Inspection on 02/03/09 for Woodham House

This inspection was carried out on 2nd March 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodham House 01/05/08

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 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Woodham House 336 Stanstead Road Catford London SE6 2SB     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: James OHara     Date: 0 3 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 33 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 33 Information about the care home Name of care home: Address: Woodham House 336 Stanstead Road Catford London SE6 2SB 02086906237 02086906171 woodhamltd@aol.comSe762SB Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Victor Morris care home 5 Number of places (if applicable): Under 65 Over 65 0 mental disorder, excluding learning disability or dementia Additional conditions: 5 The maximum number of service users who can be accommodated is: 5 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: Mental Disorder, excluding learning disability or dementia - Code MD Date of last inspection Brief description of the care home Woodham House is a registered with the Commission to provide support for up to five people with mental illness and a forensic history. It is located on the busy south circular in Catford and is close to railway stations, bus services and local community facilities. The service 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. It is in keeping with the local community and does not stand out. The stated aims and objectives of the service are to support people 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. The current Care Homes for Adults (18-65 years) Page 4 of 33 Brief description of the care home monthly fee for a placement at the service range between £900 - £1500. No additional charges are made. This information was provided to the Commission in March 2009. Care Homes for Adults (18-65 years) Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We spent five hours over two days at the service and talked with two people who use the service, the project coordinator, the deputy manager and a member of staff. Records and documents examined during the inspection included care plans, activities, medication, staffing and training and health and safety records. The deputy manager completed an Annual Quality Assurance Assessment (AQAA) to tell us about the service provided, how it makes sure of good outcomes for the people Care Homes for Adults (18-65 years) Page 6 of 33 using it and any planned developments. What the care home does well: What has improved since the last inspection? What they could do better: The registered provider must carry out visits to the service so that they can form an opinion of the standard of care provided and to ensure that the service is properly monitored. Care Homes for Adults (18-65 years) Page 8 of 33 Staff must refrain from tearing pages from the complaints book. Employment references received on behalf of potential members of staff must be taken up on company headed paper or include a company stamp. Some staff need to attend training on fire safety, food hygiene and health and safety. A medication cupboard with a lockable container for controlled drugs could be installed should the need to store controlled drugs arise. The deputy manager should apply to the Commission to become the registered manager for Woodham House. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 33 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 33 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People planning to use the service can be sure that the service can support them because their needs are fully assessed before they move in. Evidence: Peoples needs had been fully assessed prior to moving in. Peoples personal files included detailed reports and assessments including risk assessment and management plans from the referring health authority. There was also evidence that the service had carried out assessments. No new people have moved in since the last key inspection. The deputy manager told us that one person had moved to another placement more suitable to their assessed needs. Care Homes for Adults (18-65 years) Page 11 of 33 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be sure that they are properly supported and safe because care plans and risk assessments give good information about their support needs and how the service can meet these needs. Evidence: A requirement was set at the last key inspection that the registered provider must ensure that all parts of peoples care plans are fully and consistently implemented to ensure all identified and assessed needs are met. The deputy manager told us that the care planning process had been reviewed. We looked at two peoples personal files, these included care plans, evidence of health care appointments, reviews and risk assessments. Care plans identified peoples needs such as support with medication, developing social networks, contact with family and friends, drug misuse, daytime activities, daily living skills, physical health, relationships and accommodation. The care plan also included a desired outcome for Care Homes for Adults (18-65 years) Page 12 of 33 Evidence: each identified need and a timescale for action. Care plans had been regularly reviewed and people had been involved in the care planning process. Peoples files included evidence of input from care coordinators, community psychiatric nurses and psychologists. It was evident from key work sessions and minutes of resident forums that people 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. One person told us that key work sessions are held on a monthly basis and they are involved in planning their care and do all of the things that have been agreed on the plan. Minutes from key worker sessions had been agreed and signed by the person and their key worker. Concerns were raised at the last key inspection that there was no evidence that people were involved in the therapeutic programme which consisted of a relaxation group, assertiveness training, health and eating advice, budget and planning and that this had not been undertaken with them. Also, testing of illegal substances had not occurred as stated. The deputy manager showed us a list of opportunities and activities, including the therapeutic programme, that people are offered and a record detailing if these had been accepted or declined. The deputy manager also showed us documentary evidence that people had been regularly tested so find out if they had used illegal substances. A requirement was set at the last key inspection that the registered provider must ensure that