Inspection on 14/12/05 for Woodhaven Residential Home

This inspection was carried out on 14th December 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodhaven Residential Home 21/07/09

Woodhaven Residential Home 04/08/08

Woodhaven Residential Home 26/04/07

Woodhaven Residential Home 23/05/06

Woodhaven Residential Home 01/06/05

Woodhaven Residential Home 01/02/05

Woodhaven Residential Home 07/09/04

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

CARE HOMES FOR OLDER PEOPLE Woodhaven Residential Home Beacon Way (send corresspondence to Penn) Walsall Wood Walsall West Midlands WS9 9HZ Lead Inspector Maggie Bennett Announced Inspection 14th December 2005 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodhaven Residential Home Address Beacon Way (send corresspondence to Penn) Walsall Wood Walsall West Midlands WS9 9HZ 01543 377548 01543 453734 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) Woodhaven Homes Limited Linda Tye Care Home 30 Category(ies) of Dementia (30) registration, with number of places Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 55 years and above Date of last inspection 1st June 2005 Brief Description of the Service: Woodhaven provides personal care and accommodation for 30 people over the age of 55 who have dementia. The home is situated in the Walsall Wood area of Walsall, in a quiet street, with easy access to bus routes and local amenities. The property underwent extensive renovation in 1999/2000 and consists of a two-storey building with 30 single bedrooms, all of which have an en suite toilet and wash hand basin. There are lounge and dining facilities on the ground floor and a small quiet lounge on the first floor. There is a small, lawned garden, but this is not large enough to accommodate all the service users at one time. There is a passenger lift to the first floor. Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on a weekday between 8.30 a.m. and 6.40 p.m. Prior to the inspection a Questionnaire was sent to the Commission, completed by the Area Manager. Residents and their representatives were invited to complete Comment Cards and four were received back from relatives. At this inspection the standards not inspected at the unannounced visit in June, as well as those not met on that occasion, were assessed. 13 of the statutory requirements made at the last inspection were found to have been met. A further 9 requirements were made on this occasion. During the inspection the care plans of a random sample of residents were seen. A number of staff files were seen and relevant policies and procedures were inspected. Three relatives and a visiting friend were spoken to during the inspection and several residents were spoken to during the course of the day. Discussion also took place with care and kitchen staff and the Area Manager of the home. A tour was made of the premises and this included a number of bedrooms, as well as communal areas, the kitchen and laundry. Since the last inspection the Registered Manager has resigned and there is now an Acting Manager in place. What the service does well: What has improved since the last inspection? Assessment procedures have improved and there was evidence that the home is not admitting any new resident without receipt of a written assessment by a person trained to carry out this task. The home are also carrying out their own assessment prior to admission. There has been some improvement in the provision of training in dementia care. There has been a considerable improvement in the storage, administration and recording of medication and a safe system is now in place. The home has recently appointed an Activities Co-ordinator, who is to work on 5 afternoons a week. Although this person has not commenced work yet, this appointment will be of benefit to the Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 6 residents, who have lacked the opportunity to take part in structured, appropriate activities. There has been a big staff turnover since the last inspection. Staff morale has, however, improved and staff spoken to on this occasion feel that they are being well supported by the Area Manager and Acting Manager and can now move forward. One member of staff said: “I think this could be a really good home”. There have been some improvements to the décor and furnishings since the last inspection. This has included new floor covering in the lounge and some new armchairs. More are on order. The home is now carrying out all the required checks before recruiting new staff. 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. Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 (Standard 6 is not applicable). There has been further improvement in assessment procedures, but the home is still not using its own assessment systems to full effect. The training that has taken place in dementia care is benefiting the residents, but this must be regular, ongoing and underpinned by formal supervision in order to ensure that residents are cared for by people who fully understand their needs. EVIDENCE: The files of two residents admitted to Woodhaven since the last inspection, were seen. These showed, that in both cases, a full assessment had been carried out by a professional person (social worker or nurse) prior to the residents’ admission to the home. The home has good assessment systems in place, but these had not been completed in either case. The home’s pre assessment form gave very little information about the prospective resident’s personal history, social interests or spiritual needs. Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 9 Although dementia care training has taken place since the last inspection, a number of the trained staff have since left the home. Further training has been arranged for the New Year. Although there has been an improvement in the amount of dementia care training, this standard cannot be met until the majority of the staff have received the training and dementia care forms a regular part of formal supervision sessions. During the inspection staff on duty were observed be communicating sensitively and respectfully to the service users and were assisting them in an appropriate manner. Woodhaven does not offer an intermediate care or rehabilitation service. Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 10. Improvement is still needed to both personal and health care plans in order to ensure that residents’ needs are fully understood and met. There has been a considerable improvement in the storage, administration and recording of medication and a safe system is now in place. This improvement must be upheld and underpinned by regular auditing and accredited training. Staff are trained to understand the rights of the residents to be treated with dignity and respect. EVIDENCE: The care plans of five residents were seen. There has been very little improvement in care planning since the last inspection. As with the assessment information, there are systems in place, but these are not used to full effect. Although care plans give information on the person’s needs, there is very little information on how the needs are to be met. One person was described as having “aggressive outbursts”, but the care plan did not detail the strategies to be followed when this occurred. Care plans must describe the process of care (the “how” and what works for whom) for each individual. Several of the risk assessments were found to have the same wording and did Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 11 not relate to the particular risks to the individual. One person who the home described as “high dependency” had no manual handling risk assessment on file. There was no evidence of the regular reviewing of care plans or risk assessments (one person’s risk assessment had not been reviewed since July 2004). Residents’ healthcare needs are documented in their care plans. As with general care plans, there has been very little improvement in this area since the last inspection. The home states that there are no current residents with pressure areas. One person’s discharge letter from hospital stated: “pressure areas are intact, needs pressure areas observed at least daily”. There was no indication in the care plan that this was being done. Equipment is available for the promotion of tissue viability and 4 residents have pressure relieving mattresses. Advice is available from the Continence Promotion Nurse. Advice is also available from the Community Psychiatric Nurse, who is currently visiting one resident. There is no organised light exercise at present, but this is being arranged to take place on a regular basis in the New Year. There is evidence on care plans that nutritional screening does take place on admission, but information had not been updated for several residents. Residents are regularly weighed. All residents are registered with a local G.P., but the home has experienced difficulty in getting G.P.s to accept new residents. Healthcare professionals such as dentist, chiropodist and optician visit on a regular basis. A relative who was visiting at the time of the inspection felt that the home acted in a timely manner when her mother was unwell and called the Doctor straight away. There has been a great improvement in the administration, recording and storage of medication since the last inspection. The home were visited by the Pharmacist Inspector on 16th June 2005. A total of 26 statutory requirements were made following this inspection. A copy of the Pharmacist’s report is available at the CSCI office. The home’s policy and procedures documents for the safe handling of medicines has been amended and updated to include the issues identified by the Pharmacist Inspector. Quantities of medication received are now being recorded and handwritten entries double checked. A regular audit of the medication is now taking place. All G.P.s have been asked for written clarification with regard to “as directed” medicines. The home have obtained a maximum/minimum thermometer and are recording the temperature of the medicines refrigerator daily. When eye drops are opened, the home is writing the date of opening on the container. The home have obtained written authorisation from a resident’s G.P. for her to receive her medication covertly. The home have written to residents’ G.P.s in the case of three people who are prescribed risperidone or olanzapine. It was found that although the home had the appropriate recording and storage facilities in place for controlled drugs, temazepam had been provided on a blister card and could not be properly stored. The home is to request the Pharmacist to provide this in a bottle. Three of the current staff have successfully taken part in the Safe Handling of Medicines training. At the time of the inspection 7 members of Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 12 staff were undertaking the training (this includes 2 night staff). This improvement is encouraging and will continue to be monitored at subsequent visits. All service users have their own rooms and personal care giving and medical consultations take place in private. Residents are able to make and receive telephone calls in the office if they wish and there is also a portable telephone, which can be taken to individual rooms. All new staff receive induction training and this includes instruction on how to treat residents with respect. Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14. Opportunities for appropriate social activities have not markedly improved since the last inspection. This situation should improve now that an Activities Co-ordinator has been appointed. Residents are encouraged and assisted to maintain contact with their friends and families. Residents’ wishes are respected should they choose not to see a visitor. EVIDENCE: At the time of the inspection a number of activities had been arranged for the forthcoming Christmas period. Prior to that the last record of an entertainer visiting the home was 2nd November 2005. Although the home state that they have a regular Activity Programme, the last written record of a planned in house activity was recorded in October 2005. There is some equipment in place, such as art materials, music and a large ball, but the home lacks suitable equipment for activities for people with dementia. It is hoped that this shortfall will be met by the appointment of an Activities Co-ordinator, who is to commence her duties in the New Year. This person will be employed for 2 hours each weekday afternoon. Opportunities for “one to one” activities will also be increased when the home is fully staffed (see Standard 27). All residents have their own rooms and are able to see their visitors in private if they wish. There are no restrictions on visits. There are no local community Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 14 groups or volunteers visiting the home. The Acting Manager is recommended to discuss spiritual needs with residents and their families. Currently there are no representatives of any faiths visiting the home. There are, however, a number of residents for whom their religion has been important in the past. There are no residents at the home who manage their own financial affairs. An Advocacy service is available locally for any residents who do not have a representative. All service users have received a letter setting out their right of access to their personal records. Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 There are sound procedures in place to protect residents from abuse. EVIDENCE: There is an Adult Protection Policy and Procedure in the home and this is in line with the local Social Services Procedure. Any staff who have not already done so will be attending training in Adult Protection during January or February 2006. The home recently responded very appropriately to an allegation of abuse and a member of staff felt to be unsuitable to work with vulnerable adults was referred for consideration for inclusion on the Protection of Vulnerable Adults register. There are separate policies in place with regard to residents’ finances and the preclusion of staff involvement in assisting in the making of or benefiting from residents’ wills. Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26. There have been some improvements to the décor and furnishings since the last inspection. More improvement is needed to ensure that residents live in a comfortable and pleasant environment. There is insufficient outdoor space, which means that all residents cannot enjoy a garden in the summer months. The building is warm, but checks must be made to ensure that there is sufficient bedding, so that everyone is warm at night. The home is generally clean, but “yellow bag” bins must be emptied more frequently to prevent odours. EVIDENCE: There have been some improvements to the environment at Woodhaven since the last inspection. Work has commenced on the exterior paintwork (although not yet completed) and new floor covering has been fitted in the lounge. A number of new easy chairs have been purchased and more are on order. The Area Manager states that the recommendations of the Fire Officer have now been met and “green boxes” were seen during the inspection. There remain, however, several areas, which are in need of redecoration. The overflowing Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 17 drain, en route to the main door, continues to be a major problem and hazard. The Registered Persons must write to the Commission setting out how and when they intend to remedy this. There is insufficient outside space for the residents, with only a very small lawned area and an unsightly unused car park. Curtains are needed to the lounge. Several bedrooms need re-decorating and would also benefit from “personalising” with pictures, photographs, etc. It was noted a number of towels were frayed and need replacing. The