staff member had worked a late shift and the following night shift, which means the staff member had worked from 15.30 through to 08.00. The registered manager stated that she monitors staff members’ working hours to ensure they have adequate time off duty. She confirmed she would continue to monitor this so that staff do not become over-tired, as she is aware this might compromise the standard of care they deliver to service users. Comments about staffing received from the two health care professionals who responded to the CSCI survey were mixed. One stated that the home had an “empathic, flexible, patient-centred approach” and that care staff usually have the right skills and experience to support service users’ social and health care needs. If they do not have these skills and experience, they are supervised by staff who do have them. The other respondent commented that care staff needed to develop skills of working within a “recovery” rather than a “care and custody” model. The staff files I saw contained evidence of regular, recorded supervision sessions and of completed training and development. The manager said she aims to ensure that the home’s care staff are able to provide the services Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 21 commissioned. A support worker said he was doing a course in nutrition and health, and would be starting NVQ2 in care as soon as possible. The manager showed training plans for the home and records of completed training. She leads some training initiatives for staff herself. I noticed there was comparatively little specific training in the rehabilitation of service users with mental health problems and such training must be made available to all care staff, as rehabilitation is the main stated purpose of the home (Requirement 2). Also, I have suggested to the manager that handovers and staff meetings could include professional development discussions of topics relevant to rehabilitation. Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can be assured that the commission has assessed the manager as fit to run the home. Service users’ views about the quality of services are sought. Regulation 26 reports must be supplied each month. Staff receive training in relation to safe working practices. Some specific health and safety matters need further attention. EVIDENCE: The home has a manager who has been registered with the commission following a process of assessment. She has the necessary skills and experience to run the home effectively. Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 23 A sample of health and safety documentation was examined on the second day of the inspection. A ‘health and safety checklist’ had been most recently completed on 23/12/06 by the company’s health and safety lead person. All matters had been assessed as satisfactory, except for some light bulbs needing replacement. The home had a current gas safety certificate, dated September 2006. The home’s accident book was seen and found to have no entries since 2005. The manager stated she had contacted a specialist contractor to carry out Legionella testing, and would be contacting the local water authority shortly to ensure the home is complying with relevant water regulations. Documentation showed that a specialist contractor had inspected the home’s fire prevention equipment in May 2006. Six fire drills had been recorded as having taken place during 2006, and the most recent drill had been carried out in January 2007. A support worker I spoke with was aware of the fire points and the evacuation procedure. On the second day of the inspection, I saw evidence that the LFEPA had visited the home in April 2006 and raised three issues for attention. The manager stated that two of these (fire risk assessment and six-monthly testing of the fire alarm) had been dealt with but although the third (gaps around fire doors) was being addressed it had not yet been completed. I have made a requirement, to support the LFEPA’s assessment (Requirement 3). In the kitchen fridge, there were two opened jars of mayonnaise that did not have the dates of opening recorded. The labels stated they should be consumed within four weeks of opening. The person-in-charge stated such foods rarely took that long to be consumed but accepted that it is good practice to record opening dates of perishable foodstuffs and said that staff would be reminded to do this (Recommendation 5). At the previous inspection, the CSCI had not received Regulation 26 reports for March and April 2006 until July. The provider was reminded that provider visits must take place at least monthly and that copies of the reports should be sent to the CSCI promptly. Since the previous inspection, the CSCI has on a number of occasions received several reports for different months at the same time. For example, on 13/02/07 the CSCI received reports for October, November, December 2006 and January 2007. Thus, a previous requirement has been met in part only (Requirement 1). This was discussed with the manager during the inspection visit and she agreed to ensure Regulation 26 reports are sent each month in the future. A previous recommendation about obtaining service users’ views had been met and a report of a satisfaction survey conducted by the home in July 2006 was displayed on the notice board in the hallway. The person in charge showed me the anonymously completed questionnaires from service users, relatives and professionals from which the report had been drawn. Respondents had been asked to complete a rating scale indicating their level of satisfaction with Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 24 different aspects of the service provided. The residents’ forum has been commented on earlier in this report. The most recent staff meeting had been held on 5 January, and seven staff members had attended. Minutes were on file and showed that various matters had been discussed. For example, one item confirmed that there must always be at least two staff on duty on each shift. Each service user’s progress had also been discussed. The current CSCI registration certificate and a valid certificate of liability insurance were displayed prominently. There was a late response to the commission’s written request to Woodham 2 for pre-inspection information. It was understood the commission’s original written request had not been delivered to the home. The request was repeated and the information given to me on the second day of the inspection visit. The delay had an impact on the commission’s ability to invite other interested parties to contribute to the inspection. The responsible persons are reminded that it will be a legal requirement for registered providers of adult services to produce a quality assurance assessment each year. Until this is implemented, the commission is asking providers to complete the pre-inspection questionnaire. Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X 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 2 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 26 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 YA39 Regulation 26 Requirement The registered person must ensure the care home is visited unannounced at least once a month and a copy of the visit report supplied to the CSCI. Met in part only, revised timescale set. The registered person must ensure specific training is arranged for all care staff in the rehabilitation of service users with mental health problems, as this will benefit service users. The registered person must ensure all the issues raised by the LFEPA are met, including that the size of any gaps around fire doors are within safe limits. Timescale for action 31/03/07 2 YA35 18 30/04/07 3 YA42 23 31/03/07 Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 27 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 YA6 YA17 Good Practice Recommendations The registered person should ensure the home has clear evidence of care planning by the home’s staff. The registered person should ensure that service users’ contributions about their individual food preferences are recorded at the forthcoming menu review. The registered person should consider what formal arrangements could be made to designate a private area within the home for visitors, consultations or treatment. The registered person should ensure the home is complying with relevant water regulations. The registered person should ensure the opening dates of perishable foodstuffs are recorded, so that items that have been open too long are not consumed. 3 YA28 4 5 YA30 YA42 Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Woodham 2 DS0000044288.V325924.R01.S.doc Version 5.2 Page 29 - 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. 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