Inspection on 20/09/07 for Woodcote Grove House

This inspection was carried out on 20th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 16/09/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Woodcote Grove House Meadow Hill Woodcote Park Coulsdon Surrey CR3 2XL Lead Inspector Mohammad Peerbux Key Unannounced Inspection 20th September 2007 08:00 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.V351315.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.V351315.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) Mrs Lisa Bernadette Butler Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th February 2007 Brief Description of the Service: Woodcote Grove House is situated in Coulsdon and owned by the registered charity, Friends of the Elderly. It is registered, by The Commission for Social Care Inspection, to provide care for up to thirty elderly people. It is a large property set in secluded well-maintained 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 resident are able to use. The home is accessed by a private road and there is ample car parking. Accommodation is provided over two floors and all rooms have en-suite facilities. 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 range of weekly fees is between £535 and £585 and this information was gathered on the day of the inspection. Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2007/2008. 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. This was the home’s first inspection for the year 2007/08. It took place over five and half hours. Some times were spent looking at records, talking to some residents, staff and manager. A tour of the building was also carried out. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. What the service does well: What has improved since the last inspection? The home has reviewed and updated its service user’s guide to include all details as per regulation 5(1). Residents’ care plans are now being reviewed by care staff at least once a month and updated to reflect their changing needs and current objectives for health and personal care. Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 6 The recruitment procedure and supervision of staff have improved. Fire alarms test are now carried out and recorded on a weekly basis. 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. Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 7 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.V351315.R01.S.doc Version 5.2 Page 8 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home undertakes an assessment of the healthcare needs of residents prior to their admission to ensure that their needs would be met however the assessment is not always completed in full. EVIDENCE: Three residents’ files were sampled at random and evidence suggests that prospective residents have a needs assessment carried out before they are admitted to the home. However it was noted that one of the assessments was not completed fully as the resident’s spiritual and religious needs were not discussed. The home must ensure that all new residents receive a full comprehensive needs assessment before admission so that staff are aware of their needs and how to meet them. Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 9 Intermediate care for rehabilitation and return to the community is not provided by this home. Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident has a care plan in place however the care plans do not always cover all their care needs. The system for administration of medications is not always consistent and could potentially place residents at risk. EVIDENCE: Three residents’ care plans were sampled at random and it was noted they generally included information necessary to deliver the resident’s care but did not cover all the residents’ needs. For example one resident suffers from hypertension, this need was not covered in her care plan. This was discussed in depth with the manager. Residents’ care plans must include all aspects of their health, personal and social care needs to ensure that all their needs are met. Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 11 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. Records show that the home arranges for health professionals to visit residents in the home and provides facilities to carry out treatment. The home has a medication policy, which is accessible to all staff. Since September 2006 there have been concerns with regards to the administration of medications in the home. The home was served with a statutory notice for repeated failure with regards to the safe administration of medication. During this inspection it was noted again that the home is failing to ensure that medication administration records are kept accurate. One resident was commenced 21 antibiotics on the 14/09/07 and on the day of the inspection there were 17 signatures on the MAR sheet however there were still 6 antibiotics left in the box instead of 4. The Commission is very concerned as staff are signing for medication but these are not being administered. This issue was discussed at length with the registered manager. The Commission will be taking enforcement action against the home. Failure in the safe administration of medication could results to serious repercussions to the health and welfare of residents. Staff 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. One resident stated, “The staff are helpful and they look after me well”. 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. Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are being provided with a range of opportunities for recreational and social activity that is in accord with their social and cultural needs. They are assisted to maintain contact with family and friends, and links with the local community are encouraged. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Staff are aware of the need to plan the routines and activities of the home in a way, which meets the choice, and wishes of residents. The home tries to be flexible and attempts to provide a service, which is as individual as possible by using its staff and resources effectively. As far as possible the residents are consulted on how the home can work to provide them with a flexible lifestyle, and to achieve their wishes. The local Vicar visits the home on a regular basis. 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 Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 13 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 cook consults with residents and tries to meet the preferences and suggested dishes when preparing the menu. Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available 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 is conspicuously displayed in the home for all to view. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. The current complaints procedure is good and gives a clear step-by-step guide of how to make a complaint. The home is clear when an incident needs to be referred to the Local Authority as part of the local Safeguarding procedures in place. 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.V351315.R01.S.doc Version 5.2 Page 15 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 and 26 Quality in this outcome area is good. This judgement has been made using available 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. Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 16 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. Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency and to ensure their safety. The home’s recruitment procedures protect the residents through vigorous staff vetting. EVIDENCE: Resident spoken to during the visit all said they were happy with the care provided, they found the staff friendly and helpful. Generally residents have confidence in the staff that care for them. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. The registered manager informed that more than 50 of staff have an NVQ level qualification at level 2. Recruitment procedures seemed appropriate. Three staff files were examined at random and found to contain all the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 18 The home ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The manager is aware that there are some gaps in the training programme. These are being addressed and further training sessions have been arranged. Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 19 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home management generally provides guidance and direction to staff to ensure residents receive consistent quality care. EVIDENCE: The registered manager has the required experience and is competent to run the home. She works to continuously improve services and provide an increased quality of life for residents. There is a strong ethos of being open and transparent in all areas of running of the home. The registered manager is resident focused and leads and supports a strong staff team. She is also aware Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 20 of current developments both nationally and by CSCI and plans the service accordingly. 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 home is working towards gaining accreditation for Investors in People. The registered manager 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. From staff files sampled at random there were evidence that there have been improvement with regards to staff supervision. The manager stated that not all staff have had an appraisal however this issue is being addressed. The home has a health and safety policy that generally meets health and safety requirements and legislation. Records are of a good standard and are routinely completed. Certificates relating to health and safety were up to date servicing certificates. Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 21 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 2 8 3 9 2 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 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 22 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 OP3 Regulation 14(1) Requirement All new residents must receive a full comprehensive needs assessment before admission so that staff are aware of their needs and how to meet them. Residents’ care plans must include all aspects of their health, personal and social care needs to ensure that all their needs are met. Timescale for action 20/12/07 2. OP7 15(1) 20/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Woodcote Grove House DS0000007170.V351315.R01.S.doc Version 5.2 Page 24 - 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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