Inspection on 10/06/05 for Woodley Grange

This inspection was carried out on 10th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Woodley Grange 18/09/07

Woodley Grange 19/12/06

Woodley Grange 21/11/05

Woodley Grange 21/12/04

Woodley Grange 13/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Woodley Grange Winchester Hill Romsey Hampshire SO51 7NU Lead Inspector Carole Payne Unannounced 10.06.05 9:00am 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 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. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodley Grange Address Winchester Hill, Romsey, Hampshire, SO51 7NU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01794 523100 Manucourt Limited Mrs J Porteous CRH 36 Category(ies) of OP - 36; DE(E) - 36 registration, with number of places Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 21.12.04 Brief Description of the Service: Woodley Grange is a large detached property situated in a quiet residential area close to local amenities in Romsey, with close links to the M27 and M3. It is close to a local bus route into Romsey and Winchester and within easy reach of rail links to Southampton. The home is owned by Manucourt Limited. The acting manager, Mrs Christine Wood, was in post at the time of the inspection. The home is registered to provide care to thirty six service users in the categories of old age, not falling within any other category and dementia, over sixty five years of age. Accommodation is arranged on two levels. There is a shaft and stair lift giving access to the first floor accommodation. There are two large lounges, with dining areas. Both lounges open onto conservatories, which have delightful views over the homes pleasant and well maintained grounds. There is ramped access to the front of the home and steps lead out to the rear of the property. The home has eighteen single rooms and nine shared rooms. Athough there are no en suite rooms, the home benefits from three assisted bathrooms. The homes website address for information is www.lovingcare-matters.co.uk. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home’s first inspection for this year took place on Friday 10th June 2005 between 08.30 and 16.30. The visit was unannounced. During the inspection discussions took place with eight of the thirty people living in the home. The inspector also met with Christine Wood, the acting manager of the home, and two carers on duty during the course of the day, the home’s cook, the laundry person and two relatives. Care records were seen for four people living in the home and the home’s policies and procedures were sampled. The inspector toured the building and observed the daily routine in the home. What the service does well: What has improved since the last inspection? Since the last inspection some progress has been made in developing individual plans of care, which tell care staff what service users needs and preferences are with regard to the daily routine. During the last visit it was noted that some hazardous substances were not safely stored. This was not the case on this occasion. New dining room furniture has been acquired for one of the home’s communal areas. There are new chairs in the staff room. New carpets have been fitted in several individual rooms. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 6 What they could do better: Although there has been some progress in meeting previous requirements issued to the home there remains outstanding concerns regarding assessment, care planning and the safe handling of medicines. Below are the areas, which still require work: Although there has been some progress in developing care planning in the home, care plans do not adequately support the healthcare and individual needs of service users. Individual plans of care regarding specific needs would describe to staff members how care is to be provided and reviewed. The separate recording of contacts with the multi-disciplinary team was also suggested to support the tracking of care. When risks are identified assessments are not sufficiently thorough. They do not say why, how or when the service user is at risk. They must describe, and review, how risks can be minimised. Staff members responsible for the administration of medicines had failed to record, on every occasion, the medicine they administered or if it had been omitted, the reason for the omission. The accurate recording of medication records must be maintained. Other areas highlighted during this visit, that the home could do better, are: Medicines were being covertly administered to one service user in bread and jam. The home has no policy for the covert administration of medicines. The home was unable to produce a copy of The Guidelines for The Administration and Control of Medicines in Care Homes. Records of giving medicines must also be made at the point of administration. The home must, therefore, improve procedures for the safe handling of medicines. Some service users in the home are susceptible to falls and a high number of incidents occur. A process is needed which looks at how, why, when and how often accidents occur in the home and who is affected, so that patterns of occurrence can be observed and preventative action taken through a strengthened process of risk assessment. Despite ventilating measures in place, the communal areas remain hot and uncomfortable on warmer days. The monitoring of the temperatures in these areas and the adoption of further cooling devices must be considered to ensure the comfort and well being of service users. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 7 Although service users who may be at risk from wandering can currently enjoy a large degree of freedom in the home. The home’s gardens are currently not secure and service users who may wander require the supervision of staff outside the home. The providers’ have recognised this and there are plans to provide a secure outside environment in the home’s plans for an extension. At present the laundry is too small. This room becomes very hot, despite efforts to provide ventilation. Laundry is therefore arranged for distribution in one of the main corridors of the home, which is also very warm during the summer. The providers have brought in plans to the Commission for Social Care Inspection to provide enlarged separate facilities for laundry, as part of a planned extension to the home. It was agreed that the manager would risk assess current provisions on an ongoing basis, so that there is no risk to service users from tripping hazards, and the working temperature provided is comfortable and workable. 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. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 9 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 standard(s) 3 5 The home makes sure that no service user moves into the home without having his/her needs assessed and assures them, and their families, that their needs can be met. The home welcomes prospective service users and their families to visit and assess the quality of the facilities available in the home. EVIDENCE: Two pre-admission assessment forms were viewed for service users who had recently moved into the home. One service user had moved in for a short respite stay, and had since left the home. A hospital transfer form had accompanied one of the service users. The pre-admission forms included details of previous medical history, activities of daily living and personal care. Two relatives said that the home had been recommended to them. They said that they had felt confident that the home would be able to meet the needs of their relative. The manager said that service users and their families are welcome to come and look around the home and assess the facilities available. At the time of the Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 10 visit the manager received several inquiries regarding places available at the service. She arranged for a service user’s family to visit the following day. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 11 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 standard(s) 7 8 9 10 Although progress has been made in developing individual plans of care for service users, they currently fail to adequately support the healthcare needs of service users, reflect individual needs and minimise identified risks. The home has good links with external healthcare professionals. As contacts are recorded as part of daily records, it is difficult to track consultations and therefore review and support the care being provided. There are shortfalls in the home’s procedures for recording medicines administered, their policies and the availability of relevant information, to support the safe handling of medicines in the home. People living at the home are generally treated with care and respect. EVIDENCE: Records of care were seen for three service users in the home. The service has recently changed the system of care planning, which includes all aspects of daily living. This is guided by a series of tick boxes, which did not reflect service users’ individual needs. For example a tick box stated assistance needed, but did not describe how that was to be provided. Care plans also now refer to the preferred daily routine of the person, including details of what the service user like to do during the day, such as social interests. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 12 Former care plans were also still in place. One care plan seen reflected the particular personal care support that the service user needed, including encouragement for independence, and a sensitive approach to the service user’s care. Daily records are detailed. Records of both daily recording and assessments did, however, identify important care needs, which needed to be included in the care plans, including healthcare needs in relation to diabetes, wound care, aggressive behaviour and for one service user who is blind. Foe example, there was no plan regarding guidance for monitoring diabetes, and how to recognise and respond to an unstable condition. Two service users were also suffering very disturbed nights. There was no clear indication of how care staff members were responding to the service users’ confusion and anxieties. One plan simply said to tell the service user that she was disturbing other residents. The need to develop a care plan was discussed, so that care staff could work to develop a routine, which will support and allay the anxieties of the service users. The manager intended to consult with night staff regarding the development of plans for night care. Risk assessments were seen for falls. One care plan said that the person would try to get out of bed, but did not explain the action that was taken by night staff to try and reduce the risk of the person falling. One risk assessment said that the person was at risk using the stair lift. However, there was no follow up as to how the identified risk was to be minimised. Risk assessments seen were not signed and dated. The manager undertook to take action regarding the risk identified in relation to a service using the stair lift, and has confirmed that this service user with both her and her family’s permission is to be offered accommodation on the ground floor. One service user had signed the care plan to indicate that she had been involved in its development. The manager said that most service users were not able to participate in the development, or review, of their care plans. It was advised that families, or representatives, are consulted were possible, and that wishes to be part of the care planning process, or not, are indicated in the plan. The last report required that any restrictions to service users were identified and the consent of the service user or their family be obtained. The manager said that this was not relevant to any of the service users currently accommodated. This will, therefore, be reviewed during the next inspection visit to the home. Some service users in the home are at high risk of falls. This was reflected in detailed records of accidents and regulation 37 notifications of adverse incidents occurring in the home. Risk assessments for two service users prone to falls did not adequately describe the nature of the risk and there were no plans of care as to how these risks were to be minimised. Currently there is no Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 13 audit of accidents in the home so that trends can be observed and overall action taken to reduce the risks of falls to service users. The manager said that consultation takes place with healthcare professionals in relation to the safety of service users who may fall. However, this is currently difficult to track in daily records (see reference to the separate recording of contacts with the multi-disciplinary team.) The acting manager of the home is actively trying to address these outstanding issues. The manager has arranged for the manager of Barton Lodge Residential Retirement Care, the other home owned by the organisation, to come and give support to key workers who are being appointed. The key workers will take responsibility for organising the care of a number of service users, under the direction of the manager. This will include the development and review of care plans. The manager confirmed that the home has good working relationships with local healthcare professionals, including General practitioners, Community psychiatric nurse and dental and optical services. Assessments seen included a record of relevant previous medical history and information from other healthcare professionals. An assessment completed by the home includes reference to optical, dental and hearing aid support. Contacts with services are currently recorded in daily records. The separate recording of contacts with the multi-disciplinary team was discussed, particularly where service users’ healthcare needs were unstable. This would promote tracking of advice and support. Records seen included clear details of emergency contact numbers for service users next of kin, should they be unwell. Issues raised during the last inspection regarding the safe handling of medicines were reviewed. Although most records for the administration of medicines had been appropriately completed, there continue to be lapses in accuracy of recording. One medicine was recorded as omitted on three occasions for a reason marked ‘other’ with no explanation of what the reason for omission was. Pulse rates were being recorded for one service user receiving digoxin. Refused was indicated on one occasion, but no pulse rate recorded. The manager recorded medicines she said that she had been responsible for administering at the time of the visit and asked a carer to sign for a medicine that she had also been responsible for giving at another time. A carer said that she had had to give a service user’s medicine in bread and jam. The home has no policy regarding the covert administration of medicines and there was no indication of the consulting of the general practitioner or the service user’s family regarding this practice. The home did not have a copy of The Control and Administration of Medicines in Care Homes. Throughout the visit staff members were observed giving sensitive support to service users, helping them to move around the home, chatting Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 14 companionably. The manager took appropriate action regarding concern regarding care provided to one service user at the time of the visit. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 15 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 standard(s) 12 14 Service users experience a good quality of life in the home, which reflects their individual needs and preferences. People living at the home make choices about their daily routine. EVIDENCE: Service users’ social and cultural interests are recorded prior to admission. They are also included in the record of daily routine preferred by service users, which tells what service users like to do, for example reading and watching television. During the visit the members of staff on duty chatted with service users. One person living in the home said that she likes to keep busy and enjoys helping the laundry person to fold clothes and arrange them tidily. On the day of the visit it was one of the service user’s birthdays and members of staff joined together to wish her a happy birthday. The manager said that additional staffing at times during the week enables service users to enjoy arts and crafts, singing and puzzles. One service user said that she likes reading in her room. On the day of the visit a service user was sat outside in the sunshine enjoying the gardens at the front of the house. She said that she sometimes feels that there is not enough going on. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 16 The manager confirmed that religious events are organised to meet service users’ cultural needs. Service users preferred choices about the daily routine were recorded in records seen. Two service users spoken to say that they could do what they liked to do. The home is entered via a keypad system. The rear garden is not safe for service users who may wander. However, during the visit a service user, who likes to wander, was observed enjoying the freedom of the home and going outside under the supervision of staff members to enjoy a sit outside. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 17 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 standard(s) These standards were not assessed on this occasion. EVIDENCE: Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 18 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 standard(s) 19 21 22 25 26 Over recent inspection visits improvements have been made to the environment, promoting safety and raising the standard of maintenance. Plans to extend the home incorporate improvements to the current working environment. The manager confirmed that the home’s maintenance person was attending to items requiring urgent attention. The temperature in the home’s communal areas compromises the comfort of service users, sitting in the living areas, in the warmer weather. A good standard of cleanliness was observed in all areas of the home seen during the visit. EVIDENCE: During the visit items were reviewed that were highlighted in the last inspection report issued to the home. Most of the bathrooms have new flooring, some of the sealants around the toilet bases are uneven. The manager confirmed that the maintenance person would remedy this. The flooring in one bathroom and one toilet on the first floor remains worn, but provide clean, wipe able surfaces. These floors remain to be renewed. Pipes have been lagged as appropriate and the hot water pipes have been made safe in the dishwasher area. A new alarm has been fitted to an exit door since the Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 19 last inspection. The maintenance person was attending to a difficult closure on a door at the time of the visit. Two discoloured jugs were observed in two bathrooms, which were not in keeping with the standard of the environment. The manager said that these were used for hair washing. She said that they would be replaced. The call bells in the communal areas remain inadequate and potentially could be inaccessible to a service user with restricted mobility, or, in the case of a fall, if staff members were not around. The manager confirmed that the call bell system was being reviewed as part of the plans for the new extension. Since the last visit to the home new dining room furniture has been acquired for one of the dining areas. There are new chairs in the staff room. New carpets have been fitted in several of the individual rooms. The manager confirmed that this programme would continue to replace worn carpets in individual rooms. She also confirmed that the carpet cleaner was being repaired. It was noted in one of the service user’s daily records that there was reference on two occasions of a staff member locking the person’s door at night. The manager said that this referred to a person who locked their own door when they went to bed, and that staff members unlocked and relocked the door, when carrying out routine checks during the night. The home benefits from single lever action locks, which can be opened by simply operating the door handle. It was advised that the service user’s wishes are clearly reflected in care records. As noted in the last report, a lock has now been fitted to the door of the boiler room. The last report commented that this room was being used to store maintenance items. It was discussed that it was imperative to ensure that this room is not used to store flammable items, due to the heat in this room. All areas of the home visited were clean and free from offensive odours. Both communal areas were very warm on the day of the visit, despite fans in place and the opening of windows as permitted by restrictors. Two service users also commented that they found the second lounge excessively warm and uncomfortable. Two relatives also commented on the heat in these areas. Blinds are fitted to the windows in the conservatories. Two of the blinds in one of the conservatories remain broken, as noted during the last inspection visit, to the home. Blinds are not fitted to the roofs of the conservatories. It was noted that some of the chairs in the lounge areas are showing signs of wear and staining. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 20 It was noted in the last inspection report that there were post it notes around the home, which acted as reminders to staff members. This was not the case on this occasion. A homely environment was observed in all areas visited. At present the laundry is too small. There is room for the machines, but no room to arrange laundry or iron. This room becomes very hot, despite efforts to provide ventilation. Laundry is, therefore, arranged for distribution in one of the main corridors of the home, which is not in keeping with the standard of the communal environment elsewhere in the home. The providers have brought in plans to the Commission for Social Care Inspection to provide enlarged separate facilities for laundry, as part of a planned extension to the home. In the meantime the laundry person efficiently organises the laundry to provide the least interference to the running of the home. The manager agreed that this situation must be risk assessed on an ongoing basis, so that there is no risk to service users from tripping hazards and the working temperature provided is comfortable and workable. The clinical waste bag is currently being stored in one of the home’s bathrooms, as there is no sluice room. The manager said that the bag is regularly changed so that unpleasant odours are avoided. Commodes are washed in an unused bathroom. The home’s plans for extension include provision of separate sluicing facilities. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 21 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The number of staff working adequately meets service users needs. EVIDENCE: From staffing levels on the day of the visit and those maintained, as outlined by the manager, the levels are currently meeting the needs of service users living in the home. Service users said that staff members were supportive and always around to give help and came promptly if the call bell is activated. Currently four care staff members work during the day in addition to the manager and at night there are two members of care staff awake and one asleep. A service user’s room has been taken out of action to be used as a temporary sleep in room until the home is extended. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 22 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Although these standards were not assessed on this occasion it was noted that all hazardous substances were safely stored. The manager was advised to consult with the Environmental Health Department regarding the adequacy of the risk assessment, which had been completed for the building. This will be reviewed during the next inspection visit to the home. EVIDENCE: Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION 2 x x 2 x x 1 1 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 78 Regulation 13 15 Timescale for action Based on a full assessment, a 31 July detailed care plan must be drawn 2005 up, with the service users involvement. This must identifiy the objectives of the care plan, any problems, strengths and assistance needed to obtain the objectives. Any restrictions based upon service users must be identified within the care plan, and consent of the service user or family must be obtained. (Timescale of 30/10/03, 31/03/04, 31/10/04, 31/03/05 not met) Progress has been made in meeting this requirement. Assessments must include a full assessment of identified risks. Care plans must reflect the individual needs of the service user. All care records must be signed and dated. A letter of serious concern has been sent to the home regarding this issue. Record sheets must reflect that 30 June all medication administered is 2005 recorded. (Timescale of 30/09/03, 20/07/04, 31/01/04, 31/01/05 Version 1.30 Page 25 Requirement 2. 9 13 Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc 3. 9 13 4. 9 13 18 and 24 5. 25 12 and 13 not met) The remainder of this requirement from previous reports has been met. Medicines must be signed for at the point of administration. A letter of serious concern has been sent to the home regarding this issue. The service must produce a policy for the covert administration of medications in accordance with The Administration and Control of Medicines in Care Homes and Childrens Services published by the Royal Pharmaceutical Society of Great Britain, a copy of which, must be made available in the home. Medicines must be administered safely. Alongside formal training, care staff administering medicines, must receive regular on-the-job training and supervision. The manager must audit procedures for administration to maintain safe practice. Temperatures in the homes communal areas and the main corridor of the home must be monitored and recorded. According to the monitoring undertaken and feedback from service users, relatives and staff members working in the home, additional methods of ventilation must be employed. The blinds in the first lounge must be repaired. 31 July 2005 31 July 2005 30 June 2005 6. Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 26 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 Good Practice Recommendations Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 27 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW 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 Woodley Grange H54 S11795 Woodley Grange V231969 100605.doc Version 1.30 Page 28 - 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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