Inspection on 02/02/06 for Woodcote House

This inspection was carried out on 2nd February 2006.

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 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 House 23/02/07

Woodcote House 18/11/05

Woodcote House 14/03/05

Woodcote House 28/10/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Woodcote House 167 Sandy Lane South Wallington Surrey SM6 9NP Lead Inspector David Pennells Unannounced Inspection 2nd February 2006 1:40pm 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 House DS0000007206.V283025.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 House DS0000007206.V283025.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodcote House Address 167 Sandy Lane South Wallington Surrey SM6 9NP 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) 020 8395 4010 020 8395 5668 brookcarehomes@blueyonder.co.uk Brook Care Homes Elizabeth McNally Care Home 11 Category(ies) of Dementia - over 65 years of age (11) registration, with number of places Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user is under the age of 65. Date of last inspection 18th November 2005 Brief Description of the Service: Woodcote House is an extensive family style house set on a busy road to the south of Wallington. Though a distance away from local ‘town’ facilities, the home is close to bus connections and a few local amenities such as a newsagent, etc. The house provides social care with nursing - predominantly for older service users with dementia or related conditions - though some of the current service user group are under other excepted categories. This specific service has been provided here at Woodcote House - for the current user group - since the end of July 2004, when the majority of the present community moved en masse to this new location from another home, Beeches House in Carshalton Beeches. Service users and their carers have indicated that they are happy with the new location of the service and the facilities they now have. The house has seven single bedrooms and two double-occupancy rooms. Toilets and bathrooms are provided around the building. The house has a pleasant lounge, an adjoining dining room and a smoking lounge. Outside there is a patio area and a large lawned garden at the rear - both of which have a potential for development. Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This short unannounced inspection visit was conducted across the afternoon of an ordinary weekday. The principal purpose of the visit was to check on the wellbeing of service users at the home, and to review the progress in addressing the requirements and recommendations set at the last inspection visit. During this visit the inspector was able to chat to service users, to speak to, and observe staff, and to spend time reviewing general progress at the home with the Nurse on duty - Bee Lang Tsui. The inspector is grateful to the service users and staff for the welcome, hospitality and cooperation given throughout the inspection. What the service does well: What has improved since the last inspection? In the two and a half months span since the previous inspection visit, storage of kitchen supplies has been enhanced, the carpet from the front door has been reconditioned, the dining room area has been renovated / redecorated. Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 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 House DS0000007206.V283025.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 House DS0000007206.V283025.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. Prospective service users can be confident that the information that is necessary for making an informed choice as to whether the home could meet their needs will be provided, with full detail included. Service users at the home will be clear about terms and conditions set by the home through the provision of a written document served on each individual. Service users can be assured that their needs and aspirations will be fully assessed and recorded prior to a placement and on an ongoing basis, once they are resident at the home. EVIDENCE: Three standards (1,2 & 3) were inspected and the first two found ‘met’ with the third resulting in a requirement that the home must apply to the Commission for a variation to the registration to reflect the ‘out of category’ status of (at least) two service users who fall into the ‘mental health’ category rather than the ‘dementia’ focus. These service users came to the house when the transfer from the closing Cladagh Nursing Home took place in 2004; as they were long-term residents within this group of homes, the Inspector is Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 Page 9 ‘content’ with the concept of the service users remaining in the home (with familiar faces of staff and service provision) - however this situation must be regularised with the Commission - and reflected on the registration certificate, for the proprietors to be correctly ‘within the law’. To fulfil this single requirement the proprietors have purely to gain the agreement of placement of the service users formally with individual placement officers (in writing) and these supporting statements must then be submitted with an application form to the Commission for agreement of a Variation within the home’s registration. Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): none inspected this time. Service users can expect that their care will be arranged through a thorough care planning and risk assessment process and the regular reviewing of goals and achievements. Service users can be assured that their health care, in all dimensions, will be attended to - through appropriate contact with health care professionals as appropriate. Service users can also be assured that the management of medication in regard to their individual needs will be managed and administered well, within a clear policy and procedure framework. Service users and their supporters can be assured that they will be treated with respect and dignity during their stay at the home and at the point of serious illness and death. EVIDENCE: All standards in this section were found ‘met’ at the last inspection and circumstances clearly had not changed - leading the inspector to decide not to inspect this section. The judgement statements above are reiterated from the last report - for the reader’s information. Woodcote House DS0000007206.V283025.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. Service users can expect to lead a comfortable and pleasant lifestyle, based on individual assessment and the service user’s expressed likes and dislikes, and respecting the individual’s own decision-making. Contact with families and friends and the local community is positively encouraged, and service users can be assured that such links will be upheld through the home’s practices, support and encouragement. Service users can expect a pleasant and nutritious diet to be provided, with the emphasis on personal preferences and individual dietary needs - and with mealtimes being a calm, appropriate & pleasurable experience. EVIDENCE: Standard 15 had a requirement set against it at the last inspection visit concerning adequate storage containers being provided for dried goods and foodstuffs in the kitchen. Clearly more storage containers had been obtained and this standard was now fully ‘met’. All this section’s standards, therefore, are now ‘met’ - Standard 15 joining the others with a positive scoring reflected by the judgement statements quoted above. Woodcote House DS0000007206.V283025.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): none inspected this time. Service users and their advocates can be assured that any complaints will be processed and dealt with swiftly and effectively. Service users can be assured that their human and legal rights will be protected and that they will be protected from abuse of any kind - through the policies, procedures and practices of the home. EVIDENCE: All three standards above were inspected at the last inspection visit and found ‘met’ - there was nothing at this visit to suggest to the inspector that circumstances have changed - therefore the judgement statements from the last report are reiterated, for the information of the reader. Woodcote House DS0000007206.V283025.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, 20, 22, 24, 25, & 26. Service users can be assured that they will live in a well-maintained and generally safe environment, which is clean, hygienic and odour-free. Service users can have access to a variety of well-furnished comfortable facilities in the house suited to their assessed needs. The house is suitably assessed with regard to specialist service needs, in line with current professional advice - and to the benefit of service users. Once certain outstanding premises issues have been resolved, the home will be a well-ordered environment to provide sensitive nursing and personal care to the service user population. EVIDENCE: Standards 20 and 25 were found met at this inspection - along with previous findings for standards 21 & 23. A number of premises issues remain outstanding since at least the last inspection - these reflected by requirements being set against standards 19, 22, 24 & 26. Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 Page 14 The house is generally a very warm, comfortable, homely and pleasant familysized house, which provides a reassuring environment for people with dementia to feel they are cared for in a ‘cosy’ / ‘homely’ atmosphere. The main patio area (accessed via the corridor leading from the front door) has been enhanced with a safe ramp and gate at the top of the brick stairs leading down to the large lawned back garden. Outstanding work from the original requirement relates to the opposite side of the house: the side entrance / exit from the house near to the laundry - and associated steps down to the lower lawn level. These areas must be made safe and provided with such ramps and grab rails as make it safe and secure for all service users – with, especially, a secure protective gate at the top of the flight of stairs - for basic safety’s sake. Flooring in a toilet close to the lounge on the ground floor has now been provided with new (non-slip) vinyl flooring, making access into this important area much safer. The flooring outside this toilet, at the base of the stairs / chairlift, and leading to the smoking area is in a ‘bald’ condition - and must be stripped and resealed, or an alternative flooring surface provided. The Dining Room has now been ‘freshened up’ to remove the evidence of ‘wear & tear’ on the fabric of the room - the environment appears far more pleasant for service users. During the tour of the house, it was noted that the bathrooms throughout the home would still benefit from refurbishment / ‘warming up’; they continue to appear bleak and sterile in appearance. Some colourful (appropriate) domestic decoration will aid orientation and make the experience more pleasant when service users are in these areas. Call bell points are still to be provided in the lounge and dining room areas. Such facilities - especially with the ‘dementia’ client group - are as much an aid to staff as service users – and, of course, visitors would find a call bell’s presence useful, if they felt assistance was needed when staff members were not present in the room. The home - as an ‘existing’ home - is allowed to continue providing care in the current configuration of bedrooms, including a number of service users accommodated in shared rooms (four out of eleven places). The home may wish to consider - and it is strongly recommended - that a strategy concerning the future of the double rooms be devised in writing and be made available to service users and their relatives - so that both present and new service users can be appraised / reassured of the situation concerning ‘sharing a room’. Bedrooms inspected were noted to be warm, reasonably furnished and comfortable; each reflected the occupant’s personality. The single rooms were, obviously, more individualised and characterful - as service users, sometimes assisted by relatives, fully ‘take them over’. Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 Page 15 All bedroom doors within the house do not currently have an easy locking device that is deemed suitable. Such locks must be provided with a suitable type of ‘un-deadlock-able’ lock - and service users are to be offered the facility of a key if assessed to have the capability to use it. Another benefit of such locks is to allow a service user to lock their room when they are absent from the home; a great opportunity to provide reassurance – especially if some service users (as may be expected) ‘wander the home’ at times. The home still continues to have the commode steriliser situated in the garage / outhouse / laundry which is located outside across a courtyard. The active use of this machine by staff in inclement weather and during the night is less likely - as it poses a safety hazard to staff members in regard to falls / slips. Steps must be taken to urgently install a commode steriliser within the house itself - to ensure both the minimisation of potential cross-infection and to ensure the health & safety of staff. Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 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): 28. Service users can expect that their needs will be met by suitably qualified, vetted and competent care and nursing staff, who are provided in sufficient numbers to provide for the assessed needs as identified in the care plans. Staff members employed at the home undertake training, and the home strives to ensure that relevant training is provided to ensure that the home meets its statutory obligations, though certain training such as NVQs in care for care assistants and First Aid training must be seen as ‘mandatory’ to ensure the safety and best care of service users. EVIDENCE: All standards in this section were found ‘met’ at the last inspection visit though standard 28 is now ‘out of time’. Nothing seen contradicted the remaining previous assessments - so the judgement statements are reiterated above - for the reader’s information. 50 of care staff must now be qualified minimally to NVQ in Care Level 2 this was stated with a standard deadline of the end of 2005. The figure for Beeches House at the end of 2005 was that three staff out of nine (including one ‘bank’ care worker) were undertaking the qualification – so 33 will be qualified to that level in the near future – however the figure will be below the minimum standard by the deadline. More staff members - at least another two - must urgently be recruited to NVQ training. Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 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): 33, 35, 37 & 38. Service users can expect the home to be managed efficiently and well, through the manager and seniors supervising staff, and with the support - and under the guiding eye - of the proprietors. A greater focus on quality assurance measures would benefit the home, through dialogue with service users & their representatives concerning the conduct of the home. Service users can be confident in the knowledge that their finances held in safekeeping are properly managed, and that rigorous accounting ensures that any such transactions are clearly recorded and accounted for. Service users and their representatives can be confident that the home is generally kept in a safe and well-maintained way, thus ensuring the health and safety of all who engage with the home - though training for staff in First Aid would provide a ‘safety net’ of input otherwise not available to them. Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 Page 18 EVIDENCE: All standards, bar 34 & key standard 35, were inspected at the last inspection. Standards 33, 37 & 38 were revisited on the basis that they were only partially met. Standard 35 was inspected additionally this time and joins Standards 31, 32 and 36 which were found ‘met’ at the last inspection. Woodcote House is supported by a significant management structure beyond the home; the co-proprietors provide an ‘overview’ input to the home – such as Mr Brook being Appointee for a service user. The proprietors’ son, Jerry Brook, is the ‘General Manager’ and supports the two homes owned in Brook Care Homes Ltd through supervising the administrative side of the business and is currently undertaking the Registered Manager’s Award himself. The proprietors also employ a Bookkeeper / Administrator who keeps the financial side of the business in good order. Mrs Ailish (Elizabeth) McNally is the registered manager in regard to Woodcote House itself, and she supervises the care service at the home – with the associated paperwork and delegation of tasks to staff at the home. The manager has a shift per week when she is supernumerary to the care rota; this allows a specific management focus on this day, and she is clearly present on the other days to deal with any management issues arising at the time. Mrs McNally - the registered manager - is a Registered Nurse. The National Minimum Standards require that as Manager registered to the home, she should be qualified to NVQ Level 4 in Management, to complement her nursing qualification – or undertake the Registered Manager’s Award in its entirety (“Skills for Care” [previously TOPSS] can give clear advice as to ‘credits’ and transferable qualifications, and the Guidance on such qualification conditions is in the proprietor’s possession). In the light of the manager’s relatively recent bereavement, it was ‘fortuitous’ that this work has not been previously commenced. This training should now, however, be commenced at the earliest opportunity. The manager has indicated to the inspector that she would commit herself to the training as soon as it becomes available to her, with a suitable course identified. The registered manager had previously informed the inspector that the General Manager was devising ‘Quality Assurance’ survey material - but that it had not yet been implemented. The registered manager - following this current visit again verbally confirmed this impression. Such independent quality assurance / satisfaction surveys must be established to encourage service users - and their representatives - to feel they can affect / influence the way the service is being delivered at the home. Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 Page 19 Regarding Standard 35, a joint Lloyds TSB Account held in the service users’ collective name is held by the home - and interest is regularly awarded to each, dependent on the amount held by the individual. Accounts previously seen - presented by the organisation’s bookkeeper - were well kept, with cross-referencing agreeing. Placing Local Authorities are the predominant agents for service users’ finances, with one service user having Mr Brook (senior) as Appointee. The small cashbooks held for individuals on site were seen and audited, the individual corresponding petty-cash slips holding signatures confirming payments of monies handed out. An ‘Access to Personal Records’ policy and procedure was still absent, and needs to be put in place relating to both service users’ and staff members’ records held by the home. The registered manager again assured the inspector that she knew the document was ‘imminent’, and should be in place soon. Checks of records relating to fire – alarm tests, drills, etc were all found to be in order and health and safety audits were also in place. Training of staff members -including nursing staff - in First Aid - remained an issue needing attention; the Senior Nurse on duty was able to assist the inspector to decide that three carers and two nurses were currently covered by ‘in date’ qualifications. This is an important element to follow up; as a competent trained First Aider must cover all shifts at the home. Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 Page 20 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 X 8 X 9 X 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 X 17 X 18 X 1 3 X 2 X 2 3 1 STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X 2 2 Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES 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 The suitability of out-of-category service users at the home must be formally confirmed with individual placement officers - in writing - with an agreed careplan being put in place to address any specific identified needs. Timescales of 30.03.05, 30.06.05 & 30/12/05 not met. Timescale for action 30/03/06 2. OP19 13(4) & 23(2)(o) 30/03/06 The external area close to the house - the side entrance / exit from the house near the laundry and associated steps down to the lower lawn level - must be made safe and provided with such ramping and grab rails as make it safe and secure for all service users - and a protective gate provided at the top of the flight of stairs. Timescales of 30.03.05, 30.06.05 & 30/12/05 not met. The flooring at the base of the stairs / chairlift - leading to the smoking area must be stripped and resealed, or an alternative DS0000007206.V283025.R01.S.doc 3. OP19 16(2)(c) 30/03/06 Woodcote House Version 5.1 Page 22 flooring surface provided. Timescales of 30.03.05, 30.06.05 & 30/12/05 not met. 4. OP22 23(2)(n) Call bell points must be provided in the lounge and dining room. Timescales of 30.03.05, 30.06.05 & 30/01/06 not met. All bedroom doors must be provided with a suitable type of ‘un-deadlock-able’ lock and service user offered the facility of a key if assessed to have the capability to use it. Timescale of 30/01/06 not met. Steps must be taken to install a commode steriliser within the house itself (not in the garage) to ensure the minimisation of potential cross-infection and the health & safety of staff. Timescales of 30.03.05, 30.06.05 & 30/12/05 not met. 50 of care staff should be qualified minimally to NVQ in Care Level 2. Previously a recommendation - now a requirement. The registered manager must be qualified to NVQ Level 4 in Management - or undertake the Registered Manager’s Award in its entirety - this training should be commenced at the earliest opportunity. ‘Timescale’ set for admission to a course of study. Independent quality assurance / satisfaction surveys must be DS0000007206.V283025.R01.S.doc 30/03/06 5. OP24 12(4) & 23(2)(e) 30/03/06 6. OP26 23(2) (a) (k) 30/03/06 7. OP28 18(1) 30/06/06 8. OP31 9(1) (2) 30/09/06 9. OP33 24(1)(3) 30/03/06 Page 23 Woodcote House Version 5.1 established to enable service users - and their representatives - to affect / influence the way the service is delivered. Timescales of 30.03.05 & 30.06.05 & 30/01/06 not met. 10. OP37 17 An ‘Access to Personal Records’ policy and procedure must be put in place relating to both service users’ and staff members’ records held by the home. Timescales of 30.06.05 & 30/12/05 not met. Staff members must be trained in First Aid competence - in sufficient numbers to guarantee that the rota is covered on a 24/7 basis. 30/03/06 11. OP38 13(4) 28/04/06 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 OP21 Good Practice Recommendations Bathrooms throughout the home would benefit from refurbishment / ‘warming up’; they are currently very bleak and sterile in appearance (21). The situation concerning the future of double rooms and their occupancy at the home should be clearly stated in writing for the information of both current and possible new service users (23.6-8). 2. OP23 Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Woodcote House DS0000007206.V283025.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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