Inspection on 24/05/05 for Woodfalls Care Home

This inspection was carried out on 24th May 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

Woodfalls Care Home 23/01/08

Woodfalls Care Home 30/06/06

Woodfalls Care Home 27/10/05

Woodfalls Care Home 13/01/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodfalls Care Home Vale Road Woodfalls Salisbury Wiltshire, SP5 2LT Lead Inspector Thomas Webber Unannounced 24th May 2005 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. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodfalls Care Home Address Vale Road Woodfalls Salisbury Wiltshire SP5 2LT 01725 511226 01725 511226 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) Woodfalls Care Home Ltd Mrs Lorraine Hill Care Home 20 Category(ies) of DE(E) Dementia - over 65 (10) registration, with number OP Old Age (20) of places Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2005 Brief Description of the Service: Woodfalls Care Home is a private residential care home offering accommodation and personal care to 20 service users over the age of 65 who require care primarily through old age, ten of whom have been diagnosed with dementia. On the day of inspection the home had 17 residents in situ, 1 in hospital and 2 vacancies. The home is registered with Woodfalls Care Home Ltd and the registered manager is Mrs Lorraine Hill. The home is a detached property and is located in the small village of Woodfalls near Salisbury. The home provides one shared and seventeen single bedrooms which are located on the ground and first floor levels and are accessed by a stair lift. There is a small, enclosed garden to the rear and side of the property. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, undertaken during the course of one day from 09:15 to 15:15. The inspection primarily focused on the direct care provided to the residents and their views were sought on an individual and group basis. In addition, a check was carried out with regard to the requirements and recommendations previously identified at the last inspection together with a range of the core standards. A tour of the premises was undertaken and the views of most residents were sought on an individual and group basis, regarding the care and services provided by the home. The records in relation to medication, fire prevention, menus, staff rotas, staff supervision and recruitment of staff were checked and staffing levels were discussed with the deputy manager as well as the majority of the outstanding requirements from the previous inspection. What the service does well: What has improved since the last inspection? The home has continued to make improvements to the premises to enhance the residents’ living environment. The home has involved the residents in a quality assurance review into the care and services provided and a report has been produced. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 6 Some new systems have been introduced in relation to the administration of the home in respect of a complaints logging and monitoring form in relation to all complaints received and a standex system for the maintenance of residents’ records. 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. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.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 Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.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) 2, 3 and 6 The home’s written contracts provided to residents have not yet been signed and returned by them to the home. Not all residents have been fully assessed and provided with written confirmation that their needs will be met. EVIDENCE: At the last inspection it was reported that the proprietor was in the process of having the home’s contract drawn up due to the change of ownership and all residents and their relatives/representative would be provided with a copy of this document when it had been developed. Residents, who are funded by social services, would also receive a copy of the placing authority’s terms and conditions. On the day of this inspection, none of these were available. Since the inspection, the proprietor’s representative has confirmed that residents’ contracts are still not in the home as the fees have been recently increased and several residents have not yet returned their new contracts. However, those contracts that have been returned have been sent to the home to be placed on residents’ files. Management from the home meet with all prospective residents prior to admission and undertake their own assessment and documentary evidence was available to confirm this. However, the assessment tool was not fully Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 9 completed in relation to one of the two residents case tracked during the inspection. In addition, the assessment tool completed by the home would benefit from the signature of the resident or their representative. The home would also normally obtain a copy of residents’ community care assessments or the equivalent prior to admission for those who are funded by social services. However, this documentation was not available in relation to one of the two residents case tracked. The home does not provide intermediate care, therefore Standard 6 is not applicable. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8,9 and 10 Residents’ health care needs are being suitably met. Appropriate procedures have been established which recognises the rights for residents to be responsible for their own medication. However, residents have not been assessed to establish whether they can take responsibility for their own medication. Staff do not demonstrate vigilance in the administration of residents’ medication for the well-being of the residents. Resident’s privacy and dignity are respected at all times. EVIDENCE: Discussions with some residents confirmed that their health care needs are being suitably met. All residents admitted to the home are transferred and registered with the one surgery. The majority of appointments undertaken by the GP and district nurse are held within the home and residents receive any treatment in the privacy of their bedrooms. Two residents attend the Diabetic clinic and another resident attends the heart clinic. However, residents pay the costs of transport for these visits. Residents confirmed they can and do access other health care services such as dental, opticians, chiropody and hearing, as and when required. Appropriate aids are provided for those residents who require them for incontinence and mobility. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 11 The home has established an appropriate medication policy and procedure, which confirms and recognises the rights of residents to maintain control over their medication for those residents who are deemed capable following an assessment. Suitable and lockable facilities have been provided within residents’ bedrooms for this purpose. However, none of the residents are currently self-medicating and there was no evidence to confirm that they have been assessed as being not capable and the deputy manager has agreed for residents to be re-assessed. Until recently care staff, once deemed competent, administered medication to residents. However, the vast majority of care staff have recently completed a recognised “Safe Handling of Medication” course at Yeovil college. The home uses the Lloyds monitored dosage system and examination of the drug sheets showed that there are still a few gaps where staff had not initialled for medication administered. Since the last inspection an appropriate cabinet for the storage of controlled drugs has been purchased and a system has been established for the receipt of medication. A controlled drugs register is in place for the recording of controlled drugs. The pharmacist has recently carried out an inspection on the home’s storage and administration of medication and the deputy manager reported that the pharmacist has identified a few areas for improvement but she is waiting for a copy of her report. Observations and discussions with some residents confirmed that all but two residents are provided with their own bedrooms where they can conduct all their personal affairs in complete privacy, including medical examinations and treatment. Residents can also choose who and where to see any visitors. Residents have access to a mobile phone, which they can use in the complete privacy of their bedrooms and they are not charged for any calls made when using this facility. Alternatively, residents can have a telephone installed in their bedrooms and some of them have availed themselves of this facility. Residents’ mail is given directly to them unopened. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14 and 15 Residents maintain contact with their families, friends and relatives in accordance with their preferences. Residents, within their capabilities, can exercise personal autonomy and choice. Residents receive a varied, appealing and balanced diet and meals are taken in a congenial setting. EVIDENCE: Residents are able to receive visitors at any time of the day and all visitors are greeted at the front door by staff. Some residents confirmed that they can choose where they entertain their visitors either in the privacy and comfort of their bedrooms or in one of the communal rooms available. Observations and discussions with some residents confirmed that they can exercise personal autonomy and choice. Residents can and have brought items of furniture and personal possessions to make their bedrooms more homely, they can choose how and where to spend their time, where to eat, and what activities to participate in. Residents, who are capable, can also handle their own financial affairs in the privacy of their own bedrooms. The home provides a satisfactory and varied four weekly menu for the main meal of the day which includes a choice. Some residents were consulted about the new menus now in place. The home also provides residents with a choice at breakfast and teatime, which includes a cooked meal at breakfast for those Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 13 residents who wish it. Unfortunately, written records have still to be maintained for meals eaten at suppertime. Residents can choose where to eat their meals, although they tend to use the dining areas or the lounge depending on the meal. Residents spoken to commented positively about the quality and quantity of food provided. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Information is provided to residents on how to complain should they wish to and the residents felt that their complaints would be listened to and acted upon. Appropriate procedures are in place to protect the residents from abuse. EVIDENCE: Residents are provided with a copy of the home’s complaints procedure, which specifies how and who would deal with any complaints. Since the last inspection, the home has received a total of five complaints from two complainants. These relate to food, a somewhat restricted view from a resident’s bedroom, management not saying hello to a specific resident in the morning, behaviour of one resident to another and staffing levels. The home needs to establish a monitoring form for all complaints received which also clearly records the outcomes of complaints investigated, this has subsequently been established. Residents spoken to commented that they had no complaints or concerns. However, if they did have any, they felt confident in discussing them with the manager and staff who would listen and act accordingly. Appropriate policies and procedures are in place for responding to suspicion or evidence of abuse. Copies of the full and shortened version of the Wiltshire and Swindon Vulnerable Adults procedures have been obtained which are in line with the Department of Health Guidance “No Secrets” document. Copies of the shortened version of this document have been distributed to all staff. New staff cover the issue of abuse during their induction programme and the deputy manager reported that staff recently attended an “Action on Elder Abuse” course run by Age Concern. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 15 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, 21,22,23,24,25 and 26 The location and layout of the home is suitable for its stated purpose. It is accessible, safe and well maintained to meet the residents’ individual and collective needs. Residents have access to safe, comfortable and suitably furnished and decorated communal facilities. Suitable bedrooms are provided for residents to enable them to personalise these to their individual wishes. Residents have sufficient and suitable toilets and bathrooms facilities. Residents have appropriate equipment to maximise their independence. The home is maintained to a good standard being clean, tidy and comfortable and offers appropriate laundry facilities for the residents. EVIDENCE: The home is a comfortable, well-maintained detached property, which provides suitable heating, lighting and ventilation, with residents’ bedrooms being light and airy and colour co-ordinated. The home continues to make improvements to the premises to enhance the residents’ living environment which includes the installation of a new and more appropriate bath to the bathroom on the first floor, the shower to the ground floor is now in working order and a new Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 16 boiler has been fitted in the kitchen. In addition, four residents’ bedrooms have been redecorated with two of them being re-carpeted. The home provides sufficient communal space which consists of a lounge/diner, a conservatory, a small sitting room and a seating area in the front entrance hall. All these areas are comfortable and decorated and furnished to a good standard. The home has an enclosed garden to the rear and side of the property, which requires some attention. The garden contains various seating areas and is appreciated and used by the residents, weather permitting. There is a range of toilet and bathroom facilities which are located within close proximity to residents’ bedrooms and the communal rooms. There are two assisted bathrooms and shower rooms: one of each on each floor. Three of the bedrooms are provided with en-suite facilities. A stair lift has been installed which services the first floor and the proprietors had sought planning permission in order to install a passenger lift that would enable residents to access the first floor independently. However, this application was refused as it was linked to the installation of further bedrooms. All rooms are fitted with a call bell system which residents can use to summon staff assistance if required. The home provides seventeen single and one shared bedroom, three of which provide en-suite facilities. Only one single bedroom is marginally undersized. Residents’ bedrooms are suitably furnished, decorated and equipped to ensure comfort, privacy and to meet their assessed needs. Residents can and have brought items of furniture and personal possessions to make them more homely with residents having personalised their bedrooms to their individual wishes. All bedroom doors have been fitted with locks and residents’ bedrooms have been provided with a lockable storage space. A privacy screen is available and is used as required for the shared bedroom. Residents commented very favourably about the standard and cleanliness of their accommodation, stating that they are comfortable, and are kept clean and tidy. Residents’ accommodation provides suitable heating, lighting and ventilation. Radiator covers have been fitted for residents’ protection and the type of installation still enables them to control the level of heating to their bedrooms through individual radiator controls. Thermostatic valves have not been fitted to the hot water taps used by residents and the hot water is centrally regulated at the required temperature and is tested weekly. The home continues to be maintained to a good standard, being clean, tidy and comfortable and free from offensive odours. The laundry room is located on the ground floor and provides two washing machines and two tumble driers. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 17 Residents’ clothing is labelled to ensure that garments are appropriately returned and care staff undertake this task with some input from the waking night staff. Residents commented favourably about the laundry arrangements in place, stating that their clothing is returned in good condition. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 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 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 and 30. The home must ensure that there are sufficient numbers of staff on duty at all times to meet the needs of the residents. The staff team collectively have a range of experience to meet the needs of the residents. The home is also working towards achieving a trained workforce in line with the National Minimum Standards. The recruitment practices within the home do not at present ensure the protection of residents. EVIDENCE: The deployment of staff, in the main, ensures that there are three members of care staff on duty throughout the waking day with two members of waking night staff on duty each night. However, the staff rotas showed that there were the odd occasions when there were only two members of care staff on duty in the evenings. The deputy manager was advised of the need to ensure that the minimum staffing levels are maintained at all times, even if it means the employment of agency staff. This is particularly so due to the change of category in registration and with the increased numbers of people being accommodated at the home with dementia. The home will be sending copies of the staffing rotas to the Commission who will monitor staffing levels on a weekly basis to ensure compliance. The staffing levels do not include those hours worked by the manager and ancillary staff employed. Residents spoken to commented positively about the care provided by the staff, stating that staff are excellent and very good. The vast majority of staff have a lot of experience in the care profession with the home working well to achieve at least 50 of the staff team being trained Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 19 at NVQ level 2 in care by 2005. To this end, seven members of care staff have achieved this qualification with a further four care staff either completing NVQ level 2 or 3. A sample of files for two newly appointed staff were checked and showed that appropriate recruitment practices are still not