floor covering to Room 12 must be cleaned and, if necessary, replaced with washable floor covering. One door (Room 25) has a broken handle and the door to Room 9 is not closing into its rebates and is not therefore serving its purpose as a fire door. The rusting toilet frame in Room 11 must be replaced. Alternative storage must be found for the pads stored in some en suite toilets. It was noted that some rooms have duvets and some blankets, but the blankets are cotton and there was only one on some beds. The Acting Manager must ensure that residents are warm enough and check whether additional bedding is required. The Area Manager said that the heating was left on during the night. The home is generally clean and free of odours and the cleaners work very hard in a difficult building. There is a suitable laundry and policies are in place for the control of infection. There is a sluice facility in the washing machine and in addition the home has a sluicing disinfector. The “yellow bag” bin in the ground floor shower room must be emptied more frequently as it is creating an odour. Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The number of staff on daytime shifts is not sufficient to fully meet the needs of the residents. The home do not have enough staff trained to NVQ level 2 or equivalent and this must affect the quality of care provided. Recruitment procedures have improved considerably since the last inspection and now protect residents. The availability of training in other relevant areas (including dementia care) is improving and this will be of benefit to the residents. EVIDENCE: At the time of the inspection the rota showed that there are normally 4 care staff, plus the manager on daytime shifts. At night there are 2 waking carers. Although the manager’s hours should be supernumerary, the Acting Manager is currently having to assist with care duties because of staff shortages and the high dependency levels of the residents. As stated at the last inspection, there must be 5 carers on daytime shifts (in addition to the manager). Breakfast was observed during the inspection and, as at the last visit, some residents had to wait for long periods for their medication and to be assisted to the lounge area. During this time, some fell asleep at the table, one with her head on the table. The care staff were observed to rely heavily on help from the Acting Manager and the Kitchen Assistant. The Area Manager states that she and the Registered Persons are in agreement that staffing levels need to be increased and that interviews are currently being held. They also intend to have 3 waking night staff. This must be attended to as a matter of urgency in order to safeguard the residents. Staffing ratios will be inspected at Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 19 subsequent unannounced monitoring visits. Staff were observed to be very attentive to the residents and to be extremely busy. Staff spoken to were clear that they needed more help, but were hopeful that this would be forthcoming in the near future with new staff appointments. The quotes of some of the staff are as follows: “You feel as if you are doing the job of two carers.” “You are constantly chasing your shadow.” “If they don’t get staff soon, they won’t keep staff, we are exhausted.” “We can’t give any more than we already are.” There has been a high staff turnover since the last inspection, with 14 staff leaving. The home has not achieved the target of 50 of its staff trained to NVQ level 2 or equivalent. Currently only 5 members of staff have an NVQ qualification. 2 staff have, however, commenced NVQ2 and more training is planned for 2006. This standard will be assessed again at subsequent monitoring visits. The files of newly recruited staff were seen and it was clear that the home’s recruitment procedures have improved considerably since the last inspection. All the required documentation was in place and this included Criminal Records Bureau and POVA checks. All staff receive copies of their terms and conditions. There are no volunteers employed at the home. There is a Training Programme in place, with clear objectives. Within the plan, training in dementia care is now a requirement for all staff. The Area Manager is currently arranging for all new staff to take part in induction training to Skills for Care specifications. All staff receive at least 3 paid days training per year. Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The home’s Registered Manager resigned in December 2005 and there is currently an Acting Manager in place. The Commission is awaiting an application from the Registered Persons with regard to a new Manager. There are systems in place to seek the views of residents, their representatives and other stakeholders and to act upon them. Residents’ financial records are kept in good order. The health, safety and welfare of residents and staff is promoted. EVIDENCE: The Registered Manager has recently resigned her post and there is an Acting Manager in place. This person is currently undertaking the Registered Managers’ Award and already has the D32/33 qualification. In addition to the above, the Acting Manager continues to update her knowledge by taking part in periodic training. This standard cannot be fully met until the home has an Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 21 appointed Registered Manager who has successfully undertaken the Commission’s “Fit Person” interview. The Area Manager has introduced a Quality Assurance system into the home and carries out audits, which are followed by an Action Plan. The home did start to obtain the views of residents’ relatives and friends, but this has not been done since April 2005. The home also sought the views of other stakeholders, such as District Nurses and G.P.s, but none of their questionnaires were returned. Prior to the inspection, the home distributed Comment Cards to relatives, several of which were returned. No residents’ meetings have been held recently. The home are currently looking at the possibility of organising a Relatives’ Support Group in the New Year. The home keep some monies in safekeeping for residents and a sample of these, plus accompanying records were seen at the inspection. The written record of transactions and individual monies were found to be in order. The home carries out a monthly audit of these monies and this is recorded. All monies are records are kept securely. The Area Manager is trained to train in Moving and Handling and Fire Safety and regularly carries out such training at the home. Several staff recently took part in First Aid training and 9 are currently undertaking infection control training. The remainder of this standard was met at the unannounced inspection in June 2005. Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 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 X X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 2 X X X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(a)( b) Requirement The home must carry out a more thorough assessment prior to admission. More information must be obtained on the prospective resident’s personal history, social interests and spiritual needs. Staff must receive regular, ongoing training in dementia care and this must form part of regular, formal supervision sessions. Care plans must be up to date and must describe the process of care for each individual. Care plans must be regularly reviewed and updated. Each care plan must contain an individual risk assessment, which must be regularly reviewed and updated. Care plans must give clear and up to date instructions as to how individual healthcare needs are to be met. (Previous timescale of 30/06/05 not met). Timescale for action 14/12/05 2 OP4 18(1)(c) 31/01/06 3. 4. 5. OP7 OP7 OP7 15(1) 15(2)(b) 15(1) 31/01/06 31/01/06 31/01/06 6. OP8 12(1)(a) 31/01/06 Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 24 7. OP8 17(1)(a)3 p 17(1)(a) Schedule 3 16(2) 8. 9. OP8 OP12 10. OP19 13(4)(c) 11. 12. 13. 14. OP20 OP20 OP24 OP24 16(2)(c) 23(2)(o) 16(2)(c) 16(2)(c) 15. 16. 17. 18. OP24 OP19 OP24 OP24 23(2)(b) 23(4) 16(2)(c) 16(2)(c) 19. OP26 16(2)(j) Care plans must contain details of the monitoring of residents at risk of developing pressure sores. Records must be kept of nutritional screening and these must be reviewed and updated. There must be a varied programme of leisure activities, designed to meet the needs of people who have dementia. All activities must be recorded. (Previous requirement of 30/06/05 not met). (This requirement should be met early in the New Year following the appointment of an Activities Coordinator). The overflowing drain outside the laundry must be remedied as it presents a hazard. (Previous timescales of 28.02.05. and 17.06.05 not met). Curtains must be provided in the lounge. There must be sufficient outdoor, accessible space for residents. Frayed towels must be replaced. The floor covering to Room 12 must be cleaned or replaced with suitable alternative floor covering. The door handle to Room 25 must be repaired. All fire doors must close firmly into the rebates. The rusting toilet frame in Room 11 must be replaced. The Acting Manager must check that all residents are warm enough during the night and provide additional blankets or duvets if needed. The “yellow bag” bin in the ground floor shower room must be emptied more frequently. 31/12/05 31/01/06 31/01/06 13/01/06 13/01/06 30/04/06 13/01/06 13/01/06 31/12/05 31/12/05 31/12/05 14/12/05 14/12/05 Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 25 21. OP27 18(1)(a) 22. OP28 18(1) There must be sufficient care staff on duty to meet the needs of the residents. Care staff numbers must be increased to 5 on day time shifts. (Previous timescale of 18.02.05. and 30.06.05. not met). The home must achieve an improvement in the numbers of staff trained to NVQ level 2 or equivalent. Further staff must be enrolled on this training. 01/01/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP4 OP12 Good Practice Recommendations Staff training in dementia care should be provided on a regular, ongoing basis. It is recommended that residents’ spiritual needs are discussed with them and their representatives. Local religious representatives should be asked to visit the home if requested by residents. A check should be made of the central heating system to ensure that it is working adequately in all areas of the home. 3. OP25 Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Woodhaven Residential Home DS0000020843.V263318.R01.S.doc Version 5.0 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!