Inspection on 01/05/08 for Woodham House

This inspection was carried out on 1st May 2008.

CSCI found this care home to be providing an Adequate service.

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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodham House 02/03/09

Woodham House 31/05/07

Woodham House 02/05/06

Woodham House 24/10/05

Woodham House 13/04/05

Woodham House 15/09/04

Woodham House 21/04/04

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 28/09/2008.

CARE HOME ADULTS 18-65 Woodham House 336 Stanstead Road Catford London SE6 2SB Lead Inspector Ornella Cavuoto Key Unannounced Inspection 1st May 2008 10:00 Woodham House DS0000028745.V362276.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 House DS0000028745.V362276.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 House DS0000028745.V362276.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodham House Address 336 Stanstead Road Catford London SE6 2SB 020 8690 6237 0208 690 6171 woodhamltd@aol.comSe76 2SB 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) Victor Morris vacant post Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Woodham House DS0000028745.V362276.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: 5 Date of last inspection Brief Description of the Service: Woodham House is a privately owned care home for up to 5 men with mental illness and a forensic history. The home is located on the busy south circular in Catford and is close to railway stations, bus services and local community facilities. The home offers accommodation over three floors with five single rooms and comfortable communal space including a large lounge, large dining kitchen and large garden at the rear. The home is in keeping with the local community and does not stand out as a care home. The stated aims and objectives of the service are to support men discharged from psychiatric hospitals, medium secure units or special hospitals to independent living in the wider community, and to maximise their potential for normal risk taking. Ensuring privacy, dignity, independence, choice, rights and fulfilment. On the day of the inspection there was one vacancy. Potential service users are given information about the home once an initial visit has been completed in the form of a brochure, which includes the statement of purpose and service user guide. Also, potential service users are informed about CSCI reports verbally and can see the report on request. Service users are also asked about their awareness of CSCI reports as part of the home’s quality assurance surveys. The monthly fees of the service range form £1200 -£2000. No additional charges are made. This information was provided to CSCI May 2006. Woodham House DS0000028745.V362276.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 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection that took place over one day. The home’s acting manager was present and helped to facilitate the inspection process. The service co-ordinator was also present for part of the inspection. In addition one of the support workers and two people living at the home were spoken to. Other inspection methods included observation, inspection of records and a partial tour of the building. Prior to the inspection an Annual Quality Assurance Assessment AQAA document was sent to the home for completion The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also provides some numerical information about the service. This will be referred to within the report. The inspection found that previous requirements in relation to three of the National Minimum Standards (NMS) had still not been met. Continued failure of the home to comply with these requirements has led to the Commission for Social Care Inspection (CSCI) to consider enforcement action. What the service does well: Peoples’ physical and mental health needs are well met by the home with input from a range of general and specialist mental health professionals. The home ensures that residents’ mental health needs are regularly monitored and reviewed through the Care Programme Approach (CPA) system in which all professionals involved in their care meet to discuss their needs. All individuals at the home have an individual plan of care in place that is regularly reviewed and there are regular meetings with their key worker to discuss their progress and needs. People at the home are encouraged to be as independent as possible by staff to make use of local facilities and take responsibility for undertaking their own household tasks. Also, to pursue their individual interests, educational and training opportunities. Positive relationships with family and friends are encouraged. There is a varied and generally nutritious diet available and people at the home have their own individual cooking day in which to help plan and prepare a meal. People are well protected from abuse by the home having policies and procedures in place and staff have received training in adult abuse and adult protection procedures. The home is well maintained, homely and clean. Staff are supported to obtain relevant qualifications to be able to meet the needs of individuals at a competent level. Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 6 Views of those that live at the home are regularly sought to help the home identify ways they can improve the service. What has improved since the last inspection? 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 House DS0000028745.V362276.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 House DS0000028745.V362276.