Inspection on 12/06/06 for Woodland Way, 60

This inspection was carried out on 12th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodland Way, 60 12/09/07

Woodland Way, 60 13/01/06

Woodland Way, 60 28/09/04

Woodland Way, 60 22/06/04

Woodland Way, 60 11/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Woodland Way, 60 Mitcham Surrey CR4 2DY Lead Inspector Emma Dove Unannounced Inspection 12th June 2006 10:20 Woodland Way, 60 DS0000027215.V295682.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 Woodland Way, 60 DS0000027215.V295682.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. Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodland Way, 60 Address Mitcham Surrey CR4 2DY 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) 0208 687 2376 02086872376 woodland.way@unitedresponse.org.uk None United Response Care Home 6 Category(ies) of Learning disability (6), Physical disability (2) registration, with number of places Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13/01/06 Brief Description of the Service: 60, Woodland Way is a registered care home, providing personal care and accommodation for up to six adults with learning disabilities including two people who may have additional physical disabilities. Four residents are currently residing at the home. The home is owned by a housing association and is managed by a voluntary organisation, United Response. The home is situated in a residential area on the borders of Mitcham and Tooting, close to public transport, local shops and leisure facilities. The home was purpose built. Accommodation is provided over two floors with three single bedrooms, a bathroom with toilet, separate toilet and staff sleep-in room on the first floor. The remaining three single bedrooms, an assisted bathroom, separate toilet, lounge, kitchen/dining room, office and laundry room are on the ground floor. Residents have access to a garden. A lift serves both floors at the home. The home is staffed twenty-four hours a day. Residents are provided with three meals a day with drinks and snacks available in between meals. The current fees are £1056 per week. Inspection reports are available at the home and details of the CSCI are included in the Statement of Purpose and Service Users Guide to the home. Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over the course of four and a half hours on the 12th June 2006 by one regulation inspector. The inspection consisted of examination of records, inspection of communal areas of the home, talking to residents, staff and the acting manager. The inspector had the opportunity to speak with two residents and two members of staff. A Pre-Inspection Questionnaire was left with the acting manager on the 12th June 2006, which was completed by the acting manager and received by the CSCI on 26th June 2006. Questionnaires were given to one resident and relative, three members of staff and sent to one advocate, two day centres, four health professionals and a social worker. Seven questionnaires have been received and comments from these are included in each relevant section of this report. What the service does well: What has improved since the last inspection? What they could do better: The care plans should be developed further into Person Centred Plans to ensure resident’s needs are fully recorded. Reviews of care provided and care plans must be held every year, or more frequently if individuals needs change. The kitchen units require repairing or replacing to ensure the environment is maintained at a good standard. The bathroom on the ground floor must be Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 6 assessed for suitability when new residents have moved into the home, to ensure residents have full access to bathroom facilities. The organisation must put forward a permanent manager to register with the CSCI to provide stable management and to ensure consistency of care for residents. This matter has been outstanding for the past five years. 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. Woodland Way, 60 DS0000027215.V295682.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 Woodland Way, 60 DS0000027215.V295682.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Information is available to assist new and prospective residents and their relatives and representatives to make an informed decision regarding moving into the home. Assessments are completed on admission to the home and are developed into care plans. EVIDENCE: The Statement of Purpose and Service Users Guide to the home include details required to assist prospective residents in choosing whether to move into the home. Changes have not been made to these documents since the last inspection in January 2006. One questionnaire indicated that the individual received sufficient information about the home before moving in. Assessments were completed on admission to the home and are developed into care plans. The acting manager reported that a full assessment and detailed information were being provided for one potential new resident. The acting manager reported that an induction programme is being developed for the potential new resident which includes staff visiting the person in their current home and visits to Woodland Way to meet other residents and staff. Woodland Way, 60 DS0000027215.V295682.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 at least once during a 12 month period. 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 the home. Care plans are in place with further work required to develop Person Centred Plans for individuals. EVIDENCE: Care plans have been developed from assessments, assessments have been updated. One care plan had been updated in 2004 with a review in 2005 at the day centre and one resident had had a review in 2006. Further work is required to develop Person Centred Plans for all residents. Case files need updating to reflect recent changes in residents and staff at the home. Risk assessments are in place and kept under review. Questionnaires received from health and social care professionals indicated that the home has a person centred ethos and that the residents are involved in developing care plans and planning for the future. One comment indicated more regular contact with professionals to keep them updated of changes in residents needs would be beneficial, rather than waiting for the annual review. Staff feel that care planning is an area that they manage well, keeping everybody involved up to date and included in meetings and reviews. Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 10 Examination of two residents individual finances identified that records are up to date, signed by staff with the balance correct, ensuring residents financial interests are protected. Woodland Way, 60 DS0000027215.V295682.