Inspection on 02/05/06 for Woodham House

This inspection was carried out on 2nd May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report 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 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 09/07/2008.

CARE HOME ADULTS 18-65 Woodham House 336 Stanstead Road Catford London SE6 2SB Lead Inspector Ornella Cavuoto Unannounced Inspection 2 & 3rd May 2006 10:00 nd Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 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.V292492.R01.S.doc Version 5.1 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.V292492.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodham House Address 336 Stanstead Road Catford London SE6 2SB 020 8690 6237 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) woodhamltd@aol.com Victor Morris Victor Morris Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2005 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 were no vacancies. 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.V292492.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over a day and half. The acting deputy manager was present for the whole of the inspection process whilst the service co-ordinator was also available for parts of the process. One other staff member was spoken to as well as three service users and two professionals who regularly visit the home. Other inspection methods used included examining records and a partial tour of the premises also took place. What the service does well: What has improved since the last inspection? There is now a Statement of Purpose and Service User Guide that is available for both prospective and current service users providing them with the necessary information about living at the home. There have been improvements in the systems used to check the medication for service users who take responsibility for taking their own medication. The home has undergone a lot of decoration to ensure that the environment of the home is maintained to a good standard. Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 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.V292492.R01.S.doc Version 5.1 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 the following standard(s): 1,2 &5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users have the information they need about living in the home but the statement of purpose needs to be amended to ensure all information included is accurate. The needs of service users are assessed before they move into the home. All service users have been issued with a contract that now contains the correct information they need to protect their rights. EVIDENCE: The statement of purpose and service user guide were inspected. Subject to previous requirements the service user guide now contains all the information required by regulation. However, the statement of purpose still lacked some information such as the name and address of the registered provider and manager and relevant qualifications and experience held, the number of staff working at the home and any relevant qualifications and experience. An amended statement of purpose was sent shortly following the inspection that addresses all points specified with Schedule 1 of the regulations. However, the information included was not accurate. For example, with regards to staff qualifications the statement of purpose states “Some of the staff members working at the home have attained their NVQ Level 2 and 3” It was reported at the inspection that none of the staff working at the home have attained a NVQ Level 2 and although one member of staff was due to complete a NVQ Level 3 Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 9 shortly other staff members are to start this course in September 2006. This needs to be amended to accurately reflect the situation regarding staff qualifications (See Requirements). Standard 2 was inspected and assessed as met at the last inspection. The home has not had any new admissions since this inspection so it was not possible to identify if any new service users have been admitted on the basis of a full assessment. However, it was reported that it is the policy of the home to obtain a full assessment of need and the home carries out their own assessment prior to admitting service users. Subject to a previous requirement, service users have been issued with a contract that now contains the correct information they need to protect their rights. Four out of the five service user plans were inspected and all included a copy of the contract that had been signed by the service user. Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 6,7, 9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All service users have an individual plan in place that reflects their changing needs and personal goals. Service users are supported and given assistance as needed to make decisions about their lives but access to information on independent advocacy services needs to be provided. Service users are supported to take risks but action required to manage risks presented by service users needs to be set out more clearly within their individual plans. The home does not have a confidentiality policy in place to fully assure service users that information about them is handled appropriately. EVIDENCE: Four service user plans were inspected. The plans comprehensively address all aspects of personal, social support and healthcare needs with both long and short- term goals being identified. They also set out therapeutic programmes such as assertiveness and budgeting that service users are involved in as part of supporting them to acquire the necessary skills to be able to live more Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 11 independently. Furthermore, the plans include information about symptoms that may indicate that a service user maybe experiencing a relapse of their mental health problem that potentially may involve aggressive behaviour or self- harm and a plan of action to be followed by staff if these situations arise. Restrictions on service users such as curfews times are also specified. There was evidence that service user plans are reviewed three monthly. Service users sign these to indicate their involvement in the care planning and review process. In addition, in accordance with the Care Programme Approach (CPA), reviews have been held involving the service user and all professionals involved in their care. This also forms the basis of the service user plan and changes are made as decisions are taken within the CPA reviews about individual service user’s needs. All service users have regular key work sessions that generally take place on a monthly basis but it was reported that these could be held more frequently depending on the needs of the service user. All sessions are recorded. They are aimed at looking at all aspects of support and the care needs of service users such as relationships, accommodation, finances, daily living skills, day