Inspection on 23/05/06 for Woodhaven Residential Home

This inspection was carried out on 23rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Woodhaven Residential Home 21/07/09

Woodhaven Residential Home 04/08/08

Woodhaven Residential Home 26/04/07

Woodhaven Residential Home 14/12/05

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 Walsall Wood Walsall West Midlands WS9 9HZ Lead Inspector Mrs Mandy Beck Key Unannounced Inspection 23rd May 2006 09:30 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.V296837.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. Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodhaven Residential Home Address Beacon Way 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 Care Home 30 Category(ies) of Dementia (30) registration, with number of places Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 55 years and above Date of last inspection 14th December 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. The home currently charges service users between £324.08 - £365.00 per week for residency at Woodhaven. Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over two days and was undertaken by one inspector from the Commission for Social Care Inspection. The judgements made within this report are based upon information supplied by the home, from interviews with staff and service users and from relatives. A tour of the premises was also undertaken and observation of care practice and interaction between staff and service users was also completed. Five service users files were looked at in depth to enable the inspector to monitor progress in meeting previous requirements. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that all staff are recruited in a safe manner and that satisfactory references are received for all employees. Those staff who commence employment with only a POVAfirst check in place must be supervised at all times whilst on duty. Staff training is improving but there are Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 6 significant gaps in mandatory training for staff in first aid, health and safety, infection control and adult protection this must be addressed as a matter of priority. The internal environment needs attention to ensure that all rooms have light bulbs that work, that hot water is free flowing in every room and that repairs to fire doors are completed promptly. The garden area needs to be tidied to ensure that it is a welcoming place for service users to want to visit. Relatives have also commented that at times service users are not always dressed in their own clothing “my mother does not wear her own clothes and slippers and her hair is not brushed” and the manager must address this and ensure that service users have their own clothing available to them at all times. 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.V296837.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 Woodhaven Residential Home DS0000020843.V296837.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 The home provides satisfactory information to each prospective service user to enable them to make a choice about where they want to live. Each service user has a contract which details the conditions of residency whilst in the home Every service user has a needs assessment completed prior to their admission to the home this will assure them that their needs will be meet upon admission. The home will confirm that they are able to meet needs in a letter to the them. Service users are encouraged to spend time at the home prior to admission to ensure that they feel their needs will be met. Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 9 EVIDENCE: The home provides a statement of purpose and service user guide to each prospective service user, the documents are comprehensive and include information that enables prospective service users to make a choice about living in the home. All service users are encouraged to spend time at the home prior to admission to ensure that they like it and feel comfortable that the home will be able to meet their needs. One gentleman stated “I came for the day, I liked, so I came back”. At present the manager visits all prospective service users at their home or hospital prior to admission. There was evidence that professional assessments had been obtained and the manager had completed the home’s own pre admission assessment for each service user. Following this assessment the manager will write to them confirming that the home will be able to meet their needs. Each service user file seen contained a contract of terms which details the conditions of their residency however not all of these had been signed by the service user and/or their relative the manager must take steps to ensure that the terms and conditions are understood and signed by the service user . It was pleasing to see that all of the staff will be taking part in dementia training this will build on the knowledge and skills that the staff already possess and should enable them to deliver a person centred approach to care. Woodhaven Residential Home DS0000020843.V296837.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Each service user has an individual plan of care that details how their needs will be met. Health needs are addressed promptly. Medication is generally managed safely and service users are protected by the home’s policy and procedures. Service users are treated with respect and dignity most of the time. EVIDENCE: Each of the service users files seen had individual plans of care. The manager has made improvements in the way that care needs have been identified and managed by introducing these plans. There was also evidence that staff are reviewing care plans regularly but the manager must explore ways in which to involve the service users and their relatives in this process. Where this is not possible due to the nature of the mental health problems experienced by some of the service users at Woodhaven this should be clearly indicated. Daily records were also seen and as in previous inspections entries made by staff could not always be cross-referenced to care plans. The manager must ensure that staff are aware of the importance of including all