Inspection on 17/01/07 for Woodrow Retirement Home Ltd

This inspection was carried out on 17th January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodrow Retirement Home Ltd 06/06/07

Woodrow Retirement Home Ltd 06/12/05

Woodrow Retirement Home Ltd 23/08/05

Woodrow Retirement Home Ltd 08/03/05

Woodrow Retirement Home Ltd 11/05/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

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

CARE HOMES FOR OLDER PEOPLE Woodrow Retirement Home Ltd Asheldon Road Wellswood Torquay Devon TQ1 2QN Lead Inspector Michelle Finniear Unannounced Inspection 17th January 2007 09:00 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 Woodrow Retirement Home Ltd DS0000059136.V319668.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. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodrow Retirement Home Ltd Address Asheldon Road Wellswood Torquay Devon TQ1 2QN 01803 213026 01803 213026 peter@woodrowtq1.fsnet.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Woodrow Retirement Home Ltd Mr Peter James Edwards Care Home 16 Category(ies) of Physical disability over 65 years of age (16) registration, with number of places Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That Peter James Edwards completes his Managers Award (This condition has now been met and will need to be removed.) Date of last inspection Brief Description of the Service: Woodrow care home offers accommodation with personal care to older people (60/65 ) and older people with physical disability. It is registered to provide a service for up to 16 residents both male and female. Accommodation is laid out over 2 levels with a stair lift connecting the ground and first floors. The home offers 14 single bedrooms, 12 of which have en suite facilities and 1 double en suite bedroom (which is currently being used as a single). There is also 1 communal assisted bathroom. In terms of communal space, the home has a dining room with small lounge area, a separate lounge/sun room and an attractive and accessible garden. The building itself is a large detached property located within walking distance of Wellswood village and a short bus ride from Torquay town centre with its range of shops and amenities. Fees range from £290.00 to £400 per week. Inspection reports for the home are available on request. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects a summary of a cycle of Inspection activity at Woodrow since the last inspection visit to the home in December 2005. To help CSCI make decisions about the home the owner gave us information in writing about how the home is run; documents submitted since the last inspection were examined along with the records of what was found at the last inspection; a site visit totalling 8 hours was carried out with no prior notice being given to the home as to the specific date and timing of the visit; discussions were held with the manager and staff on duty; various records were sampled, such as medication records and accident logs; questionnaires were sent to staff who work at the home and the people who live there; a tour was made of the home and garden; and time was spent with the residents. In addition a sample group of residents were selected and their experience of care was ‘tracked’ and followed through records and discussions with staff and management from the early days of their admission to the current date – looking at how well the home understands and meets their needs, and the opportunities and lifestyle they experience. This approach hopes to gather as much information about what the experience of living at the home is really like, and make sure that residents views of the home forms the basis of this report. What the service does well: Woodrow provides a comfortable environment in an attractive residential area of Torquay with some rooms making very large and attractive bed sitting accommodation. The proprietor has owned the home for many years and has recently completed additional training to receive the Registered manager’s award, which is a specialised award in the management of care homes. The staff team were appreciated by residents for their kindness and caring. Food is of a high standard, with a four course home cooked lunch available each day. One resident described it as “Superb”. Several residents spoken to indicated the home was run in a very free and easy fashion with few rules or restrictions. They felt they were still able to run their own lives wherever possible. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 6 Comments from residents or their relatives included: “I have the utmost trust and faith in Peter Edwards and all at Woodrow”, “The proprietor and his staff are very good to me”, and “I have recommended Woodrow to a number of people which speaks for itself”. What has improved since the last inspection? What they could do better: Care staff must be appropriately supervised. Supervision is a system for ensuring staff are working well as a team and to their full potential to support residents. It should also help to identify any training needs staff have. The home should continue to expand upon the current quality assurance questionnaires to provide a full quality assurance and quality control system for the home. Results of the report produced should be made available. This will help residents influence the way the home is run and let them see the results of the consultation in work. The medication cupboard must be kept locked and secure at all times. This is so that resident’s medication is kept safely. A full assessment must be done before a decision is made to admit someone new to the home. This is so that the home can be sure they can meet the persons needs, and that they will fit in with the other residents currently there. Risk assessments must be carried out for the environment, moving and handling tasks and for safe working practices for staff. This is so that any risks can be identified and that staff can move residents in safety. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 7 Wedges or other objects must not be used to prop open fire doors. This is to protect residents and staff from the risks of fire and smoke spreading quickly. Staff must receive regular fire training at the frequency required by the fire authority. This is so that staff are clear what to do in case of a fire. Each resident must have a care plan, and these must be reviewed regularly to ensure they remain accurate. This is to ensure residents needs are identified, their care is planned and delivered consistently by all staff. Data sheets should be kept for all products in use. This is so that staff know what to do in the case of accidental misuse. Staff should receive training in first aid and food hygiene, so they can protect residents from risks from cross infection or give appropriate support after an accident or sudden illness. Evidence should be provided of the homes Legionella assessment, so that it is clear that the home is free from potential infection risks. Staff should attend training on the protection of vulnerable adults legislation, including what to do if abuse is suspected. This is so that they can help protect residents from poor practice. The statement of purpose should be reviewed to ensure it reflects the current situation in the home. This is so that residents can receive accurate information about the home before making a decision about whether it is the right place for them. The registered person should consider the current provision of activities and occupation, particularly with those residents who are becoming more physically or mentally frail. This is so that residents can experience full and active lives. The Registered person must follow a recruitment process including the taking up of references and a criminal records bureau check for all new staff. This is to ensure that residents are being cared for by people who are suitable to work with vulnerable adults. Care Staff must receive induction and foundation training relevant to their work at the home. This is to ensure they are trained to care for residents needs, are working in the same way and to the same standards. Please contact the provider for advice of actions taken in response to this inspection. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 8 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. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 9 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 Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 10 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 adequate . Pre-admission assessments are not being used consistently. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Woodrow has a statement of purpose and resident guide which until recently were kept in each residents room. They can also be given to prospective residents. These documents contain information on what services are available at the home and the homes complaints procedure. The documents seen were last updated in 2003. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 11 Four residents who completed questionnaires before the inspection said that they had received enough information about the home before moving in to help them decide it was the right place for them. Five resident files were seen on the site visit. Only one of these files contained evidence of a pre-admission assessment having been carried out. Pre admission assessments are important as they ensure that the home knows they can meet the needs of a proposed new resident, and that they will be suitable for the home. it also means that the proposed resident can feel confident that the home can meet their needs, which might for example include specialist equipment of staff support before making a decision about moving in. Discussion was held with the owner/manager about this. He confirmed that some assessment had taken place in each instance, however in some cases this may have included a discussion with a relative or social worker, but not seeing the resident and not in a systematic way. No recording was available to detail how a decision had been made or what information had been gathered. In one instance the home had obtained a copy of an assessment made by a professional who visited the person regularly. People who live at the home have all been issued with a contract or statement of terms and conditions, and this was confirmed in returned questionnaires and in discussions with residents, with the exception of two. Contracts set out what the fees are for the home and what the resident can expect to receive in return. Woodrow does not cater for intermediate care, but will take people for respite care if there is a vacancy. Intermediate care is a specialist service providing intensive rehabilitation with a view to the resident returning home. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is adequate. Documented care planning is inconsistent, absent or out of date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Files for five residents were selected to be seen during the site visit, and discussions were held with the majority of residents and some staff on duty. Files seen showed that none of the five residents had a full care plan available to detail what care needs the resident had and how these needs were to be addressed. Care plans are important as they identify the needs of residents and how support is to be delivered to meet those needs. They may also set goals for improvement and identify risks. For residents who are fully able to articulate their views and wishes this may not be such a major issue, but for Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 13 those who are frail, either physically or mentally this may leave them at risk of their needs being unmet or not anticipated. One file had a partial care plan, however it had not been updated since 2005. Files did not contain risk assessments, and some did not contain information on medical histories, moving and handling needs or social histories, likes or dislikes. Risk assessments are a way of identifying foreseeable risks to the individual and minimising them without undue restrictions. Discussion with a member of staff however indicated that they had a good understanding of the daily needs of individual residents at the home, and of how they liked their care to be delivered. Daily records are written for each resident, which contain information such as when they had a bath or went out that day. Some residents at the home make their own healthcare arrangements, but for those who are not able to do so the home will make arrangements for these to be accessed for them. Evidence was seen in one residents file of hospital and community medical support for a particular health need, including information available for staff on the implications of the illness. This is good practice, however it was not backed up with a care plan documenting what needed to be done by the home staff. Residents spoken to and those who completed questionnaires felt they either usually or always received the support, including medical support they needed. The home has adopted a new blister packed system for medication administration. This means that medication is bought to the home in a series of blister packs which reduces the risks or errors in administration and makes it easier to check that medication has been given out. However the medication cupboard was not locked on arrival and for periods throughout the day, and some medication was not kept in the cupboard but left on the floor in a box. This was remedied when pointed out, but had meant that medication was not being kept securely and could potentially present a risk to residents from accidental ingestion. The home had a good risk assessment for a resident who chooses to control their own medication in one file. Medication records were being completed appropriately. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. One area was excellent. Woodrow provides flexible routines for residents who are able to be active and good food. However stimulation is limited for people with memory problems or physical frailty. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents living at Woodrow vary considerably in their abilities from some who are able to follow their own chosen lifestyles, driving and socialising outside of the home to others who are completely dependant on the home for their social contacts. Limited organised activities are available at the home at present, but the planned provision of a new lounge will increase the opportunities for this. Some residents have expressed a wish to take part in more activities and discussion was held with the home owner on adopting a more person centred Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 15 approach to occupation. This might mean for example finding out what each person would enjoy or has previously enjoyed and supporting them to access this rather than trying to find activities for a group to do together. For those residents with memory loss or physical frailty this is particularly important, but at present no special opportunities or activities are provided to cater for their needs. Likewise no records were available to detail their life histories or social interests. The owner /manager confirmed he had difficulty getting this information. Visiting arrangements are open and visitors seen coming and going during the day were clearly on good terms with the staff and management. Residents confirmed that visitors were made welcome and that they could entertain them in their own room if they wished. Residents had also in many cases bought items of their own furniture and belongings into the home with them. One confirmed that the owner had been very kind in helping her to move things from her home into her room to make her feel at home. This resident also confirmed that they had chosen to come to Woodrow as there were “no rules” or rigid routines to follow. Residents or their relatives manage their own finances. One resident has a bank account where the home owner supports them in managing their finances. The meals served are of a high quality and well presented - “superb” according to one resident. On the day of the inspection site visit the meal being served was a four course lunch with the main course being Roast lamb or vegetarian lasagne. Evening meals were a free choice. Residents spoken to were very complimentary about the meals served both in quality and quantity. Meals are home cooked and based on known preferences of residents. Discussion was held with the owner concerning one resident with specific dietary needs, which are being fully accommodated. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is adequate. Residents have access to a complaints procedure and are protected by the homes policy and procedures on abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A formal complaints procedure is on display in the homes hallway and has been given to each resident in the resident guide. The procedure sets out what to do in case of a complaint and the timescales in which a response must be given. No formal complaints concerning the home have been received, other than minor issues which have been resolved immediately. Residents confirmed both in discussion and in anonymous questionnaires that they knew who they would go to with a concern or complaint about the home. The home has information available on adult protection procedures and a video which a number of staff have seen about abuse and abusive practices. No staff have attended training in adult protection at Woodrow, but the home owner has responded robustly to protect residents in the past. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good. Woodrow provides a comfortable living environment, offering residents an attractive and homely place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Woodrow is a period property, situated in a residential area of Wellswood, within a reasonable distance of local facilities and services and set within attractive gardens. There some are parking facilities at the home and nearby free on street parking. Rooms vary in size and shape from those well in excess of the minimum standard, providing lounge, bedroom and en-suite areas, to other Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 18 rooms which fall just below the current minimum size. Many rooms have period features, such as fireplaces and large bay windows. The home is on two main floors with a mezzanine floor to the rear and a purpose built extension on the ground floor. All areas of the home seen on this visit were clean and odour free. This means residents have an attractive environment in which to live. The home has a communal dining room and a small sun lounge/conservatory. Plans are in hand to improve this facility to provide larger lounge facilities, which will enhance the environment for residents. The environmental health officer last visited the home in 2006, and has made some requirements and recommendations in relation to the kitchen area and documentation for food safety. Water temperature regulators have been fitted to all outlets to which residents would have access according to the owner. This will help to protect residents from scalding. Radiator covers have been provided to protect residents from coming into contact with hot surfaces. No environmental risk assessments were available. These would be used to identify any risks to residents within the home, for example trailing wires or frayed carpets. The home does not cater for residents with severe physical disability. An environmental assessment was undertaken some time ago which indicated the premises were suitable for the then level of disability. Aids and adaptations include a specialist bath with hoist, raised toilet seats, grab rails and a chair lift to access the mezzanine floor level. This means residents physical care needs can be met at the home. One resident has had increasing needs for support with moving and handling and discussions were held on the homes management of these needs. The laundry was not seen on this inspection, however is sited in a shed to the rear of the building. The home has policies for control of infection, and training has been given to staff in this area. The home is to be redecorated externally this year. Woodrow Retirement Home Ltd DS0000059136.V319668.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): 27, 28, 29, 30 Quality in this outcome area is poor. Staff recruitment and Induction arrangements do not provide sufficient protection for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The personnel and training files for four members of staff were selected for inspection on the site visit. The files did not contain evidence of a full recruitment and selection procedure having been followed systematically for all staff. As an example only two of the four staff selected had two references taken up and some staff had not had an enhanced Criminal records bureau check undertaken. In addition some staff had only a Criminal records bureau check that had been taken up by a previous employer, which was not at the right level of protection. Criminal records bureau checks would give information on any offences committed by an individual, and other checks would show if they have previously been banned from working with vulnerable people. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 20 In addition no records were available to detail the induction training plan followed for three of the four staff. This included staff appointed in the last year. Planned Induction and foundation training is important as it ensures that newly appointed staff have good basic caring skills, understand their job role and how systems work at Woodrow. Evidence of other core training was available in the files seen, including certificates of training they had completed elsewhere. Some recent training at Woodrow has been delivered via watching videos which have been obtained by the owner. This included for one staff member training in Infection control, Dementia, and Medication in the last six months. Some of videos seen had a quiz attached for staff to complete to consolidate their training, but for those staff seen this had not been completed. The owner confirmed that several staff who had seen the dementia video had now left, so this was due to be delivered again. There was no overall training plan available or training needs assessments for each staff member. These help to identify individual training needs. Supervision is not being given to staff, despite this having been a previous requirement. Supervision is a system that involves regular meetings between a staff member and their manager, looking at their personal development, workload issues and training needs. The staff seen on this inspection were competent, caring, and experienced in care work. Staff spoken to were knowledgeable about the care needs of the residents. Residents praised staff for their kindness and thoughtfulness. Questionnaires completed indicated that staff were either usually or always available when they were needed, listened to what residents said and acted upon it and gave the support they needed. Woodrow Retirement Home Ltd DS0000059136.V319668.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 adequate. The owner /manager is experienced and qualified to manage the home. Some areas of health and safety assessment and management could put service users at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The owner/manager of Woodrow, Mr Edwards has operated the home for over 25 years and is very experienced in the care of older people. He has also achieved his registered Managers award, which is a specialist award related to Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 22 managing a care home and is currently working on his NVQ level 4, which is a management level award. The owner has been developing a quality assurance system since the last inspection, which has comprised an initial questionnaire for residents and their relatives. The results of this have been partially collated, and now are to be incorporated into a full analysis, report and action plan. A quality assurance system helps the home include the views of residents in the planning and future developments of the home, and tries to ensure that the service is achieving it’s full potential. Resident at the home manage their own finances with the support of relatives or solicitors where needed. The home supports one resident and their monies are maintained in their own bank account. Discussion was held with the owner on the management of health and safety issues at the home. All radiators are said to be covered which prevents residents being accidentally scalded. Temperature at all water outlets is restricted, which means that residents cannot be scalded by hot water. The fire officer visited in 2006, and has made some requirements to ensure that the home would be safe in case of fire. Some of these have been attended to, others remain to be achieved. This included fire training for the staff, which is not being carried out at the required frequency. Some staff have received training in moving and handling, but not all yet, and there was no risk assessment or moving and handling plan for a significant moving task. Likewise some staff have had first aid training and food hygiene, but others are waiting for this to be delivered. The owner confirmed that the premises have been inspected ad were safe from Legionella but no evidence was available to detail the results of this survey. Chemicals in use at the home such as cleaning materials were being kept safely at the home but there were no data sheets available for the products. Data sheets contain information about what to do in case of accidental misuse of the product. There were no environmental risk assessments or safe working practice risk assessments available. Risk assessments are a tool for managing foreseeable risks in the environment or in the way staff carry out their jobs. They should ensure that risks are identified and minimised. They need to be reviewed regularly. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 24 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 OP36 Regulation 18(2) Requirement The registered person shall ensure that persons working at the care home are appropriately supervised. (Care staff must be appropriately supervised.) Previous dates for completion 30/10/05, 30/03/06 not met. 2. OP33 24 The registered person shall establish and maintain a system for:- a) reviewing at appropriate intervals and b) improving the quality of care provided at the home. The registered person shall supply to the commission a report in respect of any review conducted by him… and make a copy of the report available to residents. (The home should expand upon the current quality assurance questionnaires to provide a full quality assurance and quality control system for the home. Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 25 Timescale for action 22/04/07 22/04/07 Results of the report produced should be made available). Previous date for compliance 30/03/06 not met. The registered person shall make 17/01/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. (The medication cupboard must be kept locked and secure at all times.) Previous date for compliance 06/12/05 not met The registered person shall not provide accommodation to a resident at the care home unless, so far as it shall be reasonably practicable to do so – The needs of the resident have been assessed by a suitably qualified or suitably trained person; The registered person has obtained a copy of the assessment and there has been appropriate consultation regarding the assessment with the resident or a representative of the resident. (A full systematic assessment of a persons needs must be undertaken before a decision is made about their suitability for admission.) The registered person shall ensure that – all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety. -any activities in which service users participate are so far as is reasonably practicable free from risks and DS0000059136.V319668.R01.S.doc 3. OP9 13 4. OP3 14 22/04/07 5 OP36 OP19 13 (4) (5) 22/04/07 Woodrow Retirement Home Ltd Version 5.2 Page 26 - unnecessary risks to the health and safety of service users are identified and as far as possible eliminated. The registered person shall make suitable arrangements to provide a safe system for moving and handling service users. (Risk assessments must be carried out for the environment, moving and handling tasks and for safe working practices for staff). Wedges must not be used to prop open fire doors. If hold open devices are required the advice of the fire authority must be sought concerning approved devices. The registered person shall after consultation with the fire authorityMake arrangements for persons working at the care home to receive suitable training in fire prevention; to ensure by means of fire drills and practices at suitable intervals, that the persons working at the care home …are aware of the procedure to be followed in case of fire. (Staff must receive regular fire training). The registered person, shall, after consultation with the resident, or a representative of his, prepare a written plan as to how the residents needs in respect of both his health and welfare are to be met. The registered person shall………b) keep the residents plan under review. (Each resident must have a care Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 27 6 OP38 23 17/01/07 7 OP38 23(4) (d, e) 22/04/07 8 OP7 15 17 (1) (a) 22/02/07 9 OP29 19 plan, and these must be reviewed regularly to ensure they remain accurate.) The registered person shall not employ a person to work at the care home unless-…… b) he has obtained in respect of that person the information and documents specified in paragraphs 1-7 of schedule 2. ( The Registered person must follow a recruitment process including the taking up of references, evidence of the persons identity, evidence of qualifications, two written references and a criminal records bureau check for all new staff). 22/02/07 10 OP30 18 The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users…. .c) ensure that the persons employed by the registered person to work at the care home receive – i) training appropriate to the work they are to perform. (Care Staff must receive induction and foundation training relevant to their work at the home.) 22/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000059136.V319668.R01.S.doc Version 5.2 Page 28 Woodrow Retirement Home Ltd 1 2 3 4 Standard OP38 Data sheets should be kept for all chemical and cleaning products in use Staff should receive training in first aid and food hygiene. Evidence should be provided of the homes Legionella assessment Staff should attend training in the implementation of the protection of vulnerable adults legislation, including what constitutes abusive practice and what to do if any is suspected. The statement of purpose should be reviewed to ensure it reflects the current situation in the home. The registered person should consider the provision of person centred activities and occupation, particularly with those residents who are becoming more physically or mentally frail. OP38 OP38 OP18 5 6 OP1 OP12 Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Woodrow Retirement Home Ltd DS0000059136.V319668.R01.S.doc Version 5.2 Page 30 - 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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