Inspection on 12/06/06 for Woodland Care Home

This inspection was carried out on 12th June 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 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

Woodland Care Home 05/06/07

Woodland Care Home 27/10/05

Woodland Care Home 28/04/05

Woodland Care Home 30/09/04

Woodland Care Home 01/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Woodland Care Home 189 Woodland Road Hellesdon Norwich Norfolk NR6 5RQ Lead Inspector Maggie Prettyman Unannounced Inspection 12th June 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 Woodland Care Home DS0000044375.V300072.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. Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodland Care Home Address 189 Woodland Road Hellesdon Norwich Norfolk NR6 5RQ 01603 787821 01603 403874 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) Alphacare Services (UK) Ltd Vacant Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Forty-six (46) Older People may be accommodated. Date of last inspection 27th October 2005 Brief Description of the Service: Woodland Nursing Home is situated in the residential area of Hellesdon. Purpose built in 1990 the accommodation is on the ground and first floors comprising of eighteen single rooms with en-suite facilities a further four single rooms with en-suite bathrooms, and 12 double rooms. There are five communal lounges, which are within easy access of service users own rooms. The home also offers a range of adaptations and aids to promote mobility and independence. The grounds are accessible by wheelchair users and there are car-parking facilities to the front and side of the premises. The range of weekly fees is £325 - £600. Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place between 9.30am and 5.15pm and was conducted by a single inspector. Prior to the inspection the homes’ administrator completed a Pre Inspection questionnaire and a number of feedback questionnaires were received from service users, their representatives and an attending GP. The inspection included a full tour of the premises, discussions with 10 service users and three of their relatives or representatives. Written records and files were examined. Care, catering and ancillary staff were observed and interviewed. The Administrator, Nurse manager and Proprietor were involved in interview, discussion and feedback. Woodland Care Home was found to be a comfortable, well maintained environment with a dedicated and committed staff team. All interactions between care workers and service users were observed to be polite and professional. Service users generally are happy with their service, and many positive comments were received The home is currently without an appointed manager; the administrator, nurse managers and housekeeper are sharing responsibility for management functions within the home, and are performing well as a team. The managers and staff of the home are to be commended for their hard work and professionalism during the absence of a permanent manager. A number of requirements and recommendations have been made, most of which will need to be addressed by the new manager. Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: A number of requirements and recommendations have been made at the end of this report. The requirements include; • • • The implementation of a full programme of social, cultural and spiritual activities. The standard of food provided in afternoons and evenings is to be monitored. The kitchen area needs refurbishment, and adequate ventilation/cooling provided. DS0000044375.V300072.R01.S.doc Version 5.2 Page 7 Woodland Care Home • • • • • • • All bathing areas are to be kept free of clutter and mobility aids. A plan of NVQ training to meet the standards is to be implemented. The recruitment and vetting of staff is to be improved. A systematic programme of individual and group training and development is required. A suitable permanent manager must be appointed. A quality audit system and annual development plan for the home must be devised. A planned system of supervision for all staff must be provided. 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. Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6 The overall outcome for these standards is good. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective service users have the opportunity to visit the home on a trial basis. Service users admitted for intermediate care are enabled to maximise their independence and return home. Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 10 EVIDENCE: A needs assessment for new service users was seen in their files. Information is currently being provided by the manager of another home in the group who is undertaking visits to prospective service users while the managers’ post at the home is vacant. It was noted that these assessments lack detail about social interests, hobbies etc, but inspection of files of service users who have been resident for several weeks demonstrates that this information is obtained shortly after admission. Discussions with service users and their relatives demonstrated that trial visits are available for prospective service users prior to admission. The system of Social Services block booked transitional beds at the home has been discontinued since the last inspection. Service users are coming for rehabilitative or respite stays, but these are now purchased on a spot basis by the local authority. Service users and their relatives coming for this type of stay expressed positive thoughts about their stay, and about their plans to return home. Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 The overall outcome for these standards is good. 