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home have had their needs fully assessed prior to being admitted. EVIDENCE: There had been one new admission to the home. There was evidence that their needs had been fully assessed prior to when they initially moved in. There was evidence of detailed reports and assessments including a detailed risk assessment and management plan from the referring health authority within their personal file. There was also evidence that the home had carried out their own assessment. Woodham House DS0000028745.V362276.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 &9 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. All individuals had a care plan that addressed personal goals and changing needs but parts of the care plans had still not been fully implemented. People at the home had been supported and given assistance as needed to make decisions about their lives and to take risks to live independently but not all presenting risks had been fully addressed. EVIDENCE: At the last inspection care plans that were seen had addressed personal, health and social care needs as specified within National Minimum Standards (NMS) including specialist requirements. They had also been regularly reviewed with evidence that individuals had been involved in the care planning process. However, concerns were raised that parts of the care plan where certain interventions and support had been specified had not been implemented specifically there was no evidence that where people were to be involved in the home’s therapeutic programme which consists of a relaxation group, assertiveness training, health and eating advice, budget and planning that this Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 10 had not been undertaken with them. Also, testing of illegal substances had not occurred as stated. At this inspection care plans belonging to three of the four people living at the home were checked and despite the care plans generally meeting with NMS in that all needs had been covered and regular reviews had been held there was still a lack of evidence to demonstrate that the sessions which formed part of the therapeutic programme and had been included in care plans had been held with people. This was confirmed by one of the people at the home that was spoken to. There was some evidence at the last inspection that the deputy manager had developed individual activity records for support staff to record what had been undertaken with service users but these had not been implemented. In respect to drug testing this had been carried out as outlined within care plans. Yet, action must be taken by the home to ensure all aspects of planned support identified with people are provided. Failure to comply will lead to enforcement action to be considered by CSCI In respect to a previous recommendation that key work sessions are held with individuals at the home consistently on a monthly basis this had been addressed (See Requirements). It was evident from key work sessions and minutes of ‘Resident Forums’ that people at the home had been supported to make their own decisions about their lives and that generally staff had provided information and assistance to enable them to do this. A previous recommendation regarding the home making information about independent advocacy services available had been addressed with details about this placed on the notice board in the hallway of the home. There was evidence that people living at the home had been supported to take risks as part of living an independent lifestyle, for example one person at the home had travelled to France to holiday with family and all regularly travel about locally and into London. At the last inspection it was identified that in the main risk assessments and risk management plans that had been drawn up, for example in respect to their mental health were comprehensive. However, concerns were raised as it was noted that for one person a risk assessment and management plan had not been drawn up in relation to their decision to drive a car despite having a history of substance misuse. At this inspection it was again identified that generally risk assessments and management plans for individuals were sufficiently detailed. Yet, in respect to the person that had moved into the home since the last inspection concerns were raised that not all risk behaviours with which they presented in relation to their mental health had been adequately addressed with control measures detailed. This was despite risk assessments plans having been obtained from referrers and their previous place of accommodation Failure to comply will lead to enforcement action to be considered by CSCI (See Requirements). Woodham House DS0000028745.V362276.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Generally people at the home had been supported to access training and employment opportunities and to engage in meaningful activities. People living at the home were part of the local community. Important relationships with family and friends had been maintained. The rights and responsibilities of individuals had been recognised. Generally, people at the home eat well and have a varied diet. EVIDENCE: It was evident from care plans and key work sessions that people at the home had been supported by staff to look at opportunities for training/ education and to engage in fulfilling activities, for example in respect to one individual an application to a local college was being looked into for them to do a cooking course and the home had supported them to occasionally work with their father. For another person at the home they had been supported to apply to become a personal trainer as they had wanted to do but unfortunately their Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 12 application was not accepted. Furthermore, for the person that had moved into the home since the last inspection there was evidence that they had been encouraged to attend a day centre that would specifically meet their cultural needs although to date they had refused to go. Finally, as