CARE HOMES FOR OLDER PEOPLE
Woodrow Retirement Home Ltd Asheldon Road Wellswood Torquay Devon TQ1 2QN Lead Inspector
Michelle Finniear Unannounced Inspection 08:30a 6th June 2007 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.V336767.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.V336767.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.V336767.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. That Peter James Edwards completes his Managers Award (This has been achieved and will be removed) 17th January 2007 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.V336767.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 January 2007. 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 and included in an action plan produced following that visit; a site visit totalling 7 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. Eleven people living at the home and eight staff completed questionnaires about the home, and returned them to CSCI. 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 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. People spoken to were full of praise for the food. One commented the meals were “home cooked with fresh vegetables and always a large choice of veg”. Woodrow Retirement Home Ltd DS0000059136.V336767.R01.S.doc Version 5.2 Page 6 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. Comments from residents or their relatives included: “It is a small home and we are all treated as special guests. I enjoy the homely atmosphere and it is very cosy” and “I am very happy at Woodrow & find everyone most kind and helpful.” What has improved since the last inspection?
Since the last inspection the home manager has Put in place a new system for supervision of care staff. 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 medication cupboard is being kept locked and secure at all times. This is so that resident’s medication is kept safely. A full assessment is being 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 are being 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. Wedges or other objects are not being used to prop open fire doors. This is to protect residents and staff from the risks of fire and smoke spreading quickly. Staff are receiving 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 person living at the home has a care plan, and these are being reviewed regularly to ensure they remain accurate. This is to ensure peoples needs are identified, their care is planned and delivered consistently by all staff. Data sheets are being kept for all products in use. This is so that staff know what to do in the case of accidental misuse of chemicals or cleaning materials. Staff are receiving 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.
Woodrow Retirement Home Ltd DS0000059136.V336767.R01.S.doc Version 5.2 Page 7 Staff have had 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 practices. The statement of purpose has been 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 is following a full 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 are receiving 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. 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
Woodrow Retirement Home Ltd DS0000059136.V336767.R01.S.doc Version 5.2 Page 8 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.V336767.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.V336767.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, 4, 5, 6 Quality in this outcome area is good. Good information is available about the home, which helps people to make a decision about whether the home is the right place for them; full assessments are carried out to make sure the home can meet the persons needs before they are offered a place at Woodrow. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection site visit in January 2007 the owner has updated the statement of purpose and service user guide. These contain information about the services provided at the home and can be used to help people judge whether the home is the right place for them. Files for four people living at Woodrow were seen on the site visit.
Woodrow Retirement Home Ltd DS0000059136.V336767.R01.S.doc Version 5.2 Page 11 Since the last inspection site visit the owner has updated the pre-admission system was including a new pre-admission assessment. Although no new people have been admitted since the last inspection was completed, these assessments are being implemented retrospectively for all people living at the home. In addition the home had recently received a referral, at which time the pre-assessment tool had been used. It was therefore possible to see how this system was working in practice. The form used is comprehensive, and should enable the homes management to make a clear decision about whether Woodrow is the right placement for the person referred to them and whether they can meet their needs. As an example a recent referral had been identified by the home owner as not suitable because the person referred had severe mobility problems. This demonstrates that the home only takes in people whose needs they can meet. People considering living at Woodrow are also encouraged to come and visit the home prior to making any decision. This would include if they wish an overnight stay and opportunity to have meals with the other people living at the home. Relatives or other supporters are also encouraged to visit, view any accommodation on offer and if wished help the person decide on items they wish to bring from their own home into Woodrow to help them settle quicker. One person commented “I looked at a few others and always came back to choosing Woodrow”. This process was demonstrated in files and through discussion. Each person living at the home has a contract, which gives them information about the services available at the home, the fees that are paid by them or on their behalf, and what they can expect in return. Sample contracts were seen, and most people who completed questionnaires confirmed they had received one. One said that they could not remember being given one. Woodrow does not cater for intermediate care. That means they do not provided specialist intensive programs of rehabilitation with a view to returning people to their own home. Woodrow Retirement Home Ltd DS0000059136.V336767.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. Care is being well planned and delivered. Inappropriate restraint was being used intermittently in an attempt to protect injury to one person living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans for four people living at the home were seen during the site visit. Since the last inspection plans have been considerably improved, and are much more ‘person centred’. This means that they are making the individual the focus of the plan rather than fitting the person into the service. The files also contained information, linked to the assessment, of what support people need to live their lives and how they wish this to be given. Good care plans mean that care can be given consistently.
Woodrow Retirement Home Ltd DS0000059136.V336767.R01.S.doc Version 5.2 Page 13 For some people living at the home, consultation has been held with relatives or other supporters, as the person living there has not been able to actively engage in this process themselves. Some information on individuals life histories has also been gathered. This is important as it helps carers understand the whole person they are working with, and choices people may make about their care. Information on particular issues relating to the health of the individual, for example from the Stroke association, so that staff are aware of the implications of these disorders and their effects on the individual. Risk assessments have been undertaken, including assessments of moving and handling needs and falls. This is important as it ensures that any undue risks associated with living at the home or choices people have made have been identified and are being addressed as far as possible. They also give clear instructions for staff on how people who need support with moving and handling are to be managed. This ensures that staff can work safely, consistently and in a way the person wishes. For one person the home owner had utilised a small Stair gate to the door of their room, with a view to ensuring that a did not fall unobserved in a corridor area or attempt to leave the premises where they would be at considerable risk. This was carried out with the consent of relatives and was not present all of the time, but still presents an unacceptable restraint. Discussion was held with the owner on the suitability of the placement, and this was removed during the visit. The home has good links with external professional support services such as district nurses, doctors and other paramedical staff. During the course of the side visit a member of the specialist community supports team came to the home to help staff with a person who was very frail with a particular healthcare need. Discussion about this was held with staff at the home who were very clear about the persons needs and demonstrated a strong wish to continue to care for them. The medication systems at the home were seen, and some discussion held with staff about administration and training. The home uses a monitored dosage system, which means that medication is pre-packed in a series of coloured blister packages which make it easier for staff to administer and observe if there had been errors in medication. Woodrow Retirement Home Ltd DS0000059136.V336767.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. Woodrow offers a relaxed environment for people who are active and able, but may not provide sufficient organised activity for people who are more frail. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Woodrow at time of the inspection site visit was providing care to people with a wide range of needs, from those who were very frail and in need of a lot of support both physically and mentally, to people who were practically independent and self caring. This presents a number of issues for both extremes of need. As an example when asked about activities at the home one person commented “ Not interested as I have many friends who visit me and I them”, while another said ”Not applicable as I am confined to bed”. Another commented “There is a choice and they are displayed but I do not always want to take part. I do not like group activities much”. Several relatives felt more activities would benefit the people living there.
Woodrow Retirement Home Ltd DS0000059136.V336767.R01.S.doc Version 5.2 Page 15 Discussion was held with the provider on the activities and stimulation on offer for service users. The home provides games, puzzles, and DVDs but people who are mentally frail would require considerable support and motivation to use these, and currently there is little scheduled. For those people who are very active the home provides a flexible and comfortable environment. Many people spoken to commented on the fact that the home had few rules and regulations, and that people were free to come and go or entertain their friends as they wished. Service users receive a very good diet in the home, with plenty of choice and fresh food. On the day of the inspection site visit the meal served was cottage pie and fresh vegetables, but alternative choices available were vegetable lasagne, omelettes or salad. Dessert was fresh strawberries and cream. All of the people spoken to who could express an opinion said that meals were of a very high standards. The evening meal was practically a free choice and people had requested a variety of lighter meals from sandwiches to egg on toast. Woodrow Retirement Home Ltd DS0000059136.V336767.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): 16, 17, 18 Quality in this outcome area is adequate. The home has a clear complaints procedure and people are substantially protected from abuse by the homes policies and procedures, however one issue of restraint was inappropriate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Woodrow has a complaints procedure, which is available in the homes hallway. The complaints procedure explained how and to whom people should complain if they have any issues of concern, and this included agencies outside of the homes should people feel unable to complain directly to the home. Questionnaires completed indicated that people were very clear as to who they should go to if they had any issues and would feel free to do so. One commented I have no need to complain. Some adult protection training has been given to staff, and others still need to receive this. Adult protection training helps staff understand about abuse and abusive practice. The home has a video and a copy of the local policy agreement on adult protection which is available for staff to see. For one person the home owner had installed a small stair gate to the door of their room, with a view to ensuring that a did not fall unobserved in a corridor area or attempt to leave the premises where they would be at considerable risk. This was carried out with the consent of relatives and was not present all of the time, but still presents an unacceptable restraint. This was removed during the visit and other planned action was discussed.
Woodrow Retirement Home Ltd DS0000059136.V336767.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 and homely environment for older people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Woodrow is a detached Victorian villa situated in a leafy residential part of Torquay, but close to a main road. The house is situated in attractive gardens, with patio areas where people living at the home could sit outside. Some rooms also have direct access to the gardens. There is some parking to the front of the home but plentiful free on street parking nearby. The home is reasonably close to bus routes and local shops. Rooms for people living at the home vary considerably from those which are small and cosy to large spacious rooms with high ceilings and period features. The majority of rooms have en-suite facilities of at least a toilet and wash hand
Woodrow Retirement Home Ltd DS0000059136.V336767.R01.S.doc Version 5.2 Page 18 basin, but some with baths or showers. Rooms are light and airy and overall the property is maintained in good condition. Each persons room has been individually furnished, many by the service users themselves. The is a small sun lounge to the front of the home, however this appears to be seldom used. The manager has been negotiating with the local authority on planning permission to extend this area to make it more attractive and usable. It may also provide a venue for more communal activity as currently there is not a place where people congregate other than in the dining room at meal times. Radiators are covered to protect service users from being accidentally injured, and hot water is regulated so that people living at the home cannot be accidentally scalded. This was tested at random in one persons room and found to be at a reasonable hand hot temperature. There is an administrative office in the basement, and the laundry is situated in an outbuilding to the rear of the home. People spoken to confirmed the home was kept very clean and comfortable, that their rooms were well maintained. One said “It is a real home from home”. Woodrow Retirement Home Ltd DS0000059136.V336767.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 good. The numbers of staff and training arrangements are able to meet the needs of the people at the home, and they are also protected by the systems for staff recruitment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In the last few months there has been a high turnover of staff at Woodrow, however there is a regular core of staff who have been at the home for years, and are very experienced carers. On arrival at Woodrow on this unannounced site visit, there were three staff on duty, which was later supplemented by the owner and other support staff. This was an adequate number to cater for the needs and dependency level of the people living at home, however as frailty levels increase this will need to be re-examined Since the last inspection site visit the home has spent considerable time improving their recruitment systems. This has included providing for each person a separate file, with checklists on paperwork still needed. The files sampled at random contained the required paperwork for each persons recruitment, including criminal records bureau checks and copies of references.
Woodrow Retirement Home Ltd DS0000059136.V336767.R01.S.doc Version 5.2 Page 20 A thorough recruitment process helps to ensure that people are cared for by staff who are suitable to be working with vulnerable adults. Since the last inspection the home has also been developing training systems. Currently 50 of the staff group have an NVQ level 2 in care, which is a national award recognising the competency of staff. In addition core training has been or is being provided in subjects such as infection control and care of people with memory loss. Although one persons induction book had not been completed, others had been. These demonstrated a full process is available to ensure staff are working consistently and to an agreed standard. The staff on duty had a clear idea about their roles and working practices with people living at the home. Discussion was held with two staff on the care requirements of one person in particular, and they outlined the way in which they delivered this persons care. The discussion showed that staff were working consistently and supporting this person in the same way. They also had a clear understanding of the persons emotional needs and presented as a very caring and compassionate towards them. Woodrow Retirement Home Ltd DS0000059136.V336767.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 home is being well managed. Further development is required to the quality assurance systems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The representative of the company owning the home is Mr Peter Edwards, who has owned and operated wardrobe for over 25 years. He has achieved his registered managers award, which is a qualification in managing care homes, and is currently completing his NVQ level 4, which is another specialist award in relation to management. Supervision systems have been and are being implemented since the last inspection visit. Supervision is a system that combines performance
Woodrow Retirement Home Ltd DS0000059136.V336767.R01.S.doc Version 5.2 Page 22 management and personal development for staff and should mean that they are able to work consistently to support people living at the home and also worked to their full potential. The home owner has also had some training in appraisals, and a formal system has also been implemented for this. Discussion was held on ways of keeping the process interesting and keeping staff involved with their personal development. Discussion was held on health and safety was in the home. No evidence was available to detail of the electrical tests to the home or portable appliance testing, however it is understand that this is to be done in the next few weeks. Discussion was held on increasing the environmental and risk audit systems in place to ensure they are carried out more frequently. This will allow for easier identification of problems with the premises at an early stage. The home has commenced but not completed a quality assurance programme. This has begun with the issuing of questionnaires to people living at the home about the service they receive. Their views then need to be incorporated with a wider range of audited information and wider views about the operation of the home into a full report on what the home is doing well and what could be improved. This helps people living at the home affect the way that the home is run. Woodrow Retirement Home Ltd DS0000059136.V336767.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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 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 Woodrow Retirement Home Ltd DS0000059136.V336767.R01.S.doc Version 5.2 Page 24 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 OP33 Regulation 24 Requirement The home should 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. Previous dates for compliance 30/03/06, 22/04/07 not met. 2. OP7 OP17 12 13 Physical restraint in the form of a 06/07/07 stair gate must not be used to prevent a person leaving their room or the home. A reassessment of this persons needs must be carried out. Timescale for action 30/09/07 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 OP12 Good Practice Recommendations The registered person should consider the provision of
DS0000059136.V336767.R01.S.doc Version 5.2 Page 25 Woodrow Retirement Home Ltd person centred activities and occupation, particularly with those residents who are becoming more physically or mentally frail. 2. OP38 Regular electrical wiring and portable appliance checks should be undertaken to ensure safety for people living and working at the home. Woodrow Retirement Home Ltd DS0000059136.V336767.R01.S.doc Version 5.2 Page 26 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
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