Inspection on 19/10/06 for Woodhall Park

This inspection was carried out on 19th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodhall Park 23/01/08

Woodhall Park 14/09/05

Woodhall Park 22/06/05

Woodhall Park 24/06/04

Woodhall Park 08/07/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Woodhall Park Risley Hall Derby Road Risley Derby DE72 3SS Lead Inspector Tony Barker Unannounced Inspection 19th October 2006 09:15 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 Woodhall Park DS0000002126.V315843.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. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodhall Park Address Risley Hall Derby Road Risley Derby DE72 3SS 0115 9490444 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) Mrs Linda Isobel Ann Crosbie Miss Diane Joy Quincey Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one named service user under the age 65 for the duration of their care. 14th November 2005 Date of last inspection Brief Description of the Service: The Home provides nursing for up to 41 older people. It is situated in an appropriately adapted building, in a pleasant park setting in Risley. It is situated near to public transport. The fees are currently between £420 and £580 per week. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 7.75 hours and was a routine unannounced inspection. The last inspection took place in November 2005 and was unannounced. Three residents, the Activities Co-ordinator, the chef, one care assistant, one trained nurse and the Manager were spoken to, records were inspected and there was a tour of the premises. Three residents were case tracked so as to determine the quality of service from their perspective, although only one was spoken to in depth. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection questionnaire was reviewed prior to this inspection. What the service does well: What has improved since the last inspection? The day living areas, corridors and a number of bedrooms had been redecorated and the doors and skirting boards, that had been damaged by wheel chairs, had been refurbished. Damaged seals on fire doors had been replaced. Mixer valves had been fitted beside all wash hand basins, to which residents had access, to reduce the risk of scalding. Storage of hoists and wheelchairs had improved and the two en-suite shower cubicles, that could only be accessed by stepping up to them, had been removed to make a more spacious room. The administration and recording of medicines had improved. Newly appointed staff were being provided with a structured induction training programme. Twelve of the 18 requirements and four of the five recommendations made at the last inspection had been met. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective resident were being provided with information to enable them to make an informed choice about where to live. Residents were having their needs assessed before admission to the Home so that staff could provide individually tailored care. EVIDENCE: The Home’s Statement of Purpose had been amended to reflect the appointment of the current Manager. The statement of Terms & Conditions/Contract, supplied by the Home to each resident, was not still available for inspection – although a blank copy was seen. This included all the information listed within National Minimum Standard 2.2 except that there was no space for the ‘rooms to be occupied’ to be recorded. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 9 The pre-admission assessment documents on each of the three case tracked residents included all the items listed in Standard 3.3. However, two of the Home’s ‘Assessment and Initial Care Plan’ documents were unsigned by the nurse completing the document and none had been signed by the resident or a relative. The Home was not providing intermediate care. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs were set out in individual plans of care. They were generally being protected by the Home’s practices regarding the administration of medicines and the recording of these. Residents felt they were treated with respect and their right to privacy upheld. EVIDENCE: The on-going care plans of the three case tracked residents were examined and, as far as they went, were found to be well laid out and recorded, thus guiding staff to provide individualised care. However, documentation of residents’ health was not up to standard – see Standard 8 below. Staff were appropriately signing care plan entries and care plans were generally being reviewed every month, although there were some gaps. The signatures of residents, or their relatives, were seen on only one of these care plans. It could therefore not be judged how involved residents were in the on-going review of how their needs were being met. One case tracked resident spoke of seeing his written care plan. All people, who responded to a questionnaire sent to residents before this inspection, replied that they received the care and support they needed. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 11 There were no continence assessments on file for two of the case tracked residents even though, the Manager explained, these were relevant. The Manager produced a completed continence assessment for another resident. One case tracked resident’s ‘Waterlow’ (tissue viability) assessment had not been reviewed since July 2006 and there was no recorded risk assessment on ‘wound care’. Also, there were no risk assessments on the use of bed rails. Overall, there were minimal recorded risk assessments on residents’ files. A separate folder was in place holding records such as nutritional scores and weight charts. One case tracked resident was pleased at having become a more healthy weight since moving to this Home. The Manager stated that around 80 of residents’ beds were now of a ‘profiling’ (adjustable) nature and there were plans to replace all others with this type. She said that the Home’s trained nurses were ‘link nurses’ for topics such as Palliative Care, Continence Promotion, Safeguarding Adults, Infection Control, Medicine Management, Fire and Tissue Viability. She stated that