information regarding service users well being. This was highlighted when a “bruise monitoring form” Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 11 was seen indicating that one service user had a bruise on her arm, this information had not been written in her daily notes. Service users do have access to community services such as chiropody, dentistry, opticians should they require them. Some relatives have expressed their concern about the home’s policy of not escorting service users to hospital when they require it. “my mother was taken to hospital on her own by ambulance we thought she should have been accompanied by a carer”. Each service user is assessed by staff to determine whether or not they are at risk of developing pressure sores. District Nurses visit the home regularly and support the staff with the provision of pressure relieving equipment as necessary. The home also completes a dietary assessment that details each service users abilities at meal times and lists their likes, dislikes and the type of help needed. The home does not have a specific nutritional screening tool to use that would help them detect those service users who are at risk of malnutrition. The manager was informed of this during the inspection and has already begun to rectify this situation. All service users are weighed monthly this helps the staff to monitor the service users well being and physical conditions. Service users who have specific conditions such as diabetes and epilepsy generally had management plans in place to ensure that staff were aware of their individual needs. Although in one service users file there was no management plan for epilepsy and this should be completed as soon as possible. All of the service users at Woodhaven have some form of dementia and occasionally they demonstrate some behaviour that challenges staff, one service user displays physically aggressive behaviour but there was no management plan to address this. This means that staff will find it difficult to meet the needs of service users without specific guidance. This was discussed with the manager during the inspection. Service users are also assessed for their need to have bed rails to ensure their safety whilst in bed. It was noted that one service user had bed rails but these were broken, this was also bought to the manager’s attention during the inspection for her prompt action. Medication practices within the home have improved greatly since the last inspection. The medication room was found to be clean and tidy, medication was stored appropriately. Staff are now taking part in accredited training in safe handling of medicines this will ensure that they are aware of processes involved in administering medicines and enable them to do it safely. Medication rounds were observed during the inspection staff were seen to administer and record when medicines had been given, however the home currently uses a “runner” system that means one carer administers Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 12 medications and another carer gives them to the service user, this practice is potentially dangerous and could increase the risk of drug errors occurring and harm to service users, this practice must stop. At present the home does not assess the competence of each service user when considering self medication in line with the homes own policy, currently none of the service users administer their own medication. It was observed that at all times staff spoke to service users with respect and were polite. The staff work hard to try and maintain the dignity of service users, which can be difficult at times due to the type of illness they have. Relatives have commented that they are pleased with the care their relative receives but sometimes things can go wrong. “My mothers general appearance i.e. not wearing her own clothes or slippers and her hair not being brushed as she can no longer look after herself”. Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 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): 12,13,14,15 Service users are enjoying activities that are planned around their capabilities. Family and friends are actively encouraged to visit service users. Service users are offered nutritious meals in a relaxing atmosphere. EVIDENCE: It was very pleasing to see activities taking place during the inspection. Service users were all engaged in meaningful activity at some point during the day. The home has now employed an activity organiser, this appears to have had a positive effect on staff and service users. Some staff commented “the residents are calmer, it’s like they have something to do now it’s better”. Activities are written on to the notice board in the dining room for all service users to read. Each service user has their own activity profile based upon their capabilities, likes and dislikes. Activities seen during the inspection included board games, painting, service users were engaged in conversation with each other whilst others sat tapping their feet to music. Family and friends are encouraged to visit and the home has an open visiting policy. There was a steady flow of visitors during both days of the inspection. Some commented that “it’s lovely to see them (service users) doing something, everyone is happier just lately”. Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 14 The home provides three meals a day plus snacks if service users require them. The menu is planned on a four weekly basis, the kitchen is well equipped and has a well stocked food supply. Mealtimes can be a noisy affair but staff do their best to encourage the service users to relax and enjoy their meals. Meals are a generous size and there are always two choices offered to service users. “I love the toast here”, “they always make sure we have lots to eat sometimes there’s too much” were some of the comments from service users. Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 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): 16,18 Service users can be assured that their complaints will be acted upon and taken seriously. More training is required for staff to ensure that service users are protected from abuse. EVIDENCE: There is an appropriate complaints procedure in place and records are made of all complaints made. Since the last inspection one complaint has been made and the manager has satisfactorily addressed this. The home has a policy for the protection of vulnerable adults this needs to be updated to include details of the Protection of Vulnerable Adults (POVA) guidance. Staff are being recruited only after a satisfactory POVAfirst and applying for a CRB disclosure further safeguarding service users interest. There has been a large turnover of staff recently, which has meant that the number of staff who have received training in Adult Abuse awareness has become diluted. After discussions with the staff it was clear that there was uncertainty about what constitutes abuse and where they should go for help if they suspect abuse had occurred. Woodhaven Residential Home DS0000020843.V296837.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The home is generally well maintained although improvements could be made to the décor. The home is clean and hygienic EVIDENCE: A tour of the premises highlighted a number of issues that must be addressed to improve the internal environment. Paintwork is looking tired and in need of refreshing. The manager stated that there is planned programme for maintenance with timescales for specific jobs. Since the last inspection new chairs have been purchased and there are now enough chairs for all the residents to sit on. Curtains have now been supplied in the lounge, which gives the room a more homely feel. Relatives have commented about the décor within the home stating that it would benefit from being refreshed. The hot water supply to one toilet’s hand washbasin was not working and the water pressure in some bedrooms meant that hot water only trickles from the tap, this must be addressed promptly, this is an outstanding issue from the previous inspection. Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 17 The home has now purchased some garden furniture but the garden still needs to be tidied up to make it more inviting for service users and their families to use. Throughout the home there was adequate provision of liquid soap and paper hand towels this will help reduce the potential of spreading infection. Gloves are readily available for all staff to use and they were seen make full use of them. The laundry was seen during this visit and the home has recently taken delivery of new washing machines and tumble dryers that enable clothing to be washed at correct temperatures to reduce the risk of cross infection. Woodhaven Residential Home DS0000020843.V296837.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The number of staff available on day shifts has improved and there are sufficient numbers of staff most of the time to meet service users needs. Recruitment procedures have improved but require fine tuning to fully protect service users. Not all of the staff are adequately trained to do their jobs. EVIDENCE: The manager’s hours are supernumerary and there are now five care staff on duty in the morning four in the afternoon and three waking night staff. The home also employs kitchen staff, domestic and a maintenance worker to ensure the home runs smoothly. Staff were spoken to and all agreed that despite the changes in staff recently they felt they were for the better and they were beginning to work as a team again. Relatives have also made observations about the staff team “most of the old team have left including the manager there seems to be plenty of staff with not much personality”, “recent large staff turnover has appeared to change the home atmosphere somewhat but mom still appears happy here”. Service users were full of praise for care staff stating they “are golden they do anything for us”, “I’ve not long been here but they helped me settled in”. Recruitment and selection of staff has improved since the last inspection and this was pleasing to see. All staff are now having the required checks before commencing employment but the home must not allow those staff with only a POVAfirst check to work unsupervised. Each member of staff who is employed in this way must have a dedicated supervisor during their shift. The manager Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 19 must also ensure that satisfactory references are received for each employee and that a full employment history is obtained. As staff have left the home and new employees have begun working there the numbers who have obtained their NVQ level 2 has become diluted and the home does not meet it’s target of 50 , however the manager is working hard to ensure that all new employees are enrolled and will receive necessary training. It was pleasing to see that some of the care staff have now completed both their NVQ level 2 and 3, and should be congratulated on their hard work. All new staff receive an induction and training in line with Skills for Care and staff confirmed that they are fully supported by the home for any training needs that they have. Woodhaven Residential Home DS0000020843.V296837.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The manager is not registered with the Commission for Social Care Inspection. Service users can be assured that the home is generally run in their best interests. Their financial interests will be safeguarded and the home does attempt to promote the health, safety and welfare of it’s service users and staff EVIDENCE: The home has a new manger in place who is working hard to improve the standard of service provided at the home. At present there has been no application made to the Commission for Social Care Inspection to register the manager this must be done to ensure that the home is run and managed by a person fit to do so. There have been improvements in the quality monitoring systems and monthly audits are completed. The audits look at the standards of record keeping, Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 21 medication practices, the environment and relatives views. More work needs to be done now on developing systems that will enable the voice of the service users to be heard and the manager must consider ways in which to do this. The results from service user and relative surveys must be published with an action plan this will demonstrate the homes commitment to a continuing improvement cycle. Service users can feel assured that their money is in safe hands. The home will only look after small amounts of “pocket money” for each service user. These records were seen and were generally well maintained. There were some minor discrepancies which the manager will address. Improvements are needed to ensure safe working practices within the home. The manager was unable to produce certificates that demonstrated the central heating, electrical wiring and Portable Appliance Testing had been completed. There are gaps in mandatory training for staff that includes fire training, first aid, health and safety and moving and handling. The manager is aware of this and is taking steps to rectify this situation. Woodhaven Residential Home DS0000020843.V296837.