mentioned in respect to Standard 6, despite the home stating a therapeutic programme was in place that is aimed at addressing areas such as budget and planning, assertiveness training amongst others to support individuals with progressing towards independent living this had not been implemented with individuals as specified within their care plans. This needs to be addressed. However, overall this standard is deemed met (See Requirement in respect to Standard 6). All people at the home have freedom passes to enable them to use public transport without charge and it was evident from records as previously mentioned in respect to Standard 9 that individuals at the home had made use of this travelling locally and also to go up to London. Also speaking to people they stated they made use of local facilities such as attending the gym, the library and the local shops. There was evidence within individual care plans and key work notes that people at the home had been supported to maintain links with family and friends. One of them had recently been on holiday to France with their family and they were also being supported by the home to eventually move back to the country where their family now lived. The person who was spoken to confirmed this. The home does have restrictions in place such as a curfew time but people at the home are made aware of these conditions prior to moving in and they are included in the statement of terms and conditions that they are required to sign. Overall, the rules of the house and daily routines are aimed at promoting independence, individual choice and freedom of movement. Individuals are expected to take responsibility for house keeping tasks such as doing their own laundry and tidying their rooms, they have keys to their rooms to promote their rights to privacy and on the day of the inspection people were observed coming and going from the house freely. In respect to meals people at the home arrange their own breakfast and lunch. Also, each individual has a cooking day where they are expected to take responsibility for helping to plan and prepare the evening meal with staff assistance. On the day of the inspection it was confirmed by one of the people at the home that they had assisted with the evening meal. There was also evidence from records that another person had cooked their own food. Regular feedback about the food had been obtained from individuals at the ‘Resident’s Forum’. There was a four week menu plan in place although the deputy manager reported this was not strictly adhered to and was used more by support staff for ideas of meals to cook and that generally people would be asked on the day what they would like to eat. A daily record of meals that had Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 13 been provided had been maintained and these were sufficiently varied and nutritious. Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People at the home had received support from staff flexibly and the way they prefer. Physical and mental health needs of individuals had been addressed. The home’s medication system was effectively managed by staff and protected people at the home. EVIDENCE: None of the people living at the home require support with personal care but staff provide prompting and encouragement as required. Issues regarding supporting individuals in respect to personal care had been addressed within their care plans. It was also observed that they were well groomed and well dressed. The home operates a key worker system to ensure consistency of support and as stated in respect to Standard 7 there was evidence that key work sessions had been held regularly. Interaction between staff and people living at the home was observed as warm and respectful and one of them commented that they considered they were well supported. It was evident from care plans and other information contained within personal files that the physical and mental health needs of individuals at the home had Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 15 been addressed. Regular Care Programme Approach (CPA) reviews of their mental health needs and to monitor risk factors had been held and there was regular contact with Community Psychiatric Nurses (CPN) and Consultant Psychiatrists on an out patient basis. Monthly weights had been taken and there was some evidence of contact with primary health care services such as GP services. At the last inspection it was recommended that health professionals such as Community Psychiatric Nurses that see people at the home should write up their visit in the respective person’s daily records. It was reported at this inspection that professionals had refused to do this, as it was not considered appropriate practice. This will not be restated in this report. The home’s medication system was looked at and found to be in order with no errors identified in the administration and recording of medication. The home uses a blister pack system although some medication was not in blister packs and it is advised that weekly audits to check stocks of medication are accurate and correspond to administration are carried out. Since the last inspection one of the people living at the home had been supported to take responsibility for their own medication. There was evidence that a risk assessment had been completed and weekly spot checks and a self- medication observation chart was in place to monitor that the person was managing to self administer. At the last inspection there was evidence that the deputy manager who has overall responsibility for the medication had completed an accredited course in the ‘Safe Handling of Medication’ at Croydon College and also there was a certificate in place in respect to one of the support workers that they had completed training. However, some staff were still to attend a course and for one of support workers despite it being reported they had undertaken medication training there was no evidence to confirm this. At this inspection, the deputy manager reported that all staff working at the home had completed medication training and there was evidence to confirm this with certificates in place for all but two staff. Consequently, the previous requirement in this area is deemed met but it is advised that copies of the certificates are obtained from those staff where they were absent and these are kept within their individual staff files (See Recommendations). Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home had access to information about the home’s complaints policy. Measures had been taken by the home to protect people from abuse. EVIDENCE: The home has a robust complaints policy. This was accessible to people living in the home and visitors on display on a notice board in the entrance hall of the home. There was also evidence from key worker sessions and meetings held within the home that individuals were given regular opportunities to raise any concerns they may have in relation to the home and support they were receiving. The home had a complaints log in place to record all formal and informal complaints. At the last inspection concerns were raised that two formal complaints made by one of the persons living at the home, had not been thoroughly addressed. Although it was established after discussions with the deputy manager and service co-ordinator that some appropriate action had been taken in respect to both complaints this had not been documented, for example there were no records detailing the investigation undertaken or the outcome. Also, the complainant had not been informed in writing of the outcome of the complaints in line with the home’s policy. At this inspection there was no evidence that any formal complaints had been received and therefore the previous requirement specified in this area could not be assessed. This will have to be checked at the next inspection In checking the complaints log there was evidence of two informal complaints; one was made by a service user about the heating system having broken down whilst the other was from the neighbours about loud music and rubbish being thrown into Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 17 their garden. Both complaints had been appropriately addressed (See Requirements). The home has comprehensive adult protection and procedures in place. There was evidence that all support staff apart from one that had recently been employed by the home had completed training on adult protection. The support worker spoken to had good working knowledge about the different types of abuse and what action to take if they witnessed or suspected abuse was occurring. Records also indicated that one of the staff had completed some in –house training on the Mental Capacity Act. It is advised the home completes this with all support staff as it relates closely to adult protection and also to the needs of the people living at the home. There had been no adult protection investigations carried out since the last inspection (See Recommendations). Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 &30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a safe, homely and comfortable environment for the people that live there and was clean and hygienic. EVIDENCE: The home offers access to local amenities, local transport and relevant support services to suit the personal and lifestyle needs of people living there. The premises are suitable for its stated purpose, homely, safe and generally well maintained. Subject to a previous recommendation regarding the hallway being re-painted had been addressed. In addition the lounge had been redecorated and the flooring in these areas had been replaced. The home was clean and hygienic on the day of the inspection and no offensive odours were noted. The laundry facilities are adequate for the home. Since the last inspection these had been moved from the cupboard sited under the stairs to a sheltered area outside in the back garden. Woodham House DS0000028745.V362276.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): 32,33,34 &35 People who use this service experience adequate outcomes in this area This judgement has been made using available evidence including a visit to this service. The majority of staff had achieved or were in the process of studying for a relevant qualification as required under National Minimum Standards (NMS). An accurate rota was in place indicating there were sufficient levels of staff working at the home. The home’s recruitment practices still did not fully protect people living at the home. Staff had completed some training to enable them to support people who live at the home appropriately but appraisals still need to be completed. EVIDENCE: It was reported by the acting manager that six of nine staff presently working at the home had achieved a National Vocational Qualification (NVQ) Level 3. One of these staff was reported to be undertaking a course in psychiatric nursing. There was evidence within four of the six personnel files checked to confirm this. Also, the support worker spoken to confirmed they were in the process of studying for the qualification and were due to complete at the end of May 2008. Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 20 At previous inspections concerns have been raised about the rota not providing an accurate record of staff working at the home. However, at this inspection the rota was found to be accurate and indicated that there were sufficient staff on duty for all shifts. In respect to recruitment previous inspections carried out in May 2006 and January 2007 had identified concerns about the home ‘s vetting procedures in that some staff had not completed an application form so employment history including gaps in employment could not be checked and whether appropriate references had been obtained specifically that at least one was from their last employer. Also, some staff had not specified the reason for leaving their previous post. There was no evidence of the interview process that was carried out with individual staff to assess their suitability for the post applied for. Furthermore, not all appropriate documents required by regulation were in place including the required number of references and appropriate identification. At the last inspection held in May 2007 no new staff had been recruited. However, staff files were still checked and all included the appropriate checks and documentation but no measures had been taken to address gaps in employment and to clarify with individual staff their reasons for leaving their previous posts. At this inspection it was identified that there were six new support staff working at the home although it was reported that some of the staff had been working at the other Woodham houses. All their personnel files were checked. In respect to one newly recruited worker it was noted they were on the rota to commence working at the home the following day that the inspection was held. It had been specified that they were due to begin their induction period. Yet, they were the only staff member on duty apart from the acting manager indicating there would be no other staff available to support those people living at the home. Furthermore, it was established that they had been placed on the rota without an Enhanced Criminal Record Bureau (ECRB) check having been obtained or a check against the Protection of Vulnerable Adults (POVA) list (POVA First) having been carried out. A completed application form was in place but the two required references were not in place. It was reported these had been requested but were yet to be returned. Finally, there was no evidence that a health questionnaire/ declaration had been completed to assess that they were mentally and physically fit to undertake the job. In addition, for another staff member only an ECRB check could be identified that was from a previous employer. A POVA First check had not been carried out for them. Two other staff had only one reference included in their personnel files and for one of them there was no evidence of a health questionnaire/declaration. Due to these shortfalls, which potentially place the welfare of the people at the home at risk, an immediate requirement was issued at the inspection. This stated that all necessary checks and documents that were identified as not being in place for individual staff should be obtained and evidence of this sent to CSCI within the timescale specified. Furthermore, those staff without up to date ECRB should not be allowed to work at the home Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 21 till these were in place. The home did address this requirement within timescale. However, in respect to a previous requirement that all staff must have an application form in place and are interviewed. Also, that all gaps in employment must be addressed this had been partially met. All staff whose personnel files were looked at had a completed application form but for two staff there was no evidence that an interview process had taken place. Five of the staff had gaps in employment that had not been accounted for. This requirement has now been outstanding for the past three inspections. Failure to comply will lead to enforcement action to be considered by CSCI (See Requirements). In relation to a previous requirement there was evidence that all support staff working at the home apart from one had completed an induction that met with Skills for Care specifications. The other staff member did have evidence within their file to indicate that a basic induction had been completed with them, as did two of the other support staff. It is advised evidence of both inductions are kept within staff files. However, also in respect to the requirement that staff need to have annual appraisal undertaken with them to look at personal development and individual training needs, this had not been addressed. There were only two staff where an annual appraisal was identified as necessary. For one records indicated an appraisal had last been completed 20/12/06 whilst for the other staff member who was also the acting manager at another Woodham home no evidence could be identified that an appraisal had been completed with them. This requirement has now been outstanding for the past three inspections. Failure to comply will lead to enforcement action to be considered by CSCI. Yet, there was evidence that some specific training had been completed by staff to enable them to effectively meet the needs of people living at the home, for example there was evidence four of the staff had received some in-house training that looked at mental health and forensics. One staff member had also received training in mental illness and risk assessment including looking at early warning signs and also medication related to mental illness. Other staff files looked at included evidence of a range of different training courses that had been completed by individual staff prior to starting work at the home that were relevant to people’s needs including foundation courses to NVQ Level 2 in substance misuse and mental health support, understanding personality disorders, listening and counselling skills amongst others. However, there were still gaps identified for staff in respect to mandatory training topics related to areas of health and safety (See Standard 42 for further details). Woodham House DS0000028745.V362276.