people 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. The project coordinator showed us peoples risk assessments. Where risks were identified the level of risk had been assessed as high, medium, low or none and plans reflected how these were being managed. Risk assessments had been kept under regular review. Care Homes for Adults (18-65 years) Page 13 of 33 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be sure that their social and leisure needs are met because they are offered a varied programme of activities that reflects their individual interests. People are part of the local community. Appropriate arrangements are made so that people can have contact with their friends and families. Evidence: Care plans identified peoples needs such as developing social networks, contact with family and friends, daytime activities, daily living skills and relationships. One person told us they like to go to the local library and sometimes to the gym. They showed us their room and around the house and told us that they liked sitting in the Care Homes for Adults (18-65 years) Page 14 of 33 Evidence: garden in the summer. Sometimes they have barbeques and visit other Woodham House services when they have get togethers. The other person told us that they had recently visited their family in Australia and was planning to visit them again in Belgium. The deputy manager produced an activities planner which covered areas such as open groups, laundry, cooking, gym, residents forums and shopping. The deputy manager told us that one person had applied last year to become a personal trainer but it didnt work out, this person was now doing a course that might help them towards achieving that goal. Residents forum meetings are being held monthly and are chaired by people who use the service. Minutes from these meetings indicated that people had planned DVD nights, outings, cinema trips, eating out and discussed issues such as smoking, enrolling for careers and the use of the dishwasher. People have an annual holiday, last year they went to Butlins in Bognor Regis. The deputy manager told us that they will be planning another holiday soon. People have freedom passes to enable them to use public transport and it was evident from records that people had made use of this travelling locally and also to go up to London. There are restrictions in place such as a curfew time but people 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 and they have keys to their rooms to promote their rights to privacy. People arrange their own breakfast and lunch. Each person has a cooking day where they are expected to take responsibility for planning and preparing the evening meal with staff assistance. Regular feedback about the food had been obtained from individuals at residents forums. There is a four week menu plan in place although the deputy manager told us 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 been provided had been maintained and these were sufficiently varied and nutritious. Care Homes for Adults (18-65 years) Page 15 of 33 Care Homes for Adults (18-65 years) Page 16 of 33 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are receiving flexible personal support in a way that they prefer and their physical and mental healthcare needs are being met. The medication system is well organised and managed. Evidence: People do not require support with personal care but staff provide prompting and encouragement as required. Issues regarding supporting people with personal care had been addressed within their care plans. There is a key worker system to ensure consistency of support. Interaction between staff and people was observed as warm and respectful and one person told us that 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 people had been addressed. Regular Care Programme Approach reviews of peoples mental health needs and to monitor risk factors had been held and there was regular contact with Community Psychiatric Nurses and Consultant Psychiatrists on an out patient basis. People are registered with Care Homes for Adults (18-65 years) Page 17 of 33 Evidence: a local General Practitioner and one person receives a prescribed medication at the local surgery on a regular basis. The medication system was looked at and found to be in order with no errors identified in the administration and recording of medication. Medication is stored in two locked cabinets in the office. The deputy manager produced a record of medication received into the service and returned to the pharmacy. The deputy manager told us that the basement was being refurbished and there were plans to store medication in this area. None of the people who currently use the service require controlled medication however it is recommended that a medication cupboard with a lockable container for controlled drugs is installed in the basement should the need to store controlled drugs arise. Although the service is registered to support up to five people only three people are accommodated at present. One person was admitted to hospital in December 2008 following deterioration in their mental health condition. The deputy manager told us that a number of assessments and review meetings had taken place at the hospital with mental health professionals to consider if and when it was appropriate for this person to return to the service. Staff administer medication to one person and one person is 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. It was recommended at the last key inspection that 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 deputy manager produced certificates for four staff that had completed medication training. Four new staff had covered medication administration at induction and they had arranged for these staff to attend training on the administration of medication. Care Homes for Adults (18-65 years) Page 18 of 33 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Adequate procedures are in place to make sure complaints are managed and to protect people from abuse. Evidence: There is a robust complaints policy. This was on display on a notice board in the entrance hall. There was evidence from key worker sessions and residents forums that people were given regular opportunities to raise any concerns they may have. People have the capacity to raise concerns and when we asked one person about making complaints they told us that they were very happy with the service and knew how to make a complaint if they needed to. A requirement was set at the last key inspection that the registered provider must ensure that all complaints are fully investigated in line with the complaints policy and procedures and where appropriate statements are