time activities as well as physical and mental heath needs and risk behaviour. Service users are requested to give their feedback and comments at each session and also to sign the form as evidence of their agreement of any decisions taken and their involvement in the session. It was evident through the key work sessions and also through the minutes of resident meetings that staff do respect service users’ right to make decisions about their own lives whenever possible and that staff provide assistance and information to support them to do this. Any limitations placed on service users directly relate to the home’s responsibilities and duties under law such as adhering to restrictions imposed on service users by the Mental Health Act 1983. All except one of the service users manage their own finances and the reason for the service user requiring support is documented within the service user plan. It was reported that service users could access independent representation via their solicitors or family members. However, it is advised that information is also provided to service users about local independent advocacy/self advocacy groups/peer support groups (See Recommendations). There were risk assessments in place for all service users whose individual plans were inspected. As mentioned, there are clear and comprehensive risk management plans in place in the event of a service user experiencing a relapse in their mental health and risk behaviour is explored with service users within key work sessions. However, where certain risk behaviours have been identified such as self- neglect, pushing boundaries or risk of absconding specific action to support staff and service users to look at ways of minimising risks have not been addressed in detail (See Requirements). Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 12 Although, staff spoken to did have some awareness of confidentiality and service users’ records are kept secure. The home did not have a written policy or procedure on confidentiality that sets out the home’s responsibilities as outlined within the Data Protection Act 1998 available for inspection. This needs to be addressed to enable service users to feel confident that information about them is handled appropriately (See Requirements). Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 &17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to be independent to continue their education/training and/or take part in meaningful activities. Service users are supported to integrate within the local community. A record of structured group activities provided by the home for service users needs to be maintained. Service users are encouraged and supported by staff to maintain and form appropriate relationships. Service users rights are respected and responsibilities recognised in their daily lives. There needs to be more input from service users around the choice of foods that are made available and meals prepared. EVIDENCE: There was evidence within service user plans and service users spoken to confirmed that they are supported to continue their education /training and take part in other fulfilling activities. For example one service user at the time Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 14 the inspection took place attended an interview at a local college to do a course in art and design. Previously, they had been involved in a dance music/D.J workshop and also had been on a course to become a chef. Another service user discussed how they have completed two courses in computing and is now interested in doing a course to become a gym instructor which staff are supporting them to look at. Service users are supported to become part of, and participate in the local community. There was evidence within service user plans of an induction that all service users are given on admission to the home, which involves giving them information about the local area including facilities available and transport links. Service users spoken to confirmed they do make use of some of the local facilities and services such as the library, the gym and the local shops. Also, a mental health professional that regularly visits the home stated that the home “has been quite good in rehabilitating and reintegrating people in the local community and using local services.” Service users pursue their individual interests and hobbies. This is demonstrated in the training courses they have been involved in, which has been discussed. A holiday is arranged for all service users every other year. However, in terms of other group activities offered by the home there was limited evidence available that these are being offered by the home. Bingo was the only one included in the weekly activities plan in place and service users spoken to said this had been stopped. It was reported that as the aim of the home is to support service users to become more independent they are generally encouraged to get involved in activities outside the home rather than activities being provided in house. Also, it has proved difficult to engage service users in group activities that have been arranged outside of the home, for example, on the day of a trip to a museum that was set up recently all the service users refused to go. However, in speaking to service users they expressed that they would like more group activities. One service user stated “ I’ve suggested going out to Brighton for the day” It was also seen from the minutes of weekly residents meetings that they had proposed a trip to the cinema. It is important that the home put in place opportunities for service users to engage in group activities and a record of this is maintained including those service users that participate (See Requirements). There was evidence from service user plans and also in speaking to service users that the home supports them to maintain family links and friendships in and outside the home. One service user spoken to said “I can stay overnight with my family if I want to”. The home does have curfew times for service users, which is 10pm weekdays and 1am at weekends. Service users are made aware of these conditions prior to moving in and are included in their contracts. Yet, overall daily routines and house rules do promote independence individual choice and freedom of movement. Service users are required to attend therapeutic groups provided Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 15 within the home, which is part of supporting them to increase their level of independence. Also, they are expected to take responsibility for house keeping tasks such as cooking, laundry, tidying their own rooms to help them develop and improve their skills in activities of daily living. All service users have keys to their rooms to promote rights to privacy. Also, during the inspection service users were observed coming and going from the house and interacting with staff. In respect to meal times service users arrange their own breakfast and lunch and are expected to take turns to cook an evening meal with the support of staff. There is always a choice of two meals and a daily record of the meals provided and which residents had what to eat is maintained. Feedback from service users about the food was varied. One service user said the food was “alright” whilst others stated that it was repetitive and had personal food preferences of which they would like more provided. The record of meals cooked was inspected and appeared to include a good variety of meals with little evidence of repetition. It was reported that service users are involved in food shopping for the house and there was evidence from minutes of resident meetings that food is discussed although it was not clearly evident that service users have an input in deciding what meals should be cooked. Therefore, it is advised that as part of weekly resident meetings service users suggestions for the menu are clearly recorded (See Recommendations). Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 &21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users receive personal support in the way they prefer and require. The physical and mental health of service users is addressed. The home’s system for the administration of medication and policies and procedures protect service users. Service users have been consulted about their personal wishes with regards to death and dying. EVIDENCE: As the home aims to support service users to move back into the community and live independently, service users are encouraged to do as much for themselves as possible with staff providing encouragement and guidance only when required. Consequently, service users are expected to take responsibility for maintaining their personal hygiene and as previously mentioned to do their own laundry, tidy their rooms and to cook meals. Service users spoken to confirmed they generally felt well supported by staff. There was evidence from service user plans that service users’ physical and mental health needs are addressed by the home. Regular Care Programme Approach (CPA) reviews of individual service user’s mental health needs and Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 17 presenting risks have taken place. A mental health professional that regularly visits the home confirmed that for service users living at the home “the CPA process has been good with a plan of care being followed.” Service users have also had regular assessments and reviews of their mental health and medication by consultant psychiatrists on an out patient basis as well as being seen at the home. Service user plans also demonstrated that there has been involvement and contact with other primary health care services such as G.P’s, opticians, dentists and chiropodists. The home’s medication policy was generally comprehensive except it did not include that medication needs to be retained for seven days in the event that a service user dies at the home in case there is a coroners inquest. However, this was added to the policy at the time of the inspection and was checked. Subject to a previous requirement, for those service users who take responsibility for taking their own medication the home has put in place a system in which regular spot checks are carried out to ensure they are self administering their medication correctly as well as monitoring the general condition of the service user taking the medication, for example identifying signs that there maybe a deterioration in their mental health. Four staff are presently undertaking an accredited course in the safe handling of medication at Croydon College. It was reported all staff are to be supported to attend this training. At present, the acting deputy manager takes overall responsibility for the administration of the medication system which uses both blister packs and dossette boxes to dispense medication to service users. A sample of Medication Administration Record sheets (MARS) was checked. However, the system was found to be confusing. The record sheets did not clearly correspond with medication that had been given and what was in stock. One error was identified where a tablet was missing from a blister pack and had not been signed for and no clear explanation for this could be given. A referral to the regulatory pharmacist was made for a more detailed inspection of the system to be carried out. This was completed and everything was found to be satisfactory with no changes to the system being required. All service user plans that were inspected included evidence that service users had been consulted about their personal wishes for death and dying. Two service users declined to discuss the issue. This had been recorded with the service users signing the document as evidence. Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 18 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 the following standard(s): 22 &23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are clear about to make a complaint should the need arise. The home has policies and procedures in place to protect service users from abuse and all staff are to undergo training in respect to adult abuse awareness/protection. EVIDENCE: The home has a robust complaints policy that includes the stages and timescales for the process. It is also accessible to service users and visitors on display on the notice board in the entrance hall. Service users spoken to were aware of the complaints policy and were clear about to whom they would refer their complaints if they were to make one. In respect to making complaints one service user spoken to stated, “ I have never had anything to complain about.” The home has a complaints log and all complaints including minor dissatisfactions /low-level complaints are recorded. It was noted from the complaints log that no complaints have been made since the last inspection. In respect to adult protection and whistle blowing the home has robust policies and procedures in place. However, it is also advised that the home obtain a copy of Lewisham’s Interagency Guidelines on Adult Protection for staffs’ information and guidance (See Recommendations). There was evidence to indicate that all staff working at the home will be undertaking Protection of Vulnerable Adult (POVA) training in June and October of this year. Staff spoken to did have some knowledge around adult abuse. There have been no adult protection investigations required since the last inspection. Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 19 There is a comprehensive policy with regards to service user finances. All service users except one manage their own finances. For the service user who is presently been supported with managing their personal allowance records and receipts are kept of all transactions made, money issued to the service user and these are signed by staff. Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 20 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 the following standard(s): 24, 26,28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, homely and comfortable environment. Service users bedrooms promote their independence. Shared spaces complement and supplement individual service users’ rooms. The home is clean and hygienic. EVIDENCE: The home’s premises are homely, safe and well maintained are suitable for its stated purpose. The home offers access to local amenities, local transport and relevant support services to suit the personal and lifestyle needs of service users. The premises are also in keeping with the local community. All service users have lockable individual bedrooms and with permission three were seen on the day of the inspection. All rooms were furnished with all of the required items. Subject to a previous requirement rugs within the rooms had been replaced and were clean. A chest of drawers that was identified as broken at the last inspection had been replaced. Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 21 The home has shared space that includes a large lounge, large kitchen and dining area and a large garden at the rear. Subject to a previous requirement the home has been recently decorated with the hallway being painted and the carpet on the stairs being replaced. The bathroom has also been painted. All other communal areas were well maintained bright and airy. The home was clean and hygienic at the time the inspection took place with no offensive odours being noted. The laundry facilities are adequate for the home. They are sited in a cupboard under the stairs away from the preparation of food. Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 &36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The majority of the staff team working at the home have not achieved a National Vocational Qualification (NVQ) in care. The service has sufficient numbers of staff working at the home. Service users are not currently fully supported by the home’s recruitment practice. The home has drawn up a training plan to ensure staff are trained to enable them to meet service users’ individual and joint needs appropriately. Staff are not receiving regular supervision. EVIDENCE: It was reported by the services co-ordinator that one staff member working at the home is presently studying for a NVQ Level 3 in care and is to complete shortly whilst another has completed a foundation in care. All other staff members are due to start courses to complete a NVQ Level 3 in June 2006. The home’s annual training plan provided evidence of this. None of the staff have completed NVQ Level 2 in care. Although, it was evident in speaking to staff that they had a good general knowledge of the needs of service users and were clearly very interested, motivated and committed, it is important that staff are supported to complete the necessary qualifications to carry out their work more effectively (See Requirements). Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 23 The duty rota was checked and did not accurately reflect who was duty in that although the registered manager was on the rota for the first day of the inspection he was not working at the home but carrying out other duties (See Standard 37). It was evident that there were sufficient numbers of staff on duty to meet the needs of service users. The home use a small number of bank staff and there was evidence that regular monthly staff meetings take place. (See Requirements). In relation to recruitment, four staff files were inspected. All staff had Enhanced Criminal Record Bureau Checks in place; two references and appropriate identification had been obtained as required. However, only one file had evidence of a completed application form. Therefore, for those staff where an application form was not in place previous employment history could not be checked including whether gaps in employment or reason for leaving last position of employment had been appropriately explained. Also, it could not be established that of the two references that had been obtained one was from the last employer. For the staff member that did have an application form it was evident a reference from the last employer as specified on the form had not been obtained. In addition, apart from the staff member that had an application form there was no evidence of a health declaration regarding fitness to do the job and none of the files had an up to date photograph in place. Furthermore, it was identified that the documents relating to staff that previously worked at another Woodham project but now work at the home, were not being kept on the premises. This needs to be addressed (See Requirements). Subject to previous requirements, the home has drawn up a training and development plan based on the needs of the whole staff team and the needs of service users. It provides details of where the training is to be provided and dates for commencement and completion. An induction programme has also been put in place that meets “Skills for Care ” specifications. It was reported that all staff presently working at the home are to undertake the “Skills for Care” induction but this is yet to be completed for all staff. Staff appraisals to monitor and identify future training and development needs of individual staff have not been completed. This needs to be addressed (See Requirements). From four staff files that were inspected only one included evidence that the staff member has received regular supervision. All staff must receive at least six sessions a year (See Requirements). Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, &42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements for the home are not clear and this potentially can impact on the efficient running of the home. Service users views are regularly sought as part of self- monitoring carried out by the home. Although there have been some improvements in training and systems in respect to health and safety practices there are areas that still need to be addressed to ensure the health, welfare and safety of service users are fully promoted and protected. EVIDENCE: At the last inspection concerns were raised about the management arrangements of the home in that the registered manager who is also the registered provider did not appear on the home’s rota. It was established that although he visits the home most days he does not manage the home on a full time basis. Subject to a previous requirement, the manager has now been Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 25 included on the rota and was due to be on duty the day the inspection started. However, he only visited the home briefly to explain he had to attend an assessment and then had other matters to deal with away from the home leaving the acting deputy manager in charge. Yet, the rota did not accurately reflect this arrangement. An acting deputy manager was not specified on the rota. The matter was discussed with the service co-ordinator and it was reported that there are plans to promote the acting deputy manager to become