CARE HOMES FOR OLDER PEOPLE
Woodcote Grove House Meadow Hill Woodcote Park Coulsdon Surrey CR3 2XL Lead Inspector
Alison Ford Unannounced Inspection 13:00 25 January 2006
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.V276302.R01.S.doc Version 5.1 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.V276302.R01.S.doc Version 5.1 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 Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Woodcote Grove House DS0000007170.V276302.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 22nd September 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.V276302.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/2006 and was an unannounced visit, taking place over 2 ½ hours. Some of the organisations documentation had already been assessed at the adjacent Selkirk Wing, which facilitated the inspection. A partial tour of the premises was undertaken and two residents were spoken with; the majority of the others were enjoying a post lunch rest others had gone out. A sample of care plans was also viewed. The acting manager is in the process of applying to The Commission for Social Care Inspection for registration and awaiting an interview. Over the course of the year all of those standards considered by The Commission to be key to the inspection process, have been assessed and this report should be read in conjunction with the one issued following the visit on September 22nd 2005. What the service does well: What has improved since the last inspection?
Since the last inspection, documentary evidence that appropriate preemployment checks have been undertaken .is now kept for inspection. All staff have applied for Criminal Records Bureau clearance and all have been checked against The Protection of Vulnerable Adults register. Measures have been introduced to try and address previous adverse comments about the food served in the home and residents are regularly asked for their comments.
Woodcote Grove House DS0000007170.V276302.R01.S.doc Version 5.1 Page 6 Staff training is ongoing and documentation has been completed to identify those still requiring training this year. Several staff are completing an NVQ qualification and the acting manager is undertaking The Registered Managers Award. Plans have been made to introduce residents and relatives meetings and the twice-yearly audit of care and services is about to take place. 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.V276302.R01.S.doc Version 5.1 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.V276302.R01.S.doc Version 5.1 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): 3,6 Potential residents of the home can be confident that procedures are in place to ensure that the home will be suitable for their needs This home does not offer intermediate care. EVIDENCE: The care plan of one resident who had been admitted recently was seen. There was evidence of a careful pre-admission assessment including input from her doctor, to ensure that her needs could be met. As residents in this home are generally able to make an informed choice for themselves, she had visited the home twice before deciding to move in and these visits would always be encouraged. Woodcote Grove House DS0000007170.V276302.R01.S.doc Version 5.1 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): 7,8,9 All residents have an individual plan of care, which reflects the support that they require and ensures that their healthcare needs are met. Medication administration records are not always sufficiently accurate to ensure that residents are always protected. 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. Many of the residents in the home are quite independent and require only minimal support. Any personal support that is needed is delivered in resident’s own rooms all of which have en-suite facilities. Medication records were seen and one omission was noted in recording, which was discussed with the manager at the time.
Woodcote Grove House DS0000007170.V276302.R01.S.doc Version 5.1 Page 10 Woodcote Grove House DS0000007170.V276302.R01.S.doc Version 5.1 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): 15 Residents can be confident that measures are being put in place to ensure their satisfaction with the food served in the home. EVIDENCE: Previous inspections had highlighted dissatisfaction with the food served in the home although there were fewer adverse comments noted at this visit. New menus have been compiled and comment sheets have been introduced to try and measure resident’s views of meals. The resident spoken to at this visit said how much she liked the food and that here were always drinks available too. Woodcote Grove House DS0000007170.V276302.R01.S.doc Version 5.1 Page 12 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): 16,18 A clear complaints policy is in place so that residents are aware of who to speak to with any concerns and policies and procedures are in place to prevent and report any abuse. EVIDENCE: There had not been any complaints made, either to the home or to The Commission, since the last inspection. Policies, procedures and training are in place to recognise and deal with abuse and pre-employment checks include clearance from The Criminal Records Bureau and The Protection Of Vulnerable Adults Register. Woodcote Grove House DS0000007170.V276302.R01.S.doc Version 5.1 Page 13 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 Residents live in an environment, which suits their needs however there are concerns regarding their safety in the event of a fire. 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. Some residents doors were seen wedged open. A fire safety officers visit has been planned however, until automatic door closures are fitted to bedroom doors, there must be evidence that residents have understood the risks involved in holding them open. Woodcote Grove House DS0000007170.V276302.R01.S.doc Version 5.1 Page 14 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): 27,28,29,30 Residents can be sure that they are protected by robust recruitment procedures and that staff are trained and competent to do their jobs and on duty in sufficient numbers to support them. EVIDENCE: There is now evidence, held in the home that all appropriate pre-employment checks are carried out on staff. The manager has compiled a training tracker to identify any staff training needs and is confident that all staff will have received their mandatory training by the end of the year. An induction training plan is in place and it is accepted that this will take longer for staff recruited from overseas and this is allowed for. Woodcote Grove House DS0000007170.V276302.R01.S.doc Version 5.1 Page 15 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): 33,35,38 Residents can be sure that the procedures are in place to ensure that the home is run in their best interests, their financial interests are safeguarded and their health and safety protected. EVIDENCE: Regular visits are undertaken in line with Regulation 26 and reports are sent to The Commission. Residents meetings are planned and will be taking place every six weeks and the twice-yearly audit of all of the homes services is about to be undertaken. Some pocket money is kept for residents and the records are regularly checked. A selection of maintenance records were seen and were all up to date Woodcote Grove House DS0000007170.V276302.R01.S.doc Version 5.1 Page 16 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Woodcote Grove House DS0000007170.V276302.R01.S.doc Version 5.1 Page 17 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 OP9 Regulation 13(2) Requirement Timescale for action 30/03/06 2 OP19 23(4) 3 OP19 23 (4) The acting manager must audit medication records regularly and train staff appropriately to ensure that there are no omissions in the recording process. The acting manager must ensure 30/03/06 that there is evidence that residents have understood and accept the risks involved in holding bedroom doors open. The Registered Providers must fit 30/03/06 automatic door closers, which operate in the event of a fire, where residents wish to keep their bedroom doors open 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.V276302.R01.S.doc Version 5.1 Page 18 Woodcote Grove House DS0000007170.V276302.R01.S.doc Version 5.1 Page 19 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
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