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Inspection on 04/02/09 for Woodfield Grange Nursing Home

Also see our care home review for Woodfield Grange Nursing Home for more information

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People can go and have a look around the home and pick up information about the service provided. Everyone is assessed before they move in. People have access to a range of health care providers who visit them at the home. The records of these visits are good. There are some excellent plans to develop the range of activities that are on offer. There are some good staff working at the home that are well liked by the people who live there. People are very happy with the meals provided, they enjoy the food the cook prepares and they like the choice of meals available.

What has improved since the last inspection?

The quality of the care plans is starting to improve. There is evidence that people using the service and their relatives are beginning to be consulted about the care they need. The staff have more time to talk to people and to make sure their needs are being met. The lunchtime meal arrangements are better people are not left waiting at the table for their meals. The lounges have been greatly improved with new carpets, curtains and new chairs. Everyone is very pleased with the result.

What the care home could do better:

Complete the terms and conditions documents so that they are meaningful and contain relevant information. Medication administration should be better managed so that people are not interrupted with their medication during meal times. The daily records could be less repetitive and should reflect the care and support people receive. The medication administration records need to be improved. The change in the medication system should address this issue. The faults on the heating and hot water system must be addressed so that people are warm and have hot water in their bedrooms at all times. The manager needs to make sure that all staff have had up to date training about safeguarding people.

