Inspection on 26/02/07 for Woodcote Grove House

This inspection was carried out on 26th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 20/09/07

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 26th February 2007 9:00am 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.V331365.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.V331365.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 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 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.V331365.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 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 £505 and £550 and this information was gathered on the day of the inspection. Woodcote Grove House DS0000007170.V331365.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection for the year 2006/07. It took place over four and half hours. Some times were spent looking at the records, talking to some service users and registered 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. The Commission received a number of positive feedback about the care being provided in the home. Overall the inspection confirmed that the home provides a good level of care for the service users who live there. What the service does well: What has improved since the last inspection? What they could do better: Woodcote Grove House DS0000007170.V331365.R01.S.doc Version 5.2 Page 6 The registered person must produce a service user guide to the care home that includes all details as per regulation 5(1). Service users’ care plans must be reviewed by care staff at least once a month and updated to reflect their changing needs and current objectives for health and personal care. The registered provider is required to ensure that new staff has all documentation as stated in Schedule 2 of the National Minimum Standards before starting work with vulnerable people. Staff supervision at regular intervals would ensure that the service users benefit from having a well-supported staff team. A recommendation is made for service users’ receipts be numbered for auditing purposes, as it was difficult to find one receipt on the day of inspection. The registered person needs to ensure so far as is reasonably practicable the health, safety and welfare of service users and staff are promoted and protected at all times. 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.V331365.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.V331365.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): 1,3 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 is able to demonstrate that service users needs are being properly assessed, and that the range of needs presented is being appropriately met. EVIDENCE: The registered person has produced and made available to service users an up-to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home. However no service user guide was available. The registered person is required to produce a service user guide to the care home that must include all details as per regulation 5(1). The registered person must supply a copy of the service users guide to the Commission and each service user. The registered person is reminded that service user’s guide and the statement of purpose should be kept under review and revised should any changes to the service occur. If such Woodcote Grove House DS0000007170.V331365.R01.S.doc Version 5.2 Page 9 a revision is carried out the Commission should be notified of the changes within 28 days. Service users are only admitted to the home after a full assessment of their needs has been carried out by the home and the Placing Authority for individuals referred through Care Management, involving the prospective service user/recognised representative. It was noted that the home also carries out a comprehensive needs assessment however the registered manager must ensure that the assessment is completed fully. The home does not offer intermediate care. Woodcote Grove House DS0000007170.V331365.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 good. This judgement has been made using available evidence including a visit to this service. Generally suitable arrangements are in place to ensure that service users’ physical and emotional health care needs are identified, planned for and met. Personal care is carried out in a way that service users prefer so that dignity and choice are maintained. Medication is well managed to maximise good health. EVIDENCE: Three service users care plans were sampled at random and it was noted that one of them has not been reviewed recently. The registered provider is required to ensure that service users’ care plans are reviewed by care staff at least once a month and updated to reflect their changing needs and current objectives for health and personal care. The registered manager was able to demonstrate, through individualised healthcare records, that service users are in regular contact with General Woodcote Grove House DS0000007170.V331365.R01.S.doc Version 5.2 Page 11 Practitioners and other health care specialists as required. The home also keeps records of all the service users healthcare appointments, in addition to individual daily progress notes. A number of requirements were made at the last inspection regarding medication. It was positively noted that the registered person and the staff team have worked hard to meet all the requirements. In general, medication records, including medicines received, administered and returned were all being appropriately maintained. Observation of the staff team interacting with the service users showed that the carers were mindful how they addressed service users, and they were seen to be polite and friendly. Service users are always treated with respect and dignity in accordance with the homes statement of purpose. Woodcote Grove House DS0000007170.V331365.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. The daily routines and house rules promote service users’ rights, and ensure equality and that all rights are enjoyed by service users. Service users are well supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Service users are evidenced as being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and spiritual needs. Many of the service users within the home are very frail and have limited abilities however they enjoy the sessions currently provided. The home has an activity coordinator in post. Service users are encouraged to maintain contact with friends and relatives and to develop links with the local community. Woodcote Grove House DS0000007170.V331365.R01.S.doc Version 5.2 Page 13 The service users’ comments and observation confirmed that the home is run in a manner that promotes choice and independence. 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. The menus offer a choice of meals, and when the published menu options are not desired on the day, alternatives are offered. Woodcote Grove House DS0000007170.V331365.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 service users’ and relatives’ concerns are listened to. The home’s policies and procedures help protect service users from abuse and help staff if they need to tell someone about any bad care practice they may see. 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 home has in place procedures for responding to suspicion or evidence of abuse, including whistle blowing, and passing on concerns to the Commission For Social Care Inspection. The London Borough of Sutton’s adult protection procedures were available in the office on request. There have not been any adult protection concerns raised. The registered manager informed that most of the staff have had abuse awareness training. Woodcote Grove House DS0000007170.V331365.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, clean, homely and comfortable however fire safety issue still need to be addressed as this potentially places service users and staff at risk. EVIDENCE: The home is suitable for its stated purpose. It is accessible, meet service users’ individual and collective needs in a comfortable and homely way. Service users’ bedroom 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. However the home is not complying with fire regulations (see standard 38). Woodcote Grove House DS0000007170.V331365.R01.S.doc Version 5.2 Page 16 The home is kept very 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.V331365.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 adequate. This judgement has been made using available evidence including a visit to this service. More diligence is required in the taking up of staff references as without these there is a higher risk of employing unsuitable staff and impinges the safety and protection of service users. EVIDENCE: Copies of the off duty rotas were seen. The home was evidenced to have the numbers and skill mix of staff sufficient to meet service users’ needs. Domestic staff are employed in sufficient numbers to ensure that standards relating to food, meals and nutrition are fully met, and that the home is maintained in a clean and hygienic state. The registered manager informed that more than 50 of staff have an NVQ level qualification at level 2 and two staff are undertaking the course. Three staff files were examined at random and it was noted that one staff member had only one reference on file. The registered provider is required to ensure that new staff has all documentation as stated in Schedule 2 of the National Minimum Standards before starting work with vulnerable people. Woodcote Grove House DS0000007170.V331365.R01.S.doc Version 5.2 Page 18 There is a staff training and development programme in place. The manager is very proactive in respect of staff training. The manager was able to produce documentary evidence of staff attendance of a variety of different training courses that were relevant to the work staff were expected to perform. Woodcote Grove House DS0000007170.V331365.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 adequate. This judgement has been made using available evidence including a visit to this service. The home is generally managed well however the health, safety and welfare of service users and staff are not being promoted/protected and this potentially places them at risk. EVIDENCE: The manager has been successful at her fit person interview with the Commission and is now the registered manager for the home. She stated that she has nearly completed her NVQ level 4 and Registered Manager’s Award. She also undertakes periodic training. Woodcote Grove House DS0000007170.V331365.R01.S.doc Version 5.2 Page 20 Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. The registered manager informed that small amounts of money are kept in separate envelopes for each service user 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. However it is recommended that the receipts be numbered for auditing purposes, as it was difficult to find one receipt on the day of inspection. From staff files sampled at random there were evidence that staff are being supervised on a regular basis. However the registered manager informed that she does have documented formal supervision and it states in the standard that “care staff” must be supervised. She stated that her line manager visit the home on a monthly basis to carry out Regulation 26 visits and they do have discussions about the home and any issues though this is not documented. All professionals need an element of support and supervision. The registered provider must ensure that all staff receive formal supervision at least 6 times a year and a record must be kept to evidence that supervision is taking place. Certificates relating to health and safety were up to date servicing certificates. Fire records were checked and it was identified that on four occasions no fire alarms test had been carried out. The registered provider must ensure that fire alarms test are carried out and recorded on a weekly basis. A high number of windows were opening wide on the first floor and there were no restrictors on them. The registered person is required to ensure that all windows have restrictors fitted to stop them from opening wide. The registered manager must carry out a risk assessment to ensure that service users and staff are safe until such time that restrictors are in place. Woodcote Grove House DS0000007170.V331365.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 1 Woodcote Grove House DS0000007170.V331365.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 OP1 Regulation 5(1) Requirement The registered person is required to produce a service user guide to the care home that must include all details as per regulation 5(1). The registered provider is required to ensure that service users care plans are reviewed by care staff at least once a month and updated to reflect their changing needs and current objectives for health and personal care. The registered provider is required to ensure that new staff has all documentation as stated in Schedule 2 of the National Minimum Standards before starting work with vulnerable people. The registered provider must ensure that all staff receive formal supervision at least 6 times a year and a record must be kept to evidence that DS0000007170.V331365.R01.S.doc Timescale for action 15/04/07 2. OP7 15(2) 15/04/07 3. OP29 19(1) 26/02/07 4. OP36 18(2) 15/04/07 Woodcote Grove House Version 5.2 Page 23 supervision is taking place. 5. OP38 23(4) The registered provider must ensure that fire alarms test are carried out and recorded on a weekly basis. The registered person is required to ensure that all windows have restrictors fitted to stop them from opening wide. 26/02/07 6. OP38 13(4) 15/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP35 Good Practice Recommendations It is recommended that service users’ receipts be numbered for auditing purposes, as it was difficult to find one receipt on the day of inspection. Woodcote Grove House DS0000007170.V331365.R01.S.doc Version 5.2 Page 24 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.V331365.R01.S.doc Version 5.2 Page 25 - 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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