Inspection on 31/05/07 for Woodham House

This inspection was carried out on 31st 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 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodham House 02/03/09

Woodham House 01/05/08

Woodham House 02/05/06

Woodham House 24/10/05

Woodham House 13/04/05

Woodham House 15/09/04

Woodham House 21/04/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Woodham House 336 Stanstead Road Catford London SE6 2SB Lead Inspector Ornella Cavuoto Unannounced Inspection 31st May 2007 10:00 Woodham House DS0000028745.V339739.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 DS0000028745.V339739.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 DS0000028745.V339739.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodham House Address 336 Stanstead Road Catford London SE6 2SB 020 8690 6237 0208 690 6171 woodhamltd@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) 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.V339739.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2007 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 was one vacancy. 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.V339739.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day. The registered manager was not present for the inspection but the deputy manager was available for its duration. Also, the service co-ordinator was present for part of the inspection. In addition, three of the four residents presently living at the home were spoken to and case tracking methods were used for two of them. Other inspection methods included inspection of care records and a partial tour of the building. Although five of the previous requirements were identified as met at this inspection five new requirements were specified. The home has some requirements that have not been complied with for two previous inspections and these must be given particular attention as continued non-compliance could lead to enforcement action being taken. What the service does well: Residents spoken to were generally satisfied with living at the home and the care they had received from staff. One resident said, “I’m getting on great. I’m very happy here” whilst another commented that they were grateful to the staff for “helping to turn my life around”. Residents’ physical and mental health needs are well met by the home with input from a range of general and specialist mental health professionals. The home ensures that residents’ mental health needs are regularly monitored and reviewed through the Care Programme Approach (CPA) system in which all professionals involved in their care meet to discuss their needs. All residents have an individual plan of care in place that is regularly reviewed and generally residents have regular meetings with their key worker to discuss their progress and needs. Residents are encouraged to be as independent as possible by staff to make use of local facilities and take responsibility for undertaking their own household tasks. Also, to pursue their individual interests, educational and training opportunities. Positive relationships with family and friends are encouraged. Residents are offered an annual holiday. There is a varied and generally nutritious diet available to residents and they all have their own individual cooking day in which to help plan and prepare a meal. Residents are well protected from abuse by the home having comprehensive policies and procedures in place and staff having received training in adult abuse and adult protection procedures. Generally the home is well maintained, homely and clean. Staff are supported to obtain relevant qualifications to be able to meet the needs of residents’ at a competent level. Residents’ views about the home are regularly sought to help the home identify ways they can improve the service. Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 DS0000028745.V339739.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 DS0000028745.V339739.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&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the service is available for current and prospective residents. Residents’ needs had been fully assessed prior to being admitted to ensure their needs can be fully met by the service and they had been issued with a statement of terms and conditions outlining their stay at the home although this had been updated and the new document had yet to be issued to residents. EVIDENCE: A previous requirement that the statement of purpose had to be amended to ensure that information provided about staff presently working at the home was accurate had been met. Also, subject to a previous requirement that the service user guide needed to include information about the fees of the home this had been addressed. There had been one new admission to the home. The resident who had recently moved in was previously living at one of the other Woodham homes and had been recently transferred. There was evidence that their needs had been fully assessed prior to when they initially moved in. There was evidence of a Care Programme Approach (CPA) report and a comprehensive hospital discharge report within their personal file. In addition, there was evidence that the home had carried out their own assessment. Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 9 There was evidence included in all the personal files that were looked at that a statement of terms and conditions had been issued to all residents that had been signed. This generally included all the information as specified within National Minimum Standards (NMS). However, the home had updated the document but this had yet to be issued to residents. It was also noted that for the resident transferred from the other Woodham home the statement of terms and conditions that had been signed specified their previous address. A new terms and conditions document was present in their file but had yet to be completed with them and to be signed. It is advised these issues are addressed (See Recommendations). Woodham House DS0000028745.V339739.