CARE HOMES FOR OLDER PEOPLE Woodfield Grange Nursing Home Saddleworth Road Greetland Halifax West Yorkshire HX4 8NZ Lead Inspector Lynda Jones Key Unannounced Inspection 4th February 2009 09:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodfield Grange Nursing Home Address Saddleworth Road Greetland Halifax West Yorkshire HX4 8NZ 01422 377239 01422 311863 manager.woodfield@aermid.com www.aermid.com Aermid Health Care (UK) Limited 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) Manager post vacant Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can provide accommodation and care for one named service user under 65 years of age. 12th August 2008 Date of last inspection Brief Description of the Service: Woodfield Grange is a care home with nursing providing accommodation and care for 36 older people. The home is situated on Saddleworth Road and is approximately ½ mile from the local shops and facilities in West Vale. There is a patio area to the front of the building where people can sit out in good weather. There are car-parking facilities to the side of the building; the car park is on a very steep slope. Accommodation at the home is arranged over three floors. There is one very large lounge on the ground floor that is divided into two sections by the arrangement of the chairs. The dining room adjoins the lounge on the ground floor. Each floor can be accessed by passenger lift. There are 34 single bedrooms and one double bedroom. None of the bedrooms have en suite facilities. In addition to the weekly fee there is an extra charge for hairdressing, chiropody and personal newspapers. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The last key inspection of the home took place in August 2008 when it was assessed as being poor. A pharmacy inspection was carried out in November 2008. At that inspection we found the systems for the administration, recording and storage of medicines to be poor. Aermid Health Care (the company that owns the home) provided us with an action plan telling us how they planned to address the requirements we made in the last inspection report. This inspection was carried by two inspectors to assess the quality of care provided to people living at the home. The inspection process included looking at the information we have received about the home since the last key inspection as well as a visit to the home, which was carried out over one day and lasted approximately 5.5 hours. During the visit we spoke to people who live in the home, to staff and the manager. We observed staff delivering care, looked at various records and looked around the home. We found an overall improvement in the quality of the service provided. What the service does well: People can go and have a look around the home and pick up information about the service provided. Everyone is assessed before they move in. People have access to a range of health care providers who visit them at the home. The records of these visits are good. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 6 There are some excellent plans to develop the range of activities that are on offer. There are some good staff working at the home that are well liked by the people who live there. People are very happy with the meals provided, they enjoy the food the cook prepares and they like the choice of meals available. What has improved since the last inspection? What they could do better: Complete the terms and conditions documents so that they are meaningful and contain relevant information. Medication administration should be better managed so that people are not interrupted with their medication during meal times. The daily records could be less repetitive and should reflect the care and support people receive. The medication administration records need to be improved. The change in the medication system should address this issue. The faults on the heating and hot water system must be addressed so that people are warm and have hot water in their bedrooms at all times. The manager needs to make sure that all staff have had up to date training about safeguarding people. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 8 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 Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5. 6 does not apply. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are assessed before they move in. This makes sure staff know what care and support people will need. EVIDENCE: We looked at some of the care plans and we saw that people are assessed before they move into the home. This is to make sure that the needs of each person can be met by the home. Some people have a copy of their terms and conditions of residence in their bedrooms; we saw these pinned on the bedroom walls when we looked round. The documents are not personalised, they do not have individual names on them and none of them have been signed. This needs to be improved so that the documents become meaningful. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 10 It is important that people are given a contract or terms and conditions of residence document on or before the day they move in to the home. This will make sure that people are properly informed about their rights and responsibilities. The home does not provide intermediate care. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The care plans have improved recently; they give staff more information about what they need to do to meet people’s needs. This improvement needs to be maintained. Personal support is given in a way that promotes and protects people’s privacy and dignity. Accurate records must be kept for all medicines held in the home. This will make sure that people receive their medications correctly and safely. EVIDENCE: We looked at three care plans because we wanted to see what individual needs had been identified and what action staff have to take to meet these needs. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 12 On this inspection we found some improvements in the quality of the plans, we found more detailed information about people’s needs and we could see that the plans are being reviewed regularly, this work needs to continue. One of the plans related to an individual who recently moved into the home; we could see that this person’s relative had been consulted and involved in decisions about her care. This is also an improvement since the last inspection; it shows that people are being asked about the care and support they require. We could see that people are receiving health care from a range of people such as doctors, community psychiatric nurses and tissue viability nurses. Details of visits are documented in the care plan together with any advice given. From talking to staff and observing their approach with people, it was clear they had a good understanding of the people living in the home, treating and respecting them as individuals. They know about the care and support people require but the work they do is not always reflected in the records. We found the daily records quite repetitive; they do not reflect the care and support that staff actually provide. These could be improved. We saw that staff were using good moving and handling practice and were attending to people’s needs in a discreet and dignified way. People were smart and looked well cared for These are some of the things we fed back to the manager about the content of the plans at the end of our visit: • • • Pre admission assessments need to be signed and dated when they are completed. Inventories of personal possessions should be completed when new people move into the home. Some of these records had been left blank. When there is a change to any part of a care plan the details need to be signed and dated. The plan must accurately reflect