Inspection on 07/02/06 for Woodland Hall

This inspection was carried out on 7th February 2006.

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

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

Other inspections for this house

Woodland Hall 22/08/07

Woodland Hall 04/07/06

Woodland Hall 13/10/05

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOMES FOR OLDER PEOPLE Woodland Hall Woodland Hall Clamp Hill Stanmore Middlesex HA7 3BG Lead Inspector Richard Adkin Unannounced Inspection 7th February 2006 10:00 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 Hall DS0000063588.V281584.R01.S.doc Version 5.1 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 Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodland Hall Address Woodland Hall Clamp Hill Stanmore Middlesex HA7 3BG 020 8954 7720 020 8954 5582 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) Care UK Mr Martin John Tully Care Home 72 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (55), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (12) Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 2005 Brief Description of the Service: Woodland Hall is a continuing care/respite facility that is owned and managed by Care UK. It has been registered as an independent hospital since it opened in 1995, but voluntarily changed its registration to that of a care home with nursing during the summer of 2005. This inspection represents the homes second by the CSCI since the home’s successful registration. Woodland Hall is a purpose-built; two storey building that is currently registered to accommodate 72 patients aged 65 years and older, 5 of whom may have dementia and be 59 years or over. The service provided is contracted to Harrow Primary Care Trust. The hospital is located in attractive and peaceful grounds in-between Harrow Weald and Stanmore. It is close to some local shops and facilities. Ample parking is available in the front of the hospital. All bedrooms are single rooms with en-suite toilet and sink facilities. There are numerous communal toilets and bathing facilities on the wards although the latter are kept locked at all times unless requested for use. Laundry and catering services are located centrally on the site. Woodland Hall is divided into six separate units and there are two respite beds: Greenview Unit (1) - accommodates 12 female patients. Bluebell Unit (2) - accommodates 12 female patients. Cedar Unit (3) - accommodates 12 patients of both genders. Parkview Unit (4) - accommodates 12 female patients. Sunshine Unit (5) - accommodates 12 male patients. Hillside Unit (6) - accommodates 12 male patients. There were two vacancies at the time of the first inspection and at the second visit there were nine vacancies. Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home was first registered by the Commission for Social Care Inspection in July 2005, as a care home with nursing and was previously an independent hospital. The first inspection of the home took place on 13th October 2005 with a lead Inspector supported by the Pharmacy Inspector and Nursing Inspector. The focus of the inspection was to look at the requirements and recommendations that arose at the previous inspection. The Inspector met with several residents from the Units during the inspection visit and received feedback from family members and healthcare professionals who were visiting. Several members of staff were spoken with. A number of records and policies were checked and care practices observed. The inspection took place during a midweek day in February. Opportunity was afforded to have a tour of the premises. A follow up visit took place in mid March. The homes Manager, Martin Tully was away in Poland at the time of the first inspection recruiting staff and transferred to another Care UK home by the time of the follow up visit. Kamaree Juggapah the Deputy Manager, who has become the homes acting Manager and subsequently interviewed for and given the post of Manager, kindly made herself available to support the inspection process as did the Administrator, James Mansell and the Unit Manager, Mercedes Dickso. The Inspector would like to thank everyone at the home for their contribution to the inspection process. What the service does well: The care home is purpose built building and is spacious and functional. The home was kept clean and hygienic during the two visits. Residents are supported in maintaining contact with family members and friends. Positive feedback was received from relatives interviewed during the inspection about the quality of care at the home. An IT system has been developed that has raised the standard of record keeping. There is input from a variety of health professionals. Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 6 Residents and their representatives can feel confident that the home will meet many of the residents’ needs. EVIDENCE: A number of requirements and recommendations arose at the previous unannounced inspection on 13th October 2005 around the area of Choice of Home. The Statement of Purpose and the brochure (Service User Guide) needed minor updates to reflect that the home is now registered with the Commission for Social Care Inspection and any consequences of this registration. As a result, the Statement of Purpose has been revised in January 2006 and now makes reference to the Commission for Social Care Inspection. A letter has been sent to each carer concerning the change of registration. The Brochure (August 2004) referred to the regulation of the Healthcare Commission and the Mental Health Act Commission as opposed to the Commission for Social Care Inspection and was rectified between visits. Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 9 The Manager needed to ensure that all residents have a fully comprehensive assessment of communication needs and of food likes and dislikes. This remains outstanding in the care plans as this was not evident in care plans looked at by the Inspector. It was felt at the last inspection, that the lack of sufficient staffing levels potentially left residents at risk of accident or incident and did not provide an environment that was stimulating enough for residents. A number of residents whilst growing older have become frailer at the home and their needs have increased. For example, needing hoists for bathing and getting in and out of bed. The Inspector looked at staff rotas and from discussion with the Acting Manager, established that there were 11 care assistants working on both the shifts on the day of the second visit and this was being aimed at as the norm. Recommendations made previously were that a brochure should be available within the reception area for visitors’ browsing purposes and that there should be a summary of the needs of each service user after all their needs have been comprehensively assessed which is now practice. A brochure is available in reception and was updated between the two visits by the Inspector. There is no intermediate care provided at the home. Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 Residents’ needs are mainly set out in the individual plans of care. EVIDENCE: A number of requirements and recommendations arose at the previous inspection about meeting the health and personal care of residents. The Manager needed to ensure that comprehensive care plans were in place to address all the identified needs of residents. The Manager also needed to ensure that there is comprehensive monitoring of the vital signs of residents, as necessary, relative to their identified needs. One resident was noted in the detailed Accident Forms to have had ten falls in the past month. The care plan detailed that the resident needed to have a frame beside him but the frame was not by him when interviewed by the Inspector. The care plan did not reflect the change of plan to prevent falls. It should be noted that the GP who visits weekly sees all residents that have had accidents. Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 11 The Manager needed to ensure that comprehensive records are kept about the treatment of residents with pressure sores, including regular assessment of the wound to monitor the progress of the sores with regard to healing. These were observed to be in place for several residents’ records looked at by the Inspector with input from the tissue viability nurse, taking place. The Manager also needed to ensure that the requirements of the Pharmacy Inspector’s report are addressed within a timescale. This has been acted upon with one recommendation outstanding. The recommendation remains outstanding from the Pharmacy inspection that took place on 13th October 2005, that the Pharmacist should be requested to include the history of allergies on the MAR sheet for all service users. If there is no allergy known this should be recorded. Discussion has taken place with the Pharmacist, but the matter has not been resolved. The care of clothing was observed to be undertaken with care. Several residents were observed to have noticeable name labels on the outside of their socks which gives an institutional feel and does not promote the dignity of individual residents. Also several residents were observed to be wearing just one slipper or no slippers, increasing the risk of falling. Several residents who were at risk of falling had been purchased hip protectors by their relatives on the advice from the home. Care UK have invested in a Saturn IT system for Woodland Hall. All residents’ details are entered on the system and a file is run concurrently at each unit. It is the role of each qualified nurse at every shift to make full entries on the IT system that is potentially time consuming, but should ensure up to date relevant records. Daily progress notes reflect the care plan and this is completed daily. A number of areas are captured such as food and fluid intake, pressure sores, bowel movement, continence issues etc. There is a page to capture healthcare professionals input such as the GP, Psychologist, Chiropodist, Dietician, Consultant Psychiatrist etc. and they have access to making entries. Care plans are broken down into key activities such as mobility and describing the condition and the caring goal. Multi-disciplinary reviews are also captured. There is a flagging system if updating is needed. Two recommendations remain outstanding. Firstly, where unsuccessful attempts have been made to involve residents or their advocates in the care planning process, when these care plans are being drawn up that a record be made of this. Secondly, the management team should consider keeping photographs of pressure sores or wound mapping at least monthly to help monitor the progress of pressure sores. Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 12 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, 14, 15 The recreational needs of residents are being addressed. EVIDENCE: A number of requirements and recommendations arose at the previous inspection concerning the daily life and social activities of residents. The Manager, at the last inspection, needed to ensure that a suitable activities co-ordinator was promptly recruited and that a comprehensive programme of activities for residents according to their assessed needs is in place. There is an employed activities co-ordinator five days a week at the home. A second activities co-ordinator is being looked for. The activities co-ordinator provided a programme of activities in the home matching the needs of residents. The co-ordinator had been developing a multi-sensory programme. She was leading on the creative design of the front drive and garden involving residents and their families, following the decimation caused by the loss of the 600 year-old tree. There is an active programme of worship at the home. The hairdresser was visiting on the day of the inspection to the benefit of residents. The Manager also needed to ensure that residents are only dressed when they are ready to get up and that there are enough staff in the mornings to support Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 13 in key areas such as with getting up and getting dressed. The Management Team has addressed staffing levels. The Manager needed to address that meals were served to residents in a manner that enhances their choice and enjoyment of meals as residents were not informed or shown each available meal. The Inspector observed lunch being served and eaten by residents. Positive comments were received from relatives, some of whom were supporting residents in eating their meal. A choice of the two main meals on offer are shown on a tray to each resident. There is a four-week cycle of menus. Furthermore, it was required that the Manager reviews the provision of fluid in the home to ensure that service users have adequate amounts of fluid. Water jugs had to be provided in resident’s bedrooms unless risk assessed as not appropriate for any individual. These are now provided for residents where appropriate. Two recommendations that arose at the last inspection were that a picturebased menu should be put in place for those residents who cannot easily read and for residents that want more privacy or who cannot easily leave their room. Consideration should be given to alternative phone options such as a portable phone. A portable phone is in operation in the home. However, picture-based menus are yet to be developed. Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Residents and their representatives need to be confident that their concerns will be acted upon and the residents will be protected from abuse. EVIDENCE: A Protection of Vulnerable Adults (POVA) allegation arose in December 2005 that was subject to a strategy meeting (Inter Agency Procedures for Responding to the Abuse of Vulnerable Adults) at the end of January 2006. The investigation followed a complaint made about the restraint of a resident to administer a pneumonia injection and looked at how the complaint was addressed and the issue of consent. A further POVA allegation arose, concerning the rough handling of a resident by care staff who were suspended for the rough handling and not supporting or carrying out pressure care plans. The outcome of these two investigations needs to be promptly acted upon by the management team. One complaint made by a carer was not recorded in the complaint section of how well the complaint was handled. There was no summary in the complaint book of how complaints were progressed with outcomes. Compliments were noted by the Inspector, for instance one family receiving respite care for their relative wrote, ‘she came home to us in mint condition, thank you for all your efforts.’ Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 15 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, 25 The maintaining of standards around the fabric of the building must be addressed to the benefit of the environment for residents. EVIDENCE: Several recommendations and requirements arose at the previous inspection. Many of the communal living areas required refurbishment. Carpets, curtains and some furnishings in particular, were very worn and areas of carpet had ingrained staining, which needed to be addressed. This remains to be rectified, with cigarette burns in one carpet made by a resident a number of months previously. There was some damage to walls in the corridors. The kitchenette floors needed to be replaced with flooring that supports good hygiene standards. These kitchenette floors also needed to be kept properly clean. The kitchenette floors appeared clean on inspection, they remain in need of being replaced in the six kitchenettes, particularly as the point where the floor meets the wall are damaged. Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 16 It was noted previously that all the communal toilets lacked covers that needed to be installed unless there is a written risk assessment to the contrary. These have been installed throughout. Care UK also needed to provide adjustable beds to all residents unless the individual resident did not wish for or would not gain from such a bed – in which case, there needs to be records of this decision. This has not been finalised. The Deputy Manager (who is now the Manager of the home) demonstrated how residents, carers, the GP were all party to discussion around the use of bedrails and balancing the risk of entrapment with that of preventing falls. Evidence was seen in several care plans and forms completed specifically regarding bedrails. There was no policy in place, however concerning bedrails. Recommendations that arose previously were as follows: Firstly Care UK and the Manager were recommended to discuss and establish a plan of rolling maintenance and refurbishment work in order to help ensure that no areas of the home are left to become overly worn out before their upgrading is identified and addressed. Though the maintenance man has kept some records of work undertaken (which have stopped over recent months) there is no evidence of a rolling plan. Secondly, it was recommended that, for reasons of health and safety and time management, peeling and cutting devices were invested in for the kitchen staff. The food processor needed by the kitchen staff, remains in need of repair or replacement. Thirdly, consideration needed to be given to upgrading the alarm system, so that it does not need switching on within each room to make it workable in that room. This is yet to take place. Fourthly, a system that allows service users or their representatives to adjust the heating in their rooms needed to be considered. This has been actively pursued and is resolved. Tests were taking place of the fire alarm during the course of the inspection. These tests of the fire alarm system take place weekly and are undertaken by the maintenance man. The disabled parking area at the front of the home has a temporary sign and is not clearly designated; this should be made clearer to promote access. The home was clean and free of offensive odours on both days of the inspection. Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 17 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, 30 Staff must be adequately trained to meet the needs of residents; staffing however, has been increased to improve the skill and mix and staffing levels. EVIDENCE: Four requirements around staffing arose at the previous inspection. The Manager needed to ensure that the minimum staffing levels previously agreed, of 10 care assistants working during the day (in addition to nursing staff), is upheld at all times, including late shifts during weekends. The confirmed staffing level increases had to be recruited to promptly or else temporary or agency staff had to be used. These two areas have been positively dealt with by the Manager and the Deputy with the move to 11 care assistants per shift being worked towards and observed on rotas. A plan to address the issue of ensuring that a minimum of 50 of the care staff team become promptly qualified at NVQ level 2 in care had to be provided in writing to the Commission for Social Care Inspection. The target still remains needing to be achieved. Staff that the Inspector met were experienced and knowledgeable. Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 18 The Manager also needed to ensure that all care staff have attended basic emergency first aid course, a course about dementia care and a course on infection control. The Inspector looked at a summary of training undertaken by staff in the last few years; significant gaps remain around the need for first aid training, infection control and understanding dementia. Though induction is taking place, this is not fully captured in the records. Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 19 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, 32, 37, 38 The home needs a full management team in place to ensure that residents live in a home that is well run. Some health and safety issues need addressing to protect the well being of residents. EVIDENCE: Three recommendations arose around Management and Administration. Care UK needed to ensure that the Manager was supported to undertake and complete the RMA (national management award). The Manager made a swift move on 10th March 2006, transferring to another Care UK care home. During the course of the inspection and subsequently, the experienced Deputy Manager became acting Manager to being appointed as Manager. Her Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 20 registration needs to be taken forward and a Deputy Manager appointed at the earliest opportunity to ensure that the home is well run. The Manager had to ensure that suitable electrical wiring and passenger lift inspection certificates are copied to the Commission for Social Care Inspection. The electrical wiring certificate was not available for inspection and passenger lift service certificate was also not available. Finally, the Manager had to ensure that the home developed and put into effect risk assessments around residents’ collective needs. This remains needing to be addressed. The information on respite care was inaccurate and unclear and lacked summary. This information needs updating as it referred to the year 2004/05. A recommendation that arose previously was that the home used to have Investors in People status, which is national recognition of strong staff support, but this status has lapsed. Consideration was to be given to re-aquiring the award. Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X 2 X X 3 X STAFFING Standard No Score 27 3 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X X X 2 2 Woodland Hall DS0000063588.V281584.R01.S.doc Version 5.1 Page 22 YES 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 OP3 Regulation 14 Requirement The Manager must ensure that all residents have a fully comprehensive assessment of their needs which encompasses detailed assessments of communication needs and of food likes and dislikes. (Previous timescale of 15/1/2/05 not met) The Manager must ensure that comprehensive up to date care plans are in place to address identified risks of residents. Residents must where appropriate, be wearing appropriate footwear to prevent falling. Residents should not have name labels displayed on their clothes. Complaints must be comprehensively recorded, summarised and tracked. The outcomes of the two recent POVA investigations need to be acted upon. Many of the soft furnishings of the communal living areas require further refurbishment. Carpets, curtains and some DS0000063588.V281584.R01.S.doc Timescale for action 01/06/06 2. OP7 15 15/03/06 3. OP8 13(4)(c) 15/03/06 4. 5. 6. 7. OP14 OP16 OP18 OP19 14 17(2) 22 13(6) 10(1) 23(2)(b,d ) 15/03/06 01/05/06 01/05/06 01/06/06 Woodland Hall Version 5.1 Page 23 8. 9. OP19 OP22 23(2)(b,d ) 23(2)(n) 10. 11. OP22 OP28 23(2)(n) 18(1) 12. OP30 18(1(c) 13. OP31 18(1)(a) 14. OP31 10 15. 16. OP37 OP38 17(1)(a) 23(2)(c) furnishings in particular, were very worn and some areas of carpet had ingrained staining and cigarette burns. This must be addressed. (Previous timescale of 1/2/06 not met) Some of the corridors had damage marks from trolleys etc. and need repair. Care UK must provide adjustable beds to all residents unless the individual resident does not wish for, or would not gain from such a bed, (in which case there needs to be records of this decision). (Previous timescale of 1/2/06 not met) A local policy must be developed on the use of bedrails for residents at the care home. A minimum of 50 of the care staff team becoming qualified at NVQ level 2 in care must be achieved. The Manager must ensure that all care staff have attended a basic emergency first aid course, a course about dementia care and a course on infection control. (Previous timescale of 1/2/06 not met) Care UK must ensure that the Deputy Manager is appointed and in place to ensure that the home is fully managed. The new Manager must be registered with CSCI at the earliest opportunity and supported in undertaking and completing the Registered Manager Award. A comprehensive updated list of service users receiving respite care must be available. The Manager must ensure that a DS0000063588.V281584.R01.S.doc 01/06/06 01/06/06 01/06/06 01/07/06 01/06/06 01/06/06 01/07/06 01/05/06 01/04/06 Page 24 Woodland Hall Version 5.1 17. 18. OP38 OP38 13(4) 23(2)(c) 13(4) suitable electrical wiring certificate is available for inspection and copied to CSCI. (Previous timescale not met) The Manager must ensure that the passenger lift inspection certificate is up to date. The Manager must ensure that the home develops and actions risk assessments around residents’ collective needs. (Previous timescale of 15/1/06 not met) 01/04/06 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It remains recommended that where unsuccessful attempts have been made to involve service users or their advocates in the care planning process when these are being drawn up that a record be made of this. It remains recommended that the Manager should consider keeping photographs of pressure sores or wound mapping at least monthly, to help monitor the progress of pressure sores. Outstanding recommendations from the pharmacy inspection should be addressed that the history of allergies for all service users should be included. If there is no allergy known this should be recorded. A picture-based menu is still recommended for those residents who cannot easily read. It remains recommended that for reasons of health and safety and time management, peeling and cutting devices are invested in for kitchen staff. It remains highly recommended that Care UK and the Manager discuss and establish a plan of rolling maintenance and refurbishment work, to help ensure that no areas of the home are left to become overly worn out before their upgrading is identified and addressed. A disabled parking bay at the front of the care home DS0000063588.V281584.R01.S.doc Version 5.1 Page 25 2. OP8 3. OP9 4. 5. 6. OP15 OP19 OP19 7. OP20 Woodland Hall 8. 9. 10. OP22 OP30 OP32 11. OP37 should be clearly designated. Further consideration should be given to upgrading the alarm system so that it does not need switching on within each room to make it workable in that room. Induction for new staff that is taking place needs to be fully captured on records. The home used to have Investors in People status (a national recognition of strong staff support), but it is now lapsed. Further consideration should be given to reacquiring this award. Some pages had been torn out of weighing records; good practice should see records amended, dated and signed. 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