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 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The acting manager still requires more support to ensure the effective management of the home in all areas. Feedback about the home has been sought from individuals living at the home, relatives and professionals as part of self- monitoring but an action plan to address issues raised was not in place. Areas in relation to health and safety had not been adequately addressed. EVIDENCE: Concerns were raised at previous inspections about the registered manager ‘s lack of presence within the home. Instead, the deputy manager had largely been delegated responsibility for the running of the home. Since the last inspection the registered manager who is also the registered provider had resigned from the position. CSCI were informed about this as required. The deputy manager is now ‘acting manager’ and has continued to take responsibility for the day –to- day management of the home. It was reported Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 23 by the service co-ordinator that an application for registration had been initiated. The acting manager who has achieved a NVQ Level 3 also reported that they were to start the Registered Managers Award (RMA) /NVQ Level 4 in June 2008. The acting manager has not had any previous experience managing a care home. At this inspection it was found that the home was in part well run although there have been ongoing concerns about the home’s recruitment practices and this needs attention. Failure to appropriately complete and send Regulation 37 notifications to CSCI regarding occurrences in the home is another area that needs to be addressed (See Standard 42 for further details). Also, there have been requirements that have now been persistently repeated in respect to Standards 34, 35 and 42, which need to be addressed or enforcement action will be taken by CSCI. Due to the acting manager’s lack of overall experience a requirement was specified at the last inspection that they should receive regular supervision. At this inspection although it was identified that supervision had been held rather than the service co-ordinator who is an experienced manager supervising the acting manager this was done by another acting manager from another Woodham home. The acting manager from the home then had responsibility for their supervision. Given both managers lacked experience this was not considered appropriate and alternative arrangements for supervision should be made Failure to comply will lead to enforcement action to be considered (See Requirements). There was evidence that a customer satisfaction survey with individuals living at the home, relatives and professionals to obtain their views as part of selfmonitoring had been carried out. The results of the survey had been written up in a report. This included aims and outcomes for individuals based on the results of surveys although an action/development plan had not been drawn up to address how these aims would be met. This needs to be addressed. The home’s Annual Quality Assurance Assessment (AQAA) was adequately completed (See Requirements). In terms of health and safety, a previous requirement that the home should have fire and building risk assessments in place, this was partially met at this inspection. A fire risk assessment that was adequate had been drawn up but a building risk assessment was not in place. Instead, a health and safety checklist of the building which was adequate had been put in place that it was reported should be carried out monthly. However, only two had been completed one January 2007 and another in February 2008. It is advised this is carried out monthly as intended. In addition, at the last inspection although there was evidence that an inspection of the electrical wiring system had taken place some work had to be carried out before a safety certificate could be issued. This work had been done but the home was waiting for the system to be inspected again and a new certificate to be issued. However, at this inspection an up to date certificate still could not be identified. This must be obtained and a copy of the certificate sent to CSCI. Failure to comply will lead to enforcement action to be considered. There were up to date Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 24 maintenance certificates for gas and for portable electrical appliances (PAT) and also for fire equipment. In addition, in respect to fire safety there was evidence that weekly tests of alarm points had been done and regular fire drills had taken place. Furthermore, it was reported that following an inspection by the LFEPA that some requirements had been specified including changing the back door in the kitchen, which is a fire exit and cannot be locked with a key as it is presently. The home has till August 2008 to ensure all work is carried out. Since the last inspection although some regulation 37 notifications had been sent to CSCI it was noted at this inspection looking at the incident book that a number of incidents had been recorded where the police had to be called and one person had to be taken to hospital, which had not been reported as required by regulation 37 under the Care Standards Act 2000. This needs to be addressed. Finally, subject to a previous requirement that support staff need to have completed training in risk assessment and other areas of health and safety such as food hygiene, first aid, fire safety and infection control this had still not been fully met at this inspection. Six personnel files belonging to staff working at the home were checked. Four of the staff files did not include any evidence that they had completed food hygiene training nor fire safety training; three had not done first aid whilst two had no evidence of having completed a course in health and safety. This requirement has been outstanding for the past three inspections. Failure to comply will lead to enforcement action to be considered by CSCI (See Requirements & Recommendations). Woodham House DS0000028745.V362276.