Inspection on 09/07/08 for Woodham 2

This inspection was carried out on 9th July 2008.

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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodham 2 10/07/07

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 09/11/2008.

CARE HOME ADULTS 18-65 Woodham 2 33 Newlands Park London SE26 5PN Lead Inspector David Lacey Key Unannounced Inspection 9th July 2008 11:00 Woodham 2 DS0000044288.V367990.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.V367990.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.V367990.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.V367990.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 9 10th July 2007 Date of last inspection Brief Description of the Service: Woodham 2 is a detached Victorian house 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 aged 18-65 who have been discharged from psychiatric in-patient facilities, medium-secure 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 per week. Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star, which means that people using the service receive an adequate service. This key inspection included an unannounced visit to the home, when some of the residents, members of staff, and the acting manager were spoken with. Parts of the premises were inspected and documentation such as care plans and records of care provided, staff recruitment files, and policies and procedures were sampled. At our request, the care home provided us with its annual quality assurance assessment (AQAA), which also informed the inspection. This self-assessment document focuses on how outcomes are being met for residents and also gives us some numerical information. Since the last key inspection, we carried out a random inspection of the home and used findings from that visit in planning this present key inspection. What the service does well: Provides residents with a comfortable environment to live in, including single bedrooms that they can choose to personalise, and bathing and toilet facilities for their own use. Liaises with care professionals to make sure that residents’ care plans identify their needs and how to meet them, individual risk assessments are included and that plans are kept under regular review. Supporting the appropriate care professionals to make sure residents’ physical and mental health needs are met. Allocates each resident a key worker, who they can meet with regularly to discuss their progress and obtain support. Deals with concerns raised by residents and making sure staff members have training in how to protect adults. Enables residents to contribute to the running of the home and seeking their views about the home’s services. Provides residents with a varied diet and enabling them to contribute to decisions about the food provided. Supports residents to maintain contact with their families and friends, if this is their choice. Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 6 Offers each resident an annual holiday. What has improved since the last inspection? What they could do better: Always follow their policy with regards to the safety and security of the medicine cabinet keys. Keep complete records of any medicines disposed of and of any medication audits that are carried out. Repair or replace the cold tap in the first floor bath, so that residents can adjust the water temperature as they wish. Fix the wall mirror for this bathroom so it is safe for residents to use. Make sure the wash hand-basin in the kitchen always has soap and towels, as effective hand washing is important for hygiene and control of infection. Explore any gaps in an applicant’s employment history, to enhance protection for residents. Follow up any references without a company stamp or headed notepaper to check their authenticity. Notify us without delay whenever a resident needs hospital treatment. Repair or replace the damaged door seal in the residents’ refrigerator. This will make sure the contents of the fridge are kept at the right temperature and therefore safe for residents to eat or drink. Make sure it is evident their policy is being followed that all staff have adult protection training within the first month of induction. Amend their adult protection policy as indicated in this report, to enhance protection for residents. Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 7 Make sure it is evident staff members’ working hours are monitored to check they have adequate time off and do not become over-tired, as this might compromise the standards of care they are able to deliver. 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.V367990.R01.S.doc Version 5.2 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.V367990.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have their needs assessed, to ensure the home can meet them. Prospective residents’ and their representatives are encouraged to visit the home to help them decide whether Woodham 2 is the right place for them to move into. Residents are provided with written terms and conditions for their placement at the home. EVIDENCE: A full needs assessment is undertaken before a person is offered admission to the home. In the residents’ plans 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. The home writes to each newly referred resident confirming that, following assessment, Woodham 2 can meet their needs. Copies of these letters are kept on file. Two people had been admitted to the home since the last key inspection. Their needs and risks had been fully assessed before they moved in. The home’s normal practice is to offer prospective residents the opportunity to visit the home before being offered a place. Residents confirmed they had been offered a visit to have a look around before they moved in. There is then a trial period to enable all parties time to assess if the placement is the right one for the resident. Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 10 It was evident that each resident is provided with a contract detailing the terms and conditions of their stay in the home. Copies of these were in residents’ plans sampled for inspection. Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 11 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 encouraged to be involved in planning and reviewing their care, and have care plans that set out how to meet their needs and had been implemented. Residents make decisions about their life in the home, and are supported within a risk assessment framework to maintain independence. EVIDENCE: Three residents’ care plans were sampled for inspection. Care plans had been drawn up with the involvement of the residents based on comprehensive assessment of each of these residents’ needs. There were risk assessment and risk management plans in place, which covered each resident’s mental health needs, including guidance about recurrence or deterioration of their mental health problems. There was evidence in those plans sampled to show that planned support activities had been carried out, and a resident confirmed this. For some residents it had been included within their care plans that they should be tested for substance misuse, and urine screening for this had been recorded on files. Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 12 Daily records had been made by staff, and monthly key-worker summaries were on file. Each resident is allocated a key worker, to enhance the level of service provided. The key-worker provides support, for example, by holding regular sessions with residents that consider various aspects of their identified needs. Residents spoken with knew who their key-workers were and said they see them regularly. Residents’ meetings take place regularly. Notes of these meetings showed residents are involved in making choices and decisions, and contribute their views and ideas about the running of the home. The most recent meeting had been held on 21 June. Different residents chair the meetings in turn. Staff members help residents, if they wish, to contact and find support from local independent advocacy groups. Details of two local groups, including one for people with mental health problems, were on the residents’ notice board in the hallway. Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 13 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. Engagement by residents in various activities is encouraged. An annual holiday is offered to all residents as part of the contract price. Residents were part of the local community, and their rights and responsibilities had been recognised. Residents have a varied diet and contribute to decisions about the content of menus. Residents are supported to maintain links with their families and friends, but space in the home to see visitors privately remains limited at the present time. EVIDENCE: Examination of care plans and discussion with residents showed they are encouraged to take up opportunities for personal development and to engage in fulfilling activities. Care professionals had considered the effectiveness of planned therapeutic activities for individual residents as part of their care reviews. It was evident from discussion that staff are aware of their role in supporting residents to develop their independent living skills. The home’s AQAA had confirmed residents are referred to Bromley MIND and to ISIS in Catford, as Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 14 well as attending in-house therapeutic groups. The acting manager said these groups include budgeting and planning, relaxation, and cinema nights. The activities programme stated residents attend an ‘assertive group’ on Wednesdays (the day of the inspection visit). The manager said there had been a brief 5-10 minute session in the morning. Residents said they make use of local facilities such as the cinema and local shops. There was less recorded evidence of activities carried out within the home than those undertaken outside the home. Residents had recently returned from their annual holiday, which is offered to all residents. One spoke about the holiday. He had been there before with residents from the home, said they enjoyed their break and spoke about some of the things they had been able to do while they were away. When I arrived at the home, one of the residents was helping to bring in the food shopping. He remembered meeting me before and said life at the home is “OK for me”. He is being supported to keep up his interest in music and goes out to the gym and to the cinema. He said his room had been painted recently and that, “My room is tidy today”. Later in the day, he went out to attend his cinema group. Another resident spoke about his life in the home. He said he’s happy here and that the staff are very kind to him. He likes the location of the home, as it is near to shops and good public transport links that make it easy for him to get around. Residents are allocated specific days for laundry and cleaning, as part of their contribution to the running of the home and their development of independent living skills. A resident whose day it was to do laundry was doing his laundry and cleaning, using the laundry facilities that the home provides. It was evident that residents are supported to maintain links with family and friends. For example, one of the residents arrived at the home around lunchtime. He told me he is sometimes staying with his family now as well as having a room at the home. This is part of his care plan to prepare him to move to a more independent living situation. The home has made sure residents are asked about their satisfaction with the food provided and about their food preferences. There have been recent changes in the content of menus to meet residents’ expressed cultural preferences. The home uses a four-week rotating menu, which was available for inspection and indicated that residents are offered a varied diet. Staff make sure that the food provided to residents is recorded. These records were seen during the visit and were up to date. A shopping trip had taken place on the day of the inspection visit so food stocks in the home were good, with food in the kitchen fridge and freezer and further stocks in the basement storage room. 