Inspection on 12/01/06 for Woodbury Court

This inspection was carried out on 12th January 2006.

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

Woodbury Court 14/01/08

Woodbury Court 17/01/07

Woodbury Court 04/08/05

Woodbury Court 15/10/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Woodlands Tavistock Road Laindon Basildon Essex SS15 5QQ Lead Inspector Ann Davey & Vicky Dutton Unannounced Inspection 12th January 2006 08:30 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 Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 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. Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodlands Address Tavistock Road Laindon Basildon Essex SS15 5QQ 01268 564230 01268 564231 woodlands@runwoodhomes.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) Runwood Homes Plc Ms Karen Allen Care Home 93 Category(ies) of Dementia - over 65 years of age (66), Old age, registration, with number not falling within any other category (27) of places Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2005 Brief Description of the Service: Woodlands is a purpose build 2 storey establishment which accommodated 93 residents. The home has surrounding grassed areas, a secure patio area and a large car park. The home accommodates older people and older people with dementia care needs. All residents are over the age of 65 years. All bedrooms are single and have ensuite facilities. Laindon town centre is situated near to the home. Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of 9 hours. As there were two inspectors, this equated to 18 hours input. A 3rd inspector attended the home as part of their induction. The inspection focused mainly on the progress the home had made since the last inspection, although other standards were considered. A partial tour of the home took place. Staff, residents and visitors were spoken with. Records were selected at random and various elements viewed. A notice was displayed in the home advising all visitors that an inspection was talking place with an open invitation to speak with an inspector. A full and detailed ‘feedback’ was provided during and at the end of the inspection with opportunity for further discussion and/or clarification. A photocopy of the inspector’s ‘premises audit’ was given to the home. The registered manager was present throughout the inspection. What the service does well: What has improved since the last inspection? The outcome of the last inspection was disappointing and of concern to the Commission. It was therefore positive to note the development and improvement in the home. The overall management of the home is more robust and there was a feeling of more organisation and order about the home. Staff awareness of dementia care needs has improved. The care plan documentation recording system is better, but considerable development work is still required. It was positive to see that residents now have unrestricted access to all the designated communal rooms in the home and the Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 6 inappropriate notices seen at the last inspection have been removed. Staff interaction with residents has improved and it was positive to see residents now wearing more suitable protective coverings at the meal table. Additional garden furniture has now been purchased and is in storage ready for the better weather. Morale in the home seems better and staff demonstrated a determination to raise and maintain standards. There was a commitment to provide a good service. 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. Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 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 Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 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 the following standard(s): 1,3 & 6 Prospective residents care needs are assessed before admission. Information was available to inform interested parties about what the home can offer. EVIDENCE: Pre admission and admission documentation selected at random was adequate in detail and content. Although not viewed, the Home’s Statement of Purpose and Service User’s Guide were available in the main entrance and within the visitor’s room. Copies of the Service User’s Guide were also seen in some bedrooms. The home does not provide intermediate care. Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9 & 10 The care planning recording system requires a total review as the current method(s) used is complex, fragmented and disorganised. This could lead to misunderstanding and confusion. Health care needs are facilitated. The management of the medication administration recording and storage system(s) was satisfactory. EVIDENCE: It was evident that the home has spent time and effort in trying to improve the quality of the care planning recording system. In general care needs had been recorded, but the recording system itself and/or the methods currently used are complex, disorganised, repetitive and could ultimately lead to significant misunderstanding and confusion. A random section of care plans and associated documentation was viewed and the inspector experienced some difficulty in understanding and identifying specific needs and how they were going to be met. One resident had 16 different care plans, care plan number ‘5’ had 23 separate elements and care plan number ‘7’ had 14 separate elements. This pattern was duplicated in the other care plans viewed and there were 92 residents accommodated. In reality, staff are not going to read such Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 10 lengthy documentation. In some care plans, the style of handwriting used was not legible and can only lead to confusion. There was evidence that some staff were not following the instructions on one care plan in particular. The information on care plans tends to be focused on physical care needs. Staff must be encouraged to include all possible care needs as detailed in standard 7. Furthermore, some residents are admitted under a specific ‘care package’ scheme arranged by the local funding and health authority. It was established that additional corporate records are held on these residents and do not form part of the main care plan recording system. This recording arrangement is not acceptable and all records/documentation pertaining to residents whilst in the care of