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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 3 X 2 X 2 X X 2 X Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Timescale for action 31/10/08 2. YA9 12 (2) & 13 (4)(c) 3. YA22 22(3) &(4) The registered provider must ensure that all parts of individuals’ care plans are fully and consistently implemented by the staff working at the home to ensure all identified and assessed needs are met. (Previous timescale of 30/11/07 not met) Failure to comply will lead to enforcement action to be considered. The registered provider must 31/10/08 ensure that people at the home are made aware of all the risk factors involved in decisions they make in relation to their lives and that where risks have been identified risk management plans are put in place to minimise the risk occurring. (Previous timescale of 31/08/07 partially met) Failure to comply will lead to enforcement action to be considered. The registered provider must 31/10/08 ensure that all complaints are fully investigated in line with the home’s complaints policy and DS0000028745.V362276.R01.S.doc Version 5.2 Woodham House Page 27 4. YA34 19 (4) 5. YA34 19 & Sched 2 6. YA35 18 (1) (c) (i) procedures and where appropriate statements are obtained from those involved. Also that the complainant is informed in writing within the timescale specified within the home’s policy what was the outcome of the investigation. (Previous timescale of 30/11/07 could not be assessed. New date for compliance to be set) The registered provider must 31/10/08 ensure that all staff recruited to work in the home are subject to a recruitment and vetting process specifically that all staff - Fill in an application form and are interviewed. - All gaps in employment are addressed and reason for leaving last position clarified. (Previous timescales of 31/10/06 & 31/05/07 had been partially met. Previous timescale of 30/11/07 met regarding application forms, not met regarding gaps in employment). Failure to comply will lead to enforcement action to be considered. The registered provider must 06/05/08 ensure that all checks and documents specified in Schedule 2 are obtained prior to allowing staff to commence working in the home to protect people living there. (Immediate requirement issued 01/05/08 and met within timescale specified 06/05/08. ) The registered provider must 31/10/08 ensure that all staff working at the home complete the Skills for Care induction and also that all staff have an annual appraisal DS0000028745.V362276.R01.S.doc Version 5.2 Page 28 Woodham House 7. YA37 8. YA39 9. YA42 10. YA42 completed. (Previous timescales of 31/01/06 & 17/01/07 & 31/08/07 partially metSkills for Care inductions met. Appraisals not met). Failure to comply will lead to enforcement action to be considered. 18 (2) The registered provider must ensure that the deputy manager is provided with adequate support to ensure the effective management of the home specifically that they receive regular supervision. (Previous timescale of 30/11/07 partially met) Failure to comply will lead to enforcement action to be considered. 24 The registered provider must ensure that as part of the selfmonitoring process an action plan outlining when and how aims and outcomes identified through completion of surveys with people at the home is drawn up. 18(1)(c)(i) The registered provider must ensure that staff receive appropriate risk assessment training in order that they can assess and manage risks safely and health and safety training including, infection control, control of substances harmful to health, food hygiene and first aid and these are updated on a regular basis. (Previous timescales of 31/10/06 31/03/06 & 31/08/07 partially met). Failure to comply will lead to enforcement action to be considered. 23(2)(c) The registered provider must ensure DS0000028745.V362276.R01.S.doc 31/10/08 31/10/08 31/10/08 31/07/08 Woodham House Version 5.2 Page 29 11. YA42 37 -That a maintenance certificate for the electrical wiring system of the home is obtained and a copy sent to CSCI. (Previous timescale of 31/05/07 partially met. Timescale of 31/08/07 not met). Failure to comply will lead to enforcement action to be considered. The registered provider must ensure that CSCI and all other relevant parties are notified of all incidents as specified by regulation 37 as part of maintaining and monitoring individuals’ safety and welfare. 31/10/08 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. Refer to Standard YA9 Good Practice Recommendations The registered provider should try to make sure that for those staff reported to have completed medication training that the certificates of this training are obtained and kept on their staff files. The registered provider should try to make sure that all support staff working at the home complete training in respect to the Mental Capacity Act to improve further their understanding of this and how it impacts on adult protection. The registered provider should try to ensure that evidence of both the initial basic induction and also the Skills for Care induction is kept on all individual staff files. The registered provider should try to make sure that the health and safety checks of the building are completed monthly as intended. 2. YA23 3 4. YA35 YA42 Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 30 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. Extracts may not be used or reproduced without the express permission of CSCI Woodham House DS0000028745.V362276.R01.S.doc Version 5.2 Page 31 - 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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