Inspection on 12/09/07 for Woodland Way, 60

This inspection was carried out on 12th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodland Way, 60 12/06/06

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 60, Woodland Way Mitcham Surrey CR4 2DY Lead Inspector Emma Dove Unannounced Inspection 12th September & 10th October 2007 10:50 60, Woodland Way DS0000027215.V352273.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 60, Woodland Way DS0000027215.V352273.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. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 60, Woodland Way 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 Post Vacant Care Home 6 Category(ies) of Learning disability (6), Physical disability (2) registration, with number of places 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2007 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. Five people are currently living there. 60, Woodland Way is owned by a housing association and is managed by the voluntary organisation, United Response. The home is in a residential area on the borders of Mitcham and Tooting, close to public transport, local shops and leisure facilities. 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. People who use the service have access to a garden. A lift serves both floors. The home is staffed twenty-four hours a day. The current fees are from £1,101 per week, depending on peoples assessed needs. 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. 60, Woodland Way DS0000027215.V352273.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 four hours on the 12th of September 2007 and one and a half hours on the 10th October 2007 by one regulation inspector. The inspection included looking at records, looking around communal areas and three bedrooms, talking with people who use the service, the manager, deputy and staff. Questionnaires were sent to health professionals and other professionals involved with people who use the service. We have not received any completed questionnaires. An Annual Quality Assurance Assessment was returned in good time to be included in this report. We have received copies of monthly visits and appropriate notifications. What the service does well: What has improved since the last inspection? What they could do better: Person Centred Plans should be completed for all people who use the service, to ensure that their needs are fully recorded and can be met. An audit of medication must be completed to ensure that peoples health and safety is maintained. More hooks are required on the lounge curtains so they cover the windows properly when they are closed. The garden should be maintained to ensure people who use the service can access and continue to benefit from the outside space. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 6 The kitchen units should be refurbished to ensure that the environment is maintained at a good standard for people who use the service. The manager must register with the CSCI to comply with regulations. 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. 60, Woodland Way DS0000027215.V352273.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 60, Woodland Way DS0000027215.V352273.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 and 2 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service has developed a Statement of Purpose and Service Users Guide, to provide information to people about the services provided. A full assessment is carried out before admission. EVIDENCE: A Statement of Purpose is in place, it contains information about the aims and objectives of the service, accommodation available, staffing and the admission process. A Service Users Guide has been developed which provides information about the service, key work system and how to make a complaint. A detailed induction programme is developed with people planning to move into the service. This can include short visits to the home, to meet other people using the service and staff and to familiarise with the building, overnight stays and visits to the person’s current home. Assessments were seen in case files and include details of the support and assistance individuals need. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Care plans are being developed into Person Centred Plans (PCP) with individuals. A key work system is in place, which enables staff to work on an individual basis with people involved in setting goals. EVIDENCE: Progress has been made with developing PCP’s with individuals, two have been completed and three are in progress. Case files contain information about peoples lives before the moved into the service, health and medical details, their daily and weekly timetables of activities and tasks to complete. Individuals have set goals to achieve throughout the year, that are reviewed and updated when necessary. Some peoples goals are to develop their daily living skills, clear steps have been developed to help individuals work through the tasks on a daily basis. Records are kept of progress and any changes needed. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 10 Annual reviews of the care and support people receive were seen to have been held for three people. Staff reported that all people who use the service have regular reviews. People who use the service are involved in the day to day running of the home with meal planning, shopping and house hold tasks, as well as choosing their holiday destinations, outings and activities. Risk assessments are in place and are updated when required or annually. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service is committed to enabling people who use the service to develop and maintain social, emotional and independent living skills. People are supported to develop goals and are working towards achieving them. People have the opportunity to maintain important family and personal relationships. EVIDENCE: Some people who use the service attend a day centre, while others go to specific classes of their choice some week days and spend time at the home or out in the community. One person said ‘I am so happy’ and was seen to be very relaxed and comfortable in the lounge, interacting with staff. Staff reported that people who use the service are supported to maintain relationships with relatives and friends. People who use the service confirmed 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 12 this by saying that their relatives visit. Records also noted that staff keep family members up to date with peoples changing needs. Meals are varied to suit peoples choice and any health or medical needs. People who use the service are involved in choosing the menu for the week, staff were seen to check that people still wanted their choice. One person said ‘lunch was good’ and other people were seen to eat the meal served. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Personal healthcare support are clearly recorded in individuals care plan. Records include the individuals needs, identify any changes with any actions taken. Medication is generally well managed, appropriately stored and recorded, however some tablets were unaccounted for. EVIDENCE: Good health records are kept with details of GP, hospital and other health related appointments, monitoring of peoples weight, behaviour and support needed and given with personal care. Where there are concerns about peoples health, records clearly detail the actions taken and any medical advice given. People who use the service need support to attend health and medical appointments and staff are aware of how best to support individuals. The manager reported that the service plans to continue to develop health action plans for individuals over the next year. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 14 Staff are aware of privacy and dignity issues and speak with individuals in private and ensure people who use the service are not in the room at staff handover, when information about individuals is discussed. Appropriate medication policies and procedures are in place. Medication is stored, labelled and recorded correctly. Medication Administration Record Sheets were up to date and signed by staff. The count of two medications identified more tablets than those received and administered. One ‘as required’ medication had not been recorded as given, although tablets were missing from the packet. An audit of medication at the home must be completed and when new supply is received from the pharmacist, all old medications should be returned to the pharmacy. Staff complete training in the administration of medication. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service has clear complaints and protection of vulnerable adults procedures, which are accessible to people who use the service and their relatives or representatives. Staff complete training in adult protection. EVIDENCE: The complaints procedure is included in the Statement of Purpose and Service Users Guide. The manager reported that they have not had any complaints in the last year. We have not received any complaints about the service since the last inspection. People who use the service confirmed that they have ‘no worries’ and ‘would speak to staff or the manager’ if they did have any concerns or complaints. Policies are in place for the protection of vulnerable adults, with clear guidelines for staff with the actions to be taken. Staff complete training in issues of protection. The manager is aware of her responsibilities in relation to protecting people who use the service. Some money is held for people who use the service. The records are clear, up to date and balances were correct. Good systems are in place to check individuals finances on a daily and weekly basis. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 16 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, 27, 28, 29 and 30 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to meet the needs of the people who live there. Bedrooms are single and people are encouraged to personalise their rooms. EVIDENCE: People have access to a kitchen/dining room and lounge. A small garden is available which has been redeveloped to be more accessible. People made positive comments about the garden and said they had enjoyed sitting outside in the summer. The garden will need to be maintained on a regular basis to keep it accessible for people who use the service. Bedrooms are single and have been personalised to individuals taste. People confirmed that they have everything they need in their bedrooms. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 17 Requirements have been made around refurbishing the kitchen with particular attention to the kitchen cabinets and flooring. This work remains outstanding. The manager reported that the organisation will continue to work with the housing association to get this work completed. New furniture and curtains have been bought for the lounge, a new table and dining chairs have been bought for the kitchen/dining room. People who use the service said that they were involved in choosing the new furniture and were seen to be comfortable in the lounge. The curtains need more hooks so they hang properly at the windows. A large shower room with toilet and a separate toilet are available on the ground floor with a bathroom and toilet and separate toilet on the first floor. The shower room has recently been refurbished to meet the changing needs of people who use the service. All areas of the home were clean and tidy. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 18 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 and 36 People who use the service receive excellent quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People who use the service are happy with the care that they receive. Staff have good training opportunities. The staff recruitment process is good, with systems in place to ensure appropriate checks are made. Regular staff meetings and staff supervision takes place. EVIDENCE: The rota noted two members of staff on duty during the day with one member of staff awake and one asleep, on call at night. The manager is available in addition to this on weekdays. Staff demonstrated a good knowledge and understanding of the needs of people who use the service. People who use the service were seen to be relaxed and comfortable with staff and the manager. The policies and practice for recruiting staff are in line with legislation. Staff files contain a copy of the application form, at least two written references, a Criminal Records Bureau check, the induction process and probationary report and proof of the individuals identity. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 19 The organisation has a training and development programme available to all staff. Staff have completed training in dementia awareness, manual handling, challenging behaviour, medication administration, health and safety, first aid, food hygiene, equality and diversity and personal relationships and sexuality. Staff confirmed that they have good training opportunities with courses that help them improve their practice and do their job well. The manager reported that staff have regular supervision and an annual appraisal. Staff confirmed that they get supervision and have recently had an appraisal. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 20 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 and 42 People who use the service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The manager has the required experience to run the home. Quality assurance systems are in place to seek people who use the service, their relatives and representatives and other stakeholders opinions of the services provided. Good health and safety policies and procedures are in place, with checks and records up to date. EVIDENCE: The manager has experience in similar services and has been at the home for over one year. The manager has started the process to apply to register with us and this must be completed. The manager demonstrated knowledge and understanding of the needs of people who use the service. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 21 Staff meetings take place every week with records available. A house meeting takes place every month, when people who use the service are asked their opinion on the service and make plans for outings and activities for the next month. A representative from the organisation completes a visit to the home every month. We receive a copy of the report from this visit. The manager reported that questionnaires have been sent to people who use the service relatives. The comments from these questionnaires were seen to be positive with no concerns raised. Appropriate policies, procedures and records are in place and up to date to ensure people who use the service, visitors and staffs health and safety is maintained. The electrical supply was tested in February 2007. Portable electrical appliances were checked in August 2006, this check must be completed every year. The lift is serviced and tested every three months. The fire alarm is tested weekly by staff. 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 22 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 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 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 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 2 X 2 X 3 X X 3 X 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 23 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 YA20 Regulation 13 (2) Requirement Timescale for action 21/11/07 2. YA24 16 (2) g & 23 (2) b 3. YA37 8 (1) a An audit of medication must be completed and records of medications received and administered must tally, to ensure that peoples health needs are fully met. The kitchen units must be 31/03/08 repaired or replaced to keep the environment maintained to a good standard. (previous timescales of 26/09/06 and 30/03/07 not met) The manager must complete the 21/11/07 registration process with the CSCI to comply with regulations and provide stable management within the service. (previous timescales of 24/02/06, 26/07/05, 29/08/06 and 30/03/07 not met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000027215.V352273.R01.S.doc Version 5.2 Page 24 60, Woodland Way Standard 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 60, Woodland Way DS0000027215.V352273.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!