obtained from those involved. Also that the complainant is informed in writing within the timescale specified within the policy and what was the outcome of the investigation. There is a complaints book in place to record all formal and informal complaints. The deputy manager showed us the complaints book. Four complaints had been made since at the last key inspection. These had been investigated by the service and resolved to the satisfaction of the people concerned. Care Homes for Adults (18-65 years) Page 19 of 33 Evidence: The complaints book had a page torn out. The deputy manager told us that this had been taken out because staff had recorded a regulation 37 incident in the book. This was removed and placed in the regulation 37 record book. The registered provider must ensure that staff refrains from tearing pages from the complaints book. The regulation 37 record book evidenced that incidents had been reported to appropriate parties including the Commission for Social Care Inspection. All staff had attended training on the Protection of Vulnerable Adults, two staff attended this training in 2006. It is recommended that two staff attends refresher training on the Protection of Vulnerable Adults. All staff had attended training on the Mental Capacity Act as recommended at the last key inspection. One member of staff spoken to had good knowledge on the different types of abuse and what action to take if they witnessed or suspected abuse was occurring. Care Homes for Adults (18-65 years) Page 20 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a comfortable safe environment that was clean and tidy on the day of inspection. Evidence: Woodham House 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, comfortable, safe and generally well maintained. One person showed us their room and around the house. They told us that they were very happy with their room and in particular the furniture and the en suite shower room. They told us it was nice just rolling out of bed in the morning and getting into the shower. They told us they enjoyed the garden and cooking in the large kitchen. The lounge is large, well decorated, with good quality furniture and a television. People were watching Sky Sports news, they were happy to discuss with us the events of the day. Woodham House was clean and hygienic on the day of the inspection and no offensive odours were noted. Care Homes for Adults (18-65 years) Page 21 of 33 Care Homes for Adults (18-65 years) Page 22 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can have confidence in the staff because checks have been done to make sure that they are suitable to care for them. So that people are kept safe staff need to receive training appropriate to the work they perform. Evidence: Requirements were set at the last key inspection that the registered provider must ensure that all staff recruited are subject to a recruitment and vetting process specifically that all staff fill in an application form and are interviewed and all gaps in employment are addressed and reason for leaving last position clarified. That the registered provider must ensure that all checks and documents specified in Schedule 2 are obtained prior to allowing staff to commence working to protect people living there. And that the registered provider must ensure that all staff complete the Skills for Care induction and also that all staff have an annual appraisal completed. Care Homes for Adults (18-65 years) Page 23 of 33 Evidence: The deputy manager told us that four staff had commenced employment since at the last key inspection. We looked at these staffs personnel files. All had completed an application form that included their employment history and all staff had attended an interview. All staff had Protection of Vulnerable Adults first checks, a Criminal Records Checks, completed medical questionnaires, obtained two written references and provided proof of identity and previous qualifications. Some of the references received on behalf of new staff from their previous employers had not been returned on company headed paper or include a company stamp. The deputy manager told us that they had contacted the previous employer to confirm reference. The registered provider must ensure that employment references received on behalf of potential members of staff are taken up on company headed paper or include a company stamp. This will ensure that the registered provider is satisfied on reasonable grounds that the references are authentic. All staff had completed the Skills for Care induction and had an annual appraisal. The file also included passports, employment contracts, evidence of regular supervision and further training attended. Training records showed that most staff had attended training on food hygiene, adult protection, medication, health and safety, risk assessments, infection control and managing violence and aggression. Four of the eight staff has completed a National Vocational Qualification in care at level 2 or above. The four new members of staff have enrolled with a training provider to complete the qualification. All staff had received induction and foundation training and had, in place, an individual training and development plan. However new staff had not yet attended training on food hygiene or health and safety. The deputy manager told us that this had been arranged. The registered provider must ensure that staff attend training on food hygiene and health and safety. Staff had covered fire safety training as part of their induction. Records showed that the fire alarm system was tested on a regular weekly basis and that regular fire drills had been carried out however the deputy manager told us that staff had not attended training on fire safety. The deputy manager showed us a DVD training package on fire safety and told us that arrangements had been made so that staff could complete the training. The registered provider must ensure that all staff attend training on fire safety. Records show that staff are receiving regular formal supervision and regular staff team meetings are being held. Care Homes for Adults (18-65 years) Page 24 of 33 Care Homes for Adults (18-65 years) Page 25 of 33 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be sure that their needs are met and their wishes are taken into consideration because the service is well managed. People can be sure that are protected from harm because good health and safety arrangements are in place. Evidence: The service coordinator told us at the last key inspection that an application had been initiated to register the deputy manager with the Commission to become the registered manager for Woodham House. The deputy manager told