Inspection on 10/10/07 for Woodlawn Crescent

This inspection was carried out on 10th October 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlawn Crescent 13/09/06

Woodlawn Crescent 09/01/06

Woodlawn Crescent 22/09/05

Woodlawn Crescent 13/01/05

Woodlawn Crescent 27/05/04

Woodlawn Crescent 05/02/04

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 Woodlawn Crescent 8-10 Woodlawn Crescent Whitton Middlesex TW2 6BE Lead Inspector Louise Phillips Unannounced Inspection 10th October 2007 11:10a Woodlawn Crescent DS0000017399.V352382.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 Woodlawn Crescent DS0000017399.V352382.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. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlawn Crescent Address 8-10 Woodlawn Crescent Whitton Middlesex TW2 6BE 020 8893 4948 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) h4m067mccafferty@mencap.org.uk www.mencap.org.uk Royal Mencap Society Sheena Assumpta McCafferty Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2006 Brief Description of the Service: 8-10 Woodlawn Crescent is a single storey home in a quiet residential road. Whitton town centre and local transport links are near by. The building is owned by Richmond Churches Housing Association, and the service is managed by MENCAP, a charitable organisation. The home is registered for four residents who have a learning disability. The weekly fees range from £1,406 - £1,887. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day. Time was spent talking to the manager, one service user and viewing paperwork. A tour of the premises was carried out and care records were inspected. Information has also been gained from the inspection record for the home and the Annual Quality Assurance Assessment (AQAA) that was completed by the manager prior to the inspection. 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. The summary of this inspection report can be made available in other formats on request. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 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 Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Quality in this outcome area is adequate. Improvements need to be made to demonstrate the home’s own assessment of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection a new service user has moved to Woodlawn Crescent. The information contained in their file demonstrates that good assessment information was received from significant professionals to provide the manager with relevant details about the service user’s needs and wishes. There is a lot of referral documentation from the nursing and community learning disability teams, yet little information to demonstrate the homes own assessment of how they planned to meet the needs of the service user, prior to them moving to the home. The manager said that this process involved various meetings with the community learning disability teams to ensure that Woodlawn Crescent was the right service for the service user. The service needs to formalise this and record the processes of their actual assessment of the service user and of their transition to the home. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 8 Each service user has a contract with MENCAP detailing the terms and conditions, and their rights whilst living at Woodlawn Crescent. The contracts do not use easy words and pictures and could be difficult for some service users to understand. The manager said that MENCAP is currently working on a more accessible format for the service users. The manager further said that MENCAP is looking to develop all its policies and procedures to more user-friendly and accessible formats, including the Statement of Purpose and Service User Guide. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. The service users are involved in person centred planning so they receive the support they need and want to live their lives as they wish. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection good improvements have been made to the care planning systems at the home. The manager stated that there is now a new keyworker system in place that allows more individual work with service users in the development of their care and support plans. The staff involve the service users in person-centred planning (PCP) that enables them to be fully involved in planning the support they want and how they wish to lead their daily lives. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 10 Two care files were looked at during the inspection. The PCP’s are wellformatted, including pictures of what the resident has done, eg. activities/ holidays, and what they like to do. Details are included of heir hopes for the future, and of people in their life that they feel are significant to them. In addition to the PCP each service user has a support plan that is for more daily activities such as personal care needs, their likes and dislikes in relation to food, communication and physical health needs. Sexuality is also highlighted in the support plans, in relation to each service users emotional and behavioural needs around this, and example of this being that they might enjoy a cuddle, though no more intimacy. Risk assessments are in place for areas such as risk of falls, personal care, eating and drinking and travelling in the minibus. The risk assessments are good as they are individualised and provide appropriate information for staff to manage any potential risks. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. The service has a good understanding of the individual support needs of the service users, and assistance with activities is offered in such a way as to promote each persons individual interests This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users support plans and PCP’s contain information on the different activities that they are involved in throughout the week. On the wall in the office is a weekly timetable of the activities, as a reference for staff. These include in-house ‘home-base’ days where service users are supported to tidy their bedroom and do their laundry. There also included details of external activities such as attending the daycentre, one-to-one trips, going to church, bowling or hydrotherapy. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 12 At the time of inspection the manager stated that two service users were on holiday in the Isle of Wight, one was at the daycentre, whilst the other service user was getting ready to go to the daycentre. One of these service users had recently come back from a holiday, whilst the other was due to go away at the end of the week. The manager said that all the service users have regular contact with their families who are able to telephone and visit them at Woodlawn Crescent and take them out. The manager stated that she has been encouraging the staff work proactively with families to involve them in the care and support of their relative at Woodlawn Crescent. Service users can choose what they like to have for breakfast and lunch from the foods provided at the home. Each day of the week a service user chooses what the evening meal will be, using pictures from a recipe book or magazines, and the staff prepare the food. The manager said that service users are encouraged to get involved and provide minimal assistance with the preparation of meals. Some of the service users have specialist diets and the staff ensure that these are met. A variety of fresh and frozen foods are available for the service users, and these are appropriately stored. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. The health and personal care needs of the service users are well met with the input of relevant healthcare professionals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The personal care needs are of each service user are described in their care files in the format of guidance procedures and support plans. The manager stated that there is always a female member of staff on shift, as it is the preference of some service users that a female assist them with their personal care needs. Documentation in the files demonstrates that multi-disciplinary team input is sought and utilised as necessary. In two service users files this was seen in relation to occupational therapy and speech and language therapy services. Each service user has a medical file detailing medical history, appointments with eg. dental or chiropody services, previous medical reports and ongoing healthcare reviews, which are used to update the care plans. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 14 There are appropriate medication administration policies and procedures and all staff have received training in these. Since the last inspection the home has installed a larger medication cabinet which holds all the medication safely. New systems for the recording, storing and disposal of medication have introduced and guidelines updated. This includes keeping a written record of all medicines that have been returned to the pharmacy, and ensuring that only current medicines are held at the service. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. There are appropriate procedures for dealing with complaints and protection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has policies and procedures in place in relation to adult abuse awareness and the procedures to follow in the incidence of this happening. There is a record of all staff that have received training in the Protection of Vulnerable Adults (POVA). The records indicate that the training is carried out as part of the induction process for new staff. The services uses the Mencap complaints policies and procedures to address any complaints or concerns raised about the service, and full records are maintained of this. The manager has also worked with the service users to devise a more userfriendly, accessible complaints procedure, plus also added complaints and suggestions to the agenda for service users meetings. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. A number of improvements are needed to ensure that the environment is modern and comfortable for those who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Woodlawn Crescent is a bungalow and all service users have their own bedrooms. There is a large lounge and dining room with patio doors leading the garden. Areas of the home are equipped with specialist mobility aids and track hoists The condition of the environment is mixed. Some areas of the building look smart and well kept, where others are in need of repair, redecoration and overall updating. Some areas look un-homely, particularly the mesh glass leading from the dining area into the kitchen. Carpets and some curtains in communal areas are stained and worn, in need of replacing. Tiles on the walls in the kitchen are chipped and some of the woodwork and paintwork around Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 17 the home has been damaged. Bathrooms and WCs need to be updated and redecorated. The manager said that there are plans in the near future to refurbish the bathroom next to the office, and that two bedrooms have been redecorated in the past year. The Registered Persons should put together an action plan to address the redecoration and repair needs of the building. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. Good recruitment practices ensure that risks to service users are minimised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two staff recruitment files were examined, where evidence indicates that appropriate checks are carried out prior to employment, such as a Criminal Records Bureau check, employment history and references sought form previous employers. A job description is also available for all staff roles within the home, and staff have to complete an application form and be interviewed before a job is offered to them. The previous inspection required that there be enough staff to meet the needs of the service users. The manager stated that the service is now fully staffed apart from one part-time vacancy, and a new rota system has been introduced to meet the changing needs and wants of the service users. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 19 Staff training records indicate that most staff have had recent training in food safety, health and safety and infection control. Other core training updates need to be done by all staff in lifting and handling, and managing risk. The previous inspection recommended that staff receive training in managing challenging behaviour and dementia, though there are no records to evidence this has been carried out. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. There is a committed and competent manager at the home who has helped to progress the service for the benefit of the service users. However, improvements need to be made to the heating system. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The improvements since the last inspection demonstrate that the home has a committed and competent manager who promotes the choices and interests of the service users and who sets good standards. Observations during the inspection were positive, indicating that the manager is liked and has a good rapport with the service user who was at the home at the time. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 21 The manager stated that she has done the Registered Managers Award and is now hoping to complete the NVQ level 4 in Care. Quality assurance is carried out by MENCAP through annual questionnaires sent to relatives and service users for feedback on various aspects of the care, service, furnishings and accommodation. Visits by the registered provider are conducted monthly, and a copy of the front sheet only is sent to the CSCI. This was discussed with the manager as being not very informative for the CSCI, and it was agreed that the full report of the visit will be sent in future. The home maintains records to demonstrate that appropriate health and safety checks are carried out on the fire system and equipment, first aid box, fridge and freezer temperatures, water temperatures and Portable Appliance Testing, etc. The temperature of hot water is tested routinely and the readings for this are not consistent, often falling below the recommended temperature of 43C. The manager stated that this is an ongoing issue due to Woodlawn Crescent being the result of two bungalow’s joined together. It is recommended that consideration is given to installing, in the near future, a completely new heating system that caters for the layout of the home. The electrical installation certificate was not available at the time of inspection and feedback from the manager is that this is due to be carried out in the near future. The certificate to evidence this must be available for future inspections. Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 YA2 Regulation 14 Requirement The Registered Persons must ensure that records are maintained of the service’s own assessment of new service users. The Registered Persons must ensure that full reports of visits in accordance with this Regulation are sent to the Commission. The Registered Persons should ensure that the electrical installation certificate is available at all times for inspection. Timescale for action 30/11/07 2. YA39 26 30/11/07 3. YA42 13(4) 30/11/07 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 YA1 Good Practice Recommendations The Registered Persons should develop the Statement of DS0000017399.V352382.R01.S.doc Version 5.2 Page 24 Woodlawn Crescent 2. 3. YA5 YA11 Purpose and Service User Guide to a more accessible format for the service users. The Registered Persons should develop the format of the contracts so they are more accessible to service users. The Registered Persons should consider equipping the home with some sensory equipment which may stimulate and interest some of the residents who spend a lot of their time at home. The Registered Persons should plan to update and modernise all areas of the home in the near future. The Registered Persons should put together an action plan to address the redecoration and repair needs of the building. The Registered Persons should ensure that staff have training and support to help them manage challenging behaviour, and to learn about dementia. The Registered Persons should give consideration to installing, in the near future, a completely new heating system that caters for the layout of the home. 4. 5. YA24 YA24 6. YA35 7. YA42 Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodlawn Crescent DS0000017399.V352382.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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