Inspection on 13/02/07 for Woodland Villa

This inspection was carried out on 13th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Villa 16/04/08

Woodland Villa 06/11/07

Woodland Villa 24/05/06

Woodland Villa 10/02/06

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Woodland Villa 93 Alma Road Plymouth Devon PL3 4HE Lead Inspector Doug Endean Unannounced Inspection 13th February 2007 10:40 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 Villa DS0000064463.V330170.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 Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodland Villa Address 93 Alma Road Plymouth Devon PL3 4HE 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) 01752 669625 01752 250123 Denmax Ltd Mrs Anna Kathryn McGlew Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability (5), Physical disability of places over 65 years of age (34) Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Old age, not falling within any other category (19) Physical Disability over 65 years of age (34) Physical Disability (5) There should be no more than a maximum of 5 (five) service users in the home at any one time between the ages of 50 years to 65 years. 24th April 2006 Date of last inspection Brief Description of the Service: Woodland Villa is a “care home with nursing” that is registered to provide personal care for up to 19 clients, and nursing care for up to 34 clients. It can therefore admit up to 53 clients over the age of 65 years old and of either gender. It has been developed over several years from a row of large terrace houses that have been linked internally, and has been adapted to meet the demands placed upon it by the clients, many being disabled through illness. Ramping and passenger lifts have been provided to enable clients to access to all parts of the home. The home is on the outskirts of Plymouth city and is on the bus route to the city centre. There is access also to some local amenities. The program of refurbishment is progressing well to a high standard of finish and includes total rewiring, a new fire detection system and a new nurse call system. The home presently has a residential unit at one end and the nursing home takes up approximately two thirds of the property. The units share the same main kitchen and laundry services. There is shared communal space’s of good proportion’s at each end of the building that are attractively decorated and offers several separate areas for the clients to sit in with other clients or their visitors including a library. There is a small outdoor area that has some seating for the clients to use in times of good weather and also an ample sized car park for people using the home. Registered nurses manage the nursing unit 24 hours a day and are supported by social care staff who have received training in providing care safely. Fees commence at £320 for residential care, and £438 for nursing care. Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 13th February 2007. It commenced at 10:40 hours and lasted 3 hours and 50 minutes. During this time the inspector spoke to the Registered Manager and interviewed three staff members. He also spoke to six service users (who then were case tracked) and two visiting relatives. There was a full-unaccompanied tour of the home. Service users and staff were very cooperative and informative during this time. The inspector looked at four service users files and three staff member’s files in detail. Several other staff files were selected at random for a focused assessment of specific documentation. No service users or relatives comment cards had been received. The Registered Manager had not been asked to provide a pre-inspection form on this occasion. What the service does well: What has improved since the last inspection? What they could do better: The general administrative management is still not efficient. Staff records are not as complete as they should be and there is no effective quality assurance to identify and correct this. Finding records for the inspection, such as verification of staff training that has occurred is not a straight forward task as filing is seemingly slow in a cluttered office, although the clutter is less than on previous visits. The Registered Manager is improving her skills in an ever-challenging environment but now needs to prioritise some tasks and delegate others, whilst maintaining an overview of everything. Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodland Villa DS0000064463.V330170.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 Villa DS0000064463.V330170.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 3. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre admission assessment is very thorough and clearly identifies whether prospective service users needs could be met. EVIDENCE: The home has a computer aided initial assessment package that is thorough and does result in the needs of the service users being evaluated and the cost of that care being calculated. It is a professionally produced assessment tool that includes physical, social and psychological areas of assessment that do aid the decision to admit clients or not. Examples of assessments were seen and hard copies can be printed. This information is added to by information provided from the General Practitioner, hospital discharge referral, District Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 9 Nurse, and Care Management. Copies of completed assessments were seen in the notes of clients and cross referenced with their care plans. Woodland Villa DS0000064463.V330170.