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Inspection on 11/10/05 for Woodland House Nursing Home

Also see our care home review for Woodland House Nursing Home for more information

This inspection was carried out on 11th October 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The acting home manager continues to actively involve the residents, their families and staff when planning changes and improvements. The staff team are motivated and sensitive to the needs of the residents and their families. Relatives spoken to were full of praise for the staff team and the way they managed their relatives care. They also said they were pleased that the refurbishment of the homes environment was continuing.

What has improved since the last inspection?

The decoration of the ground floor corridor had been completed since the last inspection. New carpets had been provided in five of the residents rooms and these had been redecorated. Some new furniture had been provided some replacement vanity units in residence bedrooms had been fitted. The training for staff in relation to infection control and health and safety had been completed. Clear evidence was provided that staff have access to health and safety training, planned training dates for new staff appointed were in place. The home continues to work towards achieving the outstanding requirements and recommendations and only a few things remain outstanding, in view of this the timescales for completing these improvements have been further extended.

What the care home could do better:

Not all the requirements set at the last inspection have been met. The main improvements still required relate to the upkeep of the environment, staff recruitment, records and training. The way Medication no longer used by theresidents are still being stored; the acting manager has been required to dispose of these in line with the good practice recommendations. The recruitment of new staff must include obtaining all pre-employment checks, a new CRB check must be applied for and not rely on CRB checks completed by the previous employer to protect residents from unsuitable staff. This requirement has been carried forward from the last inspection. The repairs, renewals and redecoration of the home is still ongoing. Although several rooms had been redecorated and new furniture provided. Not all the residents rooms had been completed. This distracts from an otherwise improved home environment that benefits and respects the residents. A registered manager has not been found for the home despite a continued active recruitment campaign. A registered manager must be put forward so that there is clear leadership for the staff team.

