Inspection on 19/12/05 for Woodlands (Horley)

This inspection was carried out on 19th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlands (Horley) 06/02/07

Woodlands (Horley) 25/08/05

Woodlands (Horley) 25/11/04

Woodlands (Horley) 06/07/04

Similar services:

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Insight - Eastchurch

Southfields

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33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Woodlands (Horley) Woodlands 42 Massetts Road Horley Surrey RH6 7DS Lead Inspector Helen Dickens Announced Inspection 19th December 2005 10:30 Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 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 Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 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. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodlands (Horley) Address Woodlands 42 Massetts Road Horley Surrey RH6 7DS 01293 784235 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) SeeAbility Heather Salisbury Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (7), of places Sensory impairment (7) Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 7 residents accommodated within categories SI, up to 7 may also fall within categories LD or MD Age range: 40 - 60 Date of last inspection 25th August 2005 Brief Description of the Service: Woodlands is a large detached house situated in a pleasant residential area of Horley, Surrey. It is owned and managed by the registered charity, SeeAbility. It is close to local facilities and amenities. The service provides personal care and accommodation for seven adults with learning and sensory disabilities (visual impairment). All residents have single bedrooms, some with ensuite facilities. The home is on two floors. There is no lift but none of the current residents requires that form of assistance at present. The home has a large garden area with a newly built art and crafts studio at the far end. There are plenty of car parking spaces to the front and rear of the property. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over four hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year 2005/06. The inspection was carried out by Helen Dickens, Lead Inspector for the service. Richard Fairbank, the new manager, represented the establishment. A tour of the premises took place. Four residents were spoken to in some depth, and the inspector met the other two residents who were at home on the day of the inspection. One member of staff was also interviewed. A preinspection questionnaire and a number of comment cards had been returned and were examined as part of the inspection process. A number of files and records were also used in writing this report. Fewer standards were examined during this inspection as the majority of Key National Minimum Standards were examined during the previous inspection. This was a very positive inspection. The inspector would like to thank the residents and staff of Woodlands for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? All the Requirements and Recommendations made at the previous inspection have been carried out including replacing the broken door on the kitchen cupboard, maintaining fridge temperatures within recommended levels, and carrying out a risk assessment on the hot water in the laundry room. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 Page 6 Further work has been done on the craft studio in the garden and it is now being used for a number of recreational and educational activities. SeeAbility is piloting the new induction programme for staff which is being brought in for all care homes next year – a new member of staff commented very positively on this experience. The SeeAbility training officer has also given all SeeAbility managers a presentation on these new arrangements. The home has reached nearly 100 of staff having NVQ 2 or above by the deadline of December 2005, exceeding the 50 target set down in the National Minimum Standards. All staff have had recent in-house refresher training on the Surrey multi-agency procedures for the protection of vulnerable adults. The garden maintenance has also 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. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 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 Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 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): EVIDENCE: These Standards were examined at the previous inspection. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 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 Individual resident’s plans reflect their changing needs and personal goals. EVIDENCE: Three resident’s plans were examined and found to provide a good overview of residents needs with up-to-date information about how their needs had changed. Independence is important at this home and resident’s support plans contained information on resident’s current skills and goals, with corresponding risk assessments. Independent living skills such as independent cookery, money recognition and social etiquette were identified. There was evidence that residents had been involved in drawing up these support plans and a variety of formats were available including Braille and on CD. Discussions with one resident who was planning a move to more independent living, confirmed that residents are consulted about their ambitions and goals, and supported to make choices about their futures. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 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): 11 Residents have opportunities for personal development. EVIDENCE: Staff at this home support residents with personal development in a number of ways. The requirements for each resident regarding their social and independent living skills are identified in their support plans. Staff then assist residents by encouragement and practical assistance, for example with personal care, and with cookery. Staff identify aids and adaptations, which may also assist residents to be independent, and a number of ‘gadgets’ are available at Woodlands such as speaking food tin tops (describing what is inside the tin), clocks, and a microwave oven. Assertiveness training and selfadvocacy work are other examples of resident’s goals highlighted on their support plans and during reviews. Some residents are taking part in a social inclusion project and this offers additional opportunities for personal development. Three residents have had the opportunity to work on developing their computer skills and funding was awarded from the European Social Fund for computer equipment and tuition. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 Page 11 All residents have access to the SeeAbility rehabilitation officer, as well as therapeutic interventions from health service providers. Families and friends are seen as important in the personal development of residents and involved and encouraged to continue to be part of resident’s lives. The home had just had a ‘family and friends’ day, where residents invited in their family and friends for a meal at Woodlands. The remainder of these Standards were examined during the previous inspection. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 Page 12 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): 20 The administration of medication at Woodlands is well organised and residents are protected by the home’s policies and procedures. EVIDENCE: Resident’s independence with regard to the administration of medication is promoted in this home by the following system, which was recommended by the community pharmacist. Resident’s keep their own medication in locked draws/cabinets in their own rooms and they prompt staff who will then go to the resident’s room to either administer, or supervise the administration of, the medication. The community pharmacist has supplied home medication packs (blister packs) divided into weekly dose packs for each resident. The home keeps small amounts of spare creams and medicines. There are no controlled drugs at this home. Two residents medication records (MAR charts) were examined and no unexplained gaps were found, photographs and details of allergies were noted, together with a list of all current (and recent past) medication. The staff signature list regarding who can administer medication needs up-dating, and one MAR chart needed to define what ‘F1’ means when administering one particular resident’s medicine. The manager was also advised that as medication errors potentially adversely affect the well being of residents, these Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 Page 13 should be reported to CSCI. See the final section of the report for further discussion on Regulation 37 notices. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 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 and 23 Resident’s at this home can be confident their views will be listened to and acted upon, and they will be protected from abuse. EVIDENCE: There is a complaints procedure, available in a user-friendly format, (with a tactile complaints folder) and residents are encouraged to highlight any concerns, both on a one-to-one basis with staff, but also at residents meetings. A recent complaint highlighted by a resident about menu planning had been satisfactorily dealt with and the resident was content with the outcome. Residents who had completed their ‘comment cards’ prior to the inspection all knew who to tell if they had a problem, for example ‘my key worker’, ‘the staff’ and ‘someone in the office.’ The home has a copy of the Surrey multi-agency procedures for the protection of vulnerable adults and devised a recent refresher training session for all staff on this subject. The ‘interactive training’ took place at a staff meeting where all staff were given one section of the procedures in advance of the meeting, and asked to digest and summarise this and present it to colleagues. One staff member interviewed said this had worked well and it gave a better understanding of what the procedures were about. This staff member, when questioned, was very clear about her role should an allegation of abuse be made. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 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 and 27 The home offers a good standard of accommodation to residents and is homely and comfortable throughout. However, further work needs to be done to meet these standards in full. EVIDENCE: Woodlands is generally well maintained and offers a comfortable and accessible environment for residents. The premises are bright, cheerful, airy, and free from offensive odours. Both inside and outside the property, much attention has been paid to the independence of residents, and the premises are in keeping with the local community. Toilets and bathrooms are sufficient to meet resident’s needs and are domestic in design. Sensory guides (such as a toothbrush as a ‘signpost’ on the toilet door) were used throughout the home to assist residents. There were some areas inside the property which needed additional attention such as in the training kitchen, and some of the bathrooms which needed further cleaning and redecoration. The previous inspection recommended more frequent defrosting of the freezers and this had been done and noted in the cleaning diary. It was difficult to find out how frequently certain other cleaning jobs were carried out as the cleaning diary listed only the larger jobs such as carpet cleaning; there was no comprehensive record or rota available regarding other more regular cleaning. One ensuite toilet needed to have the Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 Page 16 walls redecorated as paper had been removed to fit in a new fan. In the training kitchen there was paint peeling on one wall, and tea splashed down the wall by the bin. These concerns were highlighted to the manager and Requirements will be made on these matters. A number of other issues regarding health and safety in the premises are outlined at the end of this report. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 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): 34 Residents are protected by the home’s recruitment procedures. EVIDENCE: There is a thorough recruitment policy at this home and the staff file for a recent recruit was examined and found to be satisfactory. There was a photograph on file, and confirmation of the person’s identity together with a satisfactory Criminal Records Bureau check (which is carried out by the SeeAbility head office and confirmation is sent to the home). Staff are subject to a probationary period and ongoing assessment throughout this time. As already mentioned in the introduction to this report, SeeAbility is already piloting the new arrangements for the induction of care staff which will be brought in next year. The member of staff interviewed had positive comments to make on this new system and thought it’s similarity to NVQ assessment was particularly helpful. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 Page 18 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): 42 The health and safety of residents and staff is generally good at this home but further work needs to be done to meet this standard in full. EVIDENCE: There were many areas of good practice in this home with regard to health and safety matters. For example the home takes fire safety very seriously – residents and staff are involved in regular fire drills; the fire risk assessment for the home has just been reviewed and revised by the new manager; fire safety advice has also been taken. A fire alarm panel had just been fitted in the new craft studio. Risk assessments at the home are thorough and cover a wide range of risks, both risks relating to individual residents, and wider hazards in the home. A number of safety certificates/records were seen for example the certificate of water chlorination to prevent legionella, and the electrical wiring safety certificate. Water outlets accessible to residents were controlled to around 43C. Additional hazards had been identified and addressed by the home for example those residents and staff emptying the dishwasher now used handWoodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 Page 19 sanitising liquid which had been purchased and fitted above the dishwasher. An environmental health officer accident investigation at the home earlier in the year had made only one small safety recommendation and said no further action was needed. However, there were some concerns including the worn stair carpet which needs replacing or making safe as soon as possible; radiators which were not fitted with radiator covers to control the surface temperature; the hazardous substances cupboard key was being stored in a pot in the kitchen; and food which had been opened but not date-labelled was found in the fridge. In addition, the hazardous substances cupboard was very untidy; many of the items stored there were not hazardous, and taking up unnecessary space. Paper towels at the back of the cupboard were not easily reached unless other items were either moved or else staff would have to climb to reach them. It was suggested that there should be a review of what is stored in this cupboard and whether the current shelving was adequate. Though Standard 37 was not assessed on this occasion, 37.3 vi refers to the home complying with the Care Standards Act and Regulations. There was some discussion during the inspection about home’s policy regarding the timing of alerting CSCI to incidences reportable under Regulation 37. The inspector found that the charity’s current policy is to send these notices to their local head office for agreement before sending them to CSCI. The Responsible Individual must ensure that this local policy complies with the ‘without delay’ requirement set down in Regulation 37. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 3 X X X LIFESTYLES Standard No Score 11 4 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodlands (Horley) Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000013840.V261383.R01.S.doc Version 5.0 Page 21 No 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 YA24 Regulation 23(2)(d) Requirement The home must review the cleaning and decoration of the ensuite toilet and the training kitchen as outlined in the report. The Responsible Individual must ensure that the home’s policy of sending Regulation 37 notices to SeeAbility’s head office for agreement, does not prevent these notices reaching CSCI in a timely fashion and ‘without delay’ as set out in this Regulation. The home must review the arrangements for replacing the worn stair carpet and ensure the safety of residents until the carpet is either made safe or replaced. Risk assessments must be carried out on the radiators which do not have radiator covers. Appropriate action must then be taken to keep residents safe. The home must review the contents of the hazardous substances cupboard, and consider whether further shelving is required to eliminate DS0000013840.V261383.R01.S.doc Timescale for action 01/02/06 2. YA37 37 01/01/06 2. YA42 13(4)(a) (b)(c) 01/01/06 3. YA42 13(4)(a) (b)(c) 21/12/05 4. YA42 13(4)(a) (b)(c) 01/01/06 Woodlands (Horley) Version 5.0 Page 22 5. YA42 13(4)(a) (b)(c) the potential hazard posed by the current storage arrangements. The review should include the storage of the key to this cupboard. The home must review its protocol for labelling foods which have been opened and are being stored in the fridge. The home must ensure that all items in the fridge, which have a limited shelf life, are correctly labelled. 20/12/05 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 YA20 Good Practice Recommendations The home should update the list of staff signatures with regard to the administration of medication and ensure that all abbreviations used on the medication administration record are clearly defined. Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Woodlands (Horley) DS0000013840.V261383.R01.S.doc Version 5.0 Page 24 - 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. 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