Inspection on 23/02/07 for Woodcote House

This inspection was carried out on 23rd February 2007.

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

The inspector 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 02/02/06

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 Key Unannounced Inspection 23rd February 2007 11:30a 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.V331374.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 House DS0000007206.V331374.R01.S.doc Version 5.2 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.V331374.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user is under the age of 65. Date of last inspection 2nd February 2006 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, nearby garden centre, 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 located in Carshalton Beeches. Service users and their carers continue to indicate 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 second lounge. The few smokers now either smoke outside the building, or during inclement weather, in the small staff room adjacent to the small lounge. Outside there is a patio area and a large lawned garden at the rear - both of which have a potential for possible future development. Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector conducted the visit over two days; the first found the home running comfortably well in the registered manager’s absence - she was on holiday that week, and the inspector therefore returned a second time - on 09/03/07 in the afternoon - to meet with the manager to complete this key inspection. On the first visit, Mrs Indira Debysingh, one of the permanent senior nurses, ably assisted the inspector; the inspector was able to complete the majority of his audit regarding care practices and nursing care - whilst the management and staffing sections were completed on the second visit with Mrs Ailish McNally, the registered manager. On both occasions, the inspector was able to spend time with those who use the home - both as a group and, for some, individually. One relative was met. The inspector is grateful to the people who use the service, the staff and the manager for their welcome, cooperation and hospitality shown throughout the inspection process. What the service does well: What has improved since the last inspection? Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 6 An alarm call point has been installed in the lounge area to enhance alerting communication to staff around the home. Measures have been taken to enhance the environment and make all areas as homely and warm as possible. More staff members have undertaken First Aid training - this enhancing the emergency safety input at the home; staff members have also undertaken a number of other training courses. The registered manager has commenced her Registered Managers Award course. The ‘Access to Files’ policy has been introduced. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodcote House DS0000007206.V331374.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 House DS0000007206.V331374.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, 2, 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can be confident that the information that is available 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. Standard 6 is not applicable at the home, as intermediate care is not provided. Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 9 EVIDENCE: The home’s Statement of Purpose is in place in writing, and clearly states the information required by revised Standard 1.1. The manager confirmed that all service users or their relatives have now all been given - by the Company’s General Manager - a copy of home’s Statement of Purpose, the home’s Service User Guide and also a copy of the ‘local’ home contract – to hold alongside the tri-partite contract or the private contract, where appropriate. Two service users fall into the broad ‘mental health’ category rather than the ‘dementia’ focus; one is under the age of 65. One person with a pre-senile type of dementia is also present at the home and is also under the age of 65. These service users are all those who were displaced from the closing Cladagh Nursing Home - which closure took place in 2004. As these people were longterm residents within this group of homes, the Inspector is ‘content’ with the concept of the service users remaining in the home (with familiar faces of staff, registered provider and familiar service provision). Woodcote House DS0000007206.V331374.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, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 other health care professionals as appropriate. Service users can also be assured that the management of medication in regard to their individual needs will be generally well 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: Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 11 Care plans examined for people at the home evidenced that full attention was paid to both ‘needs’ and ‘risks’ – the provision of ‘cot sides’ for one service user had been fully explored and assessed, with the service user’s partner signing their agreement with this provision. Each personal file seen had a variety of risk assessments associated with the individual’s specific condition(s). Pressure area (‘Waterlow’), Liability to Falls, Manual Handling, General Dependency, and a generic Risk-taking form were all in place to address any identified areas of concern. All people who used the service were, as ever, well dressed and presented in a neat and tidy way, with obvious personal choices of favourite clothing, and grooming - and with many a strong character ‘shining through’. The majority of the eleven people at the home have some direct or ongoing contact with a relative - be it their partners, or offspring / relatives. One person does not have contact with any relatives; the staff and service user’s social worker are actively aware of this issue, and access to advocacy has been considered. Seven of the nine people at the home have GPs located at the main Shotfield Practice in Wallington, the other two having a different GP located elsewhere. District nursing and other paramedical services are accessed either at the home or out in the community, dependent on the service user; tissue viability expertise has, for instance, been used in the past. As the home is registered to provide care with nursing, there is always a registered nurse on every shift, and they have the sole responsibility for ensuring that medication and any treatment is appropriately given. The only current intensive nursing intervention being provided was care to a person who was close to the end of their life. The immediate relative met at the home was keen that their relative remained within the security & warmth of the home. Staff have undertaken accredited Training in all aspects of medication about two years ago. Visits for inspection and advice from the pharmacist have been undertaken; again satisfactory visit reports were noted kept at the home. The needs for one service user who was having problems with pressure areas was being addressed, but the inspector was clear that recording should have been more accurately undertaken to enable a competent ‘mapping’ system of the evident progressive deterioration. Auditing the records kept by staff, there was a clear lack of concise description of the clinical appearance of the problem - this meaning that the next person taking over the care would not be able to measure any decline in the effectiveness of treatment, as they had no recorded ‘benchmark’ to measure improvement / deterioration against. Two service users had passed away in the home in the past year, and one occurred following hospitalisation. The home has positive links for provision of palliative care in conjunction with staff from St Raphael’s Hospice. Woodcote House DS0000007206.V331374.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 - 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect to lead a comfortable and pleasant lifestyle, based on individual assessment and the service user’s expressed likes & dislikes, and respecting the individual’s own decision-making. Contact with families & 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, nutritious diet to be provided, with the emphasis on personal preference and individual dietary needs, with mealtimes being a calm, appropriate & pleasurable experience. Catering facilities and storage could, however, be improved to promote best safe catering practices. EVIDENCE: Music & gentle exercise and Sing-alongs are popular. A Newspaper Group is enjoyed, tying in with low-key Reality Orientation, as is the Reminiscence Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 13 Group. The excellent ‘Memory book’ initiative - in place for a number of service users - is a good source of discussion. An activities therapist visits the home, and appropriate simple Arts & Crafts activities are encouraged. The refurbished patio area is well used during the hot summer afternoons, with, on a number of occasions, the evening meal being served outside with attendant difficulty in persuading service users back into the house! A few people who use the service continue to enjoy ‘popping across the road’ to the shops, and the local bus service enables an opportunity (now not so much used) to visit the library, shops, doctor or chiropodist in Wallington; an important opportunity for some, when they feel up to it. Trips across to the nearby Garden Centre for a visit and coffee - and pub lunches for small groups of service users accompanied by staff are the most popular expeditions from the home. One person enjoys work on an allotment and participates in a sports club. Another service user accesses an art therapy session held at Wallington Resource centre one afternoon a week – and thoroughly enjoys it. and other local coffee shops / venues. The Commission’s questionnaire to relatives and friends elicited six very positive responses, clearly evidencing that people’s friends & relatives feel positively welcomed at the home. ‘Ailish’ - the manager receives a special mention for her ‘unceasing dedication and caring’ and the remaining staff are described as ‘very kind and helpful’ by another, who continued on about having the ‘peace of mind’ as a consequence of the good service provided. Every respondent stated they were happy with the overall care provided and none of them had ever had to make a complaint. The concept of autonomy with regard to people with significant degrees of dementia is difficult to assess, however the standard is met with regard to promoting choice, access to advocates and concerning personal possessions especially for the people using the service and those who are out of category. A written statement concerning Access to Personal Records has now been introduced by the home - stating the home’s policy concerning the holding of records, levels of access, and the processes involved when requesting access. The home is fortunate to have a competent qualified chef - who was the principal catering officer for the larger nursing home setting that has closed, and an assistant chef to cover his days off. The smaller number of service users he now has to cater for enables him to ensure that a focused and person-specific service is provided. Food provided to service users - and also kindly provided for the inspector and (later) staff - was most enjoyed; it was well presented, nutritious - and freshly prepared. Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 14 The kitchen is well set up and stocked; the chef confirmed that he had all necessary preparation equipment he required. The catering premises were generally clean and well ordered. The under surface freezer which has just been removed in the kitchen now provides an excellent space (conveniently situated) for a dishwasher - an essential piece of equipment in any communal nursing / social care environment. Food storage is generally good - except the new habit of storing potatoes in the garage - which is also used as the laundry and for sterilising commodes. This approach was inappropriate and the inspector requested that such a practice cease at once. The only other identified issue in the kitchen was a need to ensure that the large larder fridge had sufficient shelving provided inside (some fixings had broken) and that the door handle be appropriately mended / restored. Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 15 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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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: The home’s written complaints procedure confirms that all complaints will be responded to with a written response being given within 28 days of the expressing of the complaint / concern. The procedure also encourages service users to consider contacting the Commission where necessary and reassures service users that their quality of care will not be jeopardised. No complaints had been received / processed by the manager since the last inspection visit. The home has a policy concerning adult abuse and also has a separate ‘Whistleblowing’ policy. The Abuse Policy clearly states that the Community Services Care Management Team must be contacted - and that they will take the lead in - and provide guidance and support to, the home - if subject to any allegations relating to Vulnerable Adult / Safeguarding issues. Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service can be assured that they will live in a generally wellmaintained and safe environment, which is clean and odour-free. People resident at the home 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. Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 17 EVIDENCE: The house is generally a warm, comfortable, homely and pleasant family-sized house, which provides a reassuring environment for people with dementia to feel they are cared for in a ‘cosy’ and ‘homely’ atmosphere. The main patio area and stairs running down to the rear expanse of lawn have been enhanced with a ramp, and gates at the top of the brick stairs leading down to the lawn / back garden. Concerns were expressed, however that the fire exit door to the patio was sticking - and half was secured by a ‘star-key’, and that the exit gate from this area was secured by a padlock which would mean that it was difficult - in an emergency situation - to leave this fenced area. Feedback to the proprietor on 25/02/07 resulted in action being taken to resolve these issues prior to the inspector’s return to the house in early March. 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. However, the flooring outside this toilet, at the base of the stairs / chairlift point, and leading to the smoking area is in a ‘bald’ condition and must be stripped and resealed, or an alternative flooring surface provided. A call bell points is now provided in the lounge / dining room areas, for the benefit of the staff, as much 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 main rooms. The home, as an ‘existing’ home, is permitted to continue providing care in the current bedrooms, including a number of people accommodated in shared rooms (four out of eleven places). It is apparent that the two double rooms continue to serve a purpose - the ground floor bedroom providing space for those unsuited to being on the upper floor, and the first floor double being occupied by two long-term friends who have agreed to the sharing concept. Bedrooms inspected were warm, reasonably furnished and comfortable; each reflecting the occupant’s personality. The single rooms were, obviously, more individualised and characterful - as service users, sometimes assisted by relatives, fully ‘take them over’. Bedroom doors within the house do not currently have an easy locking device that is deemed suitable to such an environment. Such locks must be provided with a suitable type of ‘undeadlock-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. Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 18 The home continues to have the commode steriliser situated in the garage / outhouse / laundry, 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 the commode steriliser within the house itself - to ensure both the minimisation of potential cross-infection and to ensure the health & safety of staff. Discussion has taken place with the inspector and a location - a redundant toilet facility on the first floor - identified for this purpose. However the plumbing work and relocation has yet to happen. An issue again raised to the attention of the proprietor on 01/03/07 was that of the temperature of supposedly ‘low temperature surface’ radiator surfaces. Whilst touring the home, the surface of a supposedly low-surface temperature radiator was noted to be too hot to touch in toilet 21 - hence a burn risk to service users. Located within a small toilet cubicle, the proprietor isolated this particular radiator prior to the second visit, and the inspector was assured that the system had been adjusted to ensure that universal safety had been restored to the system. The inspector recommends that the system be closely monitored, as such a temperature variation could become apparent again. It was also noted that radiators had earthing cables attached to them (e.g. in bathroom 22) - but the cables / attachment clips were sticking out - which could provide a tear hazard for the frail skin of older people using these facilities where they would be undressed / unprotected. Such protrusions should be covered - this would serve the added benefit of covering the hot water pipework at the same time - serving to double-protect those using these facilities. Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service 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 must be seen as ‘mandatory’ to ensure the best approach to care of people using the service. EVIDENCE: The home employs twenty-three staff: ten nurses, ten care assistants and three ancillary workers. Staffing ratios are provided at three care staff (including the nurse) throughout the day, with an additional staff member on duty throughout the morning. A nurse and care assistant cover the night shift both remaining awake. There is also a chef and cleaner on duty. 50 of care staff must now be qualified minimally to NVQ in Care Level 2 this was the stated standard for the end of 2005. The figure for Woodcote House, at the point of this inspection, was that one staff member had an NVQ at level 2 or above, and two out of the ten care staff were undertaking the Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 20 course, with two more due to enrol in the future. So it is projected that 30 will be qualified to that level sometime in the near future, but the figure will still be below the minimum standard required. Other aspects of staff training undertaken included: First Aid - leading to 24hour cover, Moving and Handling, Dementia Awareness, Infection Control, and the manager and one of her seniors are undertaking training as NVQ in Care Assessors. Training planned included: more Dementia Awareness, Provision of Activities for People in Care Settings, and Nutrition for Older People. A Course on ‘Safer Food Processes’ had been undertaken just before the inspector’s second visit to the home. Induction is now based on the new ‘Skills for Care’ format of competencies this will lead more naturally into encouraging a move straight into taking NVQs. Staff records are - in the main - kept within the ‘head office’ at Beeches House in Carshalton. The inspector has recently conducted an audit of staff records in that location; assisted by the General Manager, Jeremy Brook. The inspector found that all necessary checks and records were in order, being kept in individual staff folders - and reflecting suitable recruitment processes. Such records can also be made available at the home, given appropriate notice. The manager holds records of staff training and support - through 1:1 staff supervision and also by holding staff meetings at Woodcote house - and all were found to be in generally good order, though an amount of updating was found necessary - and the need to ensure that dates and signatures are attached to all documents was emphasised. Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 21 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 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 22 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. EVIDENCE: 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. Jeremy Brook is the ‘General Manager’ and supports the two homes in Brook Care Homes Ltd, through supervising the administrative side of the business - and is currently undertaking the Registered Manager’s Award himself, alongside his mother and the manager of Woodcote House. 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 allowing a specific management focus on this day, and she is clearly present on the other days to deal with any management issues which may arise at the time. Mrs McNally 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. It is understood that she is currently undertaking the Registered Manager’s Award (RMA). The registered manager confirmed to the inspector that the General Manager had devised ‘Quality Assurance’ survey material - and that it had been circulated; the responses were now awaited. Such independent quality assurance / satisfaction surveys must be implemented to encourage service users - and their representatives - to feel they can affect / influence the way the service is being delivered at the home - and there is clearly work outstanding in this area, still. A joint Lloyds TSB Account held in the service users’ collective name is held by the home - and interest is regularly awarded to each person, dependent on the amount held by the individual. Accounts have previously been seen, presented by the organisation’s Bookkeeper - these were well kept, with crossreferencing agreeing. Placing Local Authorities are predominantly the agents for service users’ finances. Small cashbooks held for individuals on site are held, with individual corresponding petty-cash slips holding signatures confirming payments of any monies handed out. Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 23 Checks of health & safety records relating to fire – alarm tests, drills, etc were all found to be in order, and health and safety audits were also in place. Inhouse checks - such as those required for food safety - were also all generally in good order. Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 24 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 3 2 X 2 X X 2 X 2 STAFFING Standard No Score 27 3 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement Medication profiles must be rigorously maintained to accurately reflect the actual current regime of medication any specific person is taking. The under-surface vacant space in the kitchen, must be used to provide for a dishwasher - an essential piece of equipment in a communal nursing / social care environment. The ‘new’ practice of storing potatoes in the multi-purpose garage is inappropriate and the inspector requested that such a practice cease at once. Timescale for action 15/05/07 2. OP15 13(3) 30/05/07 3. OP15 13(3) 23/02/07 4. OP19 13(4) & 23(2)(o) Regular monitoring must ensure 30/06/07 that fire doors do not become difficult to open during the damp winter months - and some device other than a padlock must secure the back exit from the patio - to ensure safe evacuation away form the house. Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 26 5. OP19 16(2)(c) The flooring at the base of the stairs / chairlift - leading to the smoking area must be stripped and resealed, or an alternative flooring surface provided. Timescales of 30.03.05, 30.06.05, 30.12.05 & 30.03.06 not met. Care must be taken to ensure that bathrooms and toilets with radiators do not have protruding clips / wires which may compromise the safety of the user of this area - through potential skin tears on these clips. The presence of hot water pipes must also be assessed and covered where appropriate. All bedroom doors must be provided with a suitable type of ‘un-deadlockable’ lock and service user offered the facility of a key if assessed to have the capability to use it. Timescales of 30.01.06 & 30.03.06 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 & 30.03.06 not met. 50 of care staff should be qualified minimally to NVQ in Care Level 2. Previously a standard recommendation to 2005 now a requirement and exceeding the first timescale set of 30.06.06. 30/06/07 6. OP21 13(4) 31/05/07 7. OP24 12(4) & 23(2)(e) 30/06/07 8. OP26 23(2) (a) (k) 30/06/07 9. OP28 18(1) 31/07/07 Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 27 10. OP33 24(1)(3) Independent quality assurance approaches - including satisfaction surveys for people who use the service and their representatives - must be fully introduced to affect / influence the way the service is delivered. The Commission must be sent feedback on this work stream. 30/06/07 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 YA30 Good Practice Recommendations That the manager should ensure that dates and signatures are attached to all staffing (and other) documents - to ensure they are endorsed and fully indicate the time to which they relate. That radiator surface temperatures should be regularly monitored to ensure that they are indeed safe to the touch - otherwise they may pose a burn risk to service users. 2. YA38 Woodcote House DS0000007206.V331374.R01.S.doc Version 5.2 Page 28 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 House DS0000007206.V331374.R01.S.doc Version 5.2 Page 29 - 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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