Inspection on 16/09/08 for Woodcote Grove House

This inspection was carried out on 16th September 2008.

CSCI found this care home to be providing an Adequate service.

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.

Other inspections for this house

Woodcote Grove House 20/09/07

Woodcote Grove House 26/02/07

Woodcote Grove House 25/01/06

Woodcote Grove House 22/09/05

Woodcote Grove House 14/03/05

Woodcote Grove House 28/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/11/2008.

CARE HOMES FOR OLDER PEOPLE Woodcote Grove House Meadow Hill Woodcote Park Coulsdon Surrey CR3 2XL Lead Inspector Mohammad Peerbux Key Unannounced Inspection 09:00 16 and 20 September 2008 th th X10015.doc Version 1.40 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 Woodcote Grove House DS0000007170.V372344.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 Older People. 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. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodcote Grove House Address Meadow Hill Woodcote Park Coulsdon Surrey CR3 2XL 020 8660 2531 020 8660 6306 manager@woodcotegrove.fote.org.uk www.fote.org.uk Friends of the Elderly 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) Manager post vacant Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 30 20th September 2007 Date of last inspection Brief Description of the Service: Woodcote Grove House is situated in Coulsdon and owned by the registered charity, Friends of the Elderly. It is a large property set in secluded wellmaintained grounds and surrounded by paddocks and woods. The grounds are over forty-five acres and include flowerbeds, lawns and patio areas. Adjacent to the home is a golf club with a clubhouse that the residents are able to use. The home is accessed by a private road and there is ample car parking. There are two lifts and communal facilities include two lounges a dining room and a chapel. The home is situated a few miles from local transport and shopping facilities and the home provides transport to access these. The weekly fee is around £567.00. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2008/2009 and conducted over two days. In writing the report, consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. Some of the residents were spoken to and they commented positively on the care they are receiving. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. A tour of the building was also carried out. All registered adult services are now required to fill in an annual quality assurance assessment (AQAA) .It is a self-assessment that the provider (owner) must complete every year. The completed assessment is used to show how well the service is delivering good outcomes for the people using it. Some information from this AQAA is included in the report. A random inspection was also carried out on 10th June 2008 following concerns raised by the care management team in Sutton and reference to that inspection would be contained within the text of this report. At the last inspection the regional manager requested two months to have most of the paperwork up to date. As there had been changes to the management of the home, the Commission decided to give the home three months to ensure that all paperwork are reviewed and updated; staff training are reassessed and updated accordingly; staff supervisions happen more regularly and the home is run in the best interests of the residents and working to the basic processes set out in the National Minimum Standards. The home has improved however there is still considerable work to do to ensure that the home meets the National Minimum Standards. What the service does well: Comments from residents were generally positive, with indication that staff are kind and helpful in meeting their care needs. Residents were observed to be treated with respect by staff and to have their privacy and dignity respected. They are actively encouraged to keep in contact Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 6 with family and friends living in the community. Visitors are welcome at any time and facilities are available for them. The service actively supports people to be independent and involved in all areas of daily living in the home. Residents are encouraged to follow their faith as they wish without offending others around them. What has improved since the last inspection? What they could do better: A comprehensive needs assessment must be undertaken by the home to ensure that staff are fully aware of the presenting needs of the resident. Care plans must be drawn up with the involvement of the residents, agreed and signed by the residents whenever capable and/or their representatives (if any). All changes in people individual health care needs must be made aware to all staff and recorded to ensure they receive support and care as needed. Furthermore all records in the home must be kept accurate and up to date at all times to ensure that residents’ rights and best interests are being safeguarded. The administration/non-administration of all medication must be recorded accurately at all times to ensure that the residents are having/not having their medication for their health and wellbeing. All staff must receive relevant training that is focussed on delivering improved outcomes for residents and meets any statutory requirements and the NMS.Staff must also have regular supervision. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 7 The health, safety and welfare of residents must be promoted and protected. 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. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home undertakes an assessment of the healthcare needs of residents prior to their admission however the assessment is not always completed fully so it would be difficult to ensure that all the residents’ needs would be met. EVIDENCE: Four residents’ files were sampled at random and they all had a pre-admission assessment carried out. However it was noted that the assessments were not always completed fully. If the assessor is unable to gather information about a resident during the pre admission assessment process, this must be noted on the assessment. Without a comprehensive assessment, it would be difficult to develop an initial care plan and without such staff would be unable to provide the care required. It would also impact on the home’s ability to offer a placement, if they were not fully aware of the presenting needs of the resident. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 10 New residents must be admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective resident, his/her representatives (if any) and relevant professionals have been party. This will ensure that the home is able to meet the assessed needs of the prospective resident. It is also recommended that a date is included on the assessments and also the name of the person who carried out the assessments. For individuals referred through Care Management arrangements, a summary of the Care Management (health and social services) assessment and a copy of the Care Plan produced for care management purposes must be obtained. Evidence suggests that assessments are carried out when the residents are admitted to the home however again these assessments were not fully completed so it would be difficult to develop a comprehensive care plan. The staff is in the process of gathering more information about the residents, their life history and their past interests and this should help with formulating a person centred plan. Intermediate care for rehabilitation and return to the community is not provided by this home. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ health, personal and social care needs are not being appropriately met as their care plans are not being reviewed and updated to reflect their changing needs. The practices for administration of medications are not always consistent and could potentially place residents at risk. EVIDENCE: Four residents’ care plans were sampled at random and it was noted they generally included information necessary to deliver the resident’s care needs. However the practice of involving residents in the development and review of the plan is variable. Care plans must be drawn up with the involvement of the residents, agreed and signed by the residents whenever capable and/or their Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 12 representatives (if any). This will ensure that the residents are aware of their plan and what care they will receive. It was also noted that two of the care plans had not been reviewed recently. Residents’ care plans must be reviewed by care staff in the home at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. This will ensure that all their needs are being met. Care plans must be a working document reviewed regularly involving the person and their representatives, as appropriate. Reviews need to focus on asking what has worked for the individual, where there are progress, achievements, concerns and identifies action points. One resident had recently been admitted to hospital with low blood sugar level due to poor oral intake. The resident had also lost weight. She had been referred to the GP who recommended food supplement however there had not been any follow up and the resident had not been having any supplement. The nutritional scale had not been kept up to date either. This was discussed with the acting manager who gave reassurance that he would followed this up. Changes in people individual health care needs must be made aware to all staff and recorded to ensure they receive support and care as needed. It was identified during the inspection that the daily records were sometimes brief and did not give enough information on the changes in residents’ needs. Daily records are a good source of evidence to show that care is being provided, as detailed in the care plan. When well written they help to ensure a consistent approach and good quality of care for residents. It was positively noted that the home actively promotes the residents’ right of access to the health and remedial services that they need, both within the home and in the community. However as mentioned above residents’ needs are not always identified and covered in their assessments and reviewed so it would difficult for staff to meet them fully. There was evidence in the care plans of health care treatment and intervention, and a record of visiting professionals. The medication administration records were audited. There were several instances where prescribed medication had been omitted or administered but signed or not signed for. In all cases where medication is not given as prescribed, staff must ensure that they record the reason for this. The current practice and lack of adequate recording puts people who use the service at risk. This was also identified during a random inspection in June 2008. The administration/non-administration of all medication must be recorded accurately at all times for the health and safety of residents. The provider must take urgent action to resolve this on going issue as any further failure may lead to enforcement action being taken. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 13 The Commission is concerned that despite medication audits being carried out on a daily basis to check if staff had signed the MAR sheets, those missing signatures were not identified. It was also noted that one resident’s medication was out of stock and the resident was refusing all her medication at the times of inspection. Although the resident was refusing her medications there still need to be a stock in place as she might start taking her medications again. Prescribed medications must be in stock at all times as failure could have an impact on the health and safety of residents. Due to our concern, the acting manager informed that an assessment/training would be carried out to ensure each member of staff is competent to handle, record and administer medication properly. Staff in the home are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms. Residents who were spoken to stated that they are happy with the way that the staff deliver their care and respect their dignity. Observation of the staff team interacting with the residents showed that the carers were mindful how they addressed residents, and they were seen to be polite and friendly. There are still some concerns raised by residents and the acting manager is addressing them. Generally residents felt happier and commented positively on the action being taken by the acting manager to improve the service. We also had an opportunity to attend the residents’ meeting and again the general feedback was good. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home tries to be flexible and attempts to provide a service, which is as individual as possible. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: People using the service are given the opportunity to take part in a variety of activities both within the home and in the community. Where possible, staff gather information on community-based events and try to make individual arrangements for people to attend. Residents have the opportunity to exercise their choice in relation to leisure and social activities, cultural interests, food, meals, and mealtimes, personal and social relationships, etc. Positive comments were received regarding the activity coordinator. One resident stated: “she does a splendid job”. The provider will be recruiting volunteers and the residents will be involved in the process. Their roles would be to spend time socially with the residents. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 15 The home has open visiting arrangements and residents know they can entertain their family and friends in their own room. If they prefer they can use communal areas of the home to talk to visitors. The home is committed to the principles of inclusion and promotes and fosters good relationships with neighbours and other members of the community. Maintaining independence and enabling residents to make their own decisions about how they wish to live is a key objective of the home. Residents have the choice to bring personal possessions with them on admission to the home and are encouraged to keep personal items, which are important to them in their own room. It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. Staff are ready to offer assistance in eating where necessary, discreetly, sensitively and individually, while independent eating is encouraged for as long as possible. The chef consults with residents and tries to meet the preferences and suggested dishes when preparing the menu. The home has introduced a system where residents can comment on the quality of food being served in the home. The menu is also discussed during residents’ meeting. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are generally managed well, which should ensure that residents’ and relatives’ concerns are listened to. EVIDENCE: The home has a complaints procedure that generally meets the national minimum standards and regulations. It keeps a full record of complaints and this includes details of the investigation and any actions taken. Unless there are exceptional circumstances the service always responds within the agreed timescale. The home has an open culture that allows residents to express their views and concerns in a safe and understanding environment. There are policies and procedures for safeguarding people who use the service. The acting manager stated that most of the staff working within the home are fully trained in Safeguarding Adults and know how to respond in the event of an alert. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the residents’ health and emotional wellbeing. EVIDENCE: The home is suitable for its stated purpose. It is accessible, meet residents’ individual and collective needs in a comfortable and homely way. Residents’ bedrooms are personalised to reflect their individual needs, and personalities. Overall the home was decorated to a good standard throughout and appeared to be very comfortable, bright and warm. The home has a rolling maintenance programme in place. There are plans to refurbish the main corridors and general stair wells and complete overhaul of the laundry. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 18 It was positively noted that aids and equipment are provided to encourage maximum independence for people using services. During the inspection one of the call bells was activated and it took around ten minutes for the staff to respond. The acting manager stated that according to their policy the staff should have responded within 2 minutes. There had been concerns raised previously by residents about the length of time they had to wait when calling for help. This would be discussed with the staff team. The home is kept clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. However COSHH material was left unlocked in the laundry room and this potentially places residents at risk (see standard 38). Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Generally people using the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has the numbers and skill mix of staff sufficient to meet residents’ needs and ensure their safety however there are some gaps in the training programme. EVIDENCE: People have confidence in the staff who care for them. The acting manager ensures that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. More staff are being recruited at present. The residents will be involved in the recruitment process for key positions both as they are recruited and following the start date. The home is also introducing a mentoring scheme for less experienced staff. The acting manager informed that more than 50 of staff have an NVQ level qualification at level 2. As part of the inspection process staff records were sampled for references, criminal record checks, application forms and copies of identification. It was Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 20 noted that two files did not have all the relevant documents. Staff files must contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001 for the delivery of good quality services and for the protection of residents. The service recognises the importance of training, and tries to delivers a programme that meets any statutory requirements and the NMS. The acting manager is aware that there are some gaps in the training programme. These are being addressed and further training sessions have been arranged. All staff must be up to date with their mandatory training to ensure residents continue to receive care as is reasonable to meet their needs. A training needs assessment must also be carried out for the staff team as a whole, and an impact assessment of all staff development must be undertaken to identify the benefits for residents and to inform future planning. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37 and 38 People using the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home generally provides guidance and direction to staff to ensure residents receive consistent quality care. There is a quality monitoring system and this ensures the home is run in a way that is in the best interests of the residents. EVIDENCE: Since the last key inspection the previous manager is no longer in post. A new acting manager has been recruited. He is qualified and has the necessary experience to run the home. He is aware of and works to the basic processes set out in the NMS. He works to continuously improve services and provide an increased quality of life for residents. There have been concerns previously Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 22 about the general management of the home. The provider and acting manager is looking into ways of improving the service. During our last visit, the residents commented that they feel things are getting better. The action plan of the new acting manager will tackle matters in a structured and planned manner. The plan revolves around better staffing, staff motivation and training. All methods in use within the home are being reviewed and, where necessary, new ones introduced. Residents are being consulted at every stage both formally and informally. We will continue to monitor progress. Effective quality assurance and quality monitoring systems, based on seeking the views of residents, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. The AQAA was received on time and contains clear and relevant information. The AQAA lets us know about changes the home has made and where they still need to make improvements. It shows clearly how they are going to do this. The staff informed that small amounts of money are kept in separate envelopes for each resident with a running balance sheet appropriately maintained for sundries, such as hairdressing costs. A sample of these was seen and was accurate and well maintained. This is in line with a requirement made at the last inspection. The acting manager stated that staff are not up to date with their supervision sessions. All care staff must receive formal supervision at least 6 times a year for the delivery of good quality services. Checks show that records keeping in the home could be improved, for example medication administration records are not being completed accurately when staff are administering medication, property lists are not being completed and missing information on assessments. All records in the home must be kept accurate and up to date at all times to ensure that residents’ rights and best interests are being safeguarded. Records of routine maintenances of equipment were seen and were up to date. During the inspection it was noted that COSHH material was left unlocked in the laundry room and this potentially places residents at risk. All COSHH materials must be kept locked in accordance to Control of Substances Hazardous to Health Regulations (COSHH) 1999 for the safety of staff and residents. It is recommended that a visual inspection be carried out on a regular basis as this will help to identify any potential risks and hazards within the environment that may pose a risk to residents. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 2 2 Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? n/a 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 OP3 Regulation 14 Schedule 3 1(a) Requirement Timescale for action 20/12/08 2. OP7 15(1) 3. OP7 15 (2)(b)(c) 4. OP7 15 (2)(b)(c) New residents must be admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective resident, his/her representatives (if any) and relevant professionals have been party. This will ensure that the home is able to meet the assessed needs of the prospective resident. Care plans must be drawn up 20/12/08 with the involvement of the residents, agreed and signed by the residents whenever capable and/or their representatives (if any). This will ensure that the residents are aware of their plan and what care they will receive. Residents’ care plans must be 20/12/08 reviewed by care staff in the home at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned Changes in people individual 20/10/08 health care needs must be made aware to all staff and recorded to DS0000007170.V372344.R01.S.doc Version 5.2 Woodcote Grove House Page 25 5. OP9 13(2) 6. OP9 13(2) 7. OP29 17(2) 8. OP30 18(1) 9. OP36 18(2) 10. OP37 17(1)-(3) 11. OP38 13(4) ensure they receive support and care as needed. The administration/nonadministration of all medication must be recorded accurately at all times for the health and safety of residents. Prescribed medications must be in stock at all times as failure could have an impact on the health and safety of residents. Staff files must contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001 for the delivery of good quality services and for the protection of residents. All staff must be up to date with their mandatory training to ensure residents continue to receive care as is reasonable to meet their needs. All care staff must receive formal supervision at least 6 times a year for the delivery of good quality services. All records in the home must be kept accurate and up to date at all times to ensure that residents’ rights and best interests are being safeguarded. All COSHH materials must be kept locked in accordance to Control of Substances Hazardous to Health Regulations (COSHH) 1999 for the safety of staff and residents. 20/10/08 20/10/08 20/10/08 20/12/08 20/12/08 20/12/08 20/10/08 Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 26 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. 2. Refer to Standard OP3 OP38 Good Practice Recommendations It is recommended that a date is included on the assessments and also the name of the person who carried out the assessments. It is recommended that a visual inspection be carried out on a regular basis as this will help to identify any potential risks and hazards within the environment that may pose a risk to residents. Woodcote Grove House DS0000007170.V372344.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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