the care that is required. For example, we saw a moving and handling plan that told us about one person who could weight bear, used a zimmer frame and required one member of staff to assist her. This had been altered and assistance from two staff had been added but not signed and dated. We saw this person hoisted and taken to the dining room in a wheelchair but this was not in the moving and handling plan. From the records of weight we noted that one person had lost 6 kilos between October 08 and January 09. In December 08 the nutritional risk assessment instructed staff to weigh this person weekly but we could not find any evidence to demonstrate that this was taking place. DS0000001076.V374105.R01.S.doc Version 5.2 Page 13 • Woodfield Grange Nursing Home • We saw a plan that indicated that one person was cared for in bed and needed to be repositioned every 2 to 3 hours to relieve pressure and keep their skin intact. We could not find any records in this person’s room to show that this was taking place. The care plan for somebody with a gastric feeding tube did not tell staff how to care for the site where the tube entered the body. This means that staff might not be caring for the site properly and there could be an infection risk. There was conflicting information on one plan about the type of mattress that one person was using. The moving and handling assessment stated that a nimbus mattress was used; the moving and handling plan stated that a premier mattress was in use. During lunch we observed a nurse giving someone their tablets on a spoon, as they were mid way through eating their meal. This individual was clearly agitated by this, pushed her lunch away and then removed the tablets from her mouth, placing them on the dining table. This is poor practice and we talked to the manager about this while we were there. • • • We did not observe a full medication round. The current Medication Administration Records (MARs) were looked at. There is a list of staff authorised to administer medicines and examples of their signatures. This means it is possible to identify who was involved in administration if a query or problem occurred. The dose and administration times are highlighted on the MARs to make it clear to staff how much to given and when. However we noted that Codeine Phosphate medication that was on the records to be given at 10pm was sometimes given at 8 pm. We do not know the reason for this. Ibuprofen Gel which was prescribed to be applied three times daily had only been signed for on 15 occasions. If it had been applied as prescribed it should have been signed for 50 times on the Mar sheets. We noted that someone had handwritten on the records that this should be given when required. We could not tell who had given this instruction. One member of staff had made a handwritten entry for two types of medication on one of the MAR sheets. To make sure there is an accurate record the quantity of medication supplied, the date of entry, the signature of the person making the entry and a witness signature where possible should be included. This makes sure that there is accurate information for staff to administer from. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The staff have plenty of contact with people and they respect their preferred routines. People are offered a choice of meaningful daytime activities that suit their interests and capabilities. There is plenty of choice on the menu and people enjoy their meals. EVIDENCE: The atmosphere in the home was pleasant and relaxed. Throughout the day the staff were polite and friendly, they made time to stop and talk to people. The staff know people very well and some good-humoured banter was exchanged. At the last inspection we noticed that staff only had contact with people when they were carrying out tasks such as giving out drinks, taking people to the Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 15 toilet or taking people to the dining room at lunchtime. Routines seemed to be better organised on this occasion and staff had more time to spend with people. This could also be because only 24 people are currently living at the home. (The home can accommodate 36 people). There has been a significant improvement in the range of activities that are now available for people to take part in if they want to. The home now has an activities organiser. Throughout the day the activities organiser was very much in evidence, she is enthusiastic about her role and people appeared to enjoy her company very much. She circulated, and managed to make sure she spent some time talking to most people in the lounge. She manicured people’s nails and discussed some of the trips planned for later in the year. On the day we visited a trip had been planned to the Museum of Photography in Bradford but it had been cancelled because of the bad weather. One person told us “ we all had a wonderful time at Christmas” and other people sitting nearby all agreed with this. On the plans we looked at, two out of three contained information about the sort of life experiences people have had and the sort of daily routine that they prefer. When we talked to staff, they demonstrated a good understanding of what people like and dislike; they know about preferred routines and how people like to spend their time. During the day everyone was asked individually what they would like to eat from the menu for the day. People told us the food was “very nice”, “I have no complaints about the meals” and “nowt wrong with the food here”. We talked to staff working in the kitchen and they demonstrated a good understanding of people’s likes and dislikes and of the size of portions people prefer. They gave us an account of the special dietary needs that they cater for. In the last report we commented on the length of time that people were left sitting in the dining room while they waited for the meal to be served. On this visit we noted that the arrangements have improved, people are now served when they reach the dining room, they do not have to wait until everyone is seated. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People know how to complain. Staff take complaints seriously and make sure people’s concerns are sorted out. EVIDENCE: The complaints procedure is on display in the entrance area. Since we last visited in August 2008 we have not received any complaints about the service. The home received two complaints in January 2009 about the heating and the hot water system; we looked at these in the complaints record that is kept in the office. These are about times when there has been no hot water and heating in certain parts of the home and problems in maintaining the hot water at a steady temperature. Some people have not been able to wash in their own bedrooms and have had to use the bathrooms. The same concerns were raised at a recent meeting of residents and relatives. The manager has acknowledged the complaints and passed them to head office for a response. The fault with the hot water system is under investigation. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 17 We are still unable to tell how many staff have had training about their responsibility to protect people in their care and to report any practice they see that concerns them. Some staff told us they had received training in this area in November 2007 and according to the training matrix four staff had some training in January 2009. The manager needs to gather this information together and make sure that all staff are aware of their responsibility to protect people. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,24,26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The shared areas of the home are comfortable and the fittings and décor have been improved very recently. The environment will be improved even further when the planned developments are completed. EVIDENCE: There is level access to the home. The grounds are accessible by wheelchair and there is space to sit outside in the good weather. There are car-parking facilities to the side of the building; the car park is on a very steep slope. On our last two visits to the home toilets just inside the reception were a great source of dissatisfaction to everyone. People felt that the location of the toilets Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 19 compromised individual privacy and dignity. On this visit, the manager told us that work was about to begin to relocate the toilets and the office and upgrade the reception area. This will be a big improvement. The lounge has been improved with new carpets and curtain and all of the chairs have been replaced. People told us they are really pleased with the way this area now looks. We looked round the building but we did not see all of the bedrooms. We noted that some of the bedrooms have been redecorated and have new furniture and curtains, which has improved them but there is still a considerable amount of work to be done. In some of the bedrooms the wash basins are coming away from the walls, several appear to have been resealed but this has not solved the problem and dirt is building up in the cracked sealant. In some rooms the wallpaper is marked and peeling off, some of the bedroom furniture is chipped and handles are missing. All of theses issues should be remedied when the rooms are all upgraded. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is adequately staffed to meet the needs of the people living there. Recruitment procedures are good; all new staff are checked before they take up post to make sure they are suitable to work with older people. EVIDENCE: At the time of this visit, there were 24 people living in the home. The duty rotas showed that in the mornings there are two nurses on duty with 4-5 care staff; in the afternoons and evenings there is one nurse and 4 care staff and during the night there is one nurse and 2 care staff on duty. All staff are appropriately checked before they start work at the home. We looked at the records relating to two members of staff which showed that all of the checks had been carried out. This is done to make sure that prospective staff are suitable and to make sure that people living at the home are safe and protected. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 21 Plans are in hand to update staff training records; this will mean that there is a clear picture of what training staff have had and what they still need to do. This is an improvement. We were provided with a copy of the training matrix, which was not complete, but it did tell us that most staff have undertaken their mandatory training. The manager told us she had recently applied for funding for staff to take part in training in basic food hygiene, health and safety, dementia awareness and safeguarding people. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are now being consulted about the way the home is being run and asked how they think the service could be improved. EVIDENCE: Over the last twelve months there have been several changes of home manager. The current manager has been in post since November 2008 and although this is a relatively short period of time, we have seen improvements in the service and we have highlighted them in the report. The manager has Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 23 been registered with us in the past and she has several years experience of working with older people and of managing a care home. She intends to submit an application to the Commission to be registered in respect of Woodfield Grange. It is important that a manager is registered as this will mean that there is someone legally responsible for the direct management of the home. Aermid, the company that owns the home provided us with an action plan following our last inspection, telling us how they intended to improve the service. They have carried out the actions they outlined in the plan. The area manager visits the home on a regular basis and completes a report on the conduct and management of the home. The staff that we talked to told us the staffing levels were better and they felt able to meet people’s needs and spend more time with them. They said the atmosphere in the home was more relaxed and they felt that the people living there were much happier. They also told us they had more moving and handling equipment that they needed and this was a big improvement. There has been some investment in the home to upgrade the décor and furniture, and further developments are planned that will improve the layout of the building and general facilities. Contact with people who live there and their families has improved. A newsletter on the notice board tells visitors about new staff, invites people to attend residents and relatives meetings and informs people about a new proposal to hold managers surgeries every week for two hours where people can talk over any issues that they may have. The newsletter also tells people about any outings that are planned. We looked at the records of money held for safekeeping on behalf of people living at the home. The records could be reconciled with the balance of money held in the home. We could see that receipts are obtained for all purchases. We saw that one person’s money is looked after by an officer of Calderdale council. When this person needs money staff contact Calderdale council and arrange for a cheque to be sent to the home. At the moment the cheque is made payable to the administrator, who pays the money into her own bank account and then withdraws the same amount in cash. Details of these transactions are documented on the individual’s money record. We felt that this system could leave staff vulnerable to accusations of ‘mishandling’ money. Staff need to arrange a better system that doesn’t involve staff paying money into their own account. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 24 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 2 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X 2 X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 3 X 2 Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP8 Regulation 12 Requirement Where risk assessments identify people as being at risk of developing pressure sores or losing weight, detailed care plans must be put in place. Care plans must be updated to reflect any changes in individual needs. This will make sure that people’s healthcare needs are identified and met. All medication must be administered as prescribed. Accurate records must be kept for all medicines. This will make sure people receive their medications correctly and the treatment of their medical condition is not affected. All staff must have adult protection training so that they all know how to recognise abuse and what action they need to take if it is suspected. This will help to make sure people living in the home are not at risk. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 26 Timescale for action 31/03/09 2. OP9 13 31/03/09 3 OP18 13 31/05/09 4 OP25 23 Action must be taken to make sure that: • The home is adequately heated • There is an adequate supply of hot water 30/04/09 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 OP2 Good Practice Recommendations People using the service or their relatives, should be asked to sign their terms and conditions of residence documents. Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodfield Grange Nursing Home DS0000001076.V374105.R01.S.doc Version 5.2 Page 28 - 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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