Woodlands must be kept on the main file. It is not acceptable to have a 2 tier recording system, as important care information was not on their respective file. The above findings were fully discussed with the manager. There was also evidence that important information recorded on identified resident’s daily observation notes was not always ‘followed through’ by the home. This was concerning some bruising that had been observed and reported to a senior member of staff and a resident complaining that her room felt cold. The home maintains a regular check on residents’ body weight, but there is no system in place to monitor the causes or consequences of weight loss or gain. Two residents had significant weight loss and there was insufficient written evidence to demonstrate that this was being managed adequately. (Also see standard 15). Generally, staff spoken with had an adequate understanding of identified resident’s care needs and the manager in particular was knowledgeable of the general needs of residents currently accommodated in the home. Residents and relatives were complementary and positive about the care offered by the home. Records and information pertaining to residents was noted to be stored in designated secure areas of the home. A random selection of medication administration records held on the 1st floor was viewed. It was positive to note that records continue to be in good order, information/guidance was readily available, staff were trained and knowledgeable. The medication storage facility on the 1st floor was clean, orderly and tidy. It was positive to note that residents were wearing appropriate protective covering at mealtimes. This has improved since the last inspection. The home facilitates appropriate health and clinical care from outside agencies that visit the home on a regular basis. A visiting community nurse spoke positively about her overall professional relationship with the home. The home has/is developing a number of systems within the home whereby residents have an opportunity to voice their thoughts, views and opinions about the care in the home in general. Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14 & 15 The home continues to develop an effective social/recreation/occupational programme. There are established links with the local community. Systems continue to be developed allowing residents choice and control over their daily lives. Residents are provided with a choice of food at mealtimes. EVIDENCE: Not all aspects of these standards were assessed in full. The home recognises the need for a suitable and adequate effective social/recreation/occupational programme to be in place. Some aspects have been implemented whist others are still being worked out. The home should continue to explore the possibilities and opportunities for residents to be taken out into the community, as the current focus of activity and events still tends to be ‘in house’. A number of residents however spoke positively about their current experiences. The home accommodates a number of residents with dementia care needs and the home should be complimented on the standard of suitable and appropriate directional and orientation signage to assist these residents. In addition, many areas of the home have been decorated in a bright and visually stimulating manner using a number of different themes and styles. Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 12 The home should review its corporate approach to the daily morning routines in the home that have a direct impact on individual resident’s choice and control over what happens to them. The home has 6 designated areas and each area tends to have its own early morning routine. In one area it was noted that all residents have to be up before breakfast is served to them which could be as late as 9.30/9.45am, whilst in other areas breakfast was noted to be served as/when individual residents were ready. Systems must be in place to allow residents individual choice and control of their lives regardless of what ‘area’ they are in. The home has a pleasant visitors room on the ground floor. A number of visitors were in and out of the home during the day and those spoken with were positive about the home. Staff were observed to deal with visitors in a friendly courteous manner. Since the last inspection there has been a number of changes in menu/nutrition planning system. A new system has recently been introduced which primarily revolves around a 4-week rotation system. Menus demonstrated a good variety of food on offer for residents. It was positive to hear that the chef is to attend a course specifically designed for those involved in catering for older people. The quality of nutrition records held on the respective 6 designated areas varied from adequate to not adequate. Examples were discussed in detail with the manager. (Also see standard 7). Meal presentation on the day was good and the tables laid ready for tea/supper were attractive. The home has recently experimented using a different form of serving plate for the more dependant residents. However, whilst the intention was good, the new utensil is thought to be unsuitable and the manager agreed to review and explore other means. Residents spoke well of the food. Staff were observed to be assisting residents at mealtimes in a sensitive manner. It is recommend that attention be given to the presentation of information on the home’s menu boards that are displayed around the home. The information was not always clear and there was little evidence that care had been taken by staff when writing up the daily menu. Many of the residents have dementia care needs and a number have impaired vision. Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 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 the following standard(s): 16 & 19 Staff spoken with had an acceptable knowledge base and understanding of adult protection issues and procedures. The complaints recording system requires review. EVIDENCE: Staff spoken with at random had an adequate knowledge base of adult abuse issues. Please see standard 29 concerning CRB checks undertaken on staff. There was clear evidence at the inspection that residents are encouraged to voice any concern they may have about the home. There were a number of examples were individual residents had felt able and free enough to voice their views and feelings about different issues. The home must review the current complaints recording system, as there was evidence that investigation processes and/or investigation outcomes/conclusion have not been properly recorded and/or ‘finished off’. It is also recommended that as part of the review, the home should consider incorporating an ‘index’ within the system for easier cross-referencing. The home is currently involved in assisting with two complex complaint/concerns issues that have engaged other professional agencies. The Commission is satisfied with the manner in which the home is addressing matters and cooperating with the different authorities. Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 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 the following standard(s): 19,20,23,24,25 & 26 The general overall standard of furnishings, décor, fitments direction and orientation signage within the home is of a good standard. The management of the laundry area and other identified health and safety environmental shortfalls require review for the wellbeing, protection and safety of residents. EVIDENCE: Residents’ bedroom in the main were decorated, furnished, equipped and furnished to a good standard. Many were personalised and homely. The main reception area in the home is bright and welcoming. Woodlands is a very large home accommodating up to 93 residents. The home has 6 designated accommodation areas that are known as Jasmine, Ivy, Lotus, Lavender, Primrose and Tulip. Call bell response time was satisfactory, but not all residents had accessible call bells. The premises audit identified issues that require attention for the safety and wellbeing of residents. These include a sluice and wheelchair charging room being left unlocked, boxes of vinyl gloves left on shelves, call bells not being Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 15 accessible, soiled incontinent aids left in an inappropriate manner, dentures belonging to a current resident left in a sluice area, toilet brushes left in an unhygienic condition, soiled bedding, stained chairs in bedrooms and open bins. A full report was given to the manager. These matters and others that were contained within the full report given to the manager are of concern as the home accommodated residents who have dementia care needs and some identified shortfalls pose a potential risk. The home was also asked to review the method/system of ventilation within the home. In some identified bedrooms and other identified areas of the home, the management of odour was inadequate. In other areas particularly the communal lounges/dining areas and some corridors, the standard of ventilation was not satisfactory. The air temperature was uncomfortably hot and because of possible inadequate air flow, odour was very unpleasant. The home must urgently review the management of the laundry area to minimise the risk of cross contamination and enhance universal infection control measures. The findings on the day were not acceptable as there were numerous various containers full of soiled/dirty laundry waiting to be dealt with. Washing was in pillow cases, clear, black, red and yellow plastic bags, washing baskets, personal washing baskets, cardboard boxes, blue ‘billy’s’ etc, whilst other washing had just been piled up on the floor. A huge assortment of these various containers were piled on top of one another often with laundry spilling out over the top. There was no evidence that the home has any systems in place to adequately manage the situation or has adequate appropriate soiled laundry containers for transportation. The inspectors were informed that what was seen was a ‘normal’ morning’s workload. All the soiled/dirty laundry was in close proximity of clean laundry and as the member of staff moved around the laundry area, her clothing constantly brushed against the soiled laundry. Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 The system by which proposed staff hours and duties are recorded and those actually worked and recorded was inadequate. Staff induction and supervision records were adequate. Staff recruitment and training records and some aspects of the current staff establishment require attention. EVIDENCE: Not all aspects of these standards were assessed in full. The home did not have an accurate ‘working’ or ‘worked’ roster. It was established that if anybody wanted to know who had previously been on duty at any given time, reference to at least 3 different pieces of documentation had to be made i.e. a roster, signing in sheet and signing in book. In addition some staff interchange duties/designations and this was not always clear on documentation presented. The rota for the week ‘worked’ was in inaccurate in content and detail. In addition, the actual hours of employment were not evident for all staff. Woodlands has a very large staffing establishment and the current system in place concerning staff rosters is inadequate. A full review of care staff numbers and deployment did not take place on this occasion. This was because the information on the rosters was not conducive to clarity. The home should however keep this under constant review to ensure adequate staff in sufficient numbers and skill are on duty at all times to meet the assessed needs of residents. Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 17 It was noted that some care staff request to work 12-hour days (with breaks). This is not good practice and should be discouraged. This was raised at the last inspection. It was also noted that the home has no domestic cover in the afternoons and evenings for 4 days a week. The home accommodates 93 residents and it is not acceptable that an establishment of this size has no domestic cover. Domestic duties have to be covered by care staff, which could distract them from the own workload. The home has considerable care staff vacancies at present and is reliant on agency staff to maintain staffing levels. It is imperative that urgent attention is given to the recruitment of a full time deputy manner. At present the manager has no deputy and the expectation on her to raise, maintain and develop standards as well as managing of home this size on a daily basis, is unrealistic. In addition, the manager is attending regular training courses to enhance her own skills. Elements of staff recruitment records were selected and viewed at random. It was of concern that a member of staff had been recruited to a senior position without a cleared CRB check. The manager agreed that the current system whereby staff training was recorded was inadequate. It was positive to note that at this inspection nearly all staff were wearing a recognised uniform style of dress. It was of concern that many staff were wearing a fob style watch. The home cares for residents with dementia who may have challenging behavioural patterns and wearing an item of jewellery of this kind within a residential care setting could pose a risk to safety and should be discouraged. Staff spoken with said that they had regular supervision session and staff meetings. The inspectors observed good interaction between staff and residents during the course of the day and residents were appropriately supervised. Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 & 38 The home lacks an established local management team structure to support the registered manager. EVIDENCE: Woodlands is a very large home accommodating 93 residents, many have complex care needs. To provide the care for these residents, Woodlands has a significant staffing establishment. In addition, due the size of the home and the identified complex care needs, the home plays a vital part in the wider community especially with the various local funding authorities who have a vested interest in the quality of care provided by the home. An establishment of this size requires a robust local management team. The manager does not have the capacity to raise, maintain and develop standards as well as managing a home this size on a daily basis. In addition, the manager is attending regular training courses to enhance her own skills and development. The registered manager is competent, experienced and committed to raising Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 19 standards but in reality her workload is too much and the outcome of the inspection demonstrates this. Since the last inspection there has been some clear improvements in the home, but much still needs to be implemented, developed and monitored if the home is to meet and maintain regulatory and national minimum standards. This matter has been brought to the attention of the registered provider on previous occasions. The system whereby residents’ personal monies are kept and transactions recorded was sampled. Documentation was in good order and the monies held for safekeeping equated with the stated amounts. However, it was established that residents could only access their monies at certain times. This practice must be reviewed and systems put in place in order that residents can have full access to their monies at all times. Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 20 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 X 3 X X 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 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 X X 3 3 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 2 X X 2 Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 21 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 14 Requirement The registered person(s) must ensure that all residents have a comprehensive plan of care that contains all relevant information and detail and is reviewed on a regular basis. All other associated care documentation must be maintained in an appropriate manner and in accordance with regulatory and NMS requirements. The previous timescale of 4/9/05 to meet this requirement has not been achieved. The registered person(s) must ensure that residents have appropriate choice and control over daily routines within the home. Residents should be able to have breakfast at a time that is suitable for them. The registered person(s) must maintain a current record to demonstrate that residents have been provided with an adequate diet. The previous timescale of 4/9/05 to meet this requirement has Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 22 Timescale for action 28/02/06 2 OP14 16 28/02/06 3 OP15 16 28/02/06 4 OP16 22 5 OP26OP25 OP19 23 6 OP27 18 & 19 only been achieved in part. The registered person(s) must 28/02/06 ensure that adequate records are maintained concerning complaints received by the home. The registered person(s) must 28/02/06 ensure the environment is safe, adequately ventilated, residents have access to a call bell at all times and the furniture is in a good state of repair. In addition, universal infection control measures must be reviewed particularly within the laundry area. 28/02/06 The registered person(s) must: Review and demonstrate that sufficient staff to meet the needs of residents are on duty at all times. This is with specific reference to the appointment of a deputy and the lack of any afternoon/evening domestic staff on duty for 4 days a week. Ensure that staff rotas are accurate and include times of duty, responsibilities and duties. Rotas must be maintained in a clear, orderly manner at all times. Adequate records must be maintained to demonstrate that staff have received appropriate training. Staff recruitment checks and records must be carried out and maintained in accordance with regulation and the NMS. The registered person(s) must review all management and administration systems within the home. This is with specific reference to: DS0000061614.V271583.R01.S.doc 7 OP38OP35 OP33 13,18,19 & 24 28/02/06 Woodlands Version 5.0 Page 23 Care plan & associated documentation Daily routines particularly at breakfast Strengthening the local management team Universal infection control measures Management of residents personal monies Staff recruitment processes Staff rota Domestic staff cover Nutrition records Staff training records Health & safety measures 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(s) should ensure that adequate and suitable social, recreational and occupational activities/events are provided by the home. This should also include residents being taken out into the community if they wish. The registered person(s) should ensure that menu boards are written in a clear manner. The registered person(s) should ensure that the style of jewellery worn by care staff does not pose a safety risk to residents. 2 3 OP15 OP29 Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Woodlands DS0000061614.V271583.R01.S.doc Version 5.0 Page 25 - 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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