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 2 3 3 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 3 17 X 18 2 1 X X X X X X 3 STAFFING Standard No Score 27 2 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 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 OP8 Regulation 17(1)(a) Schedule 3 Requirement Records must be kept of nutritional screening and these must be reviewed and updated.(previous timescale of 31/01/06 not met) Staff must receive regular, ongoing training in dementia care and this must form part of regular, formal supervision sessions.(previous timescale of 31/01/06 not met) Timescale for action 01/07/06 2 OP4 18(1)(c) 01/09/06 3 OP20 23(2)(o) There must be sufficient outdoor, 01/09/06 accessible space for residents.(previous timescale of 30/04/06 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.(previous timescale of 31/01/06 not met) All contracts must be signed and dated by the service user to demonstrate their understanding of the conditions of residency DS0000020843.V296837.R01.S.doc 4 OP28 18(1) 01/08/06 5 OP2 5(1)(c ) 01/06/06 Woodhaven Residential Home Version 5.2 Page 24 6 OP7 7 8 OP8 OP8 9 10 OP8 OP9 15 (2) (c ) The manager must ensure that service users are involved in the review of their care unless it is impracticable to do so then this must be documented in the service users plan. 15 (1) The manager must ensure that all of the service users needs are reflected in their care plans 15 (1) The manager must develop care plans for dealing with behaviour that challenges staff and staff must be made aware of their content 15(1) Care and management plans must be formulated for the service user who has epilepsy 13(2) The practice of using “runners” to administer medication must cease. Only one member of staff must sign the MAR sheet to indicate that medicines have been administered (with the exception of controlled drugs) Service users must be assessed in line with the homes policy for self administration of medicines The manager must ensure that a more effective laundry system is implemented to ensure service users wear their own clothing at all times. All staff must receive adult protection training The vulnerable adult policy must be updated to include details of Protection of Vulnerable Adults (POVA) (May 2006) The manager must ensure that the bed rail identified during inspection is repaired promptly All light bulbs must be in working order. 01/07/06 01/07/06 01/07/06 01/07/06 01/06/06 11 OP10 12(4)(a) 01/07/06 12 OP18 13 (6) 01/09/06 13 OP19 23 (n)(o)(p) 01/07/06 Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 25 A copy of the programme of renewal for decoration and fabric must be forwarded to the CSCI All hot water taps must be in working order and meet recommended temperatures. Radiator cabinets must be secured to the wall. The garden must be tidied to enable service users to access it The registered provider must supply a bath hoist to enable those service users who require a bath for medical reasons to be able to have one. The manager must review staffing levels, the person employed who is not 18 must not be included in the care staff numbers. The manager must continue to ensure that care staff are enrolled onto the NVQ 2 programme to meet National Minimum Standards The manager must ensure that all staff provide satisfactory references. One must relate to the persons last period of employment of not less than 3 months duration The manager must obtain a full employment history with a satisfactory written explanation of any gaps in employment The registered person must put forward a manager for registration with the CSCI The manager must develop the quality assurance systems within the home. 14 OP21 23 (o) 01/09/06 15 OP27 18 (1)(a) 01/06/06 16 OP28 18 (1)(c) 01/09/06 17 OP29 19 (c) schedule 2,(3,6) 01/06/06 18 19 OP31 OP33 8(1)(a) 24 01/07/06 01/09/06 Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 26 This will include publishing results of service user/relatives questionnaires and producing an action plan for development The manager must develop systems for determining the views of service users with dementia who are unable to verbalise their needs. 23 (2)(c ), The registered provider must 23 (4) (iv) ensure that repairs to fire doors are completed as a matter of priority. The registered provider must forward to the CSCI certificates pertaining to the Servicing of boilers and central heating Maintenance of electrical systems and electrical equipment Regulation of water temperature and design solutions to control Staff must receive mandatory training in respect of Fire Safety Health and safety First aid 20 OP38 01/07/06 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 Refer to Standard OP29 Good Practice Recommendations It is recommended that staff files are organised into sections for ease of reading Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 27 2. OP25 A check should be made of the central heating system to ensure that it is working adequately in all areas of the home. 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. 3. OP12 Woodhaven Residential Home DS0000020843.V296837.R01.S.doc Version 5.2 Page 28 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.V296837.R01.S.doc Version 5.2 Page 29 - 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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