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 are protected by the homes 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. Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 12 EVIDENCE: Examination of service user files demonstrated that detailed care plans and risk assessments are in place for all service users. Review of these plans has also taken place, albeit not on a routinely monthly basis. It is recommended that the new manager continue to review the care planning and recording process in the home. Examination of service user files, discussion with nursing staff and direct observation of service users and routine practice demonstrates that service users are receiving a good standard of health care. Great attention is paid to issues relating to tissue viability, and both nursing and catering staff demonstrated the understanding of the importance of good nutrition to support this. Continence is promoted, and suitable aids are available. Support from external health care professionals is sought as appropriate. A GP comment card expressed the importance of having a replacement manager in place as soon as possible to oversee the general healthcare practice of the home. Concerns expressed in relatives comment cards about inconsistent timings of medication provision were explored. The inspector ascertained that those service users who choose to have medication after their meals would receive their medication towards the end of the round. This means that a cumulative delay may occur if service users earlier on the round are unwell. It is recommended that those service users wishing to have medication after their meals are made aware of this potentiality. Feedback from pre inspection questionnaires, observation of care practice and discussions with service users and their representatives demonstrates that care staff are consistently polite, respectful and caring. Nurse managers work actively on the “floor” providing guidance and leading by example. Care notes are written positively, and the inspector observed great attention to care in relation to presentation of service users and the way in which service users were assisted with feeding when required. Examination of the pre inspection questionnaire, discussions with the homes management and inspection of recent letters of thanks, all demonstrate that the majority of service users remain in the home for their final days. Admission to hospital only occurs if there is a health crisis or incident, or at the service user or their family’s request. A recent newspaper obituary commenced with the phrase “Peacefully, in the loving care of the staff at Woodlands Care Home”. The extremely frail nature of recent admissions has meant that the home is providing palliative care on a regular basis. Discussions with the nurse manager demonstrated a good understanding of palliative care management and of the support required for relatives and care staff in these circumstances. Woodland Care Home DS0000044375.V300072.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 and 15 The overall outcome for these standards is adequate. There are few activities provided by the home to meet the social, cultural and spiritual needs of service users. Service users maintain contact with their families, but few links with the community at large are maintained. Service users exercise autonomy and choice in many aspects of their daily lives. Service users are not always happy with the quality of evening meal offered to them. EVIDENCE: The full time activities post is currently vacant. The home is providing a worker to supply four hours of activities per week. Religious observance is not regularly available in the home. Feedback for service users and their relatives demonstrated that the level of social contact and activities is inadequate. It is required that a full programme of social, cultural and spiritual provision is made available to service users. Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 14 The home has a warm and welcoming atmosphere, and relatives and visitors confirmed that they are always warmly greeted, made welcome and offered refreshment. Feedback from service users and their representatives demonstrated that few community-based activities take place. It is recommended that the home make every effort to encourage involvement with local community groups. Service user surveys demonstrate that the home is interested in the views of its service users, and take action to provide a tailored service for them. Advocates are in place for three service users without the ability or family to represent their interests. Service users rooms were seen to contain a wealth of personal possessions. Family photographs in individual rooms were prominently and sensitively displayed. One service user was found to have the photograph of her late husband close by on her table, which she clearly gained great comfort from holding and looking at. The kitchen was inspected, and catering staff were found to be professional, knowledgeable and concerned that food provided is of a good standard. Fresh cakes and biscuits were being baked, and main meals were seen to be prepared from fresh and wholesome ingredients. Feedback from service users and their relatives revealed that the teatime meal may be less appetising, and that some service users are dissatisfied with its content and quality. This was discussed with kitchen staff and management who agreed that direct contact between the cooks and service users to discuss future menus may assist. It is required that the home looks closely at food provided in the afternoon/evening to ensure that it meets the same high standards provided earlier in the day. The day of inspection was very warm, and the inspector noted that working conditions in the kitchen were extremely uncomfortable, and that the kitchen itself is in need of refurbishment, with unsanitary wooden cupboard door handles and missing doors. It is required that the proprietors progress their plans for kitchen refurbishment, and that suitable environmental cooling or ventilation is provided in this area to protect the welfare of staff. Woodland Care Home DS0000044375.V300072.