Inspection on 13/01/06 for Woodland Way, 60

This inspection was carried out on 13th January 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 12/06/06

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 13th January 2006 14:15 Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 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.V280429.R01.S.doc Version 5.1 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.V280429.R01.S.doc Version 5.1 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 www.unitedresponse.org.uk United Response Care Home 6 Category(ies) of Learning disability (6), Physical disability (2) registration, with number of places Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 06/06/05 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. Six 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. Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 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 hours on the afternoon of the 13th January 2006 by one regulatory inspector. The inspection consisted of examination of records, inspection of communal areas of the home, talking to residents, the manager and staff. The inspector had the opportunity to speak with three residents and two members of staff. What the service does well: 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. Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 6 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.V280429.R01.S.doc Version 5.1 Page 7 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 Prospective residents, their relatives and placing social workers have information they require to make an informed decision regarding moving into the home. EVIDENCE: The Statement of Purpose and Service Users Guide have been updated to include the new management arrangements at the home and contain other information to assist prospective residents and their representatives in making a decision regarding moving into the home. Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 8 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 Care plans are in place which are reviewed annually, however review records were not all in place. Risk assessments ensure residents are protected. EVIDENCE: One case file examined contained personal information regarding the individual, preferences list, photographs of significant people, photographs of staff at Woodland Way, health information, personal care policy, financial guidelines, missing person policy, personal care and oral hygiene care plans. Some information requires updating to include current staff at the home and all records and reports must be dated and signed by staff. The manager reported that residents needs have recently been reassessed by health professionals to ensure that full needs are recorded and can be met in the future. An annual review of the services received and the care required are held which residents, their relatives or representatives, placing social workers and staff attend. One resident’s file did not contain a copy of the most recent review notes, these must be available to ensure staff have access to up to date information. Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 9 Residents are encouraged and enabled to make decisions regarding daily living, such as clothing, activities, television programmes and meals. Residents reported that they attend meetings and choose/discuss menus and activities. The manager reported that residents meetings have been missed over the past few weeks due to Christmas and residents illness. Risk assessments are in place which the manager was updating at the time of the inspection. The manager reported that all staff discuss individual residents risk assessments and sign that they have read and understood them at a staff meeting. Policies and procedures are in place to ensure that risks are minimised and for staff to follow in the event of a resident being missing from the home. Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 10 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): 17 Residents are offered a varied diet and are involved in choosing the menu and meal preparation. EVIDENCE: Residents reported that they continue to choose the menu for the week, each resident picks the meal and dessert for one day a week. Any dietary requirements are recorded to ensure residents receive appropriate foods. One resident told staff that they did not like the meal on the menu, a different meal was provided. Two residents confirmed that ‘staff make me a different meal if I don’t like it’. Mealtimes were observed to be relaxed and unhurried. Residents do not need assistance with eating, however staff are aware of individual residents needs and ensure they are met. Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 11 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): These standards were assessed as met at the last inspection of the home in June 2005. EVIDENCE: Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 12 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 Complaints are appropriately managed with residents and their relatives able to access the complaints procedure. Policies are in place regarding the protection of vulnerable adults. EVIDENCE: The complaints procedure is available to residents and their relatives. Residents did not raise any issues or concerns regarding the care and services that they receive at the home. No complaints have been received by the CSCI. The protection of vulnerable adults policy is available to all staff in the office. Staff completed training on the protection of vulnerable adults in 2004, staff employed since this will need to attend the training. Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 13 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, 27, 28 & 30 The home was purpose built and is maintained to a good standard with the exception of the kitchen which requires attention. Residents can access all communal areas of the home and a garden. The bathroom on the ground floor requires attention to ensure it meets the current needs of residents. EVIDENCE: The home was purpose built and is accessible to residents with the exception of the laundry room which is not accessible to residents who use a wheelchair. New flooring has been fitted throughout the entrance hall and lounge. Residents said that they like the new floor and that it looks better when you walk into the home. New carpet has been fitted on the upstairs landing. The garden has been tidied and attended to. One resident reported that they enjoy the garden when the weather is good. A bathroom with toilet is available on the ground and first floor with a separate toilet on both floors. The bath on the ground floor is adapted with an electronic chair to assist residents. At the last inspection of the home in June 2005 issues were raised regarding the suitability of the bath chair for one resident, these issues remain unresolved. An assessment has been made of the current residents needs with advice given regarding the type of equipment required to meet these assessed needs, however no progress has been made with fitting the equipment. Agreement must be made and the work must be Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 14 completed to ensure residents personal hygiene needs can be fully met at the home. An unpleasant smell was evident on first entering the home which was not apparent in the communal areas or bedroom corridors of the home. This must be addressed. The laundry room is away from the kitchen/dining area and has an impervious floor, tiles on the walls, a wash hand basin and washing machine and tumble drier. As previously mentioned residents who use a wheelchair are not able to fully access the laundry room, residents and staff did not raise this as an issue. Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 15 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): 34 & 35 Residents are protected by appropriate recruitment policies and practices and are supported and assisted by suitably trained staff. EVIDENCE: Staff files contain details required and detail training individuals members of staff have completed. The organisation has a training and development programme available to all staff. All staff have completed mandatory training in health and safety; first aid; manual handling and food hygiene. In addition to these courses staff have attended training on managing challenging behaviour and new staff complete the Learning Disability Award Framework induction training. Staff have a personal development plan which is linked to their annual appraisal. Staffing levels were observed to be appropriate during the course of the inspection. The home has been through a period where staffing has remained stable, however a number of staff changes are to occur during the first few months of 2006 due to two members of staff taking maternity leave. The organisation has put cover arrangements in place. Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 16 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): 39 & 42 Residents and their relatives views are regularly sought and residents feel involved in the development of the home. Residents and staffs health and safety are protected by policies, procedures and recording at the home. EVIDENCE: Residents and relatives views of the care and services provided at the home are sought at annual reviews. Previously questionnaires have been sent out by the home to seek relatives and other professionals views on the services provided. CSCI reports are available at the home and residents were able to speak with the inspector. Policies and procedures required are developed and reviewed by the organisation and are available to staff at the home. The organisation has detailed weekly, monthly and annual health and safety checks to be completed by staff and external professional people. Up to date records were observed of fire alarm checks, lift maintenance, hoist maintenance, electrical supply and portable electrical appliance testing. The Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 17 gas safety test certificate was not in place, however records indicated it had been completed in September 2005. The Environmental Health Officer visited in July 2004 with one issue raised which has been addressed. The Fire Officer visited in April 2003 with no issues raised. Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 18 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 X 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 1 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 X 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 2 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 2 X 3 X X 2 X Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 19 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 17 Requirement The registered person must ensure that one residents file is updated with current staff details and their key worker and ensure that staff date and sign reports and records. The registered person must ensure that all staff complete training in the protection of vulnerable adults. 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 is redeveloped to meet current residents assessed needs. The registered person must ensure that a manager is appointed and put forward to register with the CSCI. (previous timescale of 26/07/05 not met) Timescale for action 24/02/06 2. YA23 18 (1) c 24/02/06 3. 4. 5. YA24 YA24 YA27 16 (2) g & 23 (2) b 16 (2) c 23 (2) j & n 8 (1) a 24/02/06 24/02/06 24/02/06 6. YA37 24/02/06 Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA8 Good Practice Recommendations The registered person should ensure that regular residents meetings take place to ensure residents continue to be involved in aspects of the daily running of the home. Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 21 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. Extracts may not be used or reproduced without the express permission of CSCI Woodland Way, 60 DS0000027215.V280429.R01.S.doc Version 5.1 Page 22 - 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!