Inspection on 13/04/05 for Woodham House

This inspection was carried out on 13th April 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodham House 02/03/09

Woodham House 01/05/08

Woodham House 31/05/07

Woodham House 02/05/06

Woodham House 24/10/05

Woodham House 15/09/04

Woodham House 21/04/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Woodham House 336, Stanstead Road Catford London SE6 2SB Lead Inspector Kate Matson Unannounced 13/04/05 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 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 Stationary 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 G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Woodham House Address 336, Stanstead Road Catford London SE6 2SB 0208 690 6237 020 86906171 Woodhamltd@aol.com Victor Morris Telephone number Fax number Email 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 CRH Care Home 5 Category(ies) of MD registration, with number of places Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15/09/04 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 a good standard of 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.” Mr Victor Morris is the registered proprietor/manager. On the day of the inspection there were no vacancies. Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over 7.5 hours. A tour of the building and two service users bedrooms were seen. Care records, staff files and other records were examined and all five service users were spoken to. A new deputy manager had been appointed since the last inspection. What the service does well: What has improved since the last inspection? What they could do better: The information provided to service users had been reviewed though important information is still lacking. Evidence of the needs assessment must be kept on the care file so that service users’ progress can be monitored against their needs on admission. The service user contract had been reviewed but still lacked required information and had not been used for existing residents to ensure that they enjoy appropriate legal protection. The physical and mental health needs of service users are met well at the home; however, the practice of offering cigarettes as prizes for bingo sessions must be stopped as it places service users’ health at risk. The home offers a comfortable and homely environment to service users though stained rugs need to be cleaned or replaced to ensure that service users do feel that are valued. Staff receive Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 6 appropriate training at the home but a training and development plan must be developed to ensure that training is based on the needs of service users and the whole staff team. Practices at the home generally ensure that service users health, safety and welfare are protected but the frequency of fire drills and the testing and servicing of fire equipment potentially places service users at risk. Requirements have been made where issues have been highlighted under this heading. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 5 Although improvements had been made to the information provided to service users, this was insufficient for them to make a fully informed choice about where they live. Service users have contracts but these do not include all of the required information to ensure that they enjoy appropriate legal protection. Prospective service users’ needs are thoroughly assessed but must be better evidenced so that their progress can be monitored against their needs on admission. EVIDENCE: The statement of purpose and service user guide had been reviewed in accordance with a requirement made at the last inspection. These included valuable information though unfortunately there was still vital information missing from the documents and the complaints procedure included information about the wrong CSCI office. The requirement is restated in this report. Although thorough needs assessments have been evidenced by the home in the past, and the deputy manager confirmed that the same procedure is in operation, two of these were not available on the files. A requirement is made to ensure that a copy of the assessment is available on the file. The service user contract had been reviewed in accordance with a requirement made at the last inspection. Although it was improved there was still some information missing and the revised contracts had not been utilised for existing residents. The previous requirement is restated in this report. Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9 Care plans and systems at the home demonstrate that service users are supported to be involved in their care, make their own decisions (including those around risk) and are given opportunities to participate in the running of the home. EVIDENCE: Care plans had been improved following a requirement made at a previous inspection. They covered all of the required areas that had previously been missing such as physical health needs, financial matters and information about the service user’s wishes in the event of illness or death. The care plans also included a summary of the more detailed risk assessment held on other files. Service users are supported to make their own decisions in all aspects of their lives within the boundaries of any restrictions imposed by the Mental Health Act. All but one of the service users is financially independent and the man who has support has a care plan around this. Service users spoken to confirmed that they are offered opportunities to participate in the running of the home and rota’s are in place to ensure that everyone plays a part in tasks such as cooking and cleaning. Service user Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 10 meeting minutes evidenced that they are consulted about food, leisure activities including holidays and decisions about décor and furnishing of the home. The deputy manager stated that she is working towards the implementation of a previous recommendation to involve service users in recruitment processes at the home. A recommendation is made regarding the recording of meeting minutes. There are detailed risk assessments for each service user on file including contingency plans. The deputy manager has also included a summary of this information in the care plan so that the information is more readily accessible. Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 and 17 Service users are supported to be independent and to take part in a variety of meaningful activities both at the home and in the local community. They are supported to have appropriate relationships. Meals are provided flexibly at the home and the food offered is varied, balanced and nutritious. EVIDENCE: The home has close links with two local organisations involved in helping people with disabilities to find work and training opportunities. New service users are usually referred to these organisations on taking up a place at the home. Some of the service users are currently taking part in courses at college. The deputy manager has introduced several groups at the home including relaxation, budgeting skills and assertiveness skills. Service users spoken to stated that these groups were beneficial. Service users were seen coming and going throughout the day. They use local shops, cafes, library and a gym. They are informed about local places of worship. On admission to the home, all service users are supported to apply Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 12 for a “freedom pass”, which is a travel card allowing free travel on public transport. All service users are given a key to their room. Service users are supported to maintain contact with friends and family as far as they wish. This may involve accompaniment or encouragement. Service users spoken to confirmed that they may have guests and one service user had cooked a meal for friends. Service users organise their own breakfasts and lunches and are supported to cook for each other in the evenings. Service users spoken to confirmed that meal choices are flexible and the food record indicated that meals are varied, balanced and nutritious. Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 and 21 Service users physical and mental health needs are met well at the home though a practice of offering cigarettes as bingo prizes places their health at risk. EVIDENCE: Service users confirmed that they receive appropriate personal support as and when they need it. Care plans indicated that service users physical health care is considered at the home as well as ensuring that they maintain close liaison with mental health services. Information about health promotion is also provided to service users about things such as sexual health and drug taking. However it was noted that cigarettes are offered to service users as prizes at the bingo sessions provided at the home. This is inappropriate as one service user has recently stopped smoking and the home should not be promoting activities that put service users health at risk. A requirement is made to ensure that this practice is stopped. Medication systems at the home were in order and the home has regular input from a pharmacist. Staff have all completed appropriate training to administer medication. Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 14 Service users are supported towards independence with medication where appropriate. Efforts have been made to discuss service users wishes with regard to illness and death and the outcome of these discussions has been recorded in accordance with a previous requirement. Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Service users do not feel the need to complain though are clear about how to complain should the need arise. The home has policies in place to protect service users from abuse and staff are trained in appropriate areas to ensure that risk of abuse is minimised and they know how to respond in cases of possible abuse. EVIDENCE: The complaints record indicated that there had been no complaints since 2003. Service users confirmed that they did not have any complaints but were familiar with the complaints procedure should they have cause for complaint. The complaints procedure had been reviewed in accordance with a previous requirement though some discussion took place around how the presentation of the procedure could be improved further. The home has appropriate policies in place to ensure that service users are protected from abuse and to ensure that appropriate steps are taken in the event of possible abuse. All staff now have completed or are completing NVQ training that includes a module on adult abuse. The deputy manager is due to commence an instructor course on challenging behaviour to ensure that potentially aggressive situations are dealt with in a way that reduces risks to staff and service users. Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26 and 30 The home offers a comfortable and homely environment that is generally well maintained. Two stained rugs however detracted from this and could make service users feel they are not valued. EVIDENCE: The home is comfortable and homely with adequate individual and shared space. It is generally well maintained and previous requirements made at the last inspection had been implemented. All service users have individual bedrooms (three have en suite facilities) and these are furnished with all of the required items. It was noted however in two of the bedrooms seen that the rugs provided were very stained. These must be cleaned or replaced. The home was clean on the day of the inspection and policies and procedures are in place to ensure hygienic practices. Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 and 36 The home’s recruitment procedures protect service users. Staff are well supported and supervised. The staff have appropriate training though this needs to be more clearly linked to an assessment of the needs of the service users and the whole staff team. EVIDENCE: Staff files examined showed that the homes recruitment procedure protects service users. All files examined included references, criminal records bureau checks and checks against the list of people considered unsuitable to work with vulnerable adults. Statements of terms and conditions were in place in accordance with a previous recommendation. All staff have either completed NVQ’s or are currently completing courses to ensure that service users are supported by a competent staff team. There was some evidence that Induction and Foundation training meets Sector Skills Council workforce training specifications. It was noted that although the home accesses training for staff there was no formal training and development plan in place based on an assessment of the needs of the staff team as a whole and the needs of the service users. A requirement is made that this must be done and it is also recommended that the manager contacts the London “Skills for Care” office (formerly TOPSS) to ensure that the homes training programme meets Sector skills workforce training specifications. Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 18 The new deputy manager has implemented a system to ensure that supervision takes place as required in line with a previous recommendation. Staff files showed that staff had regular supervision and the home was on target of ensuring staff have supervision at least six times per year in accordance with a previous requirement. Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 41, 42 and 43 The home’s record keeping and policies and procedures for the health, safety and welfare of service users are generally good though the frequency of fire drills and the testing and servicing of fire equipment potentially places service users at risk. The home has a quality assurance system in place though this could be further improved to ensure that the consultation process is more effective. EVIDENCE: An annual development plan has been produced in accordance with a previous requirement. Surveys of the views of service users, relatives and professionals are completed every six months. The deputy manager had produced a report of the previous surveys in accordance with a previous requirement though it was noted that the report had not been publicised and also it included information gathered outside of the surveys that was not acknowledged. The quality assurance report should be made available to those participating in the surveys and the report should more accurately describe how the information is Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 20 gathered. Discussion took place about how the format of the surveys could be improved to ensure that service users are encouraged to comment more widely on more aspects of the service and that each of the surveys is appropriate for its intended participants. Records examined were properly kept and up to date apart from fire drills and fire alarm tests, which indicated that a fire drill had not been carried out for over eight months, rather than four times per year as required and fire alarm call points were tested approximately every two to three weeks instead of every week as required. Certificates were available to evidence the safety of some aspects of the premises and evidence was available that portable appliances had now been tested in accordance with a previous requirement though the deputy manager stated that the certificate was still awaited and she would follow this up. However the servicing of the fire alarm, fire extinguishers and emergency lighting was due the previous month. A cash flow forecast was available for inspection in accordance with a previous requirement. Appropriate insurance cover is in place. Lines of accountability within the home are clearly understood by staff and service users. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No Woodham House Score Standard No Score Version 1.20 Page 21 G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc 1 2 3 4 5 1 2 x x 2 22 23 ENVIRONMENT 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 2 x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 Standard No 37 38 39 40 41 42 43 Score x x 3 x 3 2 3 Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 and 5 Requirement The registered provider must review the statement of purpose and service user guide to ensure that they include all of the information listed under Standard 1 of the National Minimum Standards, and Regulations 4 and 5 of the Care Homes Regulations.(Previous timescale of 31/01/05 not met) The registered provider must ensure that copies of the homes needs assessment are kept on service users files The registered provider must ensure that the service user contract includes all of the information listed under Standard 5.2.(Previous timescale of 31/01/05 not met) The registered provider must end the practice of offering cigarettes as prizes for bingo sessions and instaed offer prizes that do not place the health of service users at risk. The registered provider must ensure that the rugs identified in two service users bedrooms are cleaned or replaced. The registered provider must Timescale for action 31/07/05 2. 2 14 31/07/05 3. 5 5 (1) (b) (c) 31/07/05 4. 19 12 (a) 31/07/05 5. 26 23 (2) (d) 31/08/05 6. 35 18 (c) (i) 30/09/05 Page 23 Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 7. 42 23 (4) 8. 42 23 (4) ensure that the home has a staff training and development plan based on an assessment of the needs of the whole staff team and the needs of the service users. The registered provider must ensure that fire drills and fire alarm tests are completed at the appropriate intervals The registered provider must ensure that current certificates are in place for the servicing of the fire alarm, fire extinguishers and emergency lighting 31/07/05 31/07/05 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. Refer to Standard 8 8 35 Good Practice Recommendations It is recommended that service users be involved in staff recruitment processes. (The deputy manager has been working on this). It is recommended that service user meeting minutes are recorded to reflect discussion of previous meetings so that matters arising can be easily tracked. It is recommended that the manager contacts the London “Skills for Care” office (formerly TOPSS) to ensure that the homes training programme meets Sector skills workforce training specifications It is recommended that the quality assurance report is reviewed to more accurately reflect the sources of information. The report should also be made avaialble to those participating. It is recommended that the format of surveys is improved to ensure that service users are encouraged to comment more widely on more aspects of the service and that each of the surveys is appropriate for its intended participants. 4. 39 5. 39 Woodham House G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection Southwark Office 46, Loman Street London SE1 0EH National Enquiry Line: 0845 015 0120 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 G52 S28745 Woodham Hse V221458 13 04 04 Stage 4.doc Version 1.20 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!