Inspection on 05/06/07 for Woodland Care Home

This inspection was carried out on 5th June 2007.

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

Woodland Care Home 12/06/06

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 Mr Jerry Crehan & Mrs Susan Golphin Unannounced Inspection 5th June 2007 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.V342766.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.V342766.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 thewoodland@schealthcare.co.uk thewoodland@schealthcare.co.uk Alphacare Services (UK) Ltd 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) Position 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.V342766.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 12th June 2006 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 twenty-six single rooms (fourteen with en-suite facilities), and eight double rooms. There are four 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 monthly fees is £1300 - £2600. Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection compromised an unannounced visit to the home that took place over 7.5 hours on 5th June 2007. Opportunity was taken to tour the premises, look at care records and policies, and communicate with the home’s service users in addition to its staff, and the Manager. The inspection report reflects regulatory activity since the last inspection and evidence from inspection of Key Standards. The Manager provided pre-inspection information to the Commission prior to the inspection. This included 5 comment cards from service users, which gave broadly favourable comments about the service provided by the home, and two comment cards from health professionals that are also generally positive. Woodland is one of several homes in Norfolk owned by the proprietors. A change in the ownership and Management of the service has disrupted compliance with requirements and recommendations made at the last inspection. What the service does well: • • An assessment of all new service users is carried out and all prospective service users are invited to the home with their relatives. People who use services receive good health and personal care that is based on their individual needs. The principles of respect and choice for people as individuals are put into practice by a committed nursing and care staff team. The service has achieved success in independent health care management, particularly in continence management and promotion. There is a good internal environment that is well equipped to meet the needs of people who use the service, and that suits the service users daily lifestyle and reflects their personal choices and preferences. The home is safe, clean, tidy and well maintained throughout. Domestic staff, like other staff, were observed to be hard working. • • • Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: • The service should provide new and prospective people who use the service with sufficient and up to date information about the home to make an informed choice about long-term care, and about how to make a complaint. The service must address the recreational and social needs of people who use the service, as they are limited in what they can do at the home to satisfy these needs. Refresher training for staff in the protection of vulnerable adults is needed to help in protecting people who use the service from possible abuse. The internal environment is generally good, however, private accommodation that is lockable to support privacy (and the security of their belongings) for people who use the service should be provided. The Management situation at the home is causing uncertainty for all those associated with the home, and this is leading to low morale within the staff group. Disruption resulting from changes in ownership and management has meant that some important requirements from the last inspection of the home have not been met. These include the continued absence of a planned system of supervision for all staff, and a system of quality audit where the views about the service have been sought and evaluated. • • • • • Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodland Care Home DS0000044375.V342766.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.V342766.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3, 5 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The individual needs of people using the service are assessed and understood in order that the service can be sure their needs will be met. Prospective people to use the service and their representatives do not have the information they need to choose a home, which will meet their needs. EVIDENCE: The home does not have an updated ‘Statement of Purpose’ or ‘Service Users Guide’ to reflect the services provided at the home since the recent change of ownership. The home’s management state that they have provided the Proprietor with the information required for these two publications, but the Proprietor has not provided the completed publications. Consequently the homes management are providing prospective service users with the Proprietors brochure. However, this document does not contain sufficient information for anyone to make an informed choice about long-term care. (See Requirements 1 & 2) Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 10 The home has a well-designed assessment pro-forma (pre-admission assessment) used by the manager or deputy when collecting information to ascertain the level of support required by prospective service users. There is evidence of assessment for new service users seen in their files. All prospective service users are invited to the home with their relatives. The manager and the administrator or other senior staff will show people around and provide information about the service and facilities. Service users and their relatives say that they were given sufficient verbal information about the home prior to moving there. The format used to assess the risk of falls needs to be checked as there is thought to be a typographical or printing error, which may compromise the risk assessment (See Recommendation 1). There is a complaint pending that refers to poor levels of care and practice. The service user was admitted earlier this year but was not provided with any written information about the service. This may be an issue within the investigation, which is being carried out by the home. Woodland Care Home DS0000044375.V342766.