Inspection on 13/09/06 for Woodlawn Crescent

This inspection was carried out on 13th September 2006.

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

Other inspections for this house

Woodlawn Crescent 10/10/07

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 Sandy Patrick Unannounced Inspection 13th September 2006 13:00 Woodlawn Crescent DS0000017399.V311808.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.V311808.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.V311808.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) h4mo67rusted@mencap.org.uk H4037@mencap.org.uk Royal Mencap Society Ms Elizabeth Rusted Ms Marie Leonard Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: 8-10 Woodlawn Crescent is a single storey home in a quiet residential road in Whitton. Whitton town centre and local transport links are near by. The building is owned by Richmond Churches Housing Association. The home is managed by MENCAP, a charitable organisation. The home is registered for four residents who have a learning disability. The home is designed to meet the needs of physically disabled residents. Residents use the local community and attend local resource centres. They are supported by staff from the home to learn new skills. The Registered Persons have produced a Service User Guide, which includes information on the aims and objectives of the service. The weekly fees range from £1,406 - £1,887. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days and was unannounced. The Inspector met all the residents, staff on duty and the Manager and was made welcome by everyone. Before the inspection, the CSCI wrote to the residents, their relatives and representatives, staff and other professionals asking them to complete questionnaires about the home. Three residents completed questionnaires, some residents were helped to do this. They all said that they were able to do the things that they wanted and that staff generally listened to them and treated them well. One resident did not know how to make a complaint. The staff should make sure they know what to do if they have any concerns. Four relatives and friends completed questionnaires. Two people said that they were made welcome at the home but two visitors said that some staff were not as welcoming as others. The visitors felt that residents were generally happy. One person raised concerns that some residents did not always feel safe when other residents were challenging or aggressive. The staff must make sure people feel safe and protected. The visitors said that they felt the staff supported residents to learn new skills and to be as independent where they could be. One of the visitors said that they felt cleaning and ironing could be improved and another visitor felt that the home could be better equipped with grab rails and even floors. One person felt that sometimes residents had a limited choice over food. A number of visitors said that they felt their were too many temporary staff. One person wrote that they felt the staff were patient, kind and caring. Four members of staff completed questionnaires. All of them described thorough recruitment procedures. They said that they were well supported and trained and were able to contribute to the running of the home. Some of the things that staff said the home did well were, ‘the residents are well looked after and proper meals are cooked daily with fresh vegetables’, ‘the residents are well looked after’, ‘the Manager is excellent and good for staff morale’, ‘the managerial and organisational skills’. Some of the things the staff said that they would like to improve were more support regarding managing challenging behaviour, more day trips for the residents and less paperwork. Two professionals who work with the home completed questionnaires. They felt the staff worked in partnership with them and generally communicated well although one person said that communication was sometimes a problem and recommended that the staff look at this issue. One person said that they felt that the home had a good friendly atmosphere. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 6 During the inspection visits the staff were kind and supported residents well. They treated residents with respect and knew the individual needs of each person. The residents appeared happy and some of them spoke about recent holidays and other activities which they enjoyed. 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. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 The quality in this outcome group is good. This judgement has been made using evidence including a visit to the service. There is a range of information for potential residents although this could be improved. Residents need to be given meaningful contracts which outline the terms and conditions of residency. The organisation needs to make sure the Manager and staff have the support they need to meet the changing needs of residents. EVIDENCE: There is a Statement of Purpose and Service User Guide for the home, which include the required areas. The Manager should look at how these documents can be improved and updated. Residents should be involved in this work and their views should be recorded to help give potential residents information about what it is like to live at the home. Two of the relatives and friends who completed questionnaires about the service said that they had not seen inspection reports and did not know that they had access to these. The Manager should consider ways to inform relatives, friends and advocates of the outcomes from inspection reports and make sure they have access to the full reports if they wish to read them. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 9 One resident moved to the home a few months before the inspection. They told the Make sure that they were happy at the home and their friend who completed a questionnaire said that they had settled in well. The resident knew some of the staff and other residents before they moved to the home and spent time at the home having meals, taking part in activities and staying over night before they made the decision to move. The needs of some of the residents have changed over the past year. The Manager has worked with other professionals to help meet these needs however has found it difficult to get all the support the staff need at times. The organisation must make sure there is enough staff, training and support so that the home can continue to meet the changing needs of residents. There was no contract in place for the newest resident and contracts had not been reviewed recently for other residents. The contracts do not use easy words and pictures and are residents may find them hard to understand. The Manager should make sure all residents receive a new updated contract and work should take place to make these documents accessible and meaningful for the residents. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 The quality in this outcome group is adequate. This judgement has been made from evidence including a visit to the service. Residents’ needs are recorded in individual care plans but these need to be improved and made more accessible to residents. The staff need to look at ways to improve communication and make information more accessible. EVIDENCE: Individual care plans are in place but information is not well presented and some information is old and needs archiving. The staff on duty had trouble locating some information for the Make sure. The Manager said that staff are starting to look at person centred plans and are receiving training in this area. She is also trying to get keyworkers more involved in care planning and taking responsibility for work with individual residents. This work is important and the care plans must be updated and sorted out so that key information can be accessed by any staff at any time. The work to produce more person centred plans is essential and should help residents to be more involved in setting the care that they want and need. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 11 The newest resident did not have a care plan or information written since they moved to the home and only had information from their previous placement. The staff must create a new care plan covering the needs of this resident in their new home. Each resident has their needs and care plan reviewed regularly. Records of review meetings, including information from the residents, relatives and day centres were seen. Some risk assessments are in place for where residents take risks. Mencap have improved the format of these hoping that the new way of assessing risks will involve residents more. The staff should update all the risk assessments, involving residents and other key people. The recorded assessments should be accessible and be incorporated into care plans. The staff use some signs and symbols to help them communicate with residents. Further work in this area is needed to improve communication. The staff should work with other professionals to improve their Makaton skills and to look at how they can make written information more accessible to the residents. Records which could be improved and made more accessible include care plans, risk assessments, the complaints procedure, contracts, staffing rotas and menus. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 12 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, 12, 13, 14, 15, 16 & 17 The quality in this outcome group is good. This judgement has been made using evidence including a visit to the service. The residents are supported to meet their social, emotional, leisure and educational needs. There could be more work to support some residents to learn new independent living skills. The residents see friends and relatives and use the local community. Staff treat residents with respect. EVIDENCE: The residents at the home have very different needs. Some residents are involved in some of the household tasks and planning and preparing meals. This is an area where some residents could be involved more. One of the staff who completed a questionnaire said that they would like to see residents being more involved. The staff should look at how they can support residents who are able to do more household tasks and learn new skills. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 13 Some of the residents attend local resource centres and take part in a range of other activities. Residents are also supported to go on outings to places of interest. The Manager 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 residents use the local community and participate in a range of activities of their choosing. One of the residents spoke about a recent holiday they had enjoyed to the Make sure. Some of the residents see their families regularly and they all have a network of friends outside of the home. Two of the visitors who completed questionnaires about the home said that not all staff made them feel welcome and that communication with some staff was difficult. One person telephoned the Make sure shortly before the inspection and spoke about this as well. This was discussed with the Manager at the inspection. The Manager must make sure that staff communicate appropriately with families and friends and make them feel welcome in the home. The staff must always put the needs of residents first but should also respect the needs and input of the people who are important to the residents. The staff on duty during the inspection visit were supportive and kind to residents. They treated them with respect and knew their needs well. The residents clearly had a good rapport with staff and trusted them. Some of the residents have specialist diets and the staff work hard to make sure their dietary needs are met. The kitchen was well stocked with fresh food and the Make sure saw staff giving residents their lunch. Residents were given choices. The menus are varied and show a healthy balance of food. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 14 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): 18, 19 & 20 The quality in this outcome group is good. This judgement has been made using evidence including a visit to the service. Personal and health care needs are appropriately recorded, monitored and met. Medication is generally well managed but needs some improvements. EVIDENCE: Personal care and health care needs are recorded and monitored by staff. All residents are registered with local GPs and the staff work with the Community Team for Learning Disabilities. Some of the residents have complex health needs and the staff have worked hard with other professionals to make sure these needs are met. Some of the changes in health needs have had an impact on staffing. The home must have sufficient staff to make sure these needs are met. There is an appropriate medication procedure and all staff have training in medication. The medication cabinet is too small for the amount of medication in the home and new storage must be arranged. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 15 Some of the staff have created medication profiles for each resident. These are good but need some additions and sorting out to make sure information is clearer. The systems for recording the receipt and disposal of medication are confusing and there is no record of medication which is carried over from one month to the next. The Manager must make sure receipt of medication and any stock carried over is recorded on the medication administration record sheets. One medicine, which the Manager said was no longer used by the resident, was out of date. The staff must make sure medication held at the home is regularly checked and any medication which has expired or is no longer used must be returned to the pharmacist for destruction. There should be a list of all staff initials, signatures and abbreviations used on the medication record sheets. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The quality in this outcome group is good. This judgement has been made using evidence including a visit to the service. There are appropriate procedures for dealing with complaints and protection. EVIDENCE: There is an appropriate complaints procedure which details time scales and how to contact the Commission for Social Care Inspection. One of the residents who completed a questionnaire about the service said that they did not know how to make a complaint. The staff must make sure residents know what to do if they are unhappy with anything. The Manager should consider how to make the complaints procedure more accessible and easy to understand. There is a record of all complaints and concerns and the action taken following these. There are appropriate procedures covering abuse and whistle blowing, including the local authority protection of vulnerable adults procedure. There are procedures for dealing with residents who are challenging. Some of the people completing questionnaires about the service said that residents did not always feel safe when others were being challenging or aggressive. Incident reports from these situations show that the staff follow procedures to make the situation safe. However, they need to also check out that everyone feels safe and supported and is able to talk about their feelings following any incident of aggression. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 17 Some of the staff said that they would like more support and training in managing challenging behaviour. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 18 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, 25, 26, 27, 28, 29 & 30 The quality in this outcome group is good. This judgement has been made from evidence including a visit to the service. The residents live in a comfortable home, which meets their needs. EVIDENCE: The home is a bungalow and all residents 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. One visitor wrote that they felt the home could be better equipped with mobility aids. The Manager must make sure the home is regularly assessed so that the residents’ equipment needs are met. The condition of the environment was mixed. Some areas of the building look smart and well kept, where others are in need of repair and redecoration. Carpets and some curtains in communal areas were stained and worn and need replacement. Some of the woodwork and paintwork has been damaged. Bathrooms and WCs need to be updated and redecorated. The Manager said that more work needs to be done to bedrooms to make them more Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 19 personalised. The Manager should put together an action plan which outlines how this work will be done and the environment improved. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 20 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): 31, 32, 33, 34, 35 & 36 The quality in this outcome group is good. This judgement has been made using evidence including a visit to the service. The staff are appropriately recruited, trained and supported. There is not enough permanent staff to meet the changing needs of residents. EVIDENCE: The staff who spoke with the Make sure and those who completed questionnaires said that they were generally happy at the home and were well supported. There have been lots of changes and challenges at the home and the staff team have worked together to make sure residents’ needs are still met. One staff member said that the Manager and team were very supportive and that they liked the changes introduced by the Manager. A member of temporary staff was working at the home on the day of the inspection visit. They said that they had good information and the Mencap had given them and induction and key training. They said that the Manager and senior managers were supportive and listened to staff. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 21 The Manager said that she is hoping that staff will start to take on new delegated responsibilities and be more involved with keyworking and the running of the home. The Manager has made slight changes to the staffing rota to make sure there is enough time for staff to handover information from one shift to the next. The Manager said that she was writing new handover guidelines for the staff. The needs of some residents have changed over the past year and some of these changes have been significant. Some of these changes have meant that more staffing is needed at times to give support. The Manager must make sure there is enough staffing to give residents the support they need, to keep them and others safe. The Manager has regularly had to work as part of the rota in order to make sure there are enough staff supporting residents. This has meant that some administrative and management tasks have been hard to achieve. There must be enough staff so that the Manager can have time allocated for managerial responsibilities. There are appropriate procedures for the recruitment of staff, including pre employment checks and a formal interview. The staff who completed questionnaires reported that the procedures were followed. The Make sure looked at a sample of staff files and these contained evidence of checks and interviews. The Manager has set up supervision contracts with all staff and holds regular supervision meetings which are recorded. The staff who spoke to the Make sure and those completing questionnaires said that they had been offered a range of training, including a full induction to the home and Mencap. There is a programme of regular training which staff can apply to participate in. Training records for staff showed that they had been on a range of different training. The Manager said that she was auditing training needs at the time of the inspection. Some staff said that they would like more support learning about how to manage challenging behaviour. The Manager must make sure all staff have had training in this area and in protection of vulnerable adults. The Manager should organise for the staff to have training in dementia and working with parents to help them better understand and meet the needs of the residents in the home. Staff are offered the opportunity to undertake NVQ qualifications and some of them are undertaking NVQs whilst others have achieved their qualifications. Team meetings are held and the Manager plans to hold these more often and invite staff to chair and minute take. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 22 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): 37, 38, 39, 41 & 42 The quality in this outcome group is good. This judgement has been made using evidence including a visit to the service. The service is well managed and there are plans for continuous improvement. There are appropriate checks on health and safety. Some records at the home need to be updated and made more accessible. EVIDENCE: The Manager was recruited earlier in the year and was applying to be registered with the Commission for Social Care Inspection. She must make this application as soon as possible. She has worked for Mencap for several years and most recently she was employed as the Deputy Manager of one of the other local Mencap homes. She demonstrated a good knowledge of the residents and the needs of the service and has clear plans for its development. The Manager has started her Registered Managers Award and was meeting with her assessor during the inspection visit. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 23 The staff who spoke to the Make sure said that the Manager was supportive and organised. The staff felt that they were able to contribute their ideas and that they were listened to. The Manager and staff have developed a continuous improvement plan for the home. This includes making improvements to the environment, to team work, to systems and to records. The Area Manager visits the home each month and conducts quality monitoring inspections. The records at the home need to be updated and organised. The way in which records are stored make sure it hard to access some of the information. Some records are unclear and need updating. The Manager was aware of this problem and has plans to update some information, archive and make changes to records to make them clearer. The staff support residents to manage their money and hold small amounts of cash on behalf of residents. The systems for managing and recording this money are complicated and the Manager has started to set up new systems to make this easier and to create a more accessible audit trail. There is a record of regular checks made on health and safety, including fire safety and the environment. There were foam tubes covering the tops of some of the radiators. These were unsightly and do not offer adequate protection against the risk of scalding. The Manager did not know whether the radiators were low surface temperature. She should check this out and provide suitable coverings if the radiators are too hot. Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 2 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 2 32 3 33 3 34 3 35 3 36 3 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 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X 2 2 X Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 25 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 YA5 Regulation 5 Requirement Timescale for action The Registered Person needs to 31/12/06 make sure all residents have a contract outlining the terms and conditions of residency. These should be produced in formats which are meaningful to residents. The Registered Person needs to: 1. Replace the medication cabinet with more appropriate storage. 2. Make sure the receipt of medication and any stock carried over is recorded on the medication administration record sheets. 3. Make sure medication held at the home is regularly checked and any medication which has expired or is no longer used must be returned to the pharmacist for 31/10/06 2. YA20 13(2) Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 26 destruction. 3. YA33 18(1) The Registered Person must 1. Make sure there is enough staffing to give residents the support they need, to keep them and others safe. 2. Make sure there is enough staff so that the Manager can have time allocated for managerial responsibilities. 4. YA41 17 The Registered Person needs to 31/12/06 make sure that records at the home are kept up to date, are well organised and accessible. The Registered Person needs to 31/10/06 make sure that radiators are safe. 31/10/06 5. YA42 13(4) 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 Manager should look at how the Statement of Purpose and Service User Guide can be developed so that they are more meaningful to residents. The residents should be involved in this task. The Manager should make sure inspection reports are available for residents and their representatives. 2. YA1 Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 27 3. YA6 The staff should work with residents to develop person centred plans and risk assessments. The staff should develop their Makaton skills and should use easy words and pictures to develop a range of accessible information to help give residents more control over their lives. The staff should look at how they can support residents who are able to do more household tasks and learn new skills. The Manager 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 Manager should offer staff training and support so that they can communicate well with families and work with them for the benefit of the residents. The staff must make sure residents know what to do if they are unhappy with anything. The Manager should consider how to make the complaints procedure more accessible and easy to understand. The staff should think about ways to make sure all residents feel safe and are able to talk about their feelings following incidents where someone may have been challenging if they need to. The staff should have training and support to help them manage challenging behaviour, and to learn about dementia. The Manager should put together an action plan to address the redecoration and repair needs of the building. 4. YA7 5. YA11 6. YA11 7. YA14 8. YA22 9. YA23 10. YA23 YA35 11. YA24 Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodlawn Crescent DS0000017399.V311808.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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