Inspection on 16/05/07 for Woodham House 3

This inspection was carried out on 16th May 2007.

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 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 3 31/03/09

Woodham House 3 13/05/08

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 3 5 Daneswood Avenue Catford London SE6 2RG Lead Inspector David Lacey Unannounced Inspection 16th May 2007 10:30 Woodham House 3 DS0000068371.V340401.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.V340401.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.V340401.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 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 Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the first 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. Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection since Woodham House 3 was registered with the CSCI. The inspection included an unannounced visit to the home. Please note that the inspection has been undertaken and judgements made at a time when the home is not yet operating fully, as it has had only one person in residence since it opened. I spoke with the resident, the staff member on duty, a visiting professional, and to the organisation’s Responsible Individual. I looked at some of the documentation kept in the home and inspected the premises. The fees for Woodham House 3 are a minimum of £1,200 per week. What the service does well: What has improved since the last inspection? What they could do better: Undertake monthly, unannounced visits to the home and make reports of these visits. Ensure the home’s safeguarding procedures follow local guidelines by including reference to the lead role of the social services department. The whistleblowing policy could be enhanced, by including reference to relevant legislation. Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 6 Identify and manage potential safety hazards. Specifically, fire doors must not be wedged open and there must be individual risk assessments for any residents admitted to the two bedrooms that have split-level floors. The window restrictors on the upper floors could be upgraded to increase their effectiveness in terms of safety, and fitting restrictors to the ground floor windows could enhance the security of the premises. Comply with all requirements and consider recommendations made to the home from the recent environmental health inspection. These include providing hygienic hand drying facilities in the toilet and kitchen, providing a wash handbasin in the kitchen, and ensuring that any eggs served are from vaccinated flocks. Designate a private area within the home for visitors, consultations or treatment. At present, communal areas can be used for these purposes but as more residents are admitted these areas will be in constant use. Remind staff members to always sign and date documentation where this is required and to leave no gaps in daily notes written about residents. Follow up written employment references without a company letterhead or stamp to confirm their authenticity. 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.V340401.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.V340401.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): 1, 2, 3, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Needs are assessed before admission, to ensure the home can meet these needs, and residents receive written confirmation of this. Prospective residents can visit the home before deciding whether to move in. A contract with terms and conditions is provided to residents. EVIDENCE: The provider supplied evidence during the home’s registration process that there is satisfactory information to enable prospective residents to choose whether they wish to move into Woodham House 3. This information included a statement of purpose and service user guide. A senior member of staff undertakes pre-admission assessments. It was evident the resident’s needs had been assessed, to ensure the home could meet his needs. He told me that a member of Woodham’s staff (the Responsible Individual) had visited him in hospital to assess him. He had then received written confirmation from the provider that the home could meet his needs, and I saw a copy of this letter on file. The home’s Intake Assessment Form had been completed for the resident but neither signed nor dated by the person(s) completing it (Recommendation 1). Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 9 During the inspection, a person was visiting the home with his representatives to see whether he wanted to take up a place. The visitors were shown around the home by the existing resident and had the opportunity to meet with staff, including the company’s Responsible Individual. The resident had been provided with a contract detailing the terms and conditions of his stay in the home. A copy was in his service user plan. Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 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. 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. The resident can make decisions about his life in the home and is supported to maintain his independence. The care plans had enough detail to guide staff on how to meet the resident’s needs, and the resident is involved in the planning and review of his care. EVIDENCE: I examined the service user plan for the home’s only resident. It identified his needs and the actions required to meet them, and risk assessments were included. It was evident from the documentation and from discussion with the resident and staff that he had been involved in planning and reviewing his care. The resident has an allocated key worker, and it is understood any new residents will also have key workers allocated to them. The resident’s plan had monthly key worker summaries on file. There were gaps between entries in the daily notes about the resident and the acting manager said she would remind staff not to leave such gaps in the future (Recommendation 2). Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 11 Both discussions and records showed that the resident is involved in decisions about how he spends his time. I saw notes of two residents’ forum meetings held since the home opened, which showed that he was involved in making choices and decisions, and had regularly given his views and ideas about the running of the home. The resident told me the home gives him good support to follow his chosen lifestyle, including going to work each day. He said he feels more confident in moving towards independent living. He may come and go from the home as he pleases, though he tells staff where he is going and returns by the agreed ‘curfew’ time. Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 12 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. The resident is encouraged and supported to maintain links with the community, including maintaining employment. The rehabilitative activities being provided within the home have benefited the resident. The resident is provided with a varied diet, and contributes to decisions about the food provided. EVIDENCE: Discussion with the resident and staff, and examination of records showed that employment opportunities are explored and encouraged. The resident has been working full-time and, at the time of the inspection, had just completed a contract and was looking forward to gaining further work. Staff are aware of their role in supporting residents to develop their independent living skills. There was some documented evidence of activities undertaken by the resident but the weekly activity planners should be dated so it is clear when particular activities have been completed (Recommendation 3). The resident told me Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 13 he had been consulted about the choice of daily activity and had benefited from these activities, for example, he now felt able to manage his money, with advice from staff on request. He told me the home also supports him to access activities outside the home, for example, a local gym facility. Discussions and examination of daily records of food provided indicated the resident is offered a varied and nutritious diet. The resident said he really enjoys the food and is able to ask that his preferences are taken into account when buying food and planning menus. I sat with him while he prepared and ate a late breakfast, which he clearly enjoyed eating. He has put on weight since moving into the home, which is being monitored by the home’s staff and by the community mental health team. Food stocks in the home were adequate on the day of my visit, and it was understood a shopping trip was about to take place. Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 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 the resident when he needs this support. Medicines are administered safely, with staff supporting the resident to self-medicate. EVIDENCE: The resident has access to health and social care, and continues to receive treatment and support in line with his present status under mental health legislation. He told me he sees staff from the psychiatric team either at the outpatient clinic or when they visit him at the home. He is registered with a local GP, who prescribes some of his medication. I was able to meet with a care professional who was visiting the home. The professional is a member of a multidisciplinary team, which supports a prospective new resident and has responsibility for his treatment. The professional said the home’s staff had communicated well with her and her client. She spoke positively of the outcome of placements she has arranged previously at another of the company’s care homes, and this had influenced the decision to offer a placement at Woodham 3 to her client. Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 15 Medication is stored in a locked cabinet in the office, plus there are storage cabinets in each bedroom. The resident showed me the medicines he keeps in his room, and for which he has been assessed as able to administer. The person in charge said that medicines are supplied from the community pharmacist or, in the case of some psychotropic medication, brought to the home by the mental health teams. The receipt and disposal of medicines is recorded in a book kept in the home. The resident’s MAR chart was up to date, with no unexplained gaps in recording. The home had a staff members’ signature and initial list, to assist medication auditing, and it was evident the home’s permanent staff had undertaken training at John Ruskin College in the administration of medicines. The home’s supplying pharmacist also supplies other homes in the group. The pharmacist had not yet visited the home since it opened but it was understood offers training at one of the other homes that Woodham 3 staff can attend. The resident’s privacy and dignity is respected, for example, through staff knocking on his bedroom door before entering. There was friendly and informal interaction between staff and the resident during my visit. The wishes of the resident in terms of death and funeral arrangements had been sought and recorded, and were being kept on file. Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Any concerns raised by the resident have been listened to and taken seriously. Training in adult protection has been made available. The home’s procedures do not make reference to local guidelines and the lead role of social services in safeguarding adults. EVIDENCE: The commission has not received any complaints, concerns or allegations about this home since it has been registered. The home has a complaints procedure in place, which is included in its service user guide and is displayed on the notice board in the hallway. It complies with regulations but is available in one format only. The resident said if he was worried or wanted to complain about something he would talk to the home’s acting manager. He said he could raise any issues freely and that he would be listened to. Two of the home’s permanent staff have undertaken safeguarding training, which is made available to all staff. The staff member on duty confirmed she had completed this. The home’s adult protection procedure does not refer to the lead role of social services in safeguarding adults. It needs to be revised, taking account of local multi-agency procedures, so that staff have clear, specific guidance (Requirement 1). Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 17 Direct reference to the Public Interest Disclosure Act would enhance the home’s whistle-blowing policy, as staff would be assured that there is legal protection if they whistle-blow in good faith (Recommendation 4). Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have an environment to live in which is generally suitable for its stated purpose. All items outstanding from the registration process had been given attention. There is no designated visitors’ room, so if the home becomes fully occupied, residents would only be able to see visitors privately in their own rooms. EVIDENCE: I toured the home with the person in charge, and inspected all the rooms. The home was clean and free from any unpleasant odours. Only one bedroom was in use, though all were equipped and ready for occupation. Two bedrooms have split-level flooring and there will need to be individual risk assessments in place for people who move into these rooms (I have not made a requirement on this occasion as both rooms are unoccupied and there are no current plans to admit anyone who will occupy them). Two bedrooms had roofline windows Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 19 that did not have any window covering. The RI agreed to ensure blinds are fitted (Recommendation 6). The home’s environment and facilities were assessed as part of determining the provider’s application to register Woodham House 3 with the CSCI. It was evident from this inspection that all items outstanding from the registration process had been given attention. These included installing wall-mounted electrical heating and purchasing a side lamp for the shed/multi purpose room at the end of the garden. The fire extinguisher in this room had been bracketed to the wall and all electrical items including the TV had been checked for electrical safety in February 2007. The registration inspector had also asked for confirmation that windows will be fitted with restrictors and that bedrooms will have tables. Restrictors had been fitted to upper floor windows but the acting manager was asked to consider upgrading these, which comprise small lengths of thin chain screwed into the window frames (Recommendation 5). These could be easily unscrewed or the chain’s broken. Restrictors fitted to the ground floor windows could enhance security of the building, and the acting manager was asked to consider this also. There were new tables placed in each bedroom. 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. The shed/multi purpose room at the end of the back garden has a bell sounder so the front door bell can be heard. The resident can have visitors in the home but, if the home becomes full, there will be no room other than his bedroom where he could meet privately with a visitor (Recommendation 7). The door between the hallway and the kitchen/diner was wedged open, and this is commented upon later in this report. Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 20 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, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels reflect that there is only one person in residence. The resident benefits from continuity of staff, but working time should be monitored to ensure staff do not work excessive hours. The home’s recruitment practices are designed to protect residents but residents would benefit from further improvement. Staff are offered training opportunities relevant to the work they do. EVIDENCE: The home has had only one service user with low dependency in residence since it opened thus, at the present time, has one staff member on the premises at all times. Other senior staff members from within the Woodham Enterprises group are available on-call. The resident said there is always at least one staff member on duty in the home. He said he gets on well with the staff and that “[names] have been brilliant, really helped me”. The permanent staff group reflects the race, gender and culture of the resident. There are three permanent staff members for Woodham House 3, with the remaining staffing needs being met by other staff from within the Woodham Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 21 group. During the inspection, I met with the company’s Responsible Individual who gave assurance that staffing levels would be increased and kept under review as Woodham 3 admits more residents. I saw the staff rota for May 2007. It showed one staff member on each shift, including one waking staff 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 08.10. I asked that 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 8). The deputy manager showed me training plans and records of completed training. The staff training plan for the home for 2006/07 was seen. It included some records of completed training but needed to be updated to include the present year. Training planned included health and safety, medication, POVA, and equality and diversity. It was understood staff were also being supported to undertake NVQs in care. The deputy manager had completed NVQ3. I examined three staff files and found two of these contained the recruitment information required. One file did not contain an application form or CV and the acting manager could not locate these filed elsewhere in the home. Thus, it was not clear how the person’s employment history had been assessed and any gaps explored (Requirement 2). Employment references should be followed up by telephone, if the source of the reference is not clear, for example, no letterhead or official stamp (Recommendation 9). The home provided evidence of regular, recorded supervision sessions for its permanent staff. Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 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. The resident’s views about the quality of services have been sought. Regulation 26 reports have not been supplied since the home opened. Some specific health and safety matters require attention. EVIDENCE: The home’s original manager resigned from the post within a short time of becoming registered with the CSCI. Since that resignation, the home has not had a manager who has been registered with the commission following a process of assessment. The deputy manager has been the acting manager. It was understood from discussion with the Responsible Individual during the Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 23 inspection that a manager for the home has been appointed and will shortly be submitting an application to the CSCI for registration. To date, the CSCI has not received any Regulation 26 reports for Woodham 3, and neither were these available in the home (Requirement 3). During the registration process, the Responsible Individual (RI) had confirmed she would be completing the monthly Regulation 26 visit and report. This was raised with the RI during the inspection and she stated she had thought Regulation 26 reports were not required until after the first inspection of the home. She visits the home regularly but had not prepared reports of her visits. She confirmed she would carry out these visits and supply the reports. A brief quality assurance report for Woodham House 3 had been completed in December 2006, shortly after the home opened. The report was on file and available for inspection. The resident’s views had been taken into account. It is understood a satisfaction survey will be carried out when there are more people living in the home, and the results made available to the residents and their representatives. The provider did not supply the pre-inspection information requested by the commission. It was apparent during the inspection visit that this information was being prepared but it had not been received by the commission either by the requested due date or by the time of this report being written. The responsible persons are reminded that it is now a legal requirement for registered providers of adult services to produce a quality assurance assessment each year. At the time of this inspection, the commission was still asking providers to complete the pre-inspection questionnaire. I examined a sample of health and safety documentation. These were up to date and within the appropriate timeframes. There had been a health and safety inspection of the home by the local authority in January 2007, at which the whole of the premises were inspected and found to be “acceptable”. A food hygiene inspection by the local authority’s environmental health department in January 2007 resulted in an immediate requirement and three recommendations. It was evident that not all the matters raised had yet been addressed (Requirement 5; Recommendations 11 and 12). Fire drills had been recorded as having taken place regularly since the home opened and there had been weekly, recorded checks of fire prevention equipment. I saw evidence that the LFEPA had visited the home in 2006 and confirmed to the CSCI during the registration process that their inspection had been satisfactory. On touring the premises, I noted that the door between the hallway and the kitchen/diner was wedged open. I drew this to the deputy manager’s attention and she took immediate action. The RI confirmed that staff would be reminded not to adopt this practice (Requirement 4). Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 24 During the registration process and at the commission’s request, the provider submitted a full breakdown of what the fees are intended to cover. There was no evidence during the inspection of any shortfalls in provision for the home’s only resident. Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 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 3 2 X 2 X X 2 X Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 26 N/A 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 YA23 Regulation 13 Requirement The registered person must ensure the home’s safeguarding adults procedures give clear guidance to staff by including reference to local multi-agency guidelines and the role of social services as lead agency. 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 the care home is visited unannounced at least once a month and a copy of the visit report supplied to the CSCI. The registered person must remind staff that fire doors are not to be wedged open. The registered person must ensure all requirements made by the environmental health officer are met, specifically, provide hygienic hand drying facilities in the toilet and kitchen. Timescale for action 30/06/07 2 YA34 19 (Sch2) 30/06/07 3 YA39 26 30/06/07 4 5 YA42 YA42 23 16 31/05/07 30/06/07 Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA2 YA6 YA12 YA23 YA24 Good Practice Recommendations The registered person should ensure the home’s intake assessment form is always signed and dated by the person(s) completing it. The registered person should ensure there are no gaps between entries in the daily notes about residents. The registered person should ensure the weekly activity planners are dated, as well as stating ‘week 1’, ‘week 2’ etc. The registered person should ensure that the home’s whistle blowing policy makes direct reference to relevant legislation (i.e. the Public Interest Disclosure Act). The registered person should consider upgrading the window restrictors on the upper floors based on assessment of risk to residents, and fitting restrictors to the ground floor windows to enhance the security of the premises. The registered person should ensure blinds are fitted to the roof windows in bedrooms 7 and 8. The registered person should consider what formal arrangements could be made to designate a private area within the home for visitors, consultations or treatment. The registered person should monitor staff members’ working hours and shift patterns to ensure they do not become overtired and thus risk compromising standards of care. The registered person should ensure that employment references without company letterhead or stamp are followed up to confirm their authenticity. The registered person should provide a wash hand-basin in the kitchen, as recommended at the recent environmental health inspection. The registered person should ensure eggs purchased for residents’ consumption are from vaccinated flocks (e.g. with ‘lion’ stamp), as recommended at the recent environmental health inspection. 6 7 8 YA26 YA28 YA33 9 10 11 YA34 YA42 YA42 Woodham House 3 DS0000068371.V340401.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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