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 Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 15 evening meal. Residents said they have enough to eat and drink, and were positive in their comments about the food. The home has some restrictions, for example, there is a curfew time. Restrictions are always explained to each prospective resident before they make a decision to move into the home, 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. Residents have keys to their rooms and were coming and going from the house freely throughout the day. Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 16 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 are satisfied with the support they receive from staff, and their physical and mental health needs are met. Residents had received support from staff flexibly and in ways they prefer. Residents who are assessed as able to self-medicate are supported to do so by staff. The home needs to update its policy on disposal of medication and make sure its policy about the security of keys to the drugs cabinets is always followed. Should the home need to store any controlled drugs, they would need to meet the relevant legislation about storing them. EVIDENCE: A resident said he gets plenty of support, which he finds helpful but also hopes he will need less as time goes on so he can eventually live independently. Another resident said he is staying mostly with his family now but still has a room at the home. He is waiting to move out into a more independent living situation, which is part of his care plan. He said he still looks to Woodham 2 staff for support and advice, and gets his medicines each week from the home in a dossette box so he can take it himself. He said he is happy with how things are going at the moment and says staff here are helpful and give him the support he needs. Later in the day, a member of staff was having a supportive conversation with this resident that included offering advice about dealing with a particular situation with which he was having some difficulty. Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 17 The home’s AQAA stated that all residents are registered with a local GP, which was confirmed by records of medical support to residents. 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. Care records sampled showed that those residents were receiving enhanced Care Programme Approach (CPA), with treatment and support coordinated by relevant health care professionals. Residents attend psychiatric outpatient clinics. Mental health professionals visit individual residents at the home. A community psychiatric nurse (CPN) visited a resident during the inspection to give depot medication by injection. The medication policy for Woodham 2 was seen on file. It had last been reviewed in September 2007 and was next due for review in September 2008. The section on disposal of medication needed amendment, and this was drawn to the acting manager’s attention. The section recommends that all unwanted medicines are returned to the supplying pharmacist for disposal but also states that, “small quantities e.g. single dropped tablets can be destroyed by flushing down the toilet”. The policy only states that records should be kept when drugs are returned to the pharmacist. The normal method for disposing of medicines is by returning them to the supplier, who can then make sure they are disposed of in the correct manner. A complete record needs to be kept of all medicines going out of the home (recommendation 1). As far as could be determined given the above, the records of receipt and disposal of medicines were in satisfactory order. At one point during the inspection visit, the keys were seen left in the locks of the drug cupboards in the office. The office was open and unattended. This contravenes the home’s policy, which states that the drug keys should be with a staff member at all times. I raised this with the acting manager who took immediate action to remove the keys from the locks and confirmed that the normal practice is that the shift leader keeps the drug keys (requirement 1). At the time of this inspection, there were no controlled drugs (CD) being stored in the home. The home’s AQAA confirmed that no CDs had been administered or stored at the home in the past year. The home’s existing medicines storage cupboards are screwed to a stud and partition wall in the office and it does not have a CD cupboard that complies with the new legislation in this respect. It was explained to the acting manager that, should the home need to store any CDs in the future, they would need to meet the relevant legislation by obtaining a CD cupboard in which to store the drugs. This would need to be a metal cupboard of specified gauge, with a specified double locking mechanism, and fixed with either rawl or rag bolts to either a solid wall or a wall that has a steel plate mounted behind it. The acting manager explained that medication compliance is often an important factor in residents’ rehabilitation. Self-medication by a resident Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 18 enables staff to assess compliance, which is important as it may precipitate a relapse if the person stops taking their medication on leaving the home. At the time of this inspection, there were two residents self-administering their medication, as part of their rehabilitation programmes and following risk assessments, which were being kept under review. An example of such a risk assessment was seen for one of the residents and the responsible medical officer from the community mental health team had written a letter to confirm the resident had been assessed as suitable to self-administer his medication. Each resident who self-medicates is given a week’s supply of their medication at a time in a dossette box, which they keep in lockable storage in their bedroom. Residents sign to confirm they have taken each dose, which makes it clear staff have not given the medication. Staff monitor compliance according to the care plan and sign when they carry out checks. This arrangement means that staff have to carry out secondary dispensing from the medicines supplied for those residents to ensure they have a supply in a separate seven-day dossette. The acting manager was aware of the potential risks involved in secondary dispensing by staff, and showed me evidence that two staff members do this and sign to confirm. The acting manager said the home now has an “in-house pharmacist” who visits to monitor residents’ medication and make sure medication administration is being carried out properly. There were some pharmacist’s notes on residents’ plans sampled for inspection. The notes related to the individual resident’s treatment. There was no evidence of medication audits and no records except the notes relating to visits to individual residents. The acting manager said audits were done verbally (recommendation 2). Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 19 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. Complaints are managed in line with the home’s complaints procedure. Residents know who to speak to if they are not happy. Most staff members have completed safeguarding training. The home’s safeguarding policy needs some amendments to ensure clarity and accuracy, and thus enhance protection for residents. EVIDENCE: The home’s complaints procedure was displayed in the hallway so that residents and visitors could see it easily. The home’s complaints book was inspected and showed five complaints recorded since May 2007, which matched the number given in the home’s AQAA. Our previous requirement about managing complaints had been met. The AQAA confirmed the complaints book is updated regularly and stated all five complaints received had been resolved within 28 days and that none had been upheld. Each of the five complaints had concerned matters to do with the home’s environment and it was evident they had been resolved. For example, two residents had complained in March 2008 about the home’s décor and it had been repainted throughout in April. There was friendly and informal interaction between staff and residents during the visit. 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. It was evident from records of key worker sessions and notes of house meetings that residents are given regular opportunities to raise any concerns they may have. The home’s stated that in the past twelve months, no restraints had been used, and there had not been any safeguarding referrals or investigations. Since the last inspection, the commission has not received any complaints, Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 20 concerns or allegations about this home, and is not aware that any safeguarding investigations have been carried out in relation to residents living at Woodham 2. The local (Bromley) safeguarding guidance was available in the home, and a council leaflet about protecting vulnerable adults in Bromley was on display in the hallway so that residents and visitors could easily see it. The home’s policy on adult protection was seen on file. It had last been reviewed in September 2007 and was due for review again in September 2008. The policy was satisfactory in part but needed some amendments to ensure clarity and accuracy, and thus enhance protection for residents (recommendation 3). These amendments were discussed with the acting manager during the inspection visit. There was an inappropriate reference to “the RIDDOR policy”, some ambiguous guidance to staff about timescales for reporting any abuse, and the need to be clear that police are called if a crime is suspected. The acting manager confirmed the AQAA statement that staff had been trained in safeguarding. He also confirmed a whistle-blowing policy is in place. There was evidence of completed training in safeguarding in three of the four staff members’ files examined during the inspection visit. This was not consistent with the home’s adult protection policy that states that all staff must have POVA training within the first month of induction (recommendation 4). A support worker said she had completed POVA training, and showed basic understanding of her responsibilities with regard to protecting residents from abuse. Most of the people living in the home at present manage their own finances and only one resident needs support with managing money. This resident was in hospital at the time of the inspection but the acting manager showed records of the home’s support to the person with regards to his finances. The home has a policy and procedure for helping residents to manage their valuables and financial affairs. Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 21 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 are satisfied with their accommodation and have a comfortable environment in which to live. EVIDENCE: The home’s communal areas were clean and free from unpleasant odours. The whole house had been re-painted internally in April 2008. It was understood the decision to do this had been influenced by some of the residents. A badminton court had been laid out in the garden, and a small snooker table obtained for use inside the house. A resident showed me his bedroom, and pointed out it had been repainted. He was pleased with his room, which he thinks meets his needs, including for an en-suite facility. Two other residents told me their rooms were comfortable and had what they needed. Residents are offered a key to their room and staff can open rooms in an emergency. There were two items in the bathroom on the first floor that needed attention. The wall mirror above the sink was loose, and the manager removed it Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 22 temporarily when this was pointed out. It will need re-fixing so a resident using this bathroom can safely use a mirror in this room (see requirement under standard 42). The cold tap in the bath was not working and needed repair or replacement (requirement 2). The manager said the tap had been reported with a view to getting a plumber to attend to it. The laundry facilities were working effectively on the day of the visit. A resident was seen using the laundry, which is in a small building near the back door of the house. The laundry facilities are adequate for the home and are away from food preparation areas. A specialist contractor had carried out legionella testing in June 2008, and the certificate showed that the results had been satisfactory. The kitchen was clean and tidy, with all cooking equipment working. The menu for the day was on a board on the wall. The refrigerator used for residents had a damaged door seal (see requirement under standard 42). The wash handbasin in the kitchen had no soap or towels, which must be addressed, as effective hand washing is important for hygiene and control of infection (requirement 3). When drawn to his attention, the acting manager made sure towels and soap were found on this occasion. The home had stated in its AQAA that it had been refused planning permission to construct an additional building in the back garden to provide a more private place for residents to meet with their visitors. The acting manager said the provider had therefore decided to erect a temporary building for this purpose, as this would not need planning permission. This had been done at another of the company’s homes where a temporary building was not only in use as a room where residents can have visitors, but also for various activities. Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 23 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. Staffing levels are satisfactory. It is not evident that working time is always monitored to ensure staff do not work excessive hours. Staff members are offered training opportunities relevant to the work they do, and either hold or are in the process of studying for a relevant qualification. The home’s recruitment procedures are designed to protect residents but must always be carried out effectively. EVIDENCE: There were six people in residence at the time of this inspection, with one other visiting the home for a few hours each day. One resident was in hospital and there was one vacant room. There were two staff members on duty when I arrived for the site visit, the acting manager and a support worker. The AQAA stated there are ten permanent care staff for the home. In discussion with the acting manager, it became evident that some of these staff members work across different Woodham care homes. There are four permanent staff members for Woodham 2, who are supported by other staff from within Woodham Enterprises. Staffing levels and skill mix appeared satisfactory from observation on the day. Information given in the AQAA, discussion with the acting manager and Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 24 examination of rotas showed there are at least two staff members on each shift, including one senior. The rotas showed many instances when a staff member had worked a late shift followed by a waking night shift. The acting manager said he and his senior colleagues always make sure staff have adequate rest and off-duty periods. At the last inspection, the former manager had stated the company was considering the introduction of permanent night staff, rather than having staff rotate through all day/night shifts, but this arrangement had not been introduced. The home needs to ensure it is evident staff members’ working hours are monitored to ensure they have adequate time off duty and do not become over-tired, as this might compromise the standard of care they deliver (recommendation 5). The AQAA stated all staff have at least NVQ3, which was confirmed at the site visit by the acting manager. There was evidence of a completed NVQ3 on two of the four staff members’ files inspected. It was understood from the manager that the other two staff had completed their programmes but had yet to receive their final certificates. Care staff had completed inductions that met with Skills for Care specifications. A staff member’s file had a Skills for Care folder, assessed internally, plus induction to Woodham 2. The AQAA stated all staff working at the home have Skills for Care inductions. A support worker who had been working at the home for nearly a year had formerly worked at another of the company’s homes. She said she had completed a two-week induction at the original home and a further period of induction when she moved to Woodham 2. She has completed NVQ3 and has completed training in safeguarding and health and safety, including food hygiene. She said she gets good support from the acting manager who has also given her informal training in how to look after the residents at the home. She said she also feels supported by the provider and by the company’s responsible individual, who visit the home regularly. We had previously required that specific training be arranged for all care staff in the rehabilitation of residents with mental health problems, as this would benefit residents. The acting manager said they had addressed this requirement, and showed details of training given by the provider entitled ‘Forensic Mental Health’. The training documentation showed it had covered topics such as mental illness, the Mental Health Act, medication, and signs of relapse. It did not specifically state it had covered rehabilitation but the acting manager said the provider had planned and delivered this training in response to our requirement. A support worker confirmed that, together with other staff members, she had received training in rehabilitation from the provider. She said part of the training had involved how to help residents with daily living skills. The home’s policy on staff recruitment was on file. It had last been reviewed in September 2007 and was next due for review in September 2008. Four staff members’ files were sampled at this inspection. These were the staff based Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 25 permanently at Woodham 2. Some 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 inspection on this occasion. The staff files seen were generally in good order and contained the information required, except there was no evidence that gaps in two of the staff members’ work histories had been explored (requirement 4) or that a handwritten reference with an illegible signature for one staff member had been followed up to ensure its authenticity (recommendation 6). Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents cannot yet be assured that the commission has judged the manager as fit to run the home, though an assessment process is underway. The provider is monitoring the quality of services, seeking views of residents and staff. The commission has not been always been notified of events concerning residents’ health and welfare. Generally, residents’ health and safety is promoted but some specific improvements are needed. EVIDENCE: At the time of the inspection visit, the home did not have a registered manager. The previous registered manager had resigned in February 2008 to take up a post elsewhere in the company. The acting manager, who was formerly the deputy manager of Woodham 2, has applied to the commission for registration and his application is presently being assessed. Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 27 There was a quality assurance report, dated January 2008, for Woodham 2 on the residents’ notice board, showing that views had been obtained from residents. These are undertaken every six months, with the next one due in July 2008. Action had been taken as regards issues identified. There was a specific report on residents’ food satisfaction and preferences, with a ‘food policy’ stated to be effective until October 2008. This confirmed changes in menus to meet residents’ expressed cultural preferences. There is a residents’ forum that takes place each month and is chaired by different residents in turn. The notes of these forum meetings were on file, with the most recent taking place in June 2008. Reports of the provider’s monitoring visits were on file. The content of the reports had been informed in part by the views of residents and staff members. Since the previous inspection, one resident had been assaulted while out in the community. He had needed hospital treatment for minor injuries. The home had notified us promptly of this incident, as well as reporting the matter to police and to the relevant mental health team. The most recent provider monitoring report mentioned a resident’s admission to hospital in June 2008. The acting manager said this resident had suffered deterioration in his mental state and had needed hospital admission. We had not been notified of this event, nor of all the admissions to accident and emergency departments mentioned in the AQAA (requirement 5). A sample of health and safety documentation was examined. Maintenance certificates seen were up to date and within the appropriate timeframes. For example, the home had a current gas safety certificate, dated November 2007. There was an up to date certificate for the electrical wiring installation and portable appliances had been tested in January 2008. The home’s fire procedure and fire risk assessment for Feb08/Feb09 were on file, and records of fire alarm tests and fire drills had been kept. So far this year, fire drills had been held in February, April and June. A staff member was aware of the home’s fire points and evacuation procedure. There was a certificate of fire inspection, dated April 2008. As noted in the ‘Environment’ section above, the refrigerator used for residents had a damaged door seal. This was drawn to the acting manager’s attention as it needed repair or replacement to make sure the contents of the fridge are kept at the right temperature and therefore safe for residents to eat or drink (requirement 6). Also noted in the ‘Environment’ section was a loose wall mirror for the bathroom on the first floor. The acting manager was made aware of this, as residents need a mirror in this room but it must be safe to use (requirement 7). A valid certificate of liability insurance cover was on display in the home. Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 28 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 3 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 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 3 2 X 2 X 3 X 2 2 X Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 29 No 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 YA20 Regulation 13 Requirement The registered person must ensure the home’s policy is always followed with regards to the safety and security of the medicine cabinet keys. The registered person must ensure the cold tap in the first floor bath is repaired or replaced, so that residents can adjust the water temperature as they wish. The registered person must ensure the wash hand-basin in the kitchen always has soap and towels, as effective hand washing is important for hygiene and control of infection. The registered person must ensure it is always evident that any gaps in an applicant’s employment history have been explored. This will enhance protection for residents. The registered person must give notice to us without delay when a resident needs hospital treatment. Such notifications are an important part of maintaining and monitoring individual residents’ safety and welfare. DS0000044288.V367990.R01.S.doc Timescale for action 15/07/08 2 YA30 23 31/07/08 3 YA30 16 15/07/08 4 YA34 19 (Sch2) 31/07/08 5 YA41 37 15/07/08 Woodham 2 Version 5.2 Page 30 6 YA42 13 7 YA42 13 The registered person must ensure the damaged door seal in the refrigerator used for residents is repaired or replaced. This will make sure the contents of the fridge are kept at the right temperature and therefore safe for residents to eat or drink. The registered person must ensure the wall mirror for the bathroom on the first floor is refixed securely. Residents need a mirror in this room but it must be safe to use. 31/07/08 31/07/08 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 3 4 5 Refer to Standard YA20 YA20 YA23 YA23 YA33 Good Practice Recommendations The registered person should ensure that when any medicine is disposed of a complete record is kept. The registered person should ensure that records are kept of any medication audits. The registered person should ensure it is evident the home’s policy that all staff have adult protection training within the first month of induction is being followed. The registered person should ensure the home’s adult protection policy is amended as indicated in this report, to enhance protection for residents. The registered person should ensure it is evident staff members’ working hours are monitored to ensure they have adequate time off duty and do not become overtired, as this might compromise the standard of care they deliver. The registered person should ensure it is evident that references without a company stamp or headed notepaper have been followed up with regards to their authenticity. 6 YA34 Woodham 2 DS0000044288.V367990.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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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