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use services receive good health and personal care that is based on their individual needs. The principles of respect and choice for people as individuals are put into practice. EVIDENCE: Several care files were looked at during the site visit. Each contained individual care plans and risk assessments with information about the person receiving care and offering an individual view of the person and their needs. Where social or life history of service users was limited there was evidence that the home’s nursing or care staff have requested additional information from their relatives. The files seen contain new care planning forms introduced by the new Proprietor, they were all well maintained and up to date. Staff say that they are able to access and use the home’s new care planning format to meet service users needs. Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 12 There are a range of health and social care assessments in service user care files. Those seen were up to date and evidently informed by community health professionals in addition to nursing and care staff. They include tissue viability assessments, nutritional assessments and screening, and continence assessments. Continence is well managed by the home with evidence of considerable success in continence promotion for some service users. Comments from two visiting health professionals indicate the view that within the resources available at the home it provides ‘good nursing home care’. Feedback from the five comment cards from service users about their staff was generally good. They indicate a view that staff usually listen and act on what the service user says. When asked if staff are available when they need them, three service users responded that they usually are, and two that they always are. Four or the five service users who responded indicated that they always receive the medical support they need, with one person indicating that they usually do. Comments from service users spoken with during the inspection visit were complementary about nursing and care staff. Comments include: ‘carers are very good’, ‘they’re very caring, I’m grateful for the help I get’, ‘they will pop in and ask how I am’. However, there is also a view from service users spoken with that there are not always sufficient staff now. Comments include: ‘all the staff seem too busy now’ and ‘they are so short staffed now’. There are suitable safe storage arrangements for medication in a dedicated room that is temperature controlled. The home has recently changed to a ‘Monitored Dosage System’ for administration of most medicines. There were apparently some initial problems with the changeover from the previous system, but the new system is now working well. One of the G.P’s who visits the home on a regular basis carries out frequent drug reviews and monitors patients’ medication. Appropriate records are kept for the receipt of medication into the home, its administration and any medication returned to the pharmacy. Woodland Care Home DS0000044375.V342766.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the services have access to a good diet that is well thought out. Social needs and recreational activities provided at the home fall short of meeting many service users expectations. EVIDENCE: The routines of daily living for service users provide some flexibility. Service users were observed to be socialising in communal areas at different times of the day. Others had obviously chosen to have a later start to the day, and staff supported this. The activities coordinator post has been vacant for some time, however, the manager indicated that the part time post had recently been filled and the appointed person would be starting work shortly. This is welcome as service users comments concerning the provision of activities at the home is very mixed, some indicating the provision of individual activities, others indicating that there is little on offer. An activities board on the ground floor of the home indicates forthcoming activities. Service users spoken to state that the vicar visits the home on occasions. Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 14 A carer had been designated to take a lead role in providing an activities programme to meet the social and recreational needs of service users. However, their time available to carry out the task was limited and their role as carer had taken precedence (See Requirement 3). It is hoped that the new activities coordinator will, with the assistance of the manager, act on a recommendation made at the last inspection of the home to encourage more involvement with local community groups (See Recommendation 2). Discussion with service users and observation during the visit to the home provided evidence that the home supports their contact with relatives and friends, and that it enables service users to bring and keep their own possessions with them. The rooms seen on the day of the inspection visit are well furnished and well equipped to suit the service users daily lifestyle and reflect their personal choices and preferences. Bedrooms have been decorated to a good standard with a mixture of colour to promote a greater sense of individuality and interest to the environment generally. Advocates are in place for several service users who require someone to represent their interests. Since the new Proprietor acquired the home the menus and meal planning processes have been under review. A new chef is in place and the management have been advised by the Proprietor’s catering adviser that they should develop menus based on the their ‘Nutmeg’ catering system. This system offers a range of designed menus that are nutritionally balanced and provide additional information about recipes, costs and what produce needs to be purchased. During discussions with management it was said that the Nutmeg system does not fit with service users choices, but the chef has drawn up draft menus based on the system, and these are to be shared with the service users (and relatives) at a forthcoming meeting (on 6th June). A range of menus and meal planning will be devised based on the outcomes of the service users views and wishes. Meals seen on the day of the inspection visit looked appetising and had been prepared using some fresh ingredients. Service users with special dietary requirements were catered for well, and other service users commented that the home knew their likes and dislikes. Service users comments at the time of the inspection visit reflected those indicated in comment cards received prior to the inspection visit. There was a very mixed response with some people indicating that they are always satisfied with the meals at the home, a similar number indicating they were usually satisfied, and a minority indicating they were never satisfied. This Standard is met in part and will need to be reviewed by the Manager when the new system in fully implemented and in place. The kitchen was clean, tidy and benefiting from recent refurbishment, however, it was noted that storage facilities are at a minimum. This is a difficulty in what is a relatively small kitchen for the size of home, and it is recommended that additional storage facilities be provided (See Recommendation 3). Woodland Care Home DS0000044375.V342766.