being followed. The home could still benefit from obtaining a full employment history and any gaps within it must be explored and the reasons recorded. In addition, there was no evidence that two satisfactory references and a CRB check had been obtained in relation to one member of staff. However, the deputy manager reported that a satisfactory CRB check had been obtained but was possibly held at head office. In respect to the other member of staff, a satisfactory CRB check had been obtained but the professional reference did not appear to have been provided from the previous employer. The home has established its induction programme, which is reported to be in line with TOPPS specification and is completed by all new staff employed. The sample files for two newly appointed staff were checked and showed that one of them had completed her induction whilst the other member of staff was still in the process of working through it. The aim of the home is to provide all mandatory training within six months of being employed and staff would then be registered to undertake NVQ training. Certificates of training undertaken by staff were clearly evident in their respective staff training files. However not all training undertaken had been recorded and individual training forms had not been established for all staff. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 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 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) 35, 36 and 37 Staff are being supervised, although the frequency of this was unclear. Residents’ rights and best interests are not being safeguarded by the home’s record keeping. EVIDENCE: The home no longer looks after money on behalf of the residents but rather bills their relatives for any expenditure accrued. Therefore Standard 35 is no longer applicable. There are a range of mechanisms in place for the manager to both brief and receive feedback from staff in order to monitor the standard of care and services provided to the residents. These include daily handover meetings, regular staff meetings, informal staff supervision and monitoring supervision. However, although there was some evidence that formal, individual and recorded staff supervision is being provided, it was uncertain whether all staff are receiving it at the frequency required in this Standard. Discussion also Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 21 took place as to the need to provide a consistent form, the areas to be covered and a copy should also be signed and retained by the person being supervised. Since the inspection, this form has been established with a copy having been received by the Commission. This task will be undertaken by the manager and deputy manager. Records checked related to residents’ medication sheets, menus, staff rotas and fire prevention. These records were found to be inappropriately maintained and require varying degrees of improvement. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 1 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 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 Standard No 16 17 18 Score 2 x 3 x x x x N/A x 2 x Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 23 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 1 Regulation 4&5 Requirement The registered individuals must ensure that the home’s statement of purpose and service users’ guide meet all the criteria as set out in the appropriate Regulations including Schedule 1 and Standard 1.2 of the National Minimum Standards. (Previous timescale of 31/03/05 - Not checked on this occasion) The registered individuals must ensure that all residents are provided with a copy of their contract. (Previous timescale of 28/02/05 not met) . The registered individuals must ensure that they receive a copy of the placing authoritys community care assessment or the equivalent prior to admission for those residents who are funded by social services. The registered individuals must ensure that a full assessment is completed prior to admission and includes the signature of the resident or their representative. The registered individuals must ensure that that minimum staffing levels are maintained at Timescale for action 30/09/05 2. 2 5(1)(c) 30/09/05 3. 3 14(1) 30/06/05 4. 3 14(1) 30/06/05 5. 27 18(1)(a) 20/06/05 Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 24 6. 29 19 7. 36 18 8. 37 17(3)(j) 9. 37 17(2) 10. 37 17(2) all times, as agreed between the proprietor and Commission for Social Care Inspection. The registered individuals must ensure that two satisfactory references have been obtained in relation to all staff appointed, one of whom is from their last employer. (Previous timescale of 28/02/05 not met) . The registered individuals must ensure that all staff receive regular formal supervision. (Previous timescale of 31/03/05 not met) . The registered individuals must ensure that all medication administered to residents are suitably initialled by staff. (Previous timescale of 28/02/05 not met) The registered individuals must ensure that all of the homes fire prevention records are suitably maintained, at the appropriate intervals. (Previous timescale of 31/03/05. The registered individuals must ensure that meals served at suppertime are suitably recorded. (Previous timescale of 13/02/05 not met) . 30/06/05 30/06/05 30/06/05 30/06/05 30/06/05 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 29 Good Practice Recommendations The registered individuals should strongly consider obtaining a full employment history for all staff employed and any gaps within it should be explored and the reasons recorded. The registered individuals should strongly consider ensuring that individual training forms are established for D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 25 2. 30 Woodfalls Care Home all staff and need to include all training undertaken. Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 26 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire, SN15 2BB 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 Woodfalls Care Home D51_D01_S62541_WOODFALLS_V214231_240505_Stage4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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