Latest Inspection
This is the latest available inspection report for this service, carried out on 9th February 2010. it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.
The inspector made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
For extracts, read the latest CQC inspection for Underwood.
Annual service review
Name of Service: Underwood The quality rating for this care home is: The rating was made on: two star good service 2 1 0 1 2 0 0 9 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.
Has this annual service review changed our opinion of the service?
No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Gary Bartlett Date of this annual service review: 3 0 1 2 2 0 0 9 Annual Service Review Page 1 of 6 Information about the service
Address of service: Sponden Lane Sandhurst Cranbrook Kent TN18 5NR 01580850167 Telephone number: Fax number: Email address: Provider web address:
Name of registered provider(s): Conditions of registration: Category(ies) : mental disorder, excluding learning disability or dementia Conditions of registration: Mrs Joan Penelope Gradwell Number of places (if applicable): Under 65 Over 65 3 0 The maximum number of service users to be accommodated is 3. The registered person may provide the following category/ies of service only: Care home only ? (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia (MD) Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Underwood is a new service that provides accommodation for up to 3 people who have mental health problems. The home relocated to new premises near Cranbrook in August 2008. The premises are located in a rural area approximately 3 miles from the nearest town, but close to the village of Sandhurst. The house is arranged over 2 floors and has been completely refurbished and redesigned to a high standard offering 3 single bedrooms with en-suite facilities.
Annual Service Review Page 2 of 6 2 1 0 1 2 0 0 9 Details of the current fees can be obtained from the service. Information about the service and the facilities are summarised within the Statement of Purpose. Annual Service Review Page 3 of 6 Service update since the last key inspection or annual service review:
What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last Key Inspection or annual service review. This included: The Annual Quality Assurance Assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous Key Inspection report and the results of any other visits that we have made to the service in the last 12 months. Relevant information from other organisations. What other people have told us about the service. What has this told us about the service? At its last Key Inspection, conducted on 21st January 2009, this care home was rated as a two star good service with judgments of good for all outcome groups. No requirements were made. This tells us that this care home is operating well within the regulatory framework. The last Key Inspection site visit did make three recommendations. The manager was advised to ensure that the training needs for the small staff team, including herself, are kept up to date. This included the provision of updates for some mandatory training topics and refresher courses for Safeguarding Vulnerable Adults and medication. It was also advised that the support staff member should be enabled to work towards achieving a National Vocational Qualification in care at level 2 or above. The Annual Quality Assurance Assessment, (AQAA), indicates actions have been taken to address these recommendations. The home sent us their AQAA slightly later than the requested return date. The Manager explained the delay was resultant of her being busy caring for an unwell service user. It was generally clear and gave us most of the information we asked for. We looked at the information in the AQAA and our judgment is that the home is still providing a good service and that they know what further improvements they need to make. However, the AQAA does not make it clear what formal quality assurance systems are in place. Whilst it is a small home and the service users views are easy to gather on a daily basis, it is not apparent how the views of other stakeholders, such as Care Managers, are obtained. Nor does the AQAA indicate how the home is ensuring it complies with the Mental Capacity Act or implementing Deprivation of Liberty Safeguards. These will need to be looked at during the next Key Inspection. Annual Service Review Page 4 of 6 There is evidence from the AQAA that the home is continuing to look at ways of improving what it does to ensure good outcomes for those living there. It accommodates three service users and the AQAA indicates the home strives to meet individuals needs and aspirations. This includes supporting a service user to have a personal laptop with internet access. A wi-fi was purchased to facilitate easy internet access without unnecessary wires. Another service user was persuaded to have a cataract operation within 8 weeks of being admitted. The home has made provision for a service user who requested to have his main meal at a different time. The AQAA also shows the home recognises the need to empower service users and encourage independence. The AQAA shows the home works with other health care professionals. An example being their liaison with a Community Psychiatric Nurse in supporting a service user to go for bicycle rides independently and safely. The AQAA indicates the home has not received any complaints since the last Key Inspection. The Commission has not directly received any information about complaints regarding the service in that time. There have not been any safeguarding alerts since the last inspection. The home actively promotes equality and diversity. Underwood encourages recruitment from various nationalities and promotes an equal opportunities policy. The AQAA indicates the home employs people of a small staff group. Currently all staff are white British but this is in line with the demographics of the area. What are we going to do as a result of this annual service review? We are not going to change our inspection plan, and will do a key inspection by 21st January 2011. However we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 5 of 6 Reader Information
Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline:
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