the Home had regular visits from health professionals such as GPs, physiotherapists, occupational therapists, chiropodists, dentist, optician, clinical psychologist and consultant psychiatrist. The people who responded to the questionnaire sent to residents felt that residents received the medical support they need – one stating that there was “excellent medical support”. There had been a number of errors in the administration and recording of medication over several months, prior to this inspection, brought to the notice of the CSCI by the Manager. She had addressed these appropriately and had put measures in place to minimise their reoccurance. Handwritten entries on the Medication Administration Record (MAR) sheets were being signed by the person making the entry, countersigned by a colleague and dated, as required at the previous inspection. No gaps on MAR sheets were noted at this inspection. On one case tracked resident’s MAR sheet the variable dose of one item of medicine was not stated beside some of the signatures. All other matters relating to the recording and storage of medicines were satisfactory. One case tracked resident said he felt he was treated with respect. He said, “I am treated very kind...I couldn’t be in a nicer place”. He was of smart appearance and he said he was happy with the Home’s laundry system. One member of care staff described the way she works with residents saying, “I tell the resident what I’m doing...the part we are washing...tell the resident she is being turned”. This was considered good practice. She also gave examples whereby residents’ privacy is respected during personal care activities. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ daily routines and activities fully matched their expectations and preferences. Their contact with family and friends was being maintained and they had choice and control over their lives. They received a wholesome and balanced diet. EVIDENCE: One case tracked resident stated that he chooses to rise each morning at 6am; chooses to have a cereal followed by a cooked breakfast every day; chooses from a choice of two alternative lunches each day; and chooses to return to his bedroom each afternoon and have his afternoon tea (meal) there. The Activities Co-ordinator described the wide range of activities she was involved in during her 35 hours per week in the Home. These included one-to-one sessions with residents – for example, hand massage, nail care, exercise bike, taking them out in their wheel chair. Group activities included word games (this was occurring on the afternoon of this inspection), ‘sing songs’, film afternoons, discussion groups, ‘music-to-movement’ and reminiscence therapy. Trips to local places of interest occur, she added, including local garden centres and a forthcoming trip to a theatre matinee was also mentioned. Details of these were recorded in her diary. Outside entertainers also visit every six weeks. This level and range of activities is commendable. The people who Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 13 responded to the questionnaire sent to residents felt that there was always or usually good levels of activities for residents to take part in. Several visitors to the Home were seen on the day of this inspection. The visitors book confirmed daily visits to the Home were taking place by residents’ relatives and friends. One case tracked resident said that a close relative visits once a week and he can stay as long as he wants. The resident also said that ex-neighbours visit too. Another resident told the Inspector, “I’ve made friends here”. There were no residents handling their own financial affairs and 12 were subject to Power of Attorney. One trained nurse spoken to said that only family members and solicitors were involved as residents’ advocates – though church ministers sometimes become involved. The Home’s menus were examined and found to be of a high standard – varied and nutritious. Both the lunch menu and teatime menu were on display in the dining room on the day of this inspection. A resident was overheard asking the chef for a boiled egg at teatime that day and he replied, “You can have anything”. Residents spoken to said they were pleased with what they had eaten. One commented that the Home had “a good chef”. One case tracked resident spoke of food at the Home being of good quality and with good portions. He said, “I love my food”. The chef said he makes cakes every day. A list of residents’ dietary needs was displayed in the kitchen. The refrigerator, freezer and larder were well stocked and fresh fruit and vegetables were seen. The chef accepted a recommendation that a daily record of what residents actually eat be made. Staff were observed helping residents with their meal. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were being protected by the Home’s procedures on complaints and Safeguarding Adults matters. EVIDENCE: The Home had a comprehensive complaints procedure that was displayed in the entrance hall. One case tracked resident said he had never been unhappy at the Home but would know who to speak to if he was. The Commission had not received any complaints about the Home within the previous 12 months. The people who responded to the questionnaire sent to residents felt that staff listen to residents and act on what they say. Most felt that staff were usually available when needed by residents. Written guidance to staff, on Safeguarding Adults matters, had been provided as part of the Home’s ‘Policy on Abuse’ and the Derbyshire Procedures were also available to staff and covered in induction training for new staff. One trained nurse spoken to said that the majority of staff had had Safeguarding Adults training although newly appointed staff had not. One member of care staff, appointed in April 2005, stated she had not received such training. She was not aware of the Home’s ‘Whistle Blowing’ policy. The trained nurse said this was normally displayed in the staff room but it was not on the day of this inspection. The Home’s ‘Policy on Abuse’ made brief reference to ‘whistle blowing’ and to not penalising the ‘whistle blower’. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 15 Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22,24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were living in a comfortable and well-maintained environment that was clean, pleasant and hygienic. EVIDENCE: The day living areas, corridors and a number of bedrooms had been redecorated since the last inspection. The Manager said that most of the doors and skirting boards, that had been damaged by wheel chairs, had been refurbished and there was evidence of protectors fitted to wall corners. The Manager also reported that the damaged seals on fire doors had been replaced, as required by the Fire Officer. All radiators had safety covers. The premises were homely in appearance and there were attractive gardens surrounding. Bathrooms were domestically decorated. The toilet opposite room 21 had an extractor fan that had accumulated a lot of dirt and was therefore a potential fire hazard. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 17 Storage of hoists and wheelchairs had improved since the previous inspection and the two en-suite shower cubicles, that could only be accessed by stepping up to them, had been removed to make a more spacious room. The Manager said that a loop system for residents with hearing impairment had still not been fitted. A small sample of bedrooms were inspected. These were well decorated and furnished and nicely personalised. The Manager confirmed that locks had still not been fitted to the majority of bedroom doors and there was no note on care plans of the matter being discussed with residents. There were lockable facilities in just two bedrooms. The Home’s adjustable beds, for providing nursing care, were seen on a tour of the premises and they had an appropriate domestic appearance. The Manager said one of the trained nurses was link nurse for infection control matters. One care assistant spoken to described good hygiene practice regarding the transportation of soiled material around the Home. However, she had not been provided with infection control training. Hygienic pad disposal units had been placed within all toilets. Both the Home’s washing machines had sluicing cycles. Sluice room doors had number key-pads fitted for residents’ safety. There were no offensive odours in one Home. Everywhere inspected was found to be clean and tidy. The people who responded to the questionnaire sent to residents felt that the Home was always fresh and clean. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs were being met by an adequate number of staff but an inadequately trained staff group was, potentially, putting them at risk. EVIDENCE: The staffing rota, sent with the pre-inspection questionnaire, indicated that staffing levels were satisfactory. One member of care staff felt that there were generally adequate numbers of staff on duty and one case tracked resident confirmed that he was always well cared for by staff. The Manager stated that there were no longer any staff members on long term sick leave and no nursing vacancies, although there were two carer vacancies. She added that agency staff were only occasionally used and then the consistency of these staff was maintained. 27 of the care staff had achieved a National Vocational Qualification (NVQ) at level 2 – an improvement on the previous inspection but still short of the 50 required by the National Minimum Standards. There was no access to staff files during this inspection and ways of addressing this, whilst securely maintaining confidential staff files, were discussed with the Registered Provider who was making a visit to the Home. A copy of the revised Regulations, in relation to information required prior to the recruitment of staff, was left with the Manager. The Manager spoke of some staff having been appointed, by the Home’s Administrator, without her involvement at the Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 19 time. The Registered Manager has overall responsibility for managing the Home and it is therefore not acceptable practice for her to be informed of staff appointments after the event. The induction records relating to a member of care staff, appointed in August 2006, were examined. These showed that induction/foundation training was meeting the Training Organisation for the Personal Social Services (TOPSS) standards. However, only a small part of the training record had been completed. The Manager confirmed that all staff had been provided with Moving & Handling training. However, few staff – apart from new staff undertaking Health & Safety as part of Induction/Foundation - had received Basic Food Hygiene training or First Aid training. The Manager went on to state that annual fire training had been provided in September 2006 by a competent person. In-house fire training for night staff had only been provided for newly appointed staff, the Manager added, though she was aware that night staff must have this training twice a year. Staff training was being recorded in respect of new staff but not regarding existing staff. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were living in a Home managed by a person who was fit to be in charge. The Home was being run in the best interests of residents although a wider research of views could be gathered. Residents’ health and welfare was being protected. EVIDENCE: The Manager had been registered with the Commission for Social Care Inspection (CSCI) since the previous inspection. She is an experienced manager and first level registered nurse. At the time of this inspection, she was undertaking NVQ level 4 Registered Managers Award training which she commenced in March 2005. The Manager said she was still aiming to allocate two working days a week to administrative duties and the rest to working beside staff – although she has been unable to fully achieve this, to date. The Inspector felt this was an important aim to ensure adequate monitoring of standards was taking place. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 21 There was a relaxed atmosphere in the Home during this inspection. One person who responded to the questionnaire sent to residents found that staff were “always friendly and caring”. Other aspects of standard 32 were not assessed on this occasion. The Manager spoke of one Relatives’ Meeting having just been being held on 17 October 2006 and the continuation of Residents’ Meetings every three months. The minutes of the last Residents’ Meeting on 6 June 2006 were seen but other minutes were not available at the time of this inspection. The Manager confirmed that the Home’s Administrator undertook monthly visits to the Home, on behalf of the Registered Provider, as required by the Regulations. However, there was no recorded evidence of these visits. The Registered Provider said she would be undertaking these visits in future. The Manager confirmed that the Home’s quality assurance measures did not include compiling an annual plan or surveying the opinions of residents, relatives, staff and external professionals via questionnaires. A copy of the previous inspection report was displayed in the entrance hall together with letters of appreciation from relatives of ex-residents. The Manager stated that a Newsletter was sent out every three months. At the time of this inspection the Manager did not have keys to access the safe containing residents’ personal monies and the relevant records. She was making a brief visit to the Home while not being on duty. The Inspector accepted the need for security and limited access to the safe. Formal staff supervision had been started, the Manager explained. All staff had received an annual appraisal and some had had an additional supervision session. The member care staff spoken to confirmed she had had an appraisal and was expecting a supervision session soon. The pre-inspection questionnaire, completed by the Manager, confirmed that mixer valves had been fitted beside all wash hand basins, to which residents had access, since the previous inspection. There were still no cleaning materials product data sheets, in the main cleaning materials store, to ensure that staff can quickly access First Aid measures in the event of an accident. The Manager confirmed that the Environmental Health Officer inspected the Home in May 2006 and made no recommendations. A daily diary was being maintained of cooked food and refrigerator/freezer temperatures. Good food hygiene practices were noted at this inspection. A recorded risk assessment of the kitchen was available. Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 3 X 3 X 3 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 3 X 3 X 3 3 X 3 Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 24 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. 2. Standard OP9 OP21 Regulation 13 (2) 23(4)(a) Timescale for action Variable doses of medicines must 01/12/06 be recorded beside staff signatures on MAR sheets. Extractor fans must be 01/12/06 maintained to ensure that dirt does not accumulate and lead to a potential fire hazard. All staff must be provided with 01/02/07 training in mandatory subjects, and at necessary intervals, as detailed in this report. Requirement 3. OP30 18(1)(a) 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 The statement of Terms & Conditions/Contract supplied by the home should be updated to include all the information listed within National Minimum Standard 2.2 (This recommendation was from an inspection dated 2/12/02) All records, in respect of each resident, should be kept in the Home and available for inspection at any time. The Home’s initial care plan should be drawn up with the involvement of the resident, or representative if necessary, and should be signed by them. Residents, or their relatives as necessary, should be involved in the review of individual care plans and a signature obtained to evidence this. DS0000002126.V315843.R01.S.doc Version 5.2 Page 25 2. 3. 4. OP2 OP3 OP7 Woodhall Park 5. 6. 7. 8. 9. 10. OP8 OP8 OP18 OP18 OP22 OP24 11. 12. 13. 14. 15. 16. 17. 18. OP24 OP26 OP28 OP29 OP29 OP30 OP31 OP33 19. 20. 21. OP33 OP33 OP38 Personal health assessments and risk assessments should be completed as necessary and reviewed regularly. An audit should be carried out to assess the risks that each resident is exposed to and for which a recorded risk assessment is required. All staff should be provided with Safeguarding Adults training. A separate ‘Whistle Blowing’ policy should be written and clearly displayed for staff to read. A loop system for service users with hearing impairment should be fitted. (This was a previous requirement) Locks suited to service user’s capabilities and accessible to staff in emergencies should be fitted in service users’ private accommodation. A note should be made on individual care plans if this facility is rejected by the resident. (This was a previous requirement) All service users should be offered lockable facilities in their bedroom. A note should be made on individual care plans if this facility is rejected by the resident. All staff should be provided with Infection Control training. 50 of care staff should be trained to NVQ 2, or equivalent, standards. Records should be maintained, and always available for inspection, regarding the recruitment of staff. The Manager should be involved in the recruitment of all staff that she is responsible for managing. Records relating to the Induction and Foundation training of new staff should be appropriately and adequately recorded. The Manager should complete her NVQ level 4 Registered Managers Award training. Records should be maintained, and always available for inspection, regarding the required monthly visits to the Home on behalf of the Registered Provider and Residents/Relatives meetings. An annual plan should be compiled. The opinions of residents, relatives, staff and external professionals should be surveyed via questionnaires. Cleaning materials product data sheets should be kept in the main cleaning materials store, as required by the Control Of Substances Hazardous to Health (COSHH) Regulations. (This was a previous requirement) Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Woodhall Park DS0000002126.V315843.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!