Inspection on 13/05/08 for Woodham House 3

This inspection was carried out on 13th May 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodham House 3 31/03/09

Woodham House 3 16/05/07

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Woodham House 3 5 Daneswood Avenue Catford London SE6 2RG Lead Inspector David Lacey Unannounced Inspection 13th May 2008 11:00 Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodham House 3 Address 5 Daneswood Avenue Catford London SE6 2RG 020 8461 2706 F/P 020 8461 2706 woodhamhousewoodhamltd@aol.com 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) Woodham ENT Ltd Manager post vacant Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home not providing medicines or medical treatment (CRH - NM) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 8 16th May 2007 Date of last inspection Brief Description of the Service: Woodham House 3 is a semi-detached house situated in a residential area of Catford. It provides care and rehabilitation for up to eight people with mental illness and forensic histories, who have been discharged from psychiatric inpatient facilities, medium-secure units or special hospitals. Residents are encouraged towards independent living in the community. All bedrooms in the house are for single occupancy and have en-suite facilities. There are public transport links and shopping facilities close to the home. The provider told us in May 2008 that the fees for Woodham House 3 start from £1,000 per week. Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star, which means that people using the service receive an adequate service. This key inspection included an unannounced visit to the home. During the visit, I spoke with two of the four people in residence, the acting manager and the deputy manager, two visiting professionals, and the owner of the home. I inspected parts of the premises and sampled documentation such as care plans and records of care provided, staff recruitment files, and policies and procedures. Since the last key inspection, we carried out a random inspection of the home and used findings from that visit in planning this present key inspection. What the service does well: What has improved since the last inspection? The home had amended its safeguarding procedure, which will enhance the protection of its residents. The provider has been undertaking visits to the home regularly to monitor the quality of services and has produced reports of those visits that are available for inspection. Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed before they move into the home. Each resident has a contract setting out the terms and conditions for their stay. EVIDENCE: Since the last key inspection, four people had been admitted to the home. From files sampled, it was evident their needs had been assessed before admission, to ensure the home could meet their needs. There was evidence of detailed reports and assessments, including a detailed risk assessment and management plan from the referring authorities. It was also evident that the home had carried out its own assessment. Residents had been provided with a contract detailing the terms and conditions of their stay in the home. Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can make decisions about their lives in the home and are supported to maintain their independence. Care plans have enough detail to guide staff on how to meet residents’ needs, and residents are involved in reviewing their care. EVIDENCE: The two care plans seen identified the residents’ needs and the actions required to meet them, and risk assessments were included. Risk assessment and risk management plans in place, which covered each resident’s mental health needs, giving information and guidance about signs and symptoms that are likely to indicate recurrence or deterioration of their mental health problems. From the documentation and from discussions with residents and staff, it was evident residents had been involved in reviewing their care. Care plans had been reviewed regularly and residents had been invited to sign, confirming their involvement in planning their care and their agreement with the plans. Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 10 The home has a system whereby each resident has an allocated key worker, and residents’ plans had monthly key worker summaries on file. It was evident from these key work summaries and from notes of residents’ forum meetings that residents had been supported to make decisions about how they spend their time and could give their views and ideas about the running of the home. The home provides information about local independent advocacy services. Residents are able to come and go from the home as they please, though they tell staff where they are going and return by the agreed ‘curfew’ time. A resident said the home gives him good support to follow his chosen lifestyle, including attending a local day centre four days each week. He said he is beginning to feel more confident in moving towards independent living. Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to maintain links with the community, including with their families and friends. They are supported to take part in meaningful, culturally appropriate activities. Residents have a varied diet, and contribute to decisions about the food provided. EVIDENCE: Discussion with residents, staff and other professionals showed that opportunities for learning and leisure are explored and encouraged. Most of the home’s residents attend a local facility offering culturally appropriate activities and counselling. Staff members from this centre were visiting a resident and spoke with me during their visit. They offered positive comments about how the home supports residents to attend the centre and meet their cultural needs. It was evident from discussion that the home’s senior staff are aware of their role in supporting residents to develop their independent living skills. Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 12 Residents said they make use of local facilities such as the gym, library and local shops. It was evident that residents had been supported to maintain links with family and friends. Activities undertaken by those residents whose care I examined had been sometimes referred to in the daily notes and recorded in the weekly activity planners used by the home. There was less evidence of activities carried within the home than those undertaken outside the home. The home has a curfew time but residents are made aware of this restriction before they moving into the home, and it is included in the statement of terms and conditions that they sign. It is apparent that the daily routines and ‘house rules’ aim to promote residents’ independence, choice and freedom of movement. Individuals are expected to take responsibility for house keeping tasks such as doing their own laundry and tidying their rooms. They have keys to their rooms to promote their rights to privacy and enable them to keep their belongings secure. On the day of the inspection, I saw that residents were coming and going from the house freely. Residents have ‘freedom passes’ so they can use public transport without charge and make use of this for local travel and also for travel further into London. For example, a resident told me he is from West London and is able to travel there to visit family regularly. A mainline rail station is close by the home. Discussions and examination of daily records of food provided showed residents are offered a varied and nutritious diet. Two resident said the food is good and that they are able to ask that their preferences are taken into account when buying food and planning menus. Residents arrange their own breakfast and lunch, and I noticed that people helped themselves to snacks and drinks as they wished. Each resident has a ‘cooking day’ when they are expected with staff assistance to take responsibility for helping to plan and prepare the evening meal. It was understood the menu plan is not strictly adhered to and that usually people are asked on the day what they would like to eat. Food stocks in the home were adequate on the day of my visit. Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and social care is made available to residents as needed. Staff offer support to meet individual needs and preferences. Medicine administration is satisfactory. EVIDENCE: Residents have access to health and social care, and those case-tracked were continuing to receive treatment and support in line with their present status under mental health legislation. Regular Care Programme Approach (CPA) reviews of their mental health needs and risk factors had been held and there was regular contact with the relevant community mental health teams. Residents are registered with a local GP, through whom they can access other primary health care services. None of the residents currently living at the home need support with their personal care but staff members offer prompting and encouragement as required. Residents’ privacy and dignity is respected, for example, through staff knocking on bedroom doors before entering. There was friendly and informal interaction between staff and residents during my visit. The home operates a key worker system to ensure consistency of support and it was Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 14 evident from discussions and from records that key work sessions had been held regularly. The home’s arrangements for medication administration were generally satisfactory. Residents said they receive the right medication at the correct times. Residents’ medication administration records (MAR) were up to date, with no unexplained gaps in recording. There were some handwritten amendments on MARs that only one person had signed. It is strongly recommended that two staff members always sign such amendments, to minimise the possibility of errors (recommendation 1). The home had a staff members’ signature and initial list, to assist medication auditing, and it was evident the home’s senior permanent staff had undertaken training in the administration of medicines. Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. Any concerns raised by residents are listened to and taken seriously. Training in adult protection has been made available and staff members understand their safeguarding responsibilities. EVIDENCE: We have not received any complaints, concerns or allegations about this home since the previous inspection. The manager confirmed that the home had not received any complaints, and there were no entries in the complaints book. The home has a complaints procedure, which is included in its service user guide and displayed on the notice board in the hallway. A resident said he knows who to speak to if he is not happy about something and that he feels safe living here. Another resident said he was told when he moved into the home that he could talk to staff anytime if he was worried or had any problems. Both residents said they had not felt the need to raise any complaints as such, as they could resolve any concerns by talking informally to staff or the manager as necessary. It was evident from records of key worker sessions and notes of house meetings that residents are given regular opportunities to raise any concerns they may have. The manager confirmed there had not been any safeguarding alerts since the home has been registered. She stated that if there was a safeguarding issue, staff would complete an incident report with timescales, and that the outcome would be used as a learning opportunity, both in this home and in other homes Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 16 within the group. As well as a safeguarding policy and procedure and staff training, residents are protected by recruitment checks carried out on applicants for care staff posts at the home. The manager stated people are supported to know their rights through the home’s service user guide, their key-worker sessions, and because they are given information about local advocacy groups. Staff training records that I sampled contained evidence of safeguarding training, both in-house and as a distance-learning course. One person had completed safeguarding training course run by the local authority. The manager said she had been the first person from the company to complete safeguarding training and had subsequently arranged for all staff to do this training also. She said her training had included whistle blowing and that she has helped to