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some people who use the services and their relatives do not have access to the complaints procedure. People who use the services are protected from abuse. EVIDENCE: There have been no internal complaints recorded by the home this year. Two formal complaints were received by the Commission, one under the former Proprietor, the other under the new Proprietor, that is currently being investigated by the Proprietor. Although the Proprietor has acknowledged the complaint there has been a delay in providing a response following investigation. This appears to be as a consequence of a lack of communication between the management of the home and wider management about how to follow the correct procedure. It is hoped that this issue is quickly rectified and a response provided within the required timescale of 28 days. It is recommended that the manager take a more proactive approach to dealing with this matter (See recommendation 4). As indicated earlier in this inspection report there has been a delay in the home being able to provide its ‘Statement of Purpose’ or its ‘Service User Guide’. Among other information these documents explain out how to make a complaint. It is a concern that new service users and their relatives do not have access to these documents and may not be absolutely clear about how they may complain if they wish to (See Requirement 2). Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 16 Each of the staff spoken with were clear about the action they would take if concerned about the possibility of abuse taking place at the home and were confident that they could deal with this appropriately. They were equally aware of the home’s ‘Whistle-blowing’ procedure and its function. There is some training documentation in place but adult protection training for all staff needs to be refreshed (See Requirement 4). Service users state in comment cards and in discussion during the inspection visit that they know who they can speak with if they are not happy, and that they know how to make a complaint if they should need to. Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 22, 24, 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes environment is safe, suited to the needs of service users and generally well maintained. People who use the services privacy is compromised as private accommodation is not lockable. EVIDENCE: The home’s environment was safe, clean, tidy and well maintained throughout. Domestic staff were observed to be thorough and hard working. There is a system for recording any repairs or maintenance matters for the attention of the maintenance engineer. The home’s grounds and gardens are well established and attractive. However, it is recommended that they are better maintained to improve the feeling of safety and confidence for service users wishing to use garden and patio areas (See Recommendation 5). Pathways around the home should be kept as clear as possible from encroaching shrubs to ensure comfortable access for people using wheelchairs. Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 18 There is adequate storage for a variety of equipment and mobility aids keeping the general environment clear and accessible. Call systems for service users are available in every bedroom, however, it was noted that these were not available in communal areas. The review of service users care files provides evidence that this facility may be required for service users using communal areas. There was discussion with management at the time of the inspection visit about the options to address this, including hand held, or pendant type call systems. It is recommended that Management make their own assessment of which option is best suited to the needs of service users and the home (See Recommendation 6). Accommodation for service users is well furnished, well equipped to provide comfort and meet assessed needs. However, service user privacy is restricted and the protection of their belongings compromised as doors to private accommodation are not fitted with locks. These should be suited to service users capabilities and accessible to staff in emergencies (See Requirement 5). Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29, 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are generally well trained and in sufficient numbers to adequately support the people who use the service. For this outcome to be good, people who use the service should not need to wait for staff support and attention, and all staff training should be up to date. EVIDENCE: People using the services are generally satisfied with the care they receive to meet their needs, but there are times when they need to wait for staff support and attention. As already indicated in this report, five comment cards from service users responded that staff are available, or usually available to them. However, there is also a view from service users spoken with that there are not always sufficient staff at the home now. Anecdotal evidence and comments include: ‘all the staff seem too busy now’ and ‘they are so short staffed now’. In addition to this there is evidence that the provision of activities has been limited recently with some service users indicating that there is little on offer for them. The recommendation made at the last key inspection that staffing levels and deployment should be monitored to ensure that service users needs are met promptly is therefore repeated (See Recommendation 7). Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 20 The Manager stated that funding is now in place for eight staff to undertake their NVQ 2 training this year. This would see the home exceed the minimum 50 requirement of trained staff (See Recommendation 8). Sample staff files and discussion with carers provided evidence that service users are protected by improved and good recruitment practices. It is recommended that staff files are reviewed, ‘filleted’ and brought up to date (See Recommendation 9). Sample staff files seen and discussion with staff provided evidence of mandatory training and some specialist training with evidence of learning in place. Training includes fire awareness, health and safety, manual handling, wound care, basic food hygiene, peg feeding, and ‘Yesterday Today Tomorrow’ (dementia care training). There is a variety of relevant training documentation in place, but all adult protection training for staff needs to be refreshed (see Requirement 4). Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36, 38 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management situation at the home is causing uncertainty for staff and service users (and other stakeholders) views about the service have not been sought in any systematic way. People using the service are being put at potential risk through an absence of proper supervision of staff practice. EVIDENCE: The Manager has been in post since March 2007 having transferred from another home owned by the proprietor in Norfolk, but has recently withdrawn her application to register with the Commission for Social Care Inspection. The Manager indicated that she is currently reviewing her position. As part of the move the Manager had to submit an application to register with the Commission (See Repeated Requirement 6). Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 22 Uncertainty about the current management situation is resulting in low morale among the staff group, which in turn is felt by service users. The atmosphere at the home appears strained but it is clear that the staff group are working as well as they can to maintain standards in difficult circumstances. There are some processes at the home for monitoring the quality of the service it provides. The Manager and the Proprietor are carrying out quality audits. The Manager provides a ‘Managers Surgery’ where service users relatives, and others are invited to meet to discuss care matters. The home has an ‘in house’ newsletter where general information about life in and around the home is shared. However, the views of service users and relatives have not been sought through the homes own quality surveys. The Manager is not aware of any process in place for a review or survey of the service provided to people who use, or are associated with the service (See Repeated Requirement 7). Copies of the outcomes of these surveys should be provided to the Commission. There is ongoing day to day supervision of the practice of staff by senior qualified staff. However, more formal arrangements for a systematic approach to supervision have not been in place for some time and this was the subject of a requirement in the last report. It is not clear whether staff are benefiting and developing from a formal direction and supervision of their work. The Manager has written a plan for supervision of the trained staff for June 2007 onwards. This should be extended to include all staff at the home. Some progress has evidently been made, however, the supervision processes are not yet in operation for all staff and the requirement made at the last inspection is therefore repeated (See Repeated Requirement 8). The home’s housekeeper supervises domestic staff. There is evidence that the process used includes a clear description of the practical observation of work undertaken, the use of equipment and comments on the way in which the staff member showed respect and consideration for the service user. Record keeping practices at the home are good. Maintenance and fire records seen were satisfactory. Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 23 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 1 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X 3 X 2 X X STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 2 3 3 Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4(1) Requirement Prospective people who use the service must be provided with sufficient and up to date information to make an informed choice about long-term care. People who use the service must be provided with an up to date written guide as to the services provided at the home and its complaints procedure. People who use the service must be provided with facilities for recreation to suit their individual needs. All staff must receive refresher training on adult protection issues, which helps to protect people who use the service. People who use the service must be provided with private accommodation that is lockable to support their privacy and the security of their belongings. The service must have a manager that meets the requirements of the Care Standards. This Requirement Is Repeated DS0000044375.V342766.R01.S.doc Timescale for action 30/06/07 2. OP1 5(1) 30/06/07 3. OP12 16(2)(n) 30/06/07 4. OP18 13(6) 31/07/07 5. OP24 12(4)(a) 30/09/07 6. OP31 9 31/10/07 Woodland Care Home Version 5.2 Page 25 7. OP33 24(1) &(2) 8. OP36 18(2) The Manager must ensure that 31/12/07 the views of people who use and are associated with the service are sought and included when making decisions that effect outcomes for people living at the home. All staff at the home must be 30/06/07 formally supervised. This will help to ensure that care provided meets the needs of people who use the service and the philosophy of care in the home. 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 OP5 Good Practice Recommendations The format used to assess the risk of falls needs to be checked as there is thought to be a typographical or printing error, which may compromise the risk assessment. The home should encourage more involvement with community groups. This recommendation is repeated. It is recommended that additional storage facilities for the homes kitchen be provided. It is recommended that the manager take a more proactive approach to dealing with complaints, to prevent uncertainty and delay for complainants. It is recommended that grounds and gardens are better maintained to improve the feeling of safety and confidence for service users wishing to use these areas. It is recommended that Management make their own assessment of which call bell option is best suited to the needs of service users using communal areas of the home. The home should continue to monitor staffing levels and staff deployment to ensure that service users needs are met promptly. This recommendation is repeated. 2. 3. 4. 5. 6. 7. OP13 OP15 OP16 OP19 OP22 OP27 Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 26 8. 9. OP28 OP29 It is recommended that all care staff are supported to undertaken NVQ 2 (or above) training. It is recommended that staff files are reviewed, ‘filleted’ and brought up to date. Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodland Care Home DS0000044375.V342766.R01.S.doc Version 5.2 Page 28 - 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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