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents social needs are appropriately met through the clubs, groups and centres they attend during the week. EVIDENCE: Residents attend various day centres and clubs during the week depending on their wishes and needs. The acting manager reported that residents also go out for walks, shopping and use other local leisure facilities depending on the individuals choice. The notice board in the kitchen included information about clubs, groups and sessions residents may wish to attend. One questionnaire indicated that there are sometimes activities arranged at the home that the individual takes part in. One questionnaire indicated good communication between staff at the home and the centre, ensuring consistency of care for residents. Residents and staff confirmed that visitors are welcome and that individuals are supported to maintain contact with relatives and friends. Letters received Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 12 at the home confirmed that relatives appreciate the support staff offer to maintain contact. Residents were observed being offered choices in meals and activity. Details of residents likes and dislikes are recorded in their case files. The menu is displayed in the kitchen and indicates that residents take it in turns to choose the lunch and evening meal. The cooked meal is now provided in the evening on weekdays to ensure residents receive a hot meal when they have been at a day centre all day. A mealtime was observed to be relaxed and unhurried with residents offered choices. One questionnaire indicated that the meals are usually good. Woodland Way, 60 DS0000027215.V295682.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 at least once during a 12 month period. 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 the home. Residents receive appropriate support and personal health care. Good systems are in place for medication storage, administration and recording. EVIDENCE: Residents are all registered with a GP and staff support residents to attend appointments. Questionnaires from health care professionals indicated that staff deal with residents health care needs well. Residents indicated that they receive the medical support they need. Medication policies, procedures and practices ensure residents health and welfare are maintained. Medication is securely stored, correctly labelled and Medication Administration Records are up to date and signed. Staff have completed training in the administration of medication. Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Appropriate complaints and protection of vulnerable adults policies and procedures are in place. EVIDENCE: The complaints procedure is included in the Statement of Purpose and Service Users Guide to the home. Questionnaires indicated that residents and their relatives are aware of who to speak to if they are unhappy about something. Records are maintained of complaints with none received since the last inspection of the home in January 2006. The CSCI has not received any complaints regarding the home. Staff have completed training in the protection of vulnerable adults and demonstrated an understanding of their role and responsibilities regarding protection of residents at the home. Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The home provides a safe and homely environment for residents, which is maintained to a good standard with the exception of the kitchen and the bathroom on the ground floor. EVIDENCE: The home was purpose built and meets the needs of current residents. Bedrooms are single and have been personalised to the individual’s tastes. Residents have access to a large lounge with doors to the garden and a kitchen/dining room. One resident reported that they like the home. Residents were observed to be comfortable in communal areas of the home. Issues were raised at the last two inspections of the home regarding the suitability of the bathroom on the ground floor, due to changes in the group of residents at the home, these issues may not be applicable, but this must be kept under review. The kitchen units are showing signs of wear and tear and as indicated at the last inspection, they need repairing or replacing to keep the home maintained at a good standard for residents. Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 16 All areas of the home were clean and maintained to a good standard. The laundry room is away from the kitchen/dining room and staff have clear guidelines to follow regarding cleaning and completing the laundry. Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Staffing levels are appropriate to meet residents needs. Staff have access to training, development sessions and courses. EVIDENCE: The published staffing rota identified two members of staff on duty during the day with one member of staff awake at the home and one member of staff asleep at the home but on call at night. The organisation has a training and development programme which is available to all staff. Records are maintained of training course staff have completed which include: food hygiene, first aid, challenging behaviour, manual handling, medication, prevention from harm and health and safety. Two members of staff have commenced training to NVQ Level 3 with four other members of staff trained to NVQ Level 2 or 3. Staff files identified that recruitment policies, procedures and practices are in line with requirements and appropriate records are maintained at the home. Staff confirmed that they have access to training and attend regular meetings and are supported in their work. One staff questionnaire indicated that Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 18 relationships between staff could be better, however this was not raised as an issue at the inspection visit. No issues were raised regarding same gender care. The staff team don’t reflect the ethnicity of the residents. Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The home is run to meet residents needs, however the lack of a permanent registered manager does not ensure consistency of care for residents and support for staff. EVIDENCE: Currently an acting manager is overseeing the home, with no registered manager having been in place for the past five years. Appropriate temporary measures have been in place to ensure the home has acting managers or managers preparing to register during this time. A representative from the organisation visits the home every month and speaks with residents, staff and checks records. Questionnaires were sent out to relatives and professionals involved with residents in March 2005. Further work is now required to seek the views of residents, relatives and their representatives regarding the services provided at the home. Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 20 Appropriate polices, procedures and records are in place and up to date to ensure residents, staffs and visitors health and safety are maintained. Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 21 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 X 5 X 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 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 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 3 X 2 X 2 X X 3 X Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 22 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 YA6 Regulation 15 Requirement The registered person must ensure that Person Centred Plans are developed for all residents. The registered person must ensure that annual reviews are held for all residents. The registered person must ensure that the kitchen units are repaired or replaced. The registered person must ensure that the lounge curtains are repaired or replaced. The registered person must ensure that the bathroom on the ground floor is assessed for suitability when new residents move into the home. The registered person must ensure that a manager is appointed and put forward to register with the CSCI. (previous timescale of 24/02/06 & 26/07/05 not met) Timescale for action 29/08/06 2. YA6 15 29/08/06 3. YA24 16 (2) g & 23 (2) b 16 (2) c 26/09/06 4. YA24 29/08/06 5. YA27 23 (2) j & n 26/09/06 6. YA37 8 (1) a 29/08/06 Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodland Way, 60 DS0000027215.V295682.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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