make staff aware there is legal protection for them if they whistle-blow in good faith. She said staff members know what to do because of their safeguarding training and their induction. She monitors their understanding through staff supervision, normally by creating a scenario and asking, “how would you handle it?” A staff member interviewed during the inspection showed a good understanding of safeguarding and of her responsibilities should she become aware of any abuse of residents. Her training had been both in-house and by distance learning. It had covered whistle blowing and she was aware of the protection available to whistleblowers. Local authority safeguarding guidance was available in the home’s office. The manager said she is familiar about the local authority’s procedures, “they give us booklets we can keep in the home”. The home had amended its safeguarding procedure in response to a previous requirement. A staff member said she had been given a copy of the home’s safeguarding policy and that she had read it. She said she would report any safeguarding incident to the person in charge and if asked she would help with any investigation. Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a comfortable environment to live in, which is generally suitable for its stated purpose. EVIDENCE: I toured the home with the deputy manager, and inspected all the communal areas, which were free from any unpleasant odours and generally clean. Four bedrooms were in use at the time of this inspection. The two residents I spoke with were happy with the facilities provided. They like their rooms, which they said are comfortable and have the things they need. The laundry room is outside in a separate, small building near the back door of the house. The laundry has a washing machine and a dryer. A resident was using the laundry during my visit. The shed/multi purpose room at the end of the back garden has a bell sounder so the front door bell can be heard. Residents can have visitors in the home Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 18 but can also use the outside multi purpose room to meet privately with visitors. A resident did this during the inspection, when other professionals involved in his care visited him. The provider also owns the adjoining house and is presently converting this with a view to increasing the number of places at Woodham 3 to fifteen. The owner discussed this with me during the inspection visit and confirmed he would be applying to the commission for a variation to the home’s registration once the building works are completed. The works were not impacting on the health, safety or welfare of existing residents, as the adjoining property is separate from the existing premises for Woodham 3. Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff rota is not always accurate in showing there are sufficient numbers of staff working at the home to meet the residents’ needs. Working time should be monitored to ensure staff do not work excessive hours. The home’s recruitment procedures are designed to protect residents but must always be carried out effectively. Staff members are offered training opportunities relevant to the work they do, and most have achieved NVQ in care at level 2 or above. EVIDENCE: When I arrived in the home, the acting manager and the deputy manager were on duty, providing care and support for the four people currently in residence. The managers confirmed there are four permanent staff members for Woodham House 3, with the remaining staffing needs being met by other staff from within Woodham Enterprises. At the last key inspection, we were given assurance that staffing levels would be kept under review as Woodham 3 admits more residents. During the recent random inspection, there were examples on the duty rota when there was only one person on duty during day shifts. At the present inspection, there were still instances when only one staff member was entered on the rota for a day shift, Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 20 despite there being four people with complex mental health needs living in the home. The acting manager stated at least two staff had been on duty, with a staff member from another Woodham home covering but that the rota had not been amended to show this (requirement 1). Staff members on day shifts are required to undertake other duties, such as catering and cleaning, as well as provide care to the residents. Also, the residents’ care plans I saw included one-to-one work. If there is only one staff member on duty, carrying out individual therapeutic work leaves no one to run the home and if necessary deal with any emergency situations that might arise. At our recent random inspection, it was evident only one staff member had been covering night duty. The company’s responsible individual agreed to take prompt action to ensure there are always enough staff members on duty. At this present inspection, discussion with the responsible individual (also the home’s acting manager) and examination of the rota confirmed two staff members were on duty at night. There were instances where a staff member had worked a late shift and the following night shift, which means working from 15.30 through to 08.00. The manager needs to ensure it is evident staff members’ working hours are monitored to ensure they have adequate time off duty and do not become over-tired, as this might compromise the standard of care they deliver (recommendation 2). I examined four staff files and found these contained most of the recruitment information required. The exception was that, for three of these staff members, it was not evident their previous employment histories had been assessed and any gaps explored. At our last key inspection, a requirement was made in this respect, which we were able to judge had been met at our subsequent random inspection. Thus, it was of particular concern to see that this previous shortfall had occurred again (requirement 2). Three of the four staff members whose files I examined had completed a National Vocational Qualification (NVQ) at level 3. The home’s deputy manager had also completed NVQ3. Other training completed by staff members included an induction meeting Skills for Care specifications, and training in health and safety, medication, safeguarding, and equality and diversity. There was evidence that some staff had completed specific training to enable them to effectively meet the rehabilitation needs of people with mental health problems. For example, in-house training sessions looking at forensic mental health issues and training about the Mental Capacity Act. Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. At the present time, residents cannot be assured that the home has a manager whom the commission has assessed as fit to run Woodham 3. Residents’ views about the quality of services need to be summarised into a report that people can access easily. Regulation 26 reports are now being produced regularly but the home did not provide its annual quality assurance assessment. Generally, residents’ health and safety is promoted but the home must ensure all required safety checks are carried out within the appropriate timescales. EVIDENCE: The home’s original manager resigned from the post within a short time of becoming registered with the CSCI. Since that resignation in January 2007, the home has not had a manager who has been registered with the commission following a process of assessment. It was understood from discussions during Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 22 this inspection visit that the acting manager (who is a former registered manager for another of the company’s homes) would shortly be submitting an application to the CSCI for registration as the manager of Woodham 3. Before the inspection, we sent an annual quality assurance assessment (AQAA) document to the home for completion. This self-assessment document focuses on how outcomes are being met for residents and also gives us some numerical information. Despite a reminder letter, we did not receive the completed document and therefore issued a formal warning letter to the provider, requiring the AQAA and an improvement plan. It is a legal requirement for registered providers of adult services to produce a quality assurance assessment each year. It was apparent during the inspection visit that this information was being prepared but, at the time of writing this report, we have not received the AQAA or the improvement plan and we are considering further enforcement action. At our last key inspection, shortly after the home opened, a brief quality assurance report for the home had been completed. The report was on file and available for inspection. It had been understood a satisfaction survey would be carried out when there are more people living in the home, and the results made available to the residents and their representatives. At the present inspection, it was evident this survey had not been undertaken and there was no recent report available (requirement 3). However, it was evident at our recent random inspection that the provider had addressed a previous requirement by ensuring that Regulation 26 visits and reports for Woodham 3 are completed each month. At this key inspection, I was able to see copies of these monthly reports on file. The content of the reports had been informed by the views of residents and staff members. The acting manager stated the home would now be implementing a suggestion made at another of the company’s homes whereby action plans with timescales are produced for issues raised through quality assurance processes. I examined a sample of health and safety documentation. These were up to date and within the appropriate timeframes, with the exception of a current gas safety certificate. The most recent certificate in the home was dated June 2006. This matter was raised with the acting manager so she could begin to take appropriate action. A gas safety certificate must be obtained and the manager agreed to send us a copy of the certificate (requirement 4). A food hygiene inspection by the local authority’s environmental health department in 2007 resulted in an immediate requirement and three recommendations. There was no evidence that any progress had been made with regard to our requirement in this respect, to provide hygienic hand drying facilities in the toilet and kitchen. The manager gave assurance that the current building works would include these improvements. I have therefore agreed to adjust the timescale on this occasion only to allow for the building Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 23 works to be completed, and it is expected this requirement will be met by the new date (requirement 5). Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA33 Regulation 18 Requirement The registered person must ensure it is evident there are always enough suitably qualified and experienced staff on duty. This is important for ensuring the residents’ health and welfare. The registered person must ensure it is always evident that an applicant’s employment history has been assessed and any gaps explored. The registered person must ensure that residents’ views about their satisfaction with the service are sought, and that the outcome is published and made readily available. The registered person must obtain an up to date gas safety certificate for the home. The registered person must ensure all requirements made by the environmental health officer are met, specifically, to provide hygienic hand drying facilities in the toilet and kitchen. Previous requirement. Timescale amended to allow for completion of current DS0000068371.V363345.R01.S.doc Timescale for action 30/06/08 2 YA34 19 (Sch2) 30/06/08 3 YA39 24 31/07/08 4 5 YA42 YA42 13 16 30/06/08 31/07/08 Woodham House 3 Version 5.2 Page 26 building works. 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 YA20 Good Practice Recommendations The registered person should ensure two staff members always sign handwritten amendments on medication administration records, to minimise the possibility of errors. The registered person should make sure it is evident staff members’ working hours are monitored to ensure they have adequate time off duty and do not become overtired, as this might compromise the standard of care they deliver. 2 YA33 Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodham House 3 DS0000068371.V363345.R01.S.doc Version 5.2 Page 28 - 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!