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 and 18 The overall quality rating for these standards is good. Service users and their representatives are confident that their formal complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse, but staff training must be improved. EVIDENCE: Two recent complaints were examined and found to have been responded to by the home. The complaints procedure is displayed in the hallway of the home. The inspector noted that a more proactive recording of minor day-today concerns and comments would lead to a more responsive service. Many written compliments are received by the home, but are not routinely filed, and are not recorded on individual care workers files. It is recommended that daily comments and compliments about the service and its staff are recorded so that they can be audited and action taken as necessary. Evidence of training in adult protection was seen on some care workers files. An in house video and exam is used. In discussion it was acknowledged that some care staff for whom English is not their first language may have difficulty in accessing this information. It is required that a suitable, accessible, updated programme of training is available within the home for all staff. Woodland Care Home DS0000044375.V300072.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, 22 and 26 The overall outcome for this area is good. Service users live in a safe, well-maintained environment. Service users have the equipment that they need to maximise their independence. The home is clean, pleasant and hygienic. EVIDENCE: The home was found to be clean, tidy and well maintained. Domestic staff were observed to be hard working, and using cleaning materials and equipment appropriately. The handyman was interviewed and his maintenance records inspected. Great attention to detail was found in these records, and an enthusiastic and proactive approach to the maintenance of the home was demonstrated and is to be commended. Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 17 The current service user group is not in need of protective security. It is recommended that home keep the abilities of its current and prospective service users under review to ensure that they continue to be safe. A wide variety of mobility equipment and aids and adaptations were found in the home. They were seen to be properly maintained and in good order. Two bathrooms were found to contain mobility aids and wheelchairs making the environment institutional and cluttered. It is required that all bathing areas are kept free of unnecessary clutter to ensure a safe and pleasurable environment. A tour of the home demonstrated that the home is hygienic and good infection control procedures are in place. The laundry area is clean and well organised, with a dedicated worker and suitable industrial machines in place. Sluices are clean and tidy, with no build up of foul waste observed. Such waste was seen to be appropriately bagged and stored in clearly marked bins outside the building. Woodland Care Home DS0000044375.V300072.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 and 30 The overall quality outcome for these standards is poor. Service users and their representatives do not always feel that needs are met by the numbers of staff on duty. The home has not yet met its NVQ training targets. The homes recruitment policies and practices must be improved. The home does not have a consistent programme of training. EVIDENCE: Feedback from service user and relative comment cards stated that there do not always appear to be enough staff on duty, particularly to assist service users in accessing lavatory facilities. Examination of staff rotas, discussion with management staff on duty, and the inspectors’ own impression and observations on the day of inspection did not necessarily support this view. It is recommended that the home continues to monitor staffing levels, and looks at staff deployment to ensure that the needs of service users are met promptly. Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 19 Since the last inspection two more care workers have commenced NVQ training. However the home continues to fall far short of the requirements of the standards in this respect. Long-term sickness of the Group’s training coordinator has affected the training plans of the home. It is required that the home implements a plan of training to include NVQ achievements to the requirements of the standards. Examination of staff records demonstrated that CRB Checks and validation of references and identity do not always meet the requirements of the standards, particularly in relation to overseas staff supplied by a recruitment agency. It is required that a thorough vetting system is in place to ensure that appropriate checks and validations are in place prior to all staff commencing work. Evidence of relevant training was seen in staff files. Induction training takes place for new staff. A training course for staff for whom English is not their first language was underway on the day of inspection. However no detailed training needs analysis for individual workers, or overall training plan for the home is in place. It is required that a systematic programme of training and development, including regular updates, is put in place. Woodland Care Home DS0000044375.V300072.