Inspection on 22/09/05 for Woodcote Grove House

This inspection was carried out on 22nd September 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodcote Grove House 16/09/08

Woodcote Grove House 20/09/07

Woodcote Grove House 26/02/07

Woodcote Grove House 25/01/06

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 Alison Ford Unannounced Inspection 22nd September 2005 12.45p 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.V250632.R01.S.doc Version 5.0 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.V250632.R01.S.doc Version 5.0 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 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) Friends of the Elderly 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.V250632.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: date of last inspection 14th March 2005 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. Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2005/2006 and was an unannounced visit, taking place over 2 ½ hours. Although the manager has worked in anther home owned by the charity, she has only been in this role for the last three weeks. With this in mind and recognising a previous good standard of care within the home this visit concentrated on a partial tour of the premises and talking to residents. A sample of care plans was also viewed. Standards applying to these areas were assessed and others will be reviewed at a further inspection later in the year. The acting manager is in the process of applying to The Commission for Social Care Inspection for registration. Prior to the inspection comment cards were received from eighteen residents, two relatives and the GP who attends the home. The majority of replies were favourable however; adverse comments were received, as at prior inspections, about the food served in the home and the lack of continuity in the management structure and it is hoped that an improvement will be seen at the next inspection in these areas. What the service does well: What has improved since the last inspection? Since the last inspection, there has been a new manager appointed who is in the process of applying for registration with The Commission. It is to be hoped that previous concerns about frequent changes in the management structure will now be rectified and the home will be able to build a sound committed staff team. Following previous discussions a rota is now in place within the home to ensure that all staff are able to contact a senior member of staff at all times. Some redecoration has occurred since the last inspection to the entrance hall and one of the bathrooms however there are still areas that would benefit from attention and these will need to be addressed. Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 6 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. Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 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.V250632.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. This home does not offer intermediate care. EVIDENCE: Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,10 All residents have an individual plan of care, which reflects the support that they require and ensures that their healthcare needs are met. Residents in this home are confident that their privacy will be respected and in a manner, which ensures that, their dignity and independence are preserved. EVIDENCE: A selection of care plans was seen and they clearly reflected the support and care currently being provided. They covered all aspects of health and psychosocial healthcare needs and included information relating to visits from medical practioners and other professionals. Risk assessments for both day and night times were also present. In some plans there was evidence that residents had been involved in their compilation and there was appropriate recording of adverse incidents that happened. Many of the residents in the home are quite independent and require only minimal support. They are able to express their wishes and it was observed that staff had a good relationship with them and treated them in a respectful and dignified manner. Any personal support that is needed is delivered in resident’s own rooms all of which have en-suite facilities. Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 10 All residents have a key to their bedroom door and to the front door and are asked to sign a book when they leave and return to the home. There is a telephone for residents use although many have their own in their rooms all of which are fitted with points. The home has ample space for visitors to be received in private if that is required. Those residents that were spoken to, all confirmed that their privacy is always maintained and all were very complimentary about the staff. Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The routines and activities of the home are flexible; to allow residents to maintain their independence and exercise choice and visitors are always welcome to ensure that relationships can be maintained. Residents are not confident that the food served in the home will always meet with their approval. EVIDENCE: Residents confirmed that they are able to exercise choice over all areas of their daily lives and many are fairly independent and require only minimal support. The pantries that are within the home allow residents to prepare their own breakfast if they wish and to make drinks and snacks for their visitors. Structured activity sessions have been offered in the past however they are rarely taken up. Concerts are enjoyed but residents usually prefer to chat or read. There is a selection of books available. Visitors are always welcome and can be entertained in resident’s rooms, in communal areas or in the beautiful gardens during the summer. Residents have been encouraged to bring in possessions from home including items of furniture, and bedrooms are all very different and personalised. Although residents all confirmed that lunch that day had been nice, as at previous inspections there were several complaints about the food. This was supported by comments received in the pre-inspection comment cards as well. Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 12 They included complaints about “meat being tough “ and “vegetables overcooked “. The manager explained that she would be hosting residents meetings every six weeks and catering issues will be discussed at each one. She will also be introducing comment cards to audit the satisfaction with the catering arrangements and these will be assessed at the next visit. Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 A clear complaints policy is in place so that residents are aware of who to speak to with any concerns. EVIDENCE: There is a complaints policy and all residents have a copy. They were all aware of how to make a compliant should it be necessary. None had been made to the home or to The Commission since the last inspection. Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Residents live in a safe environment, which suits their needs but although some redecoration has begun this will need to be continued in order maintain their comfort. EVIDENCE: The home is an attractive building set in its own secluded grounds, which are well maintained and easily accessible. The premises are well furnished in an appropriate style however some areas still require redecoration. A planned programme has begun and this must now be continued. At previous inspections there had been concerns about the cleanliness of the home however the residents all agreed that this had now improved. On the day of the inspection the home was clean and tidy and infection control procedures were all in place. The last fire officer’s visit had resulted in various recommendations being made and it was uncertain exactly what had been complied with. The registered manager agreed to contact the fire safety officer to request a further visit to clarify exactly what still needed to be implemented. There was evidence Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 15 available that fire training had taken place and an unannounced fire drill is planned for the near future. Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29, Residents can be sure that sufficient staff are always available to support them however there is not always evidence available to show that they are protected by the homes recruitment procedures. EVIDENCE: Off duty rotas were seen and complied with required numbers and residents confirmed that their perception was that there were always enough staff on duty. The staff files available in the home do not always contain copies of documentation showing that clearance has been received from the Criminal Records Bureau or Protection of Vulnerable Adults Register. This may be held at the charities central offices. These must be available for inspection and a method was discussed with the manager to make these available to be checked and it will be in place for the next inspection. Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, Residents can be assured that the manager of the home is qualified and experienced to run the home and meet its stated purpose. EVIDENCE: A new manager has been in post for three weeks however she has previously undertaken a similar role in another of the charity’s homes. She has just commenced her Registered managers Award and is in the process of applying to the Commission for registration. The pre-inspection questionnaire indicated that all equipment has been checked and maintained as necessary and this will be checked at the next inspection. Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 18 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 2 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x x x x Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 19 yes 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 OP29 Regulation 19(1)(b) Requirement The Registered Providers must ensure that all of the staff files contain all the requirements of schedule 2 of The Minimum Standards. (Previous timescale 30/06/05 not met) The homes manager must be able to provide evidence that adverse comments about the meals have been noted and steps taken to make improvements The Registered Providers must submit an action plan outlining how the redecoration and refurbishment plan will be continued. The homes manager must provide evidence that the fire safety officer has been contacted to clarify any outstanding requirements. Timescale for action 30/10/05 2 OP15 16(2)(i) 30/12/05 3 OP19 23(2)(d) 30/12/05 4 OP19 13(4)(c) 30/12/05 Woodcote Grove House DS0000007170.V250632.R01.S.doc Version 5.0 Page 20 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.V250632.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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