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 adequate. This judgement has been made using available evidence including a visit to this service. All residents had a care plan that addressed personal goals and changing needs but not all parts of the care plans were being fully implemented. Residents had been supported and given assistance as needed to make decisions about their lives. Residents had been supported to take risks to live independently but not all presenting risks had been fully addressed with action taken to ensure the safety and welfare of individual residents and also of others. EVIDENCE: Three of the four residents care plans were inspected. Care plans had addressed personal, social and health care needs. There were also risk assessment and risk management plans in place that had comprehensively covered individual residents’ mental health needs detailing symptoms that would indicate they were suffering a relapse of their mental illness and outlined any aggressive or self- harming behaviour. Care plans had been reviewed three monthly and they had been signed by residents indicating their Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 11 involvement in the care planning process and that they agreed with the contents. However, there was evidence that not all parts of their care plans had been fully implemented, for example the home has a therapeutic programme that consists of a relaxation group, assertiveness training, health and eating advice, budget and planning to support residents to acquire the necessary skills to enable them to live independently and to look at ways of managing aspects of their behaviour. These had been included in individual care plans and also as part of residents’ weekly activity plans. However, speaking to residents they stated these had not taken place. In addition, it was noted that for individual residents it had been included within their care plans that they should be tested for illegal substances but records indicated this had not occurred as frequently as it had been specified (See Requirements). The home aims to provide monthly key work sessions to residents that look at all aspects of support and care needs such as relationships, accommodation, finances, daily living skills, day time activities, as well as physical and mental health needs and risk behaviour. Residents had signed all records of key work sessions that were looked at and one resident had written up their own key work notes. Generally, records indicated that residents had received key work sessions on a regular basis although there were some gaps identified and one of the residents had not received a key work session for the previous two months. It is advised key workers try to maintain consistency in this area (See Recommendations). It was evident from key work sessions, minutes of resident meetings and also in speaking to residents that their right to make their own decisions about their lives had been respected and that generally staff had provided information and assistance to enable them to do this. However, for one resident there were concerns identified that their decision to drive a car had not been adequately addressed in respect to fully addressing the risks this could present to them and others in specific circumstances and this had not been reflected in a risk management plan (See Standard 9 for more details). A previous recommendation regarding the home making information about independent advocacy services was not looked at and will be checked at the next inspection (See Recommendations). As mentioned in respect to Standard 6 there were detailed risk assessment and risk management plans in place for all residents in respect to their mental health and also for individual residents there was evidence that other specific risk behaviours had been looked at with control measures put in place to address and minimise the risk. However, as previously stated for one resident that has a history of drug and alcohol use, there was no evidence that could be identified that staff had fully discussed and made them aware of the risks to themselves and others related to their decision to drive a car if they experienced a relapse and began using drugs or started to drink again. Neither had a risk management plan been put in place specifying action to be taken by staff if they identified that the resident was under the influence of any Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 12 substances and still had intentions to drive. In addition, it was noted from a letter within the residents’ personal file that their consultant psychiatrist had advised them that they were required to inform the DVLA that they had a mental illness and although it was reported that the resident had done this no evidence was available to confirm that they had taken action on the matter or that staff had again fully discussed with them the legal implications of them failing to do this. It is essential in supporting residents to take risks as part of an independent lifestyle that they are provided fully with information on which to base decisions and that strategies are put in place to address any identified risks (See Requirements). Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 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. 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. Generally residents had been supported where possible to access training and employment opportunities and to engage in meaningful activities although the therapeutic programme offered by the home to support residents had not always been implemented. Residents were part of the local community. An annual holiday had been arranged for all the residents. Important relationships with family and friends had been maintained with support from the home. The rights and responsibilities of residents had been recognised. Generally, residents eat well and have a varied diet. EVIDENCE: Inspection of individual care plans and also in speaking to residents demonstrated that they had been supported to continue with training/ education and also to access employment and to engage in fulfilling activities, for example one resident up till recently was attending catering college but they had to stop due to problems with their behaviour that involved them Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 14 making hoax calls to the police and eventually led to their arrest and having to spend a period of time in prison on remand. Another resident living at the home had been supported to return to work. Trained as a civil engineer they had obtained a position working as a building site manager through an agency. In addition, as was identified at the last inspection one of the other residents was still being supported to look into training to help them become a fitness instructor whilst the remaining resident was being supported by the home and their care co-ordinator to look at ways they could structure their free time more constructively, for example by going to the gym, as it was identified that they had difficulty managing their own time. Finally, as mentioned in respect to Standard 6, although the home has a therapeutic programme