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, 36, 37 and 38 The overall quality outcome for these standards is adequate. The managers’ post is currently vacant. The home is run in the best interests of service users. No formal system of supervision is in place. Service users’ rights and best interests are safeguarded by the home’s record keeping. The health, welfare and safety of service users and staff are promoted and protected. Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager’s post is currently vacant. A team of enthusiastic and professional staff are jointly managing the home and its existing policies and procedures to a good standard. Whilst their hard work and commitment is to be commended, it is essential that a permanent manager be appointed as a matter of priority. The home’s proprietor is in the process of interviewing suitable candidates, and is confident that this situation will shortly be resolved. It is required that a suitable permanent manager is appointed to the home. Two quality audits have taken place in the last year. The results of the most recent survey have yet to be compiled into a report. The home lacks an annual development plan and other ongoing audits. It is required that the new manager institutes a system of quality audit and an annual development plan for the home. Records of monies held on behalf of service users were examined and found to be correct in every instance. Secure storage facilities are available in individual service users rooms. Examination of staff files and discussions with staff demonstrated that although daily observational and interact ional supervision takes place, no formal, recorded and planned system of supervision is in place. It is required that the new manager institutes a planned system of supervision in line with the requirements of the standards as a matter of priority. Examination of the home’s records demonstrated that they are held appropriately and securely, and that they are well organised and up to date. Discussion with managers, examination of records and observations made during the tour of the home demonstrate that safe working practices are in place in the home. Maintenance records are excellent, and security and safety take a high priority in the maintenance programme. Accidents are recorded and reported appropriately. It is recommended that records of minor incidents and accidents are collated and audited to provide more information about potential hazards for service users and staff. Woodland Care Home DS0000044375.V300072.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 X X 3 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 1 3 3 Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 23 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 OP28 OP18 Regulation 19 Requirement The providers must provide a plan of training for the home and its staff to include NVQ and other relevant training opportunities for all staff. A full programme of social, cultural and spiritual activities must be provided by the home. The home must look closely at food provided in the afternoons and evenings to ensure that it meets the same high standards provided earlier in the day. The proposed refurbishment of the kitchen area must be implemented, with attention paid to hygienic door handles and adequate ventilation or air conditioning to protect the welfare of catering staff. Appropriate storage areas are to be used to ensure that bathrooms are kept free of clutter to ensure a safe and pleasurable environment. The home must have a thorough vetting system of staff in place to ensure that appropriate CRB checks and validations are in DS0000044375.V300072.R01.S.doc Timescale for action 30/09/06 2 3 OP12 OP15 16 16 31/08/06 31/07/06 4 OP38 23 30/11/06 5 OP22 23 31/07/06 6 OP29 19 30/08/06 Woodland Care Home Version 5.2 Page 24 7 OP30 13, 18 8 9 OP31 OP33 9 24 10 OP36 18 place prior to staff commencing work. A systematic programme of individual and group training and development, including regular updates must be implemented. A manager who meets the requirements of the care standards must be appointed. The new manager must implement a system of quality audit and an annual development plan for the home. The new manager must implement a planned system of supervision in line with the requirements of the standards. 30/09/06 30/08/06 30/11/06 30/09/06 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 3 4 5 6 7 Refer to Standard OP7 OP9 OP13 OP16 OP19 OP27 OP38 Good Practice Recommendations Management should continue the review and monitoring of care plans and records. Service users should be made aware of the possible consequence of late delivery of medication if they choose to have medication administered after they have eaten. The home should encourage more involvement with community groups. Informal comments, complaints and compliments about the service and its staff should be recorded and audited, with action taken as necessary. The home should continue to monitor the abilities of service users to ensure that they continue to be safe in the home without protective security. The home should continue to monitor staffing levels and staff deployment to ensure that service users needs are met promptly. Minor incidents and accidents should be recorded and collated to provide information about potential hazards for service users and staff. DS0000044375.V300072.R01.S.doc Version 5.2 Page 25 Woodland Care Home Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Woodland Care Home DS0000044375.V300072.R01.S.doc Version 5.2 Page 26 - 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!