Inspection on 27/09/05 for Woodhouse

This inspection was carried out on 27th September 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 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

Woodhouse 09/06/09

Woodhouse 17/07/08

Woodhouse 20/09/07

Woodhouse 18/10/06

Woodhouse 24/03/06

Woodhouse 01/03/05

Woodhouse 17/08/04

Woodhouse 12/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Woodhouse Wigton Crescent Southmead Bristol BS10 6DS Lead Inspector Helen Taylor Unannounced 27th September 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodhouse Address Wigton Crescent Southmead Bristol BS10 6DS tba tba Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Shaw Healthcare (Specialist Services) Ltd to be appointed CRH-PC PC Care home only 16 Category(ies) of LD Learning Disability (16) registration, with number of places Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 16 persons aged 18 years to 65 years. May accommodate one named person with a learning disability aged over 65 years. Registration will revert to 18 to 65 years when named person leaves. Date of last inspection 6 July 2005 Brief Description of the Service: Woodhouse Care Home is registered with the Commission for Social Care Inspection to provide accommodation and personal care for sixteen persons with a learning disability aged 18 to 65 years. A variation has been agreed to provide care for one named person aged over 65 years. When this person leaves the age range will revert back to sixteen persons aged 18 to 65 years. Woodhouse is a purpose built facility, first registered in July 2003 and is situated in a residential suburb of Bristol. The accommodation is arranged over two floors, and a passenger lift is installed. Individual accommodation is provided in eight apartments on one side of the building, and eight flats on the other side of the building. The accommodation is linked by communal facilties on the ground floor. The apartments have en-suite bathroom/toilet facilities, a large living area, and optional kitchen facilities. The flats consist of a lounge, bedroom, kitchen and bathroom facilities. Individual accommodation located on the ground floor has small patio gardens. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection as part of the annual inspection process to examine the care provided, and review the progress and actions taken in relation to the requirements and recommendations made during the last inspection conducted in March 2005. The area manager for Shaw Health Care Specialist Services (the organisation which own and operate the home) was present conducting a Regulation 26 monitoring visit in line with the Care Homes Regulations 2000. The Inspection took place over seven hours and during this process interactions between staff members and residents were observed. Three residents and five staff members were spoken to, and discussions with the manager and area manager also took place. Further evidence was gathered from a review of records held and a cursory tour of the building. What the service does well: What has improved since the last inspection? The home has complied with the four requirements from the last inspection as follows: • New furniture has been purchased for the communal lounge. The furniture is robust and domestic in appearance. • A new manager has been appointed, and the Commission is processing the application for registration. A new management structure has been developed. • The accident/incident records have been reviewed and now include details of any investigation and follow-up actions taken. • The Commission has received a brief financial summary of this service. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 6 Actions taken in relation to the two recommendations from the last inspection are as follows: • Staff members now sign and date recordings made in the care file information. • The head office now informs the manager of all Pova 1st checks received in relation to any new staff members. 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. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 The admission process ensures prospective residents and/or their representatives can be confident the home can meet their assessed needs. EVIDENCE: There is a detailed admission process in the home that focuses on the needs of the individual as determined through the assessment process. Placements at the home are normally funded through the Health Authority in conjunction with the Social Services department. Detailed assessments from various professionals involved with the individuals are provided with the initial application. Each admission would be on a planned basis and visits to the individual in their home or present placement would be part of the assessment process. Planned trial visits to the home would be arranged in line with the needs of the prospective resident. Each admission package is tailored to meet the needs of the individual and the needs of those already living at the home are also considered. Evidence of individual care plans developed from information gained through the assessment process was seen on file. Personal aspirations, family involvement and health care profiles were included in the plan. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9. Whilst there was evidence of good care planning processes, this wasnt consistent for all residents. Participation in activities in the local community is well managed and tailored to individual needs. EVIDENCE: A sample of care file information was reviewed. Care file information is held in three separate files, the first contains the essential life plan (ELP) with individual support plans for all aspects of daily life including associated risk assessments. Daily observation sheets, notes of review meetings, monthly key team reports, opportunity plans and general information including a record of personal possessions brought to the home. The second contains health care information with contact details of all health care professionals involved in the care of the individual. The health file records a summary of all health appointments, accidents or incidents, notes of consultations, and notes of any health care reviews. A further file contains detailed guidance in relation to all behaviour strategies in place for each individual. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 10 The files reviewed demonstrated that the home provides holistic care from a person centred approach. It was evident that information had been collated over a long period of time and reflected the residents views, and the views of family members. Staff members spoken with conveyed to the inspector a good understanding of the residents needs. One resident told the inspector she was happy in the home, and indicated that good relationships had been developed with the staff team. Another resident mentioned recent dental problems. The health care record showed that advice from the dentist had been sought and adequate care had been provided. Observations indicated positive relationships with staff members, and residents were able to communicate their preferred choices and wishes. For example one resident had chosen to stay in bed, another was going out to the local shops. Opportunity plans seen encouraged residents to participate in different activities. A recommendation from the previous inspection that staff members sign and date entries in daily observation records had been complied with, however in one care file the ELP had no date or signature to indicate when it had been developed. Directions to staff in relation to restrictions placed on one resident were not evidenced through the risk assessment process. One senior staff member spoken with was unable to explain the reason for the restrictions when asked. All assessed risks and restrictions must be documented in the care file. The care files contained a record of the residents personal possessions, however an entry in the observation sheets that one resident had recently purchased a new television set was not reflected in this persons care file. Records of residents personal and valuable possessions must be up dated when new items are purchased. Records of accidents or incidents, although appropriately recorded in the accident book, were not evident in the individual files. This is an area that needs development. The newly appointed manager has introduced a core management structure and responsibility for the co-ordination of the care file information has now been delegated to a member of the core team. This system will ensure regular monitoring of the content of the files, and ultimately improve the present system. The issues noted in relation to the care files should not detract from the high standard of individualised care being provided. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15. The residents are supported to participate in a varied range of activities in the home and the community. The promotion of personal relationships is encouraged with friends and family members involved in the development of care provision. EVIDENCE: The home was able to demonstrate that daily living routines and activities provided are flexible and varied to suit individual needs and choices. Opportunity plans were seen on file that indicated staff encourage residents to participate in new activities. The observation sheets commented on the level of enjoyment, and noted any concerns relating to interaction in group situations. This is commendable practice. The residents accommodated at Woodhouse have complex behavioural and communication needs, and the records provided evidence that staff members had developed good relationships that enabled non-verbal communication to be understood by members of the key team. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 12 Staff members confirmed a recent bulb planting session had been well attended by residents and relatives. Transport is provided for outings in the community. A life skills kitchen is part of the communal facilities and is used by residents with support from staff to prepare snacks and drinks. Staff members were observed providing sensitive, appropriate care to the residents, who moved around the home confidently. Care is provided on a one to one basis, and in certain circumstances two to one support is offered. Activities are organised daily, and transport is provided for group and individual outings. All activities are recorded in the care file, and daily observation sheets. Behaviour strategies are in place providing detailed guidance to staff in the management of complex behaviour that may impact on other residents or staff. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20,21. Health care needs are monitored effectively and action is taken promptly to address any concerns so that residents can be assured their physical and emotional health needs will be met, and personal support provided as they prefer. The systems in place for the storage and administration of medication ensure minimal risk to the residents. EVIDENCE: A dedicated health action plan is in place for each resident, providing detailed guidance for staff in relation to all health care needs. Support plans are comprehensive and indicate a focus on the preferences of the individual in relation to the provision of personal care. There was evidence of regular reviews of health care, and consultation sheets were completed after each health care appointment clearly documenting advice, guidance and notification of further interventions necessary. The residents have access to all health care professionals including, Dentist, Chiropodist, Psychiatrist and Speech and Language Therapist. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 14 The health care files contained comprehensive information relating to health care provision, however historical information meant the files were difficult to negotiate. This information should be removed and stored appropriately. The home has robust procedures and practices for the administration of medication, this includes training for staff. Only senior staff members administer the medication and a sample audit revealed no errors. The senior team leader was able to explain in detail the procedures and systems for monitoring the administration of medication. The medication was held in locked cupboards in purpose built lockable metal cabinets. The storage area was clean and well organised, and all records reviewed were appropriately maintained. The senior team leader confirmed all medication dispensed by the pharmacy is checked against individual prescriptions on delivery to the home. Mistakes are rectified immediately in consultation with the pharmacist. The home has made strenuous attempts to ensure that the residents wishes in the event of death are noted in the health care plan. There was evidence of family involvement in collating this information. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23. There is an open atmosphere in the home, and residents are encouraged to make their views known. The complaints procedure is clear, however improved response times to complaints would minimise further risks to residents. EVIDENCE: There are adequate policies and procedures in place to protect residents from any form of abuse or self-harm. The complaints procedure is detailed and provides timescales for action. No formal complaints have been recorded since the last inspection, however during a review of staffing information it was noted a member of the community had complained about a staff members attitude when out with a resident. Clearly the manager had intentions to take action in relation to this allegation, however, the time elapsed since the complaint was received meant this staff member was still supporting residents during outings in the community, and therefore a risk existed. The Inspector is aware that at this time the manager had just been appointed and the issue had not been ignored. Complaints must be investigated within the timescales in the policy, and allegations about staff misconduct should be dealt with immediately, in order to ensure residents are appropriately protected. The organisation has in place a comprehensive training and development programme that includes abuse awareness. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 25,27,28. Improvements have been made to the communal space and this means residents benefit from a more homely environment. However, in one individuals apartment a review of fixtures, fittings and decor, would ensure this resident could benefit from a more homely environment. EVIDENCE: Woodhouse is a fairly new building and generally the accommodation is of a very good standard. The organisation has recently purchased new furniture for the communal lounge. The furniture was robust and domestic in style. Improvements have also been made to the garden area, with the addition of colourful sensory decorations appropriate to meet the diverse needs of the residents. A full environmental review was not undertaken on this occasion, however the Inspector had the opportunity to view the communal lounges, dining room and three resident rooms. The communal areas were clean and tidy, and the garden was accessible. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 17 One residents room was very homely and comfortable, and had been personalised by the resident with support from staff. This resident told the Inspector she was happy in the home, and indicated she was comfortable with the accommodation provided. The standard of the fixtures and fittings was good. Each individual room has en-suite toilet and bathroom facilities. In some accommodation kitchen facilities are provided. In stark contrast to the above, another residents room caused the inspector some concern. The following issues were noted: • No lock on the front door • No door on the bedroom • Window catches broken • A tumble dryer not working for two weeks • A strong odour in the bathroom • No handle on the bathroom door • The fire door guard on the kitchen door broken • Visible concrete on the walls in the hallway • The lounge requires decoration The staff member supporting this resident agreed the environmental issues were a direct result of this residents extreme behaviour. The area manager present during the inspection was aware of these concerns and explained the financial implications were under discussion. Repairs to the room would be undertaken in due course. The organisation must review the accommodation and provide furniture and fittings robust enough to suit the needs of the individuals living in the home. A review of the internal doors, locks, window catches and general facilities provided must be undertaken. Discussion with the funding authority should be part of this process. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34,36. Sufficient and competent staff support the residents in meeting their care needs. Robust recruitment practices ensure the residents health and welfare are protected. EVIDENCE: There are clear aims and values in this home, which are client focussed, and the high staffing levels reflect this philosophy. Staff members were able to clearly demonstrate their commitment to meeting the aims and values in the home, and it was evident that meaningful relationships had been developed between the staff and residents living in the home. Each resident is allocated a key team, led by team leaders, who implement the contents of the care plan. From records reviewed and discussion with staff, it was evident they had the ability to identify the changing needs of the residents, and then provide support through the person centred planning system in place, in supporting the resident to achieve their goals. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 19 There are clear lines of accountability within the home, and job descriptions were evident in staffing information examined. Evidence of a robust recruitment policy being implemented was also seen. A recent recruitment drive has meant less use of agency staff. The manager explained a new format has recently been developed to ensure all agency staff are subject to the same stringent employment checks as permanent staff members. Confirmation of identity, and evidence of appropriate checks was part of this process. Formal supervision of staff is taking place on a regular basis. Staff members spoken with confirmed adequate support. One team leader explained support and guidance was received form the manager to ensure consistency in the implementation of formal supervision. A recommendation that team leaders be provided with lockable storage space to ensure confidentiality of supervision notes was made. The organisation have in place a comprehensive training programme, and a matrix of all staff in the home highlights any training yet to be undertaken, and also indicates when up dates of traing are required. There is a dedicated heath and safety representative in the home who confirmed attendance on a training course to ensure a good understanding of this role. The manager has developed a core management structure, and has introduced professional practice meetings to enable the management group to be kept up to date with practice issues. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,40,41,43. Improvements in the management structure means residents can be assured they will benefit from a well run home. The manager has a clear development plan and vision for the home that he is implementing in an open and transparent way. EVIDENCE: Woodhouse has faced a period of instability due to the lack of a stable management structure. This has been addressed and the feedback from staff members was positive about the changes taking place. Mr Adrian Smith is the recently appointed manager at Woodhouse. The Commission is presently processing a registration application in this respect. The manager has significant experience of practice and management in the care industry, and qualifications in Social Care, Management and Mental Health. The Commission has copies of all professional qualifications held. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 21 Throughout the inspection process the manager demonstrated a clear understanding of his role within the home, and a commitment to providing a high standard of individualised care for the individuals accommodated. The manager has developed a core management structure comprising of the Deputy Manager, the Senior Team Leader (responsible for Clinical Care), and the Manager. The core management team will meet every two weeks on a planned basis. These meetings will be in addition to team leader meetings, and monthly staff meetings. A staff briefing will be circulated between meetings to ensure staff are kept up to date with any practice developments or issues in the home. Evidence that the manager is developing an open and inclusive style of management within the home, with positive feedback to staff in communication books, and clear direction being noted as a theme in records reviewed. Positive comments were made to the Inspector by staff spoken with for example at least you know the manager will so something its good to see a manager on the floor he is approachable it was evident from these comments that staff members were feeling more supported on a day-to-day basis. The organisation has in place policies and procedures that guide daily practice. During the induction process staff members are made aware of the policy documents, staff members then sign to acknowledge their understanding of the contents. A review of the accident/incident records found that they contained accurate, sufficient information complying with a requirement from the last inspection, however, this information did not cross reference to the care notes of any resident who was the subject of any of these reports. Further development is necessary. The manager is aware that some systems and processes need to be reviewed and it was his intention to work towards improvement in many areas. The manager has been in post for only a few months, and similarly the administrator is new to her post. During the inspection the area manager reviewed the residents finances and found the records to be well organised and up to date. All other records reviewed by the inspector were in good order and up to date. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x 2 x 3 3 x x Standard No 11 12 13 14 15 16 17 3 3 3 3 x x x Standard No 31 32 33 34 35 36 Score 3 3 x 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodhouse Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 2 x 3 Version 1.40 Page 23 D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13.4 Requirement All assessed risks and any restrcitions on residents must be documented in the individuals care file. Complaints must be dealt with quickly, with appropiate action being taken and records held. Take action to repair, replace and refurbish the individual accommodation as noted in this report. Timescale for action 30th November 2005 30th November 2005 30th November 2005 2. 3. 22 25 22 23.2 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. 3. 4. Refer to Standard 6 19 36 41 Good Practice Recommendations All essential life plans should be signed and dated. Historical information should be removed from the care files and stored securely. Provide team leaders with lockable storage space to ensure confidentiality of suervsion notes. Ensure any accidents or incidents involving a resident are recorded in their care file. Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 24 Commission for Social Care Inspection 300 Aztec West Almondsbury South Gloucestershire BS32 4RG 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 Woodhouse D00_D56_44679_Woodhouse_V236336_060705_Stage 2.doc Version 1.40 Page 25 - 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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