Inspection on 14/05/07 for Badgers Wood Care Home

This inspection was carried out on 14th May 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

Badgers Wood Care Home 18/03/10

Badgers Wood Care Home 08/01/08

Badgers Wood Care Home 16/05/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Badgers Wood Care Home 29 School Road Drayton Norwich Norfolk NR8 6EF Lead Inspector Mr Jerry Crehan Unannounced Inspection 14th May & 22nd May 2007 09:45 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 Badgers Wood Care Home DS0000065307.V341241.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. Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Badgers Wood Care Home Address 29 School Road Drayton Norwich Norfolk NR8 6EF 01603 867247 01603 261114 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) www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Mrs Anne Claire Riches Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16th May 2006 Brief Description of the Service: Badgers Wood is a care home providing residential care for up to 45 older people. It is situated in a residential area of Drayton, which is approximately four miles from the city of Norwich. There are local shops, pubs and other amenities within the immediate vicinity of the home. Badgers Wood was purpose built in 1986. The accommodation is provided on two floors serviced by stairs and a shaft lift. There are 31 single rooms and 7 shared rooms. There are enclosed patio areas and grounds, which are visible from service user bedrooms. Badgers Wood is one of several homes in Norfolk owned by the proprietors. Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection compromised an unannounced visit to the home that took place over 10 hours on 14th & 22nd May 2007. Opportunity was taken to tour the premises, look at care records and policies, and communicate with the home’s service users in addition to its staff, and the Manager. The inspection report reflects regulatory activity since the last inspection and evidence from inspection of Key Standards. The Manager provided pre-inspection information to the Commission prior to the inspection. This included 3 comment cards from relatives and visitors to the home which gave broadly favourable comments about the service provided by the home, however, a recommendation has been made in this report as only two comment cards have been received from people who use the service. Badgers Wood is one of several homes in Norfolk owned by the proprietors. The range of monthly fees for the home is from £1048. What the service does well: • People who use the service each have a care plan that is regularly reviewed and that involves the service user and their relative where possible. People who use the service have access to a good programme of activities that assists in meeting their social and recreational needs. The environment at the home is safe, well maintained externally, and designed to support the needs of people who use the service. People who use the service find the staff at the home caring in their approach to them. • • • Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? • • People who use the service are afforded greater privacy, as every bedroom at the home is now lockable. The Manager has worked hard to ensure sufficient staff have access to a variety of important training including first aid, dementia awareness and infection control. There is an increase in the number of staff who are NVQ 2 trained. The Manager and Proprietor have developed new systems to ensure that the home is run in the best interests of service users. • • What they could do better: • • The health and welfare of people who use the service are not always safeguarded by record keeping practices in individual care files. Guidance and training for staff in the protection of vulnerable adults is not adequate and has not protected people who use the service from possible abuse. There have been repeated instances when there have been insufficient staff on duty to meet the needs of the service user group, which had not been reported to the Commission. Staff induction training falls short of providing newly appointed staff with the training, support and supervision they need to meet the needs of people who use the service. • • Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 & 6 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people to use the service have their needs assessed, and access to all of the information they need about the service they may choose. EVIDENCE: The home has an assessment pro-forma (pre-admission assessment) used by the manager when collecting information. The document is well designed to ascertain the level of support required by prospective service users. There was evidence of good assessment of prospective service user’s. A recently accommodated service user was spoken with. They confirmed that they had had the chance to ‘have a little look’ at the home prior to their move, and was appropriately placed at the home, as were other service users observed during the inspection visit. Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 9 Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Personal care and medication practices provided at the home are generally good, however, some care recording practices do not safeguard the health and welfare of people who use the service. EVIDENCE: Several care files were looked at during the site visit. Each contained individual care plans and risk assessments. The files were seen were all well maintained and up to date. Each care plan had evidence of review that involved the service user and their relative where possible. Care plans contained generic and individual risk assessments. The care planning system is generally well used by staff at the home to describe care needs clearly, and to record care provided and the progress of service users. However, a care plan for service user indicates significant recent weight loss over recent months, though a malnutrition screening risk assessment indicates Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 11 a score of zero. A nutritional risk assessment indicates ‘Cause for Concern’, but does not indicate the recent weight loss, which should indicate ‘At Risk’. There was no care plan that indicated the service users problems with eating/nutrition and indicating planned care. The same service user has a care plan for falling, which is evidently reviewed monthly, however, reviews clearly do not reflect that the service user has had three falls over recent months. Consequently the care plan in place did not address the actual risk from falls to the service user (see Requirement 1). Care records provided evidence of liaison with, and visits from a variety of health professionals including the G.P, chiropodist, district nurse and the hearing aid clinic. Comments from the three comment cards received from relatives/visitors to the home prior to the inspection include: ‘happy with my mothers care’, ‘home prepared to run the extra yard to make stay comfortable’ ‘the care staff are efficient and caring, however, they seem to be constantly short staffed’. Care staff were observed working well in supporting the health needs of service users at the time of the inspection visits. Good care practice was observed as care staff talked to service users and explained their actions as they hoisted service users. Some service users were observed to be being pushed in wheelchairs with no footplates, or with footplates that were not used and their feet nearly dragging on the floor. There are suitable safe storage arrangements for medication. There were no service users responsible for their own medication at the time of the inspection visit. However, the manager stated that this is promoted at the home where possible. This is important because the home regularly offers care to service users on a short term or respite basis. There were service user-identifying photographs alongside Medication Administration Charts (‘MAR’) charts to assist in the safe administration of medicines. The administration of painkilling medicines prescribed on a PRN (as required) basis at the discretion of members of care staff was considered. For these medicines there is an absence of care plan guidance alongside MAR charts to ensure they are administered as appropriate (see recommendation 1). MAR charts reviewed correspond with stock held on sample audits undertaken. There is a concern at the length of time the medication administration round takes to complete, particularly in the morning. At the time of the inspection visit the 8am medication round was still in process at 9.40am. The manager said that she was aware of this and would monitor the issue taking appropriate action to address if required. When asked whether care staff listen and act on what they say, service users gave good responses such as ‘they spoil me’ and ‘staff are excellent’. Service users spoken to stated that their right to privacy is respected at the home, and that their visitors are made welcome and can be seen in private if they wish. Visitors also confirmed that they are made welcome and can see service users in private. Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have access to a good diet. Social and recreational activities meet individual’s expectations. EVIDENCE: There is a dedicated activities coordinator employed on a part time basis at the home who publicises the activities on offer. A comment card received prior to the inspection indicated that one of the things the home does well is ‘the rapport between staff and residents, and the organisation of social events for residents’. The home has records of activities participated in by service users. This provided evidence of activity including one to one discussion, reading, story telling or singing taking place at least weekly. A service user with physical disability spoken with stated that they liked to listen to the radio, which broke recently but which was replaced by staff. The same service user said that they would like to participate in musical events in the main lounge area but that the appropriate seating isn’t always available. This matter was brought to the manager’s attention to deal with at the time of the inspection visit. Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 13 The social and leisure needs of service users were generally met. The manager, visiting relatives and service users confirmed that visitors and relatives can attend the home at any time. There were visitors to the home at the time of the inspection visit. The rooms seen on the day of the inspection visit are furnished and equipped to suit the service users daily lifestyle and reflect their personal choices and preferences. The menu on the day of the inspection visit was lamb stew or toad in the hole with vegetables and mashed potato. There was also a choice of sweet option available. Service users generally choose where they wish to take their lunch. About twenty service users took their lunch in the main lounge, a further eight service users who require some assistance at mealtime took their lunch in a smaller dining room. Other service users took their meals in their own bedrooms. Two comment cards from service users received prior to the inspection visit made specific reference to food at the home, one indicating a view that ‘meals too bland, often lukewarm or even cold, ready to eat foods poor quality’, the other that they usually like the meals at the home. However, at the time of the inspection visit service users gave generally positive views as to the food on offer at the home, with one service user who was taking their meal in their bedroom stating that it was ‘lovely and hot’. Tea, biscuits and other drinks were made available to service users during the morning and afternoon, and there was evidence of fluids available to service users in their bedrooms. A care plan for a service user seen indicated that they must have access to ‘plenty of fluids at hand and a clean jug’. The guidance had evidently been followed with a jug of water and clean glass by their bed. Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 14 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): Standards 16 & 18 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have access to an effective complaints procedure. Practice guidance and training for staff in the protection of vulnerable adults is not adequate. EVIDENCE: The home has a detailed complaints procedure and information on how to make complaints is detailed in the home’s guide for service users. Each of the three comment cards from relatives/visitors to the home indicate that they know how to make a complaint about the care provided by the home if they needed to. Both of the comment cards from service users received prior to the inspection indicated that they also know how to make a complaint. The manager provided information that that the home had received two complaints in the last 12 months one of which had been substantiated, the other partly substantiated, which was investigated through the Norfolk Adult Protection Protocol. The home has recent experience of appropriately referring matters for investigation through this Protocol, for the protection of vulnerable adults living at the home. The manager keeps records of complaints all of which are responded to in writing. It was evident following disclosure from staff spoken with that service users have not been protected from possible abuse. Matters that should have been referred through the Norfolk Adult Protection Protocol had not been brought to Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 15 the attention of the home’s Manager. Consequently discussion took place during the inspection visit and it was agreed that a referral should be made following this disclosure of possible abuse. Staff who had not worked at the home for long have had limited training and limited knowledge of the adult protection policy and practice of the home. The induction training records for some staff were reviewed and did not demonstrate a satisfactory approach to induction training generally or in relation to the protection of vulnerable adults (see Requirement 2). There were some records of training that had evidently occurred on a single day soon after the staff member had started with no further follow up in the following two months. Records for another staff member were not available. New staff appeared to have little knowledge of their training progress or of induction training expectations of them. Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment at the home is safe, well maintained and designed to support the needs of people who use the service. EVIDENCE: A tour of the premises was undertaken. The grounds and garden were safe, attractive and very well looked after. There are accessible patio areas with seating for service users, and a pathway around the gardens and home. Bedrooms are reasonably decorated, as are communal areas. However, the carpet in the smaller of the two dining rooms is very stained and should be replaced (see recommendation 2) and dining tables very wobbly (though are apparently due to be replaced). Every bedroom door is lockable to support the privacy of service users and the security of their belongings. Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 17 An assessment of the suitability of the premises, including its design and layout has been completed following a requirement from a recent complaint investigation. This includes a range of matters including the external grounds, laundry area, equipment suitability, water temperature, bedroom safety and fire safety. The home has an under floor central heating system with individual thermostats in each bedroom. A number of service users were observed to be using portable radiators in their bedrooms to maintain a temperature that they prefer. The internal and external environment is generally safe and accessible for service users and staff. A keypad has been fitted to the front door and on the route to the ground floor for additional security. Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 & 30 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There have been improvements in staff training, though staff in the home are not deployed in sufficient numbers, or in some cases trained sufficiently to support and protect the people who use the service. EVIDENCE: There is a total care staff compliment of twenty-five. Staff rotas and the manager indicate that there is six care staff on duty for the morning and afternoon shifts every day of the week, with five care staff available each evening. Staff rotas indicate the provision of three care staff each night. The manager indicated that where there have been problems with maintaining this allocation, care agency staff have been used. The Proprietor’s representative reported to the Commission that there had been a repeated instance in early March 2007 where there had been two care staff on duty at night, which is insufficient to meet the needs of the service user group. At that time this shortfall had not been reported to either the Proprietor’s representative or to the Commission, though this has now been rectified (see Requirement 3). Staffing numbers and deployment present a concern regarding the length of time the medication round is taking to complete. However, the manager will monitor this issue as indicated already in this report. There was only one carer Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 19 available to the twenty service users taking their lunch in the main dining room at this peak time of the day. Some service users required assistance to return to their armchairs in the lounge or to their bedrooms and had to wait for some time as the carer worked hard to meet the needs of those requiring support. Two staff were taking their break at the same time, and although it is acknowledged that staff should take regular breaks when on duty it is recommended that the Manager rearrange the staff break roster in order that sufficient staff should be allocated at this peak time (see recommendation 3). A service user commented that the District Nurse had visited them during the morning, they had rung their call bell for assistance, though, no carers came so they managed on their own. Comment cards from relatives/visitors received prior to the inspection visit which comment specifically on staffing at the home included the following: ‘the care staff are efficient and caring, however, they seem to be constantly short staffed’ and ‘staff are very approachable if any query about a relative is needed’. At the time of the inspection visit twelve of the twenty-five care staff had achieved NVQ 2 or above (or equivalent), with a further five care staff working towards this qualification. This represents a significant improvement from previous inspections and will see the home exceed the minimum Standard of 50 of all care staff with NVQ 2 (or equivalent) training. Sample staff files and discussion with carers provided evidence that service users are protected by good recruitment practices. Sample staff files seen and discussion with staff provided evidence that staff induction training falls short of providing newly appointed staff with the training, support and supervision they need (See Requirement 4). The Manager has worked hard to ensure sufficient staff have access to a variety of other training including first aid, dementia awareness and infection control. Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35 & 38 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Management of the home has developed quality assurance systems and is qualified. People using the service are being put at potential risk through staffing and training shortfalls compromising the protection of the vulnerable adults who use the service. EVIDENCE: The registered manager has three years management experience and has recently successfully completed the Registered Managers Award qualification, in addition to undertaking other relevant training periodically. One of the two complaints referred to above was made by relatives of a service user and concerned the attitude of Manager and was investigated by the Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 21 Proprietor’s representative as a consequence. A comment card received from a relative/visitor prior to the inspection visit indicated that the ‘Manager has always taken time to listen and take action’. Service users and staff spoken to during the visit describe the Manager as approachable. The Manager and Proprietor have developed systems to ensure that the home is run in the best interests of service users. These include surveys of the views of service users and others associated with the home, copies of which are sent to the Commission with other copies available in the home, an ‘in home’ quarterly newsletter for service users, quarterly team meetings, quarterly residents and relatives meetings, and various audits and validation audits undertaken by the proprietor’s representatives. Only two comment cards completed by service users were received prior to the inspection visit, these should be more effectively promoted at the home in order to provide a representative view from people who use the service (see recommendation 4). Service users financial interests are safeguarded by the home; their relatives manage the vast majority of service users financial affairs. Record keeping at the home was generally good with clear records kept up to date. However, there is a concern that care records containing confidential information are kept in unlocked filing cabinets near the staff station off the general corridor. On the first day of the inspection there were toileting charts with names of service users on top of the same filing cabinets. On the second inspection visit these had been removed – though the issue still brought to the Manager’s attention. The health, safety and welfare of service users are generally met, however concerns associated with potential failures to act to protect vulnerable adults from abuse, and with staff training and deployment shortfalls compromise this. Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 1 Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15(1) Requirement People who use the service must have a detailed care plan that reflects their needs to ensure that they receive the correct support to meet their needs. All staff must receive training on adult protection issues and understand how to report bad practice, which helps to protect people who use the service. Any event in the care home which adversely affects the wellbeing or safety of people who use the service must be reported to the Commission without delay. All staff must receive training on induction that meets current good practice requirements and is appropriate to the work they are to perform for people who use the service. Timescale for action 22/05/07 2. OP18 13(6) 30/06/07 3. OP27 37(1)(e) 22/05/07 4. OP30 18(1)(c) 22/05/07 Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 24 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. 2. 3. 4. Refer to Standard OP9 OP19 OP27 OP33 Good Practice Recommendations It is recommended that clearer guidance as to the circumstances when PRN medications may be administered be entered on MAR charts or in care plans. It is recommended that the carpet in the smaller of the home’s two dining rooms be replaced. It is recommended that the Manager rearrange the staff break roster in order that sufficient staff are available to people who use the service at lunch periods. People who use the service should have the opportunity to complete inspection comment cards provided by the Commission. Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Badgers Wood Care Home DS0000065307.V341241.R01.S.doc Version 5.2 Page 26 - 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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