CARE HOMES FOR OLDER PEOPLE Woodland House Nursing Home Middle Warberry Road Torquay Devon TQ1 1RN Lead Inspector Rachel Proctor Announced 11 October 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodland House Nursing Home Address Middle Warberry Road, Torquay, Devon, TQ1 1RN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01803 296809 01803 311525 Woodland Healthcare Ltd Vacancy Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (30), Old age, not falling within any other category (3), Physical disability over 65 years of age (3) Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Registered for a maximum of Registered for a maximum of Registered for a maximum of Registered for a maximum of 30 DE(E) 3 OP 30 MD(E) 3 PD(E) Date of last inspection 19/04/05 Brief Description of the Service: Woodland house is a nursing home that provides care for people who suffer from mental health problems, mainly elderly people with dementia. It is located in the suburb of Wellswood, and is approximately 1 mile from the town centre at Torquay. The home has 18 single rooms and 6 shared rooms spread between three floors that are accessible by two shaft lifts. The lower ground floor at is a modern extension to the main house. There are two lounges (one on the ground floor and one on the lower ground floor) and a medium-sized dining room on the ground floor close to the kitchen. Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has introduced key standards to be inspected on each inspection year. Therefore, unless it is felt necessary by the inspector, some standards will not be inspected. To obtain the full picture of the home it is recommended that previous reports also be taken into consideration. This was an announced inspection, which took place on the 11th October 2005 between 9:45 a.m. and 4:30 p.m. The requirements and recommendations set at the last inspection were reviewed. A tour of the home was completed. The inspectors spoke to visiting relatives, some residents and staff. Some records were inspected. One relatives comment card was received prior to the inspection. What the service does well: What has improved since the last inspection? What they could do better: Not all the requirements set at the last inspection have been met. The main improvements still required relate to the upkeep of the environment, staff recruitment, records and training. The way Medication no longer used by the Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 6 residents are still being stored; the acting manager has been required to dispose of these in line with the good practice recommendations. The recruitment of new staff must include obtaining all pre-employment checks, a new CRB check must be applied for and not rely on CRB checks completed by the previous employer to protect residents from unsuitable staff. This requirement has been carried forward from the last inspection. The repairs, renewals and redecoration of the home is still ongoing. Although several rooms had been redecorated and new furniture provided. Not all the residents rooms had been completed. This distracts from an otherwise improved home environment that benefits and respects the residents. A registered manager has not been found for the home despite a continued active recruitment campaign. A registered manager must be put forward so that there is clear leadership for the staff team. 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 House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 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 standard(s) 3, The comprehensive assessment process continues to enables staff to provide care that meets the resident’s health, social and personal care needs. EVIDENCE: Copies of completed social services assessment and health care assessments were kept with the resident’s plans of care, where these had been provided. A comprehensive assessment process remains in place; these have been completed in the five resident’s plans of care seen during the inspection. These assessments include the resident’s personal, physical and emotional care needs. The residents personal preferences and choices and had been established through working with them, these had been recorded in their plans of care. Two residents relatives visiting during the inspection advised how the senior staff had regularly reassessed their relative to ensure that the care needs required were being met. They went on to say that they had been kept informed and any changes made to the way the care was provided and senior staff discussed this with them. Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 9 Registered nurses continue to complete assessments for the residents. The staff observe providing care for residents were doing so in a respectful supportive way using the residents preferred form of address. A plan of care had been developed from the initial assessment of need and changes recorded. Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10, The failure to document risk assessments for the residents using bed guards and the lack and stock control for some prescribed treatments, which residents no longer require could put them at risk. EVIDENCE: Five residents plans of care covered all aspects of the health and personal care identified in their assessment. Care planning included risk management for risk of falls, manual handling, nutrition screening, pressure sore risk and continence assessments. Care planning also included the resident’s self-care abilities and where prompting an encouragement would assist the residents to maintain the level of independence they had. A record of health professional visits including the residents GP and community psychiatric nurse are recorded in their plans of care. Each plan of care seen during the inspection had been reviewed at least monthly or sooner if the residents care needs have changed. The visiting community psychiatric nurse reviewed one of the residents during the inspection. They commented that the resident they had seen appeared to have settled well at Woodlands house and the care staff were meeting their needs. Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 11 Although four of the residents had bed guards fitted to their beds a risk assessment, which included consent for their use had not been completed for two residents. The acting manager has recently admitted six new residents following the closure of another home. The transfer information including assessments from the mental health team had been provided prior to their transfer, copies of these were available in the care plan is viewed. Not all the aspects of medication management were reviewed during this inspection. The acting manager advised that H&A waste were now providing a disposal service for the medication they use in the home. However medication, which the inspector was advised was disposed of prior to this inspection, did not have a record provided to indicate which medication had been disposed of. The medication in the store cupboard was checked. Medication for residents no longer at home was still being kept. Some of this medication was past its expiry date and could pose a risk if given to the residents. All the staff observed on duty during the inspection appeared to have a genuine rapport with the residents they were caring for. They were speaking to them in a friendly supportive way often answering the same question with the same enthusiasm, as did the first time they were asked. The residents were being addressed by the preferred name recorded in the plan of care. Two relatives spoken to during the inspection advised that the staff are always courteous and treat the residents with respect at all times. Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14, 15, Staff at Woodland house have the residents best interests at heart. The routines of daily living and activities provided are flexible and encourage the residents to exercise choice where they are able. EVIDENCE: Activities are provided for the residents from an outside agency, who visit weekly. A record of the activities provided and the names of those residents who participated was available. These evidenced that the residents have a variety of entertainment and activities provided for them. This included quizzes, reminiscing, sing-along and various craft making. One staff member advised that of local entertainer visits weekly and the residents enjoy singing along with them. The acting manager provided the minutes of the residents meetings that had taken place. The minutes of the last meeting in July showed the topics covered in the meeting. Two residents’ relatives visiting said they could not fault the care the relative was receiving. The staff had been friendly and supportive of their needs as well as the residents during their illness. Visitors were coming and going throughout the inspection. They were seeing the residents in the communal lounge or in the privacy of their own room. The acting manager confirmed that visiting is actively encouraged. Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 13 The residents care planning includes the activities they prefer. The acting manager advised that these had been recorded following discussion with the resident and their families. Staff were responding to requests from residents in a way that enabled them to choose. Two relatives said staff are very helpful and assist the residents with their choice of activity. One residents was looking at a book with a member of staff after lunch. Other staff on duty were chatting to the residents on a one-to-one basis. Some of the residents had chosen to remain in their own rooms. The staff had enabled them to do this and meals were provided in their rooms. Discussion with visiting relatives and staff on duty confirmed this. 15 of the 20 residents were eating their lunchtime meal in the dining room. They were being assisted by five members of staff. Circular tables are provided in the dining room, which were being shared by three residents. Four residents had chosen to eat their meals in their own room and one resident was poorly. The cook advised that there is a three weekly rotational menu provided, two of these were seen during the inspection. These showed a variety of meals provided, which were nutritionally balanced. Very little wastage was seen at the lunchtime meal. The relatives asked said the food is always attractively presented and the meals of varied. The acting manager advised that the residents who required puréed food appeared to eat more if this was puréed together. The cook advised that puréed food is prepared separately if the staff request this for a particular resident. Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 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 standard(s) 16, 17, 18, The residents and their relatives can have confidence that any concerns they have will be dealt with sensitively by the staff team. The failure to ensure that new CRB checks are completed when a new staff member is appointed may put the residents at risk. EVIDENCE: The Commission has not received any complaints about the care provided at Woodland House since the last inspection. The acting manager advised of three complaints that had been recieved. The records of these showed the actions taken following the complaint; this had been completed within timescales and indicated that the complainant was satisfied with the complaint investigation cared out. The complaints policy is easily available in the home; this included the timescales for response and the name and address of the Commission The relatives visiting during the inspection advised that they knew who to complain to if they had any concerns. They also went on to say that the staff listen to them and dealt with their concerns in a sensitive way. Information regarding postal voting was available in the office. Although the acting manager advised that none of the current residents were able to participate. Robust policies and procedures are in place to protect the residents from abuse. These guide staff how to deal with incidents of suspected abuse. The acting manager provided training matrix, which identified the staff that had completed adult protection training. Training provided also includes managing challenging behaviour. Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 15 The inspectors saw the in-house training workbook that is used to update staff in adult Protection. The administrator provided information regarding how individual residents accounts were prepared. Receipts for expenditure and an example of how the placement costs were charged were seen. The home has a recruitment policy, which should protect residents from unsuitable staff. However a review of the staff files showed that a new CRB had not been applied for when the staff member started. Copies of the CRB checks from previous employers were available. The administrator told the inspector that she was unaware that staff had to have a new CRB for each employment dispite this being required at the last inspection. She further advised that these would now be applied for. Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 24, 26 The residents have fresh clean environment which is free from odour. Although some outstanding redecoration and renewals of furnishing has still to be completed, once finished this will provide a comfortable and well maintained home. EVIDENCE: A tour of the home revealed that five of the residents bedrooms had been decorated and carpeted since the last inspection. The acting manager advised that all rooms were due to have new carpets and be redecorated as part of the homes development plan. The maintenance man working in the home during the inspection advised that he would be fitting new vanity units and sinks in the resident’s bedrooms. Two residents bedrooms entered had had new furniture provided. Some of these had been replaced since the last inspection. Two new chairs had been provided in the lounge. The acting manager advised that because of problems with the lounge carpet this was going to be replaced. Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 17 The home has a large communal lounge, which is separated into two areas. The dining room provided could seat all the residents at one sitting if required. The furnishings in these rooms are domestic in character and communal rooms are sufficiently bright. The residents have access to outdoor space. The acting manager confirmed that staff the company residents when they use the garden. Cleaning and up keep of the external building had been completed since the last inspection. Where shared rooms were being used no more than two residents share these, screening is provided. The residents have access to toilets within easy reach of the lounge, dining room and their individual bedrooms. Several of the resident’s bedrooms have en suite facilities provided. The residents bedrooms entered had been personalised with items of their choice. These included photographs, pictures and small items of furniture. The system for risk assessing the residents use of a lockable door to their room or lockable space is recorded in the individual plans of care. The acting manager confirmed that none of the existing residents had been assessed as able to benefit from the provision of a lockable door or lockable space in the room. During the inspection the home was fresh, clean and free from odour in all areas. The domestic advised that she worked alongside another person, and felt that between them they had enough time to ensure the home was kept clean and fresh. Two relatives spoken to during the inspection said the home is always pleasantly presented and they havent noticed any odour when they visited. New flooring had been provided under the disinfecting sluice, which is easily cleanable. The laundry area was tidy, the floor was clean and staff using the laundry had easy access to hand wash sink. Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The continued reliance on agency registered nurses to provide the professional support for residents does not always allow continuity of care. Recruitment of staff must include a CRB check prior to their employment to protect the residents from unsuitable staff. EVIDENCE: The minutes of the last staff meeting (29.09.05) were provided; this showed that staff are able to influence the way care is delivered. Two healthcare assistants spoken to said they felt that the numbers of staff on duty enabled them to cover the amount of work they needed to do for each shift. Two relatives asked said they were pleased that there was a more stable staff group of healthcare assistants and were hopeful that more full-time registered nurses would be appointed soon. The staff rota showed that more staff were on duty at peak times of activity during the day. This also showed that the management team had recruited more healthcare assistants since the last inspection, which had reduced the dependency on agency healthcare assistants. However there is still a shortfall of full-time registered nurses. The acting manager confirmed that the agency still provides cover for some registered nurse shifts. Although the organisation has a robust recruitment procedure which is based on equal opportunities and ensuring the protection of the residents. Not all the information required for pre-employment checks for the staff employed had been obtained prior to them starting work. Copies of completed CRB checks Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 19 are available for staff however 16 of these had been provided from a previous employer. The registered provider advised that the organisation was currently looking at the homes categories of care and may wish to change the status of the home from nursing to residential. He went on to say that social services and health teams have been requested to reassess the residents to establish their current care needs. He also advised that so far the organisation had been unsuccessful in finding the right manager to take Woodland House forward. Staff training and personal development plans had been completed, these were being kept with the staff member supervision records. The training matrix provided identified the training courses that staff had completed and which they had still to complete. Six staff had completed a food hygiene training course and obtain certificates. The acting manager advised that five staff had received training for skin wound care products in May and four staff had achieved a first aid certificate. An infection-control workbook, which had been introduced since the last inspection, was provided. Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,36,37, 38 Although the management of the home and away care is delivered continues to improve, a registered manager to take the home forward and continue the improvements made is still required. EVIDENCE: The home has still to appoint a registered manager. Several interim and tempory managers have been in post since the previous manager left. Currently the deputy manager (acting manager) is supported by a first level general nurse. The registered provider advised that there had been difficulties finding a suitable permanent manager to take Woodland House forward. As a result of the difficulty recruiting a suitably qualified nurse manager and full time registered nurses the category of care the home provides is in the process of being reviewed. A quality audit system is in place, which ensures consistency. The results of the care plan audit, summary of accidents records completed in August 05 Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 21 were provided. Two relatives asked said they are regular asked for their opinions and staff listen to their suggestions. The acting manager advised that none of the current residents have their finances managed by staff at the home. She confirmed that family are encouraged to do this on behalf of the resident. A centralised billing system is operated from head office. Examples of this billing system were seen and discussed with the administrator during the inspection. Copies of receipts for purchases on behalf of the residents were being kept with the resident’s contract. A folder, which contained the supervision records for the staff, was being kept. The acting manager confirmed that all staff have supervision as part of their work. Two health care assistants spoken to advised that they felt supported to do their work. Not all records were inspected on this occasion. The medication returns record had not been completed for the last amount of drugs returned/disposed of. The records required in staff files did not include an up to date CRB check applied for by this employer. The dates when equipment had been maintained and fire systems checked were recorded in the pre-inspection questionnaire. A list of the staff and current residents was also provided as part of this process. The staff list indicated that some staff are employed as bank staff who cover shifts shortfalls and dont always do regular hours at the home. The inspector was provided with copies of the induction programme used for new staff. The acting manager confirmed that staff receive mandatory fire safety, manual handling and health and safety practice training. The training matrix identified the staff who had completed this since the last inspection. A policy is available for staff regarding the organisation and arrangements for maintaining safe working practices. Health and safety information is available for staff use in the office of the home. Environmental risk assessments and fire risk assessments were provided for inspection. The system for recording and reporting accidents that happen to residents, staff or visitors is in place. These accident record books were provided for inspection. The acting manager advised that the circumstances of the accidents are reviewed and any actions that can be taken to prevent a reoccurrence are completed. Individual risk assessments were available in the residents care plans viewed. However two residents who were using bed guards had not had these risk assessed or consent is obtained. Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 2 x 3 x 3 3 2 3 Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 23 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. 2. Standard OP 9 OP18 Regulation 13 (2) Schedule 2 (7)(a) 19(4) (b) 8, 18, 9 Requirement All medication which the service users no longer require must be returned or disposed of. Criminal records bureau checks must be completed for all new staff employed prior to them starting employment. All staff must have the required information provided within staff files The registered provider must register with the commission a manager for the home Timescale for action 25/11/05 31/05/05 extended 01/01/06 31/05/05 extended 01/01/06 31/05/05 extended 01/01/06 3. 4. OP 29 OP 31 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. Refer to Standard OP 8 OP 19 OP 37 Good Practice Recommendations Risk assessments for the use of bed guards should be recorded for all the service users who use them Areas within the home that had been identified as in need of redecoration and repair should be completed. (Carried forward from the last inspection) All records should be completed. Risk assessments for bed guards should be recorded. Confirmation that two references have been received for staff should be available D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 24 Woodland House Nursing Home Woodland House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Unit D1 Linahy Business Park Ashburton TQ13 7UP 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 House Nursing Home D54-D07 S28763 Woodland House V242151 111005 Stage 4.doc Version 1.40 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. 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