us that they had not yet applied to the Commission. The deputy manager told us that they had achieved a NVQ Level 3 in Care and started the Registered Managers Award NVQ Level 4 in June 2008. They told us that they were under the impression that they needed to complete the Registered Managers Award in order to become a registered manager. It is not required by the Commission that a person must complete the Registered Managers Award before making an application to become the registered manager of a Care Homes for Adults (18-65 years) Page 26 of 33 Evidence: service. As the deputy manager has managed the service on a day to day basis since at the last key inspection, holds NVQ Level 3 in Care and is completing the Registered Managers Award it is recommended that the deputy manager apply to the Commission to become the registered manager for Woodham House. A requirement was set at the last key inspection that 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. The deputy manager showed us documentary evidence that since the last key inspection they had received regular supervision from either the project coordinator or the registered provider once every two months. A requirement was set at the last key inspection that the registered provider must as part of the self monitoring process produce an action plan outlining when and how aims and outcomes identified through completion of surveys with people at the home is drawn up. The deputy manager produced surveys completed by people who use the service, relatives and health care professionals. The deputy manager also produced a report of the feedback obtained from the surveys, the report indicated how the feedback would be used to improve the service. The registered provider is required under regulation 26 of the Care Home Regulations to visit the service, interview with their consent and in private people who use the service and their representatives and staff working in the service as appears necessary in order to form an opinion of the standard of care provided. Inspect the premises, its records of events and records of any complaints and prepare a written report on the conduct of the service. The deputy manager told us that these visits had been carried out however were held by the project coordinator. They told us visits had not been carried out on a regular monthly basis as the registered provider was not always around. The deputy manager was advised that these visits can be carried out by a partner in the organisation, another director or other persons responsible for the management of the organisation or an employee of the organisation who is not directly concerned with the conduct of the service. The registered provider must ensure that visits are carried out under regulation 26 of the Care Home Regulations and the reports from these visits must be available at the service for inspection. Copies of these reports must be sent to the Commission until Care Homes for Adults (18-65 years) Page 27 of 33 Evidence: further notice. A requirement was set at the last key inspection that 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. Staff training records indicated that staff had attended training on risk assessments, infection control, and control of substances harmful to health, food hygiene and first aid. As previously stated new members of staff have yet to attend training in food hygiene. A new requirement has been set in respect of this. A requirement was set at the last key inspection that the registered provider must ensure that a maintenance certificate for the electrical wiring system is obtained and a copy sent to the Commission. The deputy manager produced a certificate dated the 2nd of March 2009 indicating that the electrical wiring system had been tested. A requirement was set at the last key inspection that the registered provider must ensure that the Commission and all other relevant parties are notified of all incidents as specified by regulation 37 as part of maintaining and monitoring peoples safety and welfare. The regulation 37 record book evidenced that incidents had been reported to relevant parties including the Commission for Social Care Inspection. As recommended at the last key inspection health and safety checks of the building are being carried out on a monthly basis. The deputy manager produced a landlords gas safety certificate dated 27th June 2008, a portable appliance testing certificate dated 29th January 2009 and a legionellas testing certificate dated 16th May 2008. Care Homes for Adults (18-65 years) Page 28 of 33 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 29 of 33 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 22 22 The registered provider must ensure that staff refrain from tearing pages from the complaints book. To ensure that there is an accurate record of complaints available for inspection. 30/04/2009 2 32 18 The registered provider must ensure that staff attend training on food hygiene and health and safety. So that staff recieve training appropriate to the work they perform. 05/06/2009 3 32 23 The registered provider must ensure that all staff attend training on fire safety. To make sure that people and staff are not placed at risk in the event of a fire. 17/04/2009 4 32 19 The registered provider must ensure that 31/07/2009 Care Homes for Adults (18-65 years) Page 30 of 33 employment references received on behalf of potential members of staff are taken up on company headed paper or include a company stamp. This will ensure that the registered provider is satisfied on reasonable grounds that the references are authentic. 5 39 26 The registered provider must ensure that visits are carried out under regulation 26 of the Care Home Regulations and the reports from these visits must be available at the service for inspection. Copies of these reports must be sent to the Commission until further notice. So that the registered provider can form an opinion of the standard of care provided and to ensure that the service is properly monitored. 30/04/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 20 It is recommended that a medication cupboard with a lockable container for controlled drugs is installed in the basement should the need to store controlled drugs arise. It is recommended that two staff attends refresher training on the Protection of Vulnerable Adults. It is recommended that the deputy manager apply to the Page 31 of 33 2 3 23 37 Care Homes for Adults (18-65 years) Commission to become the registered manager for Woodham House. Care Homes for Adults (18-65 years) Page 32 of 33 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 33 of 33 - 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!