the registered manager of the home although no timescale for this was given. In the interim period that this arrangement is put in place, the home must ensure that the home has adequate management cover at all times and this is accurately recorded on the rota (See Requirements). In relation to quality assurance the home completes surveys seeking the views of service users, relatives and all professionals involved in the home every six months. The results of the surveys were compiled into a report. The last report completed that was seen for inspection was dated 20/01/06. It is advised that the report includes the number of surveys that were sent out for completion and the number of responses received (See Recommendations). The home has health and safety procedures in place. As previously recommended there was evidence that staff had signed to indicate they have read and understood policies and procedures. One of the workers takes responsibility for ensuring health and safety aspects of the home are maintained to required standards. Subject to a previous requirement the home has carried out regular fire drills and also as part of fire maintenance has carried out weekly tests of fire alarm call points. However, the fire risk assessment was inspected and was very briefly written and did not fully address all fire risks. This needs to be reviewed. Also, the home did not have a building/environment risk assessment in place, which needs to be addressed (See Requirements). Previous requirements made with regards to staff requiring training in respect to food hygiene, first aid, infection control, control of substances harmful to health and general risk assessment training have been partially met. There was evidence within the training plan that two of the staff team are due to have training in food hygiene and infection control. It was also reported that the health and safety representative has completed a First Aid course with St John’s Ambulance which enables them to provide training to staff in –house. The “Skills for Care “ induction introduced by the home also covers areas such as risk assessment. The home must ensure that all staff working at the home receive training in these areas and that these also kept updated on a regular basis (See Requirements). Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 26 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 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 1 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 1 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 X 3 X X 2 X Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 27 Yes Are there any outstanding requirements from the last inspection? TATUTORY 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 YA1 Regulation 4 and 5 Requirement Timescale for action 30/06/06 2. YA9 12 (1)& 13 (4) (c) 3. YA10 12 (4) (a) 4. YA14 16 (2) (n) The registered provider must amend the statement of purpose to ensure that all the information included specifically the information regarding qualifications held by staff presently working at the home is accurate. The registered provider must 31/10/06 ensure that risk assessments are more comprehensive and in relation to specific risk behaviours presented by service users action to be taken to support staff and service users to minimise and manage the risk should be detailed. The registered provider must 31/10/06 ensure that the home has a policy on confidentiality in place that outlines the home’s responsibilities about sharing information on service users and storing documents/records in line with the Data Protection Act 1998. The registered provider must 31/10/06 ensure that a record is maintained of when service users are offered opportunities DS0000028745.V292492.R01.S.doc Version 5.1 Woodham House Page 28 5. YA32 18 (1) (a) 6. YA33 18 (1) (a) 7. YA34 19 (4) & Sched 2 8. YA34 19 (4) 9. YA34 19(4) 10. YA35 18 (1) (c) (i) to be involved in group activities inside and outside of the home and include who participated. The registered provider must ensure staff working at the home who are due to start a National Vocational Qualification in care in June 2006 complete the course to enable them to undertake their work more effectively. The registered provider must ensure that the rota accurately reflects at all times staff who are on duty and the arrangements for management cover of the home. The registered provider must ensure that all the required documents are obtained for staff working at the home specifically - Two references are in place one of which needs to be from the last employer. - A health declaration has been completed to establish fitness to do the job. Also, all staff must have an up to date photograph on file. The registered provider must 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. The registered provider must ensure that recruitment records for all staff working at the home are kept on the premises. The registered provider must ensure that all staff working at the home complete the “ Skills for Care” induction and also that all staff have an annual appraisal completed. DS0000028745.V292492.R01.S.doc 31/01/07 30/06/06 31/10/06 31/10/06 30/06/06 31/10/06 Woodham House Version 5.1 Page 29 11. YA37 12. YA42 13. YA42 (Previous timescale of 31/01/06 partially met). 8 The registered provider must 30/06/06 ensure that there is adequate management cover at the home at all times specifically that there is a manager on site to ensure the home is effectively managed. (Previous timescale of 31/01/06 partially met) 13 (4) (a) The registered provider must 31/10/06 ensure that there is a comprehensive fire and building risk assessment in place for the home. 18(1)(c)(i) The registered provider must 31/10/06 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 timescale of 31/03/06 partially met) 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 YA7 Good Practice Recommendations The registered provider should try to make information available to service users about independent advocacy/self advocacy and peer support groups to support them when having to make decisions or requiring representation. The registered provider should try to ensure that suggestions and input about meals to be cooked are clearly recorded within the minutes of residents meetings. The registered provider should consider obtaining a copy of London Borough of Lewisham’s interagency guidelines DS0000028745.V292492.R01.S.doc Version 5.1 Page 30 2. 3. YA17 YA23 Woodham House 4. YA39 on adult protection for staffs’ information. The registered provider should consider including the number of surveys issued and those responses received when compiling a report of the results. Woodham House DS0000028745.V292492.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark 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 DS0000028745.V292492.R01.S.doc Version 5.1 Page 32 - 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. 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