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Inspection on 20/07/06 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 20th July 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 home has a friendly supportive committed team of health care assistants who have the resident`s best interests at heart. Registered nurses who oversee the resident`s health care needs support them. The relatives spoken to during the visits to the home were full of praise for the staff who cared for their relatives. The management team listens to the relatives and residents and takes their concerns and wishes into account when changes are planned.

What has improved since the last inspection?

The refurbishment and redecoration of the home has continued since the last inspection. The exterior of the home has been painted and windows repaired. The home continues to improve and the majority of the requirements made have been met. The commission recognises the difficulty finding a suitable manager to lead the home. The interim arrangement has worked well in continuing to push forward improvements to the overall care and management of the home. For this reason the timescales to register a manager with the commission have been further extended.

What the care home could do better:

Although the home no longer stores medication no longer required for the residents the records of return medication had not been completed as required. A registered manager has not been put forward despite an active recruitment campaign. A registered manager must be put forward to ensure there is clear leadership for the staff team. Care planning has continued to be recorded and reviewed. However the resident`s social care needs and the needs of residents with challenging behaviour are not clearly addressed in the care planning. This may put residents at risk of isolation. It was unclear from the records provided whether staff had received training in the management of challenging behaviour. The staff will be better equipped to understand residents challenging behaviour if they receive appropriate training. The resultsof quality audits have not been provided for the Commission, relatives or residents.

CARE HOMES FOR OLDER PEOPLE Woodland House Nursing Home Middle Warberry Road Torquay Devon TQ1 1RN Lead Inspector Rachel Proctor, Douglas Endean Unannounced Inspection 20th July 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 House Nursing Home DS0000028763.V293192.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 House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 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 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) 01803 296809 01803 380144 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 DS0000028763.V293192.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Registered for a maximum of 30 DE(E) Registered for a maximum of 3 OP Registered for a maximum of 30 MD(E) Registered for a maximum of 3 PD(E) Date of last inspection 11th October 2005 Brief Description of the Service: Woodland House is a nursing home that provides care to people who suffer from mental health problems, mainly elderly people with dementia. It is located in the suburb of Wellswood, which is approximately one mile from the town centre of Torquay. The home has eighteen (18) single rooms and six (6) shared rooms spread between three floors that are accessible by two shaft lifts. The lower ground floor is actually a modern extension to the main home. 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. Fees from £423 -£530 dependant on care needs. Chiropody, hairdressing and daily papers extra. Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection, which has taken into account information received since the last inspection, comments cards received from relatives and Heath care professional. Two site visits were also completed as part of this inspection. A tour of the home was completed and some records were inspected. Staff relatives and visiting professionals were spoken to as part of this inspection. The second visit was announced to ensure the acting manager was available. What the service does well: What has improved since the last inspection? What they could do better: Although the home no longer stores medication no longer required for the residents the records of return medication had not been completed as required. A registered manager has not been put forward despite an active recruitment campaign. A registered manager must be put forward to ensure there is clear leadership for the staff team. Care planning has continued to be recorded and reviewed. However the resident’s social care needs and the needs of residents with challenging behaviour are not clearly addressed in the care planning. This may put residents at risk of isolation. It was unclear from the records provided whether staff had received training in the management of challenging behaviour. The staff will be better equipped to understand residents challenging behaviour if they receive appropriate training. The results Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 Page 6 of quality audits have not been provided for the Commission, relatives or residents. 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 DS0000028763.V293192.R01.S.doc Version 5.2 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 House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 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): 3 The quality of the outcomes for service users in this outcome area is adequate. The assessment process in place and the committed caring staff team should enable the residents to receive the care they need EVIDENCE: Five residents care plans were review during the inspection. These had been updated monthly. Copies of completed social services assessments and health professional’s assessments were being kept with the resident’s plan of care. A comprehensive assessment process remains in place. Each of the residents care plans viewed had copies of risk assessments completed. These risk assessments included: -- use of bed guards, nutrition, elimination, mobilising, Risk of Falls and pressure sore risk. Plans of care had been developed from the initial assessment of need for each of the residents. The home has an assessment for support workers to complete, this includes and assessment of the residents personal choice and preference. Although the majority of the residents assessments viewed had a support workers assessment not all were signed and dated. A plan of care had not been developed to address the residents social care preferences and choices. Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 Page 9 Four relatives visiting during the inspection advised that up until the deputy manager left the relatives had regular reviews and they were kept informed of any changes relating to the care. However three commented that they were unsure who was taking the lead in managing the health care of their relative. They further commented that the staff were caring and friendly and appeared to understand the needs of the residents in the home. They also said they were always made to feel welcome at the home. Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 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): 7,8,9,10 The quality of the outcomes for service users in this outcome area is adequate. It was unclear during the inspection who was taking overall responsibility for the health care of the residents, without this the residents may be at risk of not receiving continuity of care. EVIDENCE: Five residents plans of care were reviewed during the inspection. Each had an individual plan of care, which had been reviewed monthly. However none of these had a plan of care, which promoted the social aspects of care for the residents. One resident who had challenging behaviour did not have a plan of care to guide staff how to manage this behaviour. The resident was being cared for in isolation to prevent them disturbing other residents. An assessment had not been made, which looked at the reasons behind the behaviour or how planning could enable this resident to participate in activities within the home. This resident’s plan of care did not include activities, which may reduce the risk of challenging behaviour. Although regular contact with the residents GP had been recorded it was unclear if the registered nurses in the home had sought advise from a community psychiatric nurse regarding the nursing care of this resident. Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 Page 11 The inspectors noted that one resident who required one to one support had not been reassessed by their social worker since their care needs had increased. The fee levels paid for this resident did not reflect the level of care they were receiving. The manager advised that the care manager had been asked to reassess the resident and they were awaiting a response. Two residents whose risk assessment indicated that they were at medium risk of falls did not have a plan of care, which highlighted how the risk of falls could be reduced. The inspector was told verbally of measures staff had put in place to reduce the risk of falls for two residents. A psychiatric nurse who regularly visits the home to assess the patients for their NHS care was contacted. They advised they felt that the residents were well cared for at Woodland house. They commented that the interaction between the staff and residents was always friendly and supportive of the resident. However they did have some concerns about who was taking the lead for the resident’s health care since the deputy manager had left in May. One GP comment card received indicated that they felt the homes staff team managed a difficult client group well. The medication storage has changed since the last inspection. All medication is now stored in the treatment room. A lockable trolley is available which enables a registered nurse to take medication to the residents. A locked drug fridge had a record of temperatures completed. The nurse in charge advised that all controlled drugs are stored in a locked cupboard within a locked cupboard. None of the current residents required controlled drugs at the time of the inspection. The controlled drug record book was checked; they showed when medication had been returned to the pharmacy. Each entry in the controlled drug book had been signed. The medication records for residents had been signed appropriately. The nurse in charge was observed giving made medication. They observed the resident taking the medication, and then signed for medication record sheet. However not all return drugs were entered into the returns drug book. One residents medication had been placed in a box ready to return to pharmacy, this medication had not been recorded or signed for in the returns medication book. None of the residents at Woodland house are able to self medicate. Registered nurses are responsible for medication administration in the home. Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 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): 12,13,14,15 The quality of the outcomes for service users in this outcome area is good. The majority of the residents appeared satisfied with the activities provided. However unless clear plans are in place for managing challenging behaviour for the few residents who have this. These residents may be at risk of being denied access to entertainment and planned group activities. EVIDENCE: A list of activities the residents can take part in is available. The group providing activities for the residents on a weekly basis provides a written report regarding the activities undertaken and which residents participated. These were easily available. During the inspection a visiting musician was playing an accordion. Several other residents were joining in either dancing or singing along to the music. Staff were assisting the residents who were able to take part. At the second site visit the acting manager confirmed that several activities are organised for the residents throughout the month. She also commented that some of the residents dont like all the activities provided for them. Four relatives spoken to during the inspection said they felt the staff tried to encourage their relative to take part in activities in a friendly supportive way. Visitors were coming and going throughout the inspection. They were seeing the residents in the communal lounge in the privacy of their own room. The Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 Page 13 relatives spoken to during the inspection confirmed that visiting is actively encouraged at the home and they always feel welcome. Although some activities have been recorded in the residents plan it wasnt always clear which activities they preferred. One resident with challenging behaviour did not have an activity plan as part of their treatment therapy. One relative commented that their relative’s cloths are always nicely laundered. Several of the female residents had had their nails manicured. One resident who was able indicated that they like the colour of the nail polish the carer had applied. The inspector observed staff speaking to the residents. They were courteous and kind and appeared to have a good rapport with the residents they were caring for. One resident who repeatedly asked the same question was greeted with answers in the same friendly way each time they asked. Staff appeared skilled in diverting resident’s attention if they appeared distressed. All the relatives spoken to said how nicely presented and how good the food was. Very little wastage was seen at the lunchtime meal. The residents who required assistance to feed were being given this on a one-to-one basis with a staff member. The staff assisting the residents to feed were trying to engage the residents by talking to them about the meal they were eating. The residents that needed prompting to eat their meals were prompted in a friendly discreet manner. The acting manager advised that the menus are changed on a regular basis in discussion with the cook, the staff, the residents and their representatives. Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 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 The quality of the outcomes for service users in this outcome area is good. The residents and their relatives can have confidence that any concerns they have will be dealt with sensitively by the staff team. Staff should be given the opportunity to access training for managing challenging behaviour to ensure the residents who exhibit challenging behaviour are understood and their specialist care needs met. EVIDENCE: The commission has not received any concerns or complaints about the home since the last key inspection in April 2005. The acting manager advised that concerns and complaints were dealt with as they occurred. Records of concerns raised and the action taken to address these were provided. The five relatives spoken to during in the inspection said any concerns they had were dealt with in a sensitive way by the staff team. The acting manager confirmed that none of the current residents had the capacity to be able to vote. Policies and procedure relating to adult protection were easily available for staff. The company has developed a training package for adult protection, which contains a workbook for staff to work through. Examples of these were available. A training matrix provided in May 2006 prior to the inspection showed the training staff had received in the last 12 months. This included specialist and mandatory training. The information required for staff working at the home now meets requirements. Three staff records were viewed. They all contained application forms, a photo of the staff member, 2 written references and a current CRB check. Although challenging behaviour training is identified in the training matrix none of the staff appear to have accessed this since the last inspection. Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 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): 19,26 The quality of the outcomes for service users in this outcome area is good. The planned improvement to the environment have continued to ensure that the residents live in a clean pleasant environment that is free from odour EVIDENCE: The exterior of the home has been refreshed in the last 12 months. Several rooms had been refreshed and new furniture and vanity units for individual residents rooms have been provided since the last inspection. The manager confirmed that she was still awaiting replacement carpet for the lounge and corridors. The home has a large communal lounge and a separate dining room both of which were being used by residents and their relatives during the inspection. The residents have access to a garden area although the manager confirmed the residents are accompanied by staff when they access the garden. Where shared rooms were in use screening had been provided. Each resident had a separate wardrobe and dresser for their personal clothing. Toiletries had been stored in separate areas in the en-suit . Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 Page 16 The residents have access to toilets with in easy reach of the lounge, dining room and their individual accommodation. Several of the individual rooms have en-suit facilities. The residents rooms entered during the inspection had been personalised with items of choice. These included photographs and small items of furniture. During both visits to the home the home was fresh and clean in all areas. Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 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): 27,28,29,30 The quality of the outcomes for service users in this outcome area is adequate. The continued reliance on agency registered nurses to provide the professional support for residents does not always allow for continuity of care. EVIDENCE: Three staff spoken to during the inspection said that they felt the numbers of staff on duty enabled them to care for the residents. During the lunchtime meal four health care assistants were assisting the residents in the dining room. The agency registered nurse on duty confirmed that she had been working several shifts at the home since May and had got to know the staff team and the residents. The duty rota confirmed this. The staff rota showed that more staff are on duty at peak times during the day. As at the last inspection there was a team of health care assistants employed by the home, which reduces the need to access agency health care assistants. The acting manager was not available the first day of the inspection. The deputy manager who was a registered nurse had left since last inspection. Although it was later confirmed that a registered nurse had been appointed as deputy manager. At the time of the first visit the relative spoken to were unsure who to speak to to discuss their relative’s health care. A robust recruitment procedure, which is based on equal opportunities and ensuring protections of residents continues to be used. Three staff files were viewed during the inspection. Each contains the information required for staff working at the home. This included an application form, two references, a CRB Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 Page 18 check and a photograph of the staff member. Two of the staff were spoken to during the inspection. Both said they felt supported to do their work and had been given the opportunity to undertake training. One said there had been enable to continue their NVQ training started prior to joining the home. The staff observed during both visits to the home had a good rapport with the residents. One relative commented how helpful and supportive the staff working at the home were towards their relative. One staff member was observed speaking to one of the residents. They answered this residents questions in a friendly helpful way no matter how many times they asked the same question. The acting manager provided a training matrix for 2005/6, which identified the training staff, had undertaken during that period. This included health and safety, fire, food hygiene and adult protection. A further training matrix for 2005/6 identifies the specialist training staff had completed. This included tissue viability, first aid, infection control, medication and nutrition. The manager confirmed that further training is due to be provided for dementia care and managing challenging behaviour. Staff training and personal development plans had been completed for the previous year, however this had not been renewed this year. The manager confirmed that she was in the process of completing appraisals with staff, which would also update the training, and development plans. Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 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): 31,33,35,38 The quality of the outcomes for service users in this outcome area is adequate. The management of the home and the way care is delivered continues to improve. However a registered manager has not been put forward to the Commission, this does not give clear lines of accountability. EVIDENCE: The manager appointed is not a first level nurse although she has several years experience working in the care industry and is in the process of completing an NVQ award. A deputy manager who is a registered nurse has supported the manager; she takes responsibility for the resident’s health care needs. Since the last inspection the deputy manager has left and at the time of the first visit to the home it was unclear who had been taking the clinical lead since she left in May. Several relatives spoken to during the inspection were unclear who was taking responsibility for the overall heath care of their relative. Before the second visit to the home the organisation confirmed that they had Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 Page 20 appointed a first level registered nurse to be the deputy manager, who was due to start work the following week. They also confirmed that the residents and relatives would be informed. There is a quality monitoring system in place however the results of a recent survey were not available. The manager advised that she monitors training and staff records/ profiles using a matrix. These were provided for inspection. At previous inspection a planned environmental improvement plan was provided. The improvements to the environment have continued. The manager confirmed that a residents and relatives meeting was planned to introduce the new deputy manager and discuss any issues relatives or residents had. The majority of requirements made have been meet with in time scales. However the requirement to register a manager with the commission has still to be met. The manager explained how finances are organised for the residents. A computer billing system is used with items the residents need being purchased and the amount added to the account to be paid. Separate records were provided on each resident on the computer database. The manager confirmed that none of the residents have their money managed by staff at the home. She advised that family are encouraged to do this on behalf of the resident. Samples of records kept in the home were viewed during the inspection. Not all records were inspected. Although each resident had a plan of care that was reviewed and updated regularly, none had a social care plan and challenging behaviour had not been fully addressed in the care plan of one resident. The returns drug record book had not been filled in for the drugs ready to be returned to pharmacy. One member of staff had signed the returns drug record book on a previous return drug record. The dates when fire equipment had been maintained and fire systems checked were provided in the pre inspection questionnaire. A list of staff and residents was also provided as part of this process. The staff list indicated that some registered nurses work bank shifts to cover shift shortfalls and don’t work regular hours in the home. One new member of staff spoken to confirmed they had completed an induction programme. A copy of the induction used for staff was available. This broadly follows the Skills For Care recommendations. Policies and procedures are available for staff in the office. The Commission is kept informed of incidents and accidents in the home that adversely affect the residents. The accident records seen had been completed as expected. The manager confirmed that she continues to look at accidents records and any actions that can be taken to reduce re-occurrence are taken. Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 3 Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 Page 22 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 OP31 Regulation 8,18,9 Requirement The registered provider must register with the commission a manager for the home Extended from 31/05/05, and 01/01/06 2. OP9 13 (2) All medication no longer required by the service users and ready for return to the pharmacy must be recorded in a drug returns/disposal book and signed for by the staff member responsible 14/09/06 Timescale for action 01/10/06 Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 Page 23 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 OP3 OP7 OP8 Good Practice Recommendations Social care assessments should be followed with a plan of care to address the residents social care needs Resident’s plans of care should include a social care plan. A plan of care, which identifies how therapeutic interventions for challenging behaviour are managed should be provided for residents who have challenging behaviour All residents should have the opportunity to maximise their personal choices. All Staff should receive training in managing challenging behaviour Areas within the home that had been identified as in need of redecoration and repair should be completed. (Carried forward from the last inspection) A core team of registered nurses should be employed to reduce the reliance on agency registered nurses. Results of quality audits should be made available to the Commission, the residents and their representatives. 4 5 6. 7 8 OP14 OP18 OP19 OP27 OP33 Woodland House Nursing Home DS0000028763.V293192.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay 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 DS0000028763.V293192.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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