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes documentation relating to the care of clients is good. The manner in which it identifies the care giver is good. The staff has an approach to care that includes the client and maintains their dignity. The overall medication arrangements are good. EVIDENCE: There is anti-bacterial gel at each entrance of the home for staff and visitor to the home to use as they arrive and leave the home. The care plans are well structured and provide the staff with information on what care is needed and how it should be delivered. They have improved over consecutive inspections. There was evidence that the care plans have been reviewed regularly and many have been produced in the new format used by Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 11 the home. The care plans have comments on such issues as tissue viability (Waterlow score), mobility, manual handling, eliminations care plan and sleep. The registered Manager has produced a floor by floor planning chart that provides “at a glance” information to the care staff on the needs of the service users in each zone such as how often turns are to occur, what toileting needs there are and what dietary needs are to be met. This enhances the likelihood that care plans will be followed. The service user records have specimen signature sheets with the names and signature of those who are providing care to individuals so as to identify anyone who has made a record of care in a clients file. A daily verification sheet for each service users provided evidence that personal care needs had been met and by whom. These sheets are in service users rooms with their plan of care. Three care plans were read as a part of the case tracking process. The care was discussed with the Registered Manager, the service users, and also with two relatives and it was found that the care did match that planned. The chiropodist attends every six weeks, the District Nurse and Community Psychiatric Nurse will attend as needed to provide nursing care to any resident who has been assessed as needing it where the home is only contracted to provide personal care. The optician will attend annually or when requested to do so. There were good medication procurement, administration and disposal records for each of the files that were seen. At the moment there are two separate storage areas for medication. The Registered Manager told the inspector that it is planned to bring the medication together to be stored in the centrally located treatment room/dispensary. The inspector spoke to six service users during the tour of the home. Each paid compliment to the management of their care needs, the way the staff addressed them and the level of choice and independence that they are afforded. The staff were said to speak to them in a respectful way at all times. Where care is provided the staff sign that they have carried out the task. Woodland Villa DS0000064463.V330170.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an atmosphere where clients feel that they are not loosing their independence, or choice, and generally receive care on their terms. The food provided is of a high standard and meets with the clients approval. EVIDENCE: The service users spoken to said that they have a life style that is acceptable to them that is only restricted by the level of disability that they suffer. One service user explained how independent she is and that she attends the General Practitioner practice for consultations and to see the practice nurse then brings information back to the home for the Registered Manager to record any changes in her care plan. She also showed the inspector her room that included a large en-suite. This service user expressed a high level of satisfaction with the home environment, the staff and her personal accommodation. She did say that the owner had agreed to fit more cupboard space in her en-suite but that this has not happened yet. Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 13 The views expressed by the majority of client were that the activities at the home are varied, meet social and physical needs, and are entertaining. The planned activities can be seen displayed on notice boards dotted around the home. They include music and also exercise sessions on a regular basis with the right not to attend if an individual wishes. The keyboard player attends weekly and there are armchair exercises weekly. Birthdays are celebrated with a cake that is produced by the cook at the home. There is also a library that is regularly topped up by the Plymouth Library service. The inspector spoke to one relative who was visiting. She was very complimentary about the overall service provided by the home. She did offer an opinion about the activities saying that trips around the area of Plymouth would make all the difference to some of the service users who are now not able, or motivated to leave the home themselves. One Care Assistant expressed a view that some staff do not deliver the “little personal touches” such as a cup of tea and a biscuit outside of the normal rounds of drinks. A change in attitude and understanding of care delivery was said to be needed to achieve this level of service. The food is prepared in the homes kitchen and follows the menu sheets that have been prepared with the knowledge of service users needs. These needs were seen to have been recorded in the service users nutritional assessments that are in service users records. Likes and dislikes are recorded and service users who are able to express a choice at meal times are given the opportunity to do so. The inspector saw the main meal being prepared and later enjoyed by all service users apart from one. She was asked what she would like but declined to comment. Five service users specifically made a point of saying that they liked the food that is served to them at meal times. The home has been designed to meet the needs of those who have a disability of some nature. This is its purpose. They will admit anyone who meets the criteria that their registration allows. There staff group and service users group are of mixed race and culture. The home has made arrangements to meet any dietary needs brought about by the service users disability and culture. The home has its own hairdressing salon that is attended by the hