Inspection on 28/06/05 for The Woodlands

This inspection was carried out on 28th June 2005.

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

The Woodlands 22/01/08

The Woodlands 14/02/07

The Woodlands 10/08/05

The Woodlands 04/01/05

The Woodlands 20/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE The Woodlands 176 Alcester Road Studley Warwickshire B80 7PA Lead Inspector Deirdre Nash Unannounced 28 June 2005 11:45 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Woodlands Address 176 Alcester Road Studley Warwickshire B80 7PA 01527 852815 01527 853697 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Dr M Crooks & Mrs M Crooks Mrs Wendy Louise Lewis PC 18 Category(ies) of OP 18 registration, with number of places The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 04 January 2005 Brief Description of the Service: The Woodlands is located on the outskirts of Studley within reach of a variety of shops and other facilities. The home is situated on a bus route to Studley, Redditch and Alcester. The home was originally a care home for seven people; in 1994 it was extended and now provides personal care for 18 older people. The home is fully accessible to users throughout and has a shaft lift giving access to the first floor. Seven bedrooms have en-suite facilities and the home has two lounges and a conservatory, all of which are located on the ground floor. The home has car parking spaces to the front of the house. The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector arrived without notice and toured the home with the Deputy Manager. She also spoke to six residents and two relatives about the home. It was a warm summer day in the middle of the week and the atmosphere in the home was calm, cheerful and friendly. Doors were open onto the back garden and residents were in the two lounges or in their rooms as they pleased. People were given their lunch and tea wherever they wanted to eat it. Relatives were visiting. Staff treated everyone with kindness and respect. What the service does well: What has improved since the last inspection? There were only five things that the home was told that it had to improve on at the last inspection in January 2005. It has made some progress on making sure hot radiators are safe, staff training and on staff recruitment procedures. The most improvement has been made on checking out the quality of the service they provide with their customers. The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 4 The home makes sure that it gets proper information about what each person needs before they move in and writes these needs down in a care plan. People do not move into the home if it cannot properly look after them. EVIDENCE: The home has an up to date statement of purpose and a service user guide. It also produces a quarterly newsletter for anyone with an interest in the home and has a website. The Inspector looked at the care files for three residents, two of whom are bed fast. There were written and regularly updated assessments of need for each resident. A Community Care assessment was in the file of one resident who’s stay at the home is funded by social services. All records were clear and detailed. There was also a plan for the daily and nightly care of each resident in the file. The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10, 11 Residents are looked after according to their individual needs. EVIDENCE: Individual plans of care were seen for three residents. The plans included risk assessments, health needs and nutritional screening. It was clear that these care plans are reviewed and updated every three months. Two residents who are bed fast also had ‘special care plans’ kept outside of their bedrooms that reflected their need for extra care and monitoring as they have become increasingly frail. Residents care files showed that people are visited by G. Ps and by district nurses when necessary. One resident was being treated for pressure damage that had happened after a short stay in hospital. The dressing is changed and monitored by the District Nurse. Regular written assessment of pressure damage was seen in care files. Records of regular weight checks were seen in the files. Two relatives spoken to confirmed that their family member living in the home gets good health care and that the home does not hesitate to call in medical The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 10 attention when its needed. The chiropodist was expected at the home later in the week. The Inspector saw residents being treated with respect, dignity and warmth throughout the day of the inspection. Residents and relatives spoken to confirmed that this is always the case. Residents that prefer to keep themselves to themselves are not put under pressure by staff to spend time in the public rooms. The Inspector saw that one resident had withdrawn to his room because he was not feeling well enough for company. Staff dropped by his room periodically to check that he was all right. Two bedrooms in the home are shared. Each is occupied by two residents. Both rooms have screening curtains to provide individual privacy when needed. The Inspector noticed that in one room the curtain between the beds and the curtain around the washbasin area were short. The Inspector sat on the commode chair and demonstrated that the closed curtain came as far as the hipline of an average size woman seated, and would leave thighs, lower bottom and legs exposed to view. The curtain around the washbasin would leave the whole of the lower part of a standing adult on view. This means that there is nowhere in the room that the residents can have visual privacy from each other. The home must put this right and make sure that residents in shared rooms have more privacy. There was evidence in care plans that changing needs of two residents with deteriorating conditions were being regularly reviewed and met. The relatives of one mentioned to the Inspector that the home had obtained a more suitable bed for their relative who is bedfast and they had asked if it could be positioned to give a view out of the window rather than a blank interior wall. The view showed tall trees and skyline. The room size and shape probably does make this difficult but the problem needs to be solved and the relatives need to be included in its resolution. The least that must be done is that a large mirror is put on the wall to reflect the view to the immobile resident. The deputy manager reports that the home still retains a policy of carrying out the final care task and ‘laying out’ residents when they die in the home and does not leave this to undertakers. The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 Daily life in the home takes into account what individual residents like. Residents are not treated as a group. EVIDENCE: The deputy manager reported that care staff organise some activity for residents each afternoon including at the weekends. The Inspector heard a ‘sing along’ while she was in the home. A fitness instructor comes to the home once each week for a session with residents. Many residents go out on Sundays to church and or lunch with their families. The back and conservatory doors to the garden were open all day as the weather was very warm and dry. Residents were free to stroll or sit in the garden but none did on this occasion. When the Inspector asked some residents if they intended to go out into the garden that afternoon they said that they did not think it warm enough or that they would not enjoy the breeze. The Inspector heard one resident say that she wanted to go out and staff tell her that she could as soon as someone was free to go with her. The deputy manager confirmed later that she was subsequently taken out for a short walk along the street. The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 12 The Inspector joined residents for lunch and saw dinner being taken later in the day. The Woodlands makes food and eating part of the life of the home. Residents are served a light lunch in the lounges or their rooms and dinner in the conservatory, lounges or in their rooms during the late afternoon. There is a cook present from 8am to 6pm every day including weekends and the Inspector could see that the cook is an important part of the care team who sees a lot of the residents. Residents are welcome in the kitchen. It was a hot day and there were jugs of cold drinks in bedrooms and lounges. The condition of the kitchen became an issue during this inspection and it is dealt with later in the final section of this report under ‘safe working practices’. The food served during the day was wholesome and tasty, well prepared and presented with choices offered. Residents who need soft diets and support with taking their food were helped with sensitivity. No one was rushed; food was not taken away from any one who did not immediately eat it. One resident who did not take dinner because he did not feel like eating told the Inspector that he would be able to have whatever he wanted later on in the evening. Relatives spoken to confirm that the food served in the home is good. The Inspector did note however that on this day lunch was served at 1.30 and then dinner served at 4.30. The cook said that lunch was a little behind due to a delivery (and probably the inspection of the kitchen) but that residents do get mid morning tea and cakes or biscuits. However, serving dinner at 4.30 does seem a little early. Although meal times need not be rigid, the home should take care that they are properly spaced apart so that residents don’t go for a long period at the end of the day without a meal. The manager should address this. The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 0 EVIDENCE: The home was judged as performing to standard on dealing with complaints and enabling residents to exercise their rights at the last inspection in January 2005. It was judged as exceeding the minimum standard on its policy and practice concerning the protection of vulnerable adults at the inspection of July 2004. These standards were not looked at therefore on this occasion. The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20,21 23,24, 25 Residents enjoy freedom of movement around a home with good facilities and gardens. Parts of the home around the areas used by residents are poorly kept and managed. This chaos could start to encroach on residents space. EVIDENCE: The home is at the western edge of a rural town that has shops, including two supermarkets, a post office, take away food restaurants and a leisure/community centre. It is on a busy road with a bus route but the building itself is set back from the road and shielded by high hedging sufficiently to cut down the impact of the passing traffic. The original house has been extended and a conservatory added to the rear. There is a front lawned garden and a safe enclosed back garden with a level lawn and mature shrubs and trees. The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 15 The Inspector toured the home and the garden and visited most of the bedrooms and also the staff sleeping in accommodation. The front and rear gardens are beautifully kept. The home has some chickens in an area of the back garden enclosed by hedge. There was discarded furniture and collections of cigarette butts on the ground at the side of the house. The manager should arrange for these to be cleared away. The inside of the home is light and bright and airy with a feeling of space between rooms. There are two lounges and the conservatory is used as a dining room. It was clear that most of the bedrooms had been recently painted. Toilets en suite to bedrooms have windows. All of the residents accommodation and communal space was clean and tidy. There are no long corridors of rooms. The deputy reports that one member of staff has the responsibility of testing each light bulb around the home once a week and replacing any that have stopped working. Routine repair and maintenance jobs are put into a book for the handyman and staff are expected to report them in to the manager. The exterior of the property is well maintained except for a ‘lean too’ construction around the outside wall of the kitchen at the back of the original house. Paint is peeling on most of the window frames. These should be repainted. This store area contains two freezers that are in use. There was also a considerable amount of ‘stuff’ including paint pots, bags of old clothes and odd tools accumulated on ledges and on the floor. Residents do not use but have access to this area as they must pass across the end of it to get out to the garden from this side of the home. It must be tidied up and made safe. Staff sleeping in accommodation includes a shower room. This is positive. However the bedroom was cluttered with household ‘stuff’ and had no wardrobe, drawers or locker for staff to store their belongings. The larger room next door under the eaves is used for storage but it was so disorganised that it was impossible to get in to. In the newer part of the home there is what the deputy described as a staff toilet. It was dirty and smelled badly. Next to it there is a bathroom that the deputy says is rarely used. It was also dirty and had no soap for hand washing. The space used by residents is well maintained, the outcome for residents has to be judged as positive therefore. Other areas of the home are untidy and some are dirty. The Inspector remarks on the surrounding disorder because it shows lack of consistent good management of the environment that could begin to encroach upon residents. This becomes clearer later in the report over the kitchen. The home has 17 toilets including those en suite to bedrooms. There are also two toilets near the main lounge. There is one shower room on the ground The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 16 floor and two bathrooms on the first floor with assisted baths. This is sufficient for eighteen residents. The home has yet to demonstrate that a suitably qualified person including an occupational therapist has made an assessment of the premises and facilities. Bedrooms contain the necessary furniture and electric points and there are adjustable beds in the rooms of those residents that need them. There is carpet in rooms unless care plans indicate the need for a different floor covering and residents hold keys to their bedrooms unless it is not safe for them to do so. Each bedroom has a lockable drawer for valuables. A comment has already been made on the screening in the double bedrooms. Most radiators in the home have been covered to protect residents but a few remain uncovered. The home was told about this during the January inspection. The heating was on although it was a very warm summer day and windows were open. The home must get the remaining radiators covered without further delay The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 Staffing arrangements for the home are adequate and consistent including at weekends. Residents benefit from being cared for by people that they can get to know. The home is not taking enough care over its recruitment procedures and residents could be exposed to people that are unsuitable to care for them. EVIDENCE: The home employs 19 staff in all including 3 cooks and a part time cleaner. It is carrying one vacancy. The cleaner works Monday to Friday and care staff clean and tidy at the weekends. The kitchen is staffed seven days a week. The Inspector looked at the staff roster as it was actually worked, for the week of 20 to 26th of June 2005 sampling the cover for the Tuesday and the following Sunday. There were two care staff on duty from 7am and three from 8am, three from 2pm and three from 6pm to 9pm followed by two staff over night, one awake and one sleeping in on call. This pattern was the same when the Inspector called unannounced on the day of this Inspection. Staffing levels are adequate for the number of residents in the home. The deputy manager reports that the home has not needed to make use of agency staff during the last twelve months. The Inspector saw the personnel file for the last member of staff recruited to the home. It did not contain a photograph, copy of current passport or evidence that the two referees supplied by the worker were contacted by the home as they should be. The home was told about such shortfalls after the The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 18 January inspection. If the home continues to fail to get all of the documents necessary to show that staff recruited are safe and suitable to work with vulnerable adults the Commission may take enforcement action. The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30, 38 The home actively seeks the opinion of residents and relatives about the service it provides. Resident’s have a voice in the running of the home. Health and safety management in the home is inadequate. This puts residents at risk of infection and of falls. EVIDENCE: The Deputy Manager reported that the home had undertaken a recent survey of the views of residents, relatives and professionals connected with the home about the service that it provides. The results of this quality assurance exercise must be written up and sent to the Commission. The Inspector saw minutes of a residents meeting held on 2nd June 2005 that twelve residents attended. Keeping chickens was discussed. During the tour of the home the Inspector saw that the kitchen was in a poor state of organisation and general hygiene. Fittings were worn, dirty and broken, a dirty greasy patch from peoples hands had built up on doors, open storage shelves were covered in dust, there were food crumbs in cupboards, The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 20 mould on the wall of one cupboard used to store groceries and some baking tins in a cupboard were covered in old food. Saucepans were stored away wet, which produces an environment for bacteria to thrive. The cooker was dirty with old grease. Fridges were clean and the food inside was properly stored and opened packets were dated. Records of daily fridge and freezer temperatures were seen. The dishwasher chemicals were stored on the floor next to the machine where residents could have access to them. Those with some confusion could mistake them for drinks. The boiler room was full of clothes, which is a fire hazard. The home was told to make improvements to the kitchen at the inspection of July 2004. Most of the small and specific actions required were carried out by the January 2005 inspection but it is clear that the kitchen environment is badly managed and the fabric, fixtures and fittings now need to be replaced with new in order to provide an hygienic workplace that can be easily cleaned. The manager was told to make sure that the kitchen was deep cleaned within 48 hours of the inspector leaving the home. The manager must make sure that the kitchen is kept in a clean and hygienic condition to protect residents. The home has recently acquired chickens that are kept in the garden and also has two caged birds in the house that belong to residents. They looked clean and healthy but a policy and procedures must be put in place setting out how they are managed and looked after so they don’t cause any difficulties or health hazards to frail residents. Floorboards in a front first floor bedroom felt spongy in one spot and could be rotten, they must be looked at and repaired if necessary. The carpet at the threshold of the rear lounge was worn and is a trip hazard. A mat had been placed over a similarly worn spot in a bedroom, the Inspector caught her foot under it as she walked into the room. A resident that uses a zimmer frame occupies this room. These floors must be made safe. Many of the arms of chairs in the large lounge were dirty and food stained. They must be cleaned and kept clean. Hot water temperature test records were not available for inspection. Mobility equipment servicing records were not available for inspection. They should be. These will be followed up at the next inspection. The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 x 3 3 2 x STAFFING Standard No Score 27 x 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 2 x x x x 1 The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP10 Regulation 12 Requirement The registered person must ensure that screening in shared rooms is improved to provide privacy. The registered person must ensure that the bedfast resident identified during the inspection can see the view from her window or be moved to a bigger room in which her bed could face a window. The registered person must ensure that the lean to area is made safe for residents. The registered person must ensure that staff sleeping in have somewhere to store their belongings. The registered person must demonstrate that a suitably qualified person has made an assessment of the premises and facilities. The registered person must ensure that all remaining radiators are safety covered (part complied 30/04/05) The registered person must ensure that a minimum of 50 of care staff hold NVQ Level 2 in Health and Social Care excluding Timescale for action 15th August 2005 15th August 2005 2. OP11 23 3. 4. OP19 OP19 13 23(3) 15th August 2005 1st September 2005 1st November 2005 15th August 2005 31st December 2005 Page 23 5. OP22 23 6. OP25 13 7. OP28 18 The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 8. OP29 19 9. OP33 24 10. 11. OP38 OP38 13 13 12. OP38 13 13. 14. OP38 OP38 13 13 15. OP38 13 the manager and/or care manager (not inspected:30/06/05) The registered person must ensure that all proofs and documents required in Schedule 2 of the Cre Homes Regulations 2001 as amended are obtained and kept in the home for each person working in the home (not complied 28/02/05) The registered person must ensure that a summary of the review of the quality of service ofered by the home undertaken this year is submitted to the Commission (not complied 30/03/05). The registered person must ensure that the kitchen is deep cleaned. The registered person must ensure that a system is put in place to keep the kitchen in a clean and hygienic condition The registered person must ensure that kitchen worktops with breached laminate finish are replaced. The registered person must ensure that home has a pet/livestock hygiene policy. The registered person must ensure that the tears in carpets and the spongy floorboards identified are made safe. The registered person must ensure that the arms on the chairs in the front lounge are cleaned and kept clean of grease and foodstains. 15th August 2005 1st September 2005 5pm 30th June 2005 (48 hours) 15 th August 2005 1st September 2005 15th August 2005 COMPLIED 15th August 2005 15th August 2005 The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 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 OP15 OP19 OP19 OP30 Good Practice Recommendations The manager should monitor the times at which meals are actually served and make sure they are space apart at appropriate intervals The manager should arrange for the discarded furniture and the cigarrette ends to be removed from the side garden . The registered person should arrange for the window frames on the lean to to be repainted The registered person should ensure that there is a staff training and programme that meets the National Training Organisation workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of residents. Supervision notes should be signed by staff A risk assessment to be undertaken of the fire procedures in each fire zone. 5. 6. OP36 OP38 The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Woodlands E53 S4259 The Woodlands V231650 280605 Stage 4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!