in place that is aimed at addressing areas such as budget and planning, assertiveness training amongst others to support residents with progressing towards independent living that had been included as part of their individual care plans and weekly activities schedules, this had not been carried out and this needs to be addressed. However, overall this standard is deemed met (See Requirement in respect to Standard 6). It was evident from speaking to residents that they were part of the local community and had made use of facilities such as the library, the shops and the local gym. The residents also spoke of having been to the cinema, ten pin bowling and to local cafés. At the last inspection held in May 2006 residents spoken to expressed that they wanted to do more group activities although staff at the home reported it was difficult to identify activities that all the residents wanted to be involved in. Also, residents were encouraged to get involved in activities outside the home rather than to do activities in- house as a way of further promoting their independence. It was then identified at an additional visit to the home held in January 2007 that all the residents had been on a short holiday to Butlins and they had also been involved in a day trip to Brighton. Other group activities mainly day trips had been discussed as part of resident meetings but these had still to take place. A resident who was spoken to at the additional visit reported that some in-house activities had taken place such as bingo and video nights although there were no records maintained to confirm this, which had been required. At this inspection, in respect to the previous requirement that a record of activities offered to residents should be maintained particularly those that they are involved in on a group basis inside and outside of the home, it was identified that individual activity records had been drawn up but these were still to be implemented. Residents spoken to on this occasion reported that they were going on holiday again this year to Butlins, which they were looking forward to and that they had also attended a BBQ recently at one of the other Woodham houses. They reported that there had not been any in- house activities but that they did not really mind as one of them commented, “we go out.” Given that residents have had some opportunity to be involved in group Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 15 activities and that the home had drawn up individual activity records albeit that these had not yet begun to be used the previous requirement is assessed as met. However, this will be monitored at future inspections to ensure that records of activities have been maintained and residents’ involvement in leisure activities have continued to be supported. There was evidence within residents’ care plans and key work notes that they had been supported to maintain links with family and friends by the home. One of the residents had been accompanied by a staff member to see his mother on the day the inspection was held and another resident had taken action to re-establish contact with their family after initially refusing to see them. The home does have restrictions in place such as a curfew time but residents are made aware of these conditions prior to moving in and they are included in the statement of terms and conditions that they are required to sign. Overall, the rules of the house and daily routines are aimed at promoting independence, individual choice and freedom of movement. Residents 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 on the day of the inspection residents were observed coming and going from the house freely. In respect to meals residents arrange their own breakfast and lunch and each of them has a cooking day in which they are expected to take responsibility for helping to plan and prepare the evening meal with staff assistance. The two residents that were spoken to confirmed this. Records that had been kept indicated that residents were generally provided with a diet that was nutritious and healthy. Feedback about the food was mainly positive. One of the residents stated, “ Food is alright on the whole.” The other stated that they could choose their own food and could cook it if they preferred. Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 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. 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. Residents were satisfied with the support they had received from staff and their physical and mental health needs had been addressed. The home’s system for the administration of medication does protect residents but all support staff need to complete medication training. EVIDENCE: None of the residents at the home required support with personal care but staff provide prompting and encouragement as required, which was evident within individual care plans. Residents were observed as generally well groomed and well dressed. The home operates a key worker system to ensure consistency of support. Residents spoken to were familiar with their key workers and on the whole were satisfied with the support they had received. It was evident from residents’ care plans and other information contained within personal files that their physical and mental health needs had been addressed. Individual residents had been in contact with primary health care services including GP services, a chiropodist and an optician. Residents had also had regular Care Programme Approach (CPA) reviews of their mental Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 17 health needs and to monitor risk factors whilst also being seen by Consultant Psychiatrists on an out patient basis. There was also evidence of mental health professionals such as Community Psychiatric Nurses (CPN) having visited the home via the home’s visitor’s book. However, it is advised all visiting professionals should write up their visits and contact with residents in their respective personal files where daily records are kept (See Recommendations). The home’s medication system was looked at and found to be in order with no errors identified in the administration and recording of medication. At the time the inspection was held none of the residents were taking responsibility for their own medication. It was reported that the Community Pharmacist carries out an annual check of the medication and also discusses with residents the medication they have been prescribed of which there was evidence. They were due to attend the day of the inspection but had to cancel. The deputy manager has overall responsibility for the medication and they had completed an accredited course in the ‘Safe Handling of Medication’ at Croydon College. It was reported that another two support workers had completed medication training although a certificate of completion for this was only seen for one of them, as one of the staff files was not available for inspection. However, it is important all staff working at the home complete medication training (See Requirements). Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 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. 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. Residents were clear about how to make a complaint should the need arise but complaints had not been addressed in line with the home’s complaints policy and procedure. Measures had been taken by the home to protect residents from abuse. EVIDENCE: The home has a robust complaints policy, which was accessible to residents and visitors on display on a notice board in the entrance hall of the home. Residents spoken to reported they did not have any complaints about the home but were clear to whom they would refer their complaints if they were to make one. The home had a complaints log in place in which all formal and informal complaints had been recorded. There had been two complaints made since the last inspection by the same resident. The first complaint concerned an allegation against one of the support workers that they had shouted at the resident on a number of occasions. Also, that the worker had discussed confidential matters regarding the resident in front of other people who live at the home. The second complaint alleged that another support worker had made an inappropriate remark towards them. Records indicated that neither complaint had been appropriately investigated. Statements had not been taken from the resident nor the support workers against whom the allegations had been made to clarify exactly what had happened and when and the outcome of both matters had not been specified. This was discussed with the deputy manager who had responsibility for addressing the complaints and also the service co-ordinator. As a result, it became evident that some appropriate Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 19 action was taken to address the complaints with meetings held with the resident and the support workers involved to discuss the allegations. It was reported that both complaints were not substantiated with the resident deciding to withdraw their complaint against the support worker that they had alleged made an inappropriate remark. However, given both matters involved allegations of actions by staff that were abusive towards a resident these should have been more thoroughly investigated with clear records maintained. Both support workers no longer work at the home (See Requirements). The home has robust adult protection and procedures in place. A previous recommendation that the home should obtain a copy of Lewisham’s Interagency Guidelines on Adult Protection had been addressed although it was reported that the home had been only sent some leaflets that were seen. These included some information on adult abuse and protection with the home being informed that the borough do not provide any other detailed guidelines. There was evidence that all support staff working at the home had completed training on adult protection. There had been no adult protection investigations carried out in relation to residents living at the home since the last inspection. All the residents apart from one manage their own finances. At the last inspection the finances of the resident who is presently supported to manage their personal allowance were checked and were found to be accurate with receipts and records kept of all transactions. This was not checked at this inspection although receipts for transactions that had taken place were seen within their personal file. This will be looked at in more detail at the next inspection. Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 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. 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. Generally, residents live in a safe, homely and comfortable environment. The home was clean and hygienic. EVIDENCE: The home offers access to local amenities, local transport and relevant support services to suit the personal and lifestyle needs of the residents. The premises are suitable for its stated purpose, homely, safe and generally well maintained although it was noted that the communal corridor walls particularly those upstairs and the bedroom doors were quite marked and dirty and it is advised that this area should be washed down or consideration given to re-decorate (See Recommendations). The home was clean and hygienic at the time of the inspection and no offensive odours were 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.V339739.R01.S.doc Version 5.2 Page 21 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 &36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The majority of staff working at the home had achieved or were in the process of achieving a relevant qualification as required under National Minimum Standards (NMS). An accurate staffing rota is still not being maintained by the home. Although there had been improvements in relation to the home’s recruitment practice there were still areas in the way staff are vetted that needed to be worked on. Staff were still to have annual appraisals carried out to assess their training needs. Staff had received regular supervision. EVIDENCE: Five of the seven staff working at the home had completed or were in the process of completing a National Vocational Qualification (NVQ) Level 3. This meets the required target as specified within the National Minimum Standards (NMS) that 50 of staff must have achieved or be working towards a NVQ Level 2 or 3. Those that had completed were still awaiting certificates although there was evidence of a certificate for one staff member that was seen in their staff file. Also, dates when staff commenced the course were included in individual staff records. Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 22 On the days that the past two inspections were held the rota was found not to provide an accurate record of staff working at the home. At this inspection the rota specified that the registered manager should be on duty but they were not present and only the deputy manager was working at the home when the inspection began. It was reported that another staff member had left to escort one of the residents to visit their mother. The service co-ordinator later arrived at the home to provide additional cover. This is not acceptable practice. Staff cover for the home should generally be arranged in advance to ensure the home is adequately staffed at all times apart from when unforeseen circumstances arise such as staff sickness. Also, as previously required any changes to the staff cover must be recorded on the rota for health and safety reasons and to evidence that appropriate staffing levels are being consistently maintained (See Requirements). The previous inspection that took place in May 2006 identified concerns about the home’s vetting procedures when recruiting staff in that not all staff working at the home had completed an application form. Consequently, previous employment history could not be checked to identify if there were any gaps in employment or that appropriate references had been obtained specifically one from the last position of employment. Also, there was no evidence that staff had signed a health declaration regarding their fitness to do the job. At an additional visit to the home in January 2007 there were ongoing concerns about their vetting procedures in that for a new staff member there was no evidence of the interview process that was carried out with them to assess their suitability for the post applied for. Furthermore, although applications forms were found to be in place for all staff whose files were looked at, gaps in employment had not been addressed whilst one did not include any details of their employment history and two had not specified their reasons for leaving their previous posts. Also, individual staff records checked did not include all the required documents specifically the required number of references and an appropriate form of identification. At this inspection five staff files were checked and subject to a previous requirement all included the documents required by regulation in respect to recruitment including two references, appropriate identification and an up to date Enhanced Criminal Record Bureau (ECRB) check. In relation to a previous requirement regarding vetting procedures, there had not been any new staff recruited to work at the home since the additional visit in January 2007 so this could not be fully assessed. However, as identified at the additional visit gaps in employment and reasons for leaving previous posts for those staff presently working at the home had still not all been fully addressed (See Requirements). Positively, there was evidence provided at the inspection of a new interview format that had been drawn up for the recruitment of new staff. Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 23 Finally in respect to recruitment, a previous requirement that staff records should be kept at the home for all staff working at the home to be made available for inspection is not to be re –stated. This is because although certain staff occasionally work at the home it was reported their main post of employment was based at one of the other Woodham Houses, which means their records would still be available for inspection by CSCI. The timescale for a previous requirement that all staff should complete an induction that meets with Skills for Care specifications and all staff should have an annual appraisal had not been exceeded at the time the inspection was held. It was reported that the majority of staff were still in the process of completing the Skills for Care work booklets although there was evidence for one staff member within their staff file that they had completed it. In respect to appraisals there was evidence that dates had been arranged for these to be carried out and it was reported that an annual training plan for 2007-08 would then be drawn up. In respect to training completed by staff there was evidence included in staff files that some had completed training in mandatory topics including health and safety, infection control, food hygiene and first aid (For further details see Standard 42). Other training staff had undertaken included adult protection as mentioned in respect to Standard 23, forensic mental health training that had been completed in house and was provided by the registered manager who has worked as an Approved Social Worker within the mental health field. It was also reported that some of the staff team are currently undertaking a course in equalities and diversity provided by Croydon College (See Requirements). Subject to a previous requirement staff files that were checked included evidence that staff had received regular supervision to ensure that staff should receive at least six supervision sessions within the year as specified within NMS. Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 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. 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 home is reasonably well run although the deputy manager requires more support to ensure the effective management of the home. Feedback about the home has been sought from residents, relatives and professionals as part of self- monitoring. The home was taking measures to ensure that staff receives training to ensure the health, safety and welfare of residents would be met although risk assessments in this area were still to be completed. EVIDENCE: The registered manager was not present at this inspection and had not been available for the previous two inspections carried out at the home. In the registered manager’s absence the deputy manager is delegated overall responsibility for the running of the home with support from either the registered manager or the service co-ordinator. This meets the previous requirement that the registered provider should ensure adequate management Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 25 cover of the home. However, although the deputy manager has demonstrated a good level of competence at previous inspections they have not had any previous experience of managing a care home. They have completed a NVQ Level 3 and it was reported they were presently in the process of completing courses in supervisory management and conflict management and the aim is that they will then go on to commence the NVQ Level 4 / Registered Managers Award in September 2007 and proceed to apply to become the registered manager of the home. However, there was no evidence that the deputy manager had received regular supervision. This should be carried out either by the registered manager or the service co-ordinator to provide the deputy manager with support and guidance and to further ensure the effective management of the home (See Requirements). In relation to quality assurance the home had carried out a customer satisfaction survey with residents, relatives and professionals last year to obtain their views about the home as part of self-monitoring. The results of the survey had been written up in a report, which also included aims and outcomes for residents based on the results of surveys. It was reported that another survey was due for completion in July 2007. A previous requirement that staff needed to receive training in risk assessment and other areas of health and safety including first aid, infection control, food hygiene amongst others had not been exceeded at the time the inspection was held. However, although some gaps were still identified where individual staff needed to complete training in these areas there was evidence within staff files that were inspected that some staff had done this training, for example there was evidence within two staff files that they had completed general health and safety training that addressed manual handling, fire safety, infection control and both had also done food hygiene. It was reported that two other staff were still in the process of completing a food hygiene course. Staff had also received training in fire safety and first aid from a staff member who is qualified and acts as the Health and Safety representative for all the Woodham Homes and some had completed health and safety training including risk assessment (See Requirements). Also as part of health and safety, it was identified that the home had up to date maintenance certificates in relation to gas safety, fire equipment and portable electrical appliances had been tested. However, in respect a previous requirement that the home needed to obtain an up to date certificate for electrical wiring, this had been partially met. There was evidence that an inspection of the electrical system of the home had been carried out but work needed to be completed before a safety certificate could be issued. This had been done but the home was waiting for the system to be looked at again and a new certificate to be obtained. Other requirements in respect to a risk assessment being completed that identified that the testing of water temperatures was not necessary, that a certificate for the testing of legionella be obtained and that all incidents that have occurred in the home as specified Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 26 under Regulation 37 of the Care Standards Act should be reported to CSCI had all been met. However, a previous requirement that a comprehensive building/ environment risk assessment and a fire risk assessment should be drawn up had still not been addressed (See Requirements). Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 27 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 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes 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 YA6 Regulation 15 Requirement The registered provider must ensure that all parts of residents’ care plans are fully and consistently implemented by the staff working at the home to ensure all identified and assessed needs are met. The registered provider must ensure that residents are made aware of all the risk factors involved in decisions they make in relation to their lives and that where risks have been identified risk management plans are put in place to minimise the risk occurring. The registered provider must ensure that all staff receives formal training that addresses the handling, storage, recording and administration of medication. The registered provider must ensure that all complaints are fully investigated in line with the home’s complaints policy and procedures and where appropriate statements are obtained from those involved. Also that the complainant is DS0000028745.V339739.R01.S.doc Timescale for action 30/11/07 2. YA9 12 (2) & 13 (4)(c) 31/08/07 3. YA20 13(2) 01/01/08 4. YA22 22(3) &(4) 30/11/07 Woodham House Version 5.2 Page 29 5. YA33 18 (1) (a) 6. YA34 19 (4) 7. YA35 18 (1) (c) (i) 8. YA37 18 (2) informed in writing within the timescale specified within the home’s policy what was the outcome of the investigation. The registered provider must ensure that the rota accurately reflects at all times staff that are on duty and the arrangements for management cover of the home. (Previous timescale of 30/06/06 & 31/05/07 not met.) 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. (No new staff recruited since last visit to the home so standard could not be fully assessed. In respect to staff presently employed at the home previous timescales of 31/10/06 & 31/05/07 had been partially met. 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. (Previous timescale of 31/01/06 & 17/01/07 partially met. Timescale of 31/08/07 not exceeded) The registered provider must ensure that the deputy manager is provided with adequate support to ensure the effective management of the home specifically that they DS0000028745.V339739.R01.S.doc 31/08/07 30/11/07 31/08/07 30/11/07 Woodham House Version 5.2 Page 30 receive regular supervision. 9. YA42 13 (4) (a) The registered provider must 31/08/07 ensure that there is a comprehensive fire and building risk assessment in place for the home. (Previous timescale of 31/10/06 & 31/05/07 not met.) The registered provider must 31/08/07 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 timescales of 31/10/06 &31/03/06 partially met. Timescale of 31/08/07 not exceeded) The registered provider must 31/08/07 ensure -That a new maintenance certificate for the electrical wiring system of the home is obtained and a copy sent to CSCI. (Previous timescale of 31/05/07 partially met) 10. YA42 18(1)(c)(i) 11. YA42 23(2)(c) 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. Refer to Standard YA5 YA6 Good Practice Recommendations The registered provider should try to ensure all residents are issued with and sign an updated copy of the statement of terms and conditions outlining their stay with the home. The registered provider should try to ensure that key DS0000028745.V339739.R01.S.doc Version 5.2 Page 31 Woodham House 3. YA7 4. 5. YA19 YA24 workers hold monthly key work sessions with residents. 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 when health professionals visit the home they write up their contact with the resident within their daily records. The registered provider should consider cleaning up the walls and doors in the communal corridor upstairs or possibly to redecorate this area. Woodham House DS0000028745.V339739.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent 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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