Inspection on 06/02/07 for Woodlands (Horley)

This inspection was carried out on 6th February 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlands (Horley) 19/12/05

Woodlands (Horley) 25/08/05

Woodlands (Horley) 25/11/04

Woodlands (Horley) 06/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

1 Marten Road

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 Key Unannounced Inspection 6th February 2007 09:45 Woodlands (Horley) DS0000013840.V327609.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 Woodlands (Horley) DS0000013840.V327609.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. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 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 Richard Peter Fairbank 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.V327609.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age range: 18 years and over Date of last inspection 19th December 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 current cost per person per week is £1056.00. 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.V327609.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of a key inspection and was unannounced. The inspection took place over seven hours. The inspection was carried out by Helen Dickens and Sarah MacLennan, Regulation Inspectors. The Registered Manager represented the establishment. A partial tour of the premises took place. Discussions were held with three residents and two staff members, and a number of other residents were conversed with during the inspection. Returned ‘comment cards’ from residents, relatives and professionals involved with the home were also used to write this report. Two resident’s care plans and a number of other documents and files, including four staff files, were examined during the day. The CSCI would like to thank the residents, relatives, manager and staff for their hospitality, assistance and co-operation during the inspection. What the service does well: Woodlands continues to be a well-run establishment, which offers a very homely environment for its residents. The focus on promoting independence ensures that residents reach their full potential and currently one resident is working towards moving on to more independent living; one resident has successfully moved on since the last inspection. Residents stated that they were happy at Woodlands and in particular commented positively on their rooms, the food, and the staff. They talked about their activities and interests and plans for the future. Residents were very well informed about planned changes to the home. The home has a committed staff team. Staff were respectful to residents at all times. One staff member spoken to stated that the residents were a really nice bunch of people and that it was a really great place to work. The staff member particularly enjoyed going out with the residents, thus enabling them to be part of the local community. The home promotes equal opportunities for residents in many ways for example encouraging them to be part of the recruitment process for new staff, and taking part in a social inclusion project to enable residents to play a greater part in the local community. Staff are aware of, and have taken up issues related to the Disability Discrimination Act where residents rights were thought to have been at risk. More details are contained later in this report. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 8 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.V327609.R01.S.doc Version 5.2 Page 9 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): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Arrangements for assessing prospective resident’s aspirations and needs are excellent at this home. EVIDENCE: Three resident’s pre-admission assessments were examined during the inspection, one being for a prospective resident who was planning to move into Woodlands in the near future. All three files had a very good level of information on resident’s needs and there was evidence that residents had been involved and had had input into their own assessment. One resident had been able to complete a self-assessment questionnaire prior to admission, which gave a very good overview of their needs at that time. Both Local Authority and NHS professionals had been involved and copies of their assessments were also on file. Residents were encouraged to have pre-admission visits to the home and the resident who was yet to move in was already visiting every week in preparation for the transfer to Woodlands from their present accommodation. In addition to the above, SeeAbility has a very clear admissions procedure set down in their ‘Referral and Admissions Manual’. This covers all aspects of the Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 10 process from initial referral, the preparation for various assessments, arrangements for staff visiting the prospective resident in their current home, and concluding at the first Review at Woodlands. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 11 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents assessed and changing needs are reflected in their support plans, and they are encouraged to make decisions about their lives with assistance. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: Two support plans were sampled and found to contain a good deal of information about resident’s assessed needs, the arrangements for meeting those needs, and specific goals which had been agreed with residents. All relevant areas were covered including health and personal care needs, mobility and rehabilitation, activities and social interaction, and educational activities. Both of these residents were interviewed and the needs and support they highlighted were clearly documented on their files. Both stated they were satisfied with the support they got from staff, and had no outstanding needs which were not being met. The plans sampled had been regularly and thoroughly reviewed and residents had participated in these reviews. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 12 Residents are encouraged to make decisions about their lives from relatively minor decisions, to more important areas such as where they wished to live. A third resident was interviewed and outlined their progression with regard to their main goal which was to move out of a care home setting and into their own home. The resident outlined how SeeAbility staff had supported them in this and on the day of the inspection the resident was going out with the rehabilitation worker to practise the walk from their new home to the supermarket. At the previous two inspections another resident had told the inspector that they wanted to move out and again a series of goals were set and the resident progressed towards moving out into supported living. By the time of this latest inspection, that resident had moved out and, according to residents at Woodlands who keep in touch with her, she is doing very well. One resident stated that they and three other residents participated in a local selfadvocacy network; this gives residents the opportunity for peer support from others who have similar disabilities. Residents are encouraged to take risks and are given good information and guidance on which to base decisions. Residents interviewed gave examples of the activities they were engaged in where some risk may be involved. For example moving about safely within home, the gardens, and the local community. Risk assessments were on file for these activities and residents had been given support and training on how to enable them to carry out these activities as safely as possible. Hazards were minimized within the home for example a textured surface on the landing lets resident’s know that they are approaching the top of the stairs; and a speaking microwave and a belling cooker with raised dots on the controls enables residents to cook safely. Appropriate risk assessments were in place regarding the uneven pathway to the side of the building and the risk of injury from the radiators which do not have radiator covers. The Registered Manager stated that he was planning to involve one of the Service Users in the construction of the radiator covers, as he is interested in woodwork. However, some of the risk assessments had not been reviewed in line with the specified review date set by the home, and one risk assessment was found to contain incorrect information. A requirement has been made in this regard. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents at Woodlands have opportunities to take part in appropriate activities, and are encouraged to be part of the local community. Residents are supported to maintain personal and family relationships, and they are treated with respect. Arrangements for meals and mealtimes are good at this home. EVIDENCE: A SeeAbility rehabilitation officer works with residents at this home on two days per week and residents spoken to gave examples of the education and training on offer. One resident described to the inspectors how he been taught to be independent out in the community, and to do his own cooking, including a roast dinner. This resident volunteered that ‘SeeAbility do an extremely dedicated job – it’s been a very good stepping stone for me to get where I am now.’ There is a ‘training kitchen’ at the home (which has recently been Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 14 refurbished) and this enables residents to practise their cooking skills in a specially adapted environment. Another resident has been improving their computer skills and the manager said real progress had been made. The craft studio at the bottom of the garden has been used for computer training sessions, but there are also computers within the quiet room in the home that have been adapted for use by residents. Residents are encouraged to be part of the local community and some staff at the home are taking part in a social inclusion project which provides residents with the support they need to take a full and active part local life. Residents use many local facilities including the doctor’s surgery, the gym, the day centre, and local shops and supermarkets. The manager was knowledgeable on resident’s rights under the Disabilty Discrimination Act and when asked for an example of difficulties experienced by residents, he said the home had had to advocate of behalf of residents to ensure they did not have their access to local dentistry withdrawn. The home seeks to reflect the cultural diversity of the residents and staff are mainly from the same ethnic background as the residents. Staff at this home encourage family and friendship links and both staff interviewed were knowledgeable on residents family support. The home actively seeks feedback from resident’s relatives and friends and includes them in the annual questionnaire as part of their quality assurance processes. Their input was taken seriously and the manager highlighted how some comments received from relatives in the latest survey were being dealt with. Residents are treated respectfully at this home. The manager and staff were observed to knock on resident’s doors and did not enter unless specifically given permission by the resident. One resident prefers to have a doorbell on their door and staff were seen to use this and wait for the resident to come to the door. There were no instances of staff speaking exclusively with each other in the presence of residents, and several incidences where the manager or staff stopped their conversation to include a resident who entered the room. Residents have unrestricted access to the home and grounds and one of the ways in which SeeAbility promote equal access and opportunity for residents is by adapting the environment within the home to take account of residents sensory and physical disabilities. Residents are encouraged to take an active part in meals and meal planning. The ‘training kitchen’ has been adapted so that residents can cook safely, despite their visual impairment. A variety of aids and adaptations have been acquired to help residents including a speaking microwave, a table top oven with specially highlighted controls, and talking tops for tin cans (for baked beans for example) which are pre-recorded by residents to tell them what is in the tin. Resident’s support plans noted dietary needs and special diets are catered for; one resident’s file had an assessment and advice from a dietician. Two residents have chosen to attend the local weightwatchers and staff Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 15 support them to do this. There is also a small greenhouse, herb garden and vegetable bed and though these were not at their best at the February inspection, they had clearly been well used in the summer and the last of the sprouts were still in evidence. The dining room is bright and nicely set out providing a pleasant place for communal dining. There is a speaking menu in the dining room which residents press to hear what is on the menu for the day; residents were seen to use this facility. On the day of the inspection residents were having homemade steak and mushroom pie for supper, cooked by the housekeeper who oversees the main meals. The housekeeper also oversees the general cleanliness of the kitchen and communal areas which had improved noticeably since the last inspection. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and require and their health needs are met. Arrangements for the administration of medication are good. EVIDENCE: Resident’s support plans contained a good overview of their personal care needs and preferences; some were working towards more independence in personal care matters and this was reflected in their goals. Residents had clearly chosen their own individual dress styles and assistance with personal care was offered in private. Residents would have some choice about the gender of staff who assist them with personal care as there are both male and female staff employed at this home. One key worker outlined the very minimal assistance which she offered to the resident she was working with and was knowledgeable on how best to offer that help. Healthcare needs are well met at this home. There are good records on resident’s files of their past medical history, current health matters, records of Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 17 specialist and other health appointments, and treatments given. One resident who wanted to reduce their weight had a good record of measures already taken, fortnightly weight recording and specialist input from the dietician. This resident stated they were pleased with the progress they had made and outlined the support from staff with the goal to lose weight. As previously noted with SeeAbility residents, there are very good records of eye health and visual disabilities, and specialist assessments which have taken place with regard to their vision. The medication administration records were seen and found to be satisfactory. Medication was stored securely in the office, and then distributed to residents on a weekly basis. Residents are then individually supported to administer their medication as prescribed and in accordance with their personal wishes, for example one resident prefers their evening medication with a cup of tea. One resident was totally self-administering of their medication and an appropriate risk assessment was in place. However there was an additional ‘general’ medication risk assessment which stated that ‘no Service Users self medicate’ and this will need to be changed; a Requirement will be made under Standard 9 on risk assessments. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s views are listened to and acted upon, and they are protected from abuse. EVIDENCE: The home has a complaints procedure and a ‘tactile’ complaints book which enables residents to identify it more easily. Resident’s could also highlight concerns at residents meetings, with their key worker, or with the area manager during Regulation 26 visits to the home. Four complaints had been received since the last inspection which had been appropriately investigated. The Registered Manager stated that all the complaints had been resolved. The manager reviews the complaints log on a regular basis as part of the home’s quality assurance processes. Residents spoken to on the day of the inspection had no complaints and had only praise for the staff and the service provided at Woodlands. On the questionnaires completed by residents they stated they knew how to make a complaint and the majority made no negative comments; one or two issues highlighted by residents on these questionnaires were raised with the manager. It was noted that the complaints log had not been fully updated to reflect the outcome of all four complaints and a Requirement will be made in this regard. This home has a copy of the latest (February 2005) Surrey multi-agency procedures for the protection of vulnerable adults, and a copy of the SeeAbility policy on the same subject. One staff member spoken to was asked about Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 19 what action they would take if they suspected a resident had been the subject of abuse and they demonstrated a good understanding of adult protection issues, knew how to access the relevant policies, and stated that they would feel confident in raising any concerns with the manager. The manager was asked how staff had their safeguarding adults training up-dated from time to time and he stated that this had been covered in a staff meeting; all staff had presented one part of the procedure and this was followed up by a discussion to highlight any practise issues. A recent safeguarding issue unrelated to this home was raised by staff at Woodlands to the proper authorities. The in-house SeeAbility policy was examined and found to need up-dating to dovetail with the Surrey multi-agency procedures and this will be discussed with the area manager. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable and safe environment which is clean and hygienic, though more work needs to be done to meet these Standards in full. EVIDENCE: Woodlands offers a very homely environment for residents and the premises are bright and cheerful throughout. Furnishings and fittings are domestic in character and two bedrooms visited were found to be very personalised and comfortable, both residents confirming they had everything they needed. The new stair carpet and redecorating in the hallway, stairs and landing really made a difference to the overall look and feel of the home which is much improved. A number of adaptations have been made to ensure the present residents can safely access the home and the gardens. Rooms have tactile items on the doors and some have Braille stickers to help residents when moving around the home. There is a special tread on the landing to denote the Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 21 top of the stairs, and in the garden there are a range of flagstones, a mosaic decoration, and gravel areas to help residents with a visual impairment to identify where they are walking. There is a specially adapted ‘training kitchen’ so that residents can learn their cooking skills in a safe environment. There are plans to change some of the internal rooms and residents are kept fully up to date with the progress of these new arrangements, one resident going through the entire plan for the ground floor with the inspector. There is a maintenance programme and a designated budget. On the day of the inspection there were a number of issues raised with the manager which will need attention. Though the majority are neither dangerous nor urgent, they do detract from the otherwise well kept and homely environment provided at Woodlands: • The shared shower/toilet on the ground floor is cleaner than at the last inspection but had mildew in the tiling in the shower and dirt and dust in the corners where the finish made it difficult to keep it clean. In the same room there was a slight odour, probably coming from the flooring which was worn, as was the sealant around the toilet. The manager stated this room was on the maintenance list for a complete refurbishment and he would consider bringing this work forward rather than addressing individual shortfalls. The downstairs bathroom also needs work done and on the day of the inspection the toilet seat was broken. The flooring in the hallway has bubbled due to a radiator leak, and one part of the floor has a small gap where the floor tiles have shifted. The manager stated that this flooring, together with the stained carpet in the small hallway was going to be replaced by a new floor covering and quotes were being taken. The flagstones on the drive were uneven and coming up; despite having a risk assessment, one flagstone at the end of the drive was particularly hazardous and the manager was asked to take some remedial action. Residents only use this area with assistance from staff as it is outside the main garden area, but it is an unnecessary hazard that needs to be removed. The patio needs cleaning (the main pathway has already been done) as moss and other greenery is building up and will be slippery for residents when they are able to use the patio again. The home was checked by the local environmental health department almost three years ago and the manager was asked to follow up when the next inspection was due. DS0000013840.V327609.R01.S.doc Version 5.2 Page 22 • • • • • • Woodlands (Horley) The home has a designated laundry room which was being decorated on the day of the inspection. There is a commercial washing machine which has been adapted to make it easier for residents to use independently, and a tumble dryer. The washing machine also has high temperature washing programmes. The home was fresh smelling throughout, with the exception of one small area mentioned above. Hand washing facilities are excellent with every basin having individually dispensed soap and paper towels; the kitchen also has hand gel and residents were encouraged to use this when helping with household tasks such as emptying the clean dishes from the dishwasher. There is a cleaning rota in place and the though residents help keep their own rooms and some of the communal areas clean, the housekeeper gives all areas a thorough clean on a monthly basis. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 23 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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by qualified and competent staff and arrangements for training are good. However more work needs to be done on recruitment to meet these Standards in full. EVIDENCE: The staffing arrangements in place on the day of the inspection were sufficient to meet the needs of the residents. One of the staff members spoken to stated that there were always two support workers on duty during the day and that this was sufficient. Staff were observed to communicate well with residents. Returned ‘comment cards’ to the CSCI prior to the inspection demonstrated the home had good relationships with other professionals involved in the care of residents. Staff are knowledgeable on rehabilitation techniques and promoting independence and one key worker interviewed explained/. how she continued the work of the rehabilitation officer when supporting the resident she worked with. The home exceeds the Standard on NVQ2s which recommends 50 of staff should have this qualification or above; 75 of staff at Woodlands had NVQ2 or above at the time of this inspection. An ongoing training plan was in place to ensure that all staff Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 24 received adequate training in mandatory areas of knowledge, and there was evidence that specialist courses identified in supervision were also arranged such as autism. The home has a recruitment and an equal opportunities policy in place and residents are now involved in the recruitment of new members of staff. Four staff files were examined at this inspection. The staff file of a bank staff member did not contain all the information specified in Schedule 2 of the Care Homes Regulations (as amended). The Registered Manager stated that this was because the employee also worked at another SeeAbility site where the full staff file was kept. The home must obtain copies of the relevant information and ensure these are available as set down in the Care Homes Regulations 2001 (as amended). The staff files of two volunteers contained the required checks including two written references and Criminal Records Bureau checks. The home had a structured induction programme using the Common Induction Standards which are now mandatory for all new care home staff; SeeAbility introduced these Standards before they became mandatory and have adapted their training programme to fit with these standards. Staff members spoken to stated that they had access to relevant training, and regular bank staff had equal access to training courses. A training and development plan was seen for mandatory training and the manager stated that other training such as for autism was available where this had been identified during staff supervision and to meet the needs of current residents. Samples of staff files were examined and it was noted that staff had undertaken regular training including first aid, food hygiene and protection of vulnerable adults training. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 25 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home and their views are sought and taken into account in the running and development of the home. The health, safety and welfare of residents are promoted and protected. EVIDENCE: The registered manager has now completed the Registered Manager’s Award and NVQ4. He has been managing this home since 2005 and prior to this was managing another SeeAbility home in Leatherhead. The manager has ensured that all the Requirements and Recommendations arising from the last inspection have been met. He undertakes periodic training and development to maintain and update his knowledge and is currently on a management course arranged by SeeAbility for all its care home managers. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 26 Quality assurance processes at this home are very good. There is a quality assurance policy, which sets out the arrangements for monitoring and evaluating the service. There are many ways in which residents are given opportunities to provide feedback on the service provided and to have input into developing the home. There is an annual questionnaire arranged by head office which goes to all residents and to relatives and other professionals who have contact with the home. Feedback is given to the home manager for action and he goes through the response and the actions to be taken during residents meetings. Regular resident’s meetings are held and currently one of the residents chairs these meetings; a volunteer takes the notes and the agenda is set in advance. Residents can have the notes from their meetings taped, but the manager stated that so far they have opted to have these notes read out to them. There are also regular staff meetings to enable staff input into the running and development of the home and the organisation carries out Regulation 26 visits to Woodlands. There is an annual development plan for the home and a staff training and development plan. Samples of health and safety certificates were inspected and seen to be in order to ensure so far as is reasonably practicable, the health, safety and welfare of service users and staff. The latest gas and electrical installation checks were sampled, and the home’s insurance certificate was displayed and up to date. Risk assessments on radiators and a review of arrangements regarding the hazardous substances cupboard, requested at the last inspection, have been completed. Staff have completed first aid and health and safety training. Fire training is taken seriously and staff complete an in-house course followed by written tests before receiving their certificate. The health and safety policies and practises are contained within the SeeAbility operations manual. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 2 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 4 X X 3 X Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 28 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 YA9 Regulation 13(4)(a) (b)(c) 13(2) Requirement Timescale for action 08/02/07 2. YA22 3. YA24 4. YA34 The registered person must ensure unnecessary risks are identified and so far as possible eliminated and in particular: a)Risk assessments must be reviewed in line with the home’s policy and b)The incorrect statement in the medication risk assessment must be removed. 17(2) The registered person must 13/02/07 Schedule ensure that the complaints 4, 11. record is up-dated to show the action taken by the registered person and how the issue was satisfactorily resolved. 23(2)(b)(d) The registered person must 13/02/07 ensure the premises are kept in a good state of repair and kept clean and reasonably decorated. The items set out under the Environment section of this report (p.21) must be reviewed and a plan made which identifies remedial actions to be taken in a timely fashion. 17(2) The registered person must 13/02/07 Schedule ensure that a record is kept of 4, 6. all persons employed at the care home as set out in this DS0000013840.V327609.R01.S.doc Version 5.2 Woodlands (Horley) Page 29 Schedule, including all Bank Staff. 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 YA23 Good Practice Recommendations The registered person should ensure that the in-house policy for safeguarding vulnerable adults dovetails with the Surrey multi-agency procedures on the same subject. Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Woodlands (Horley) DS0000013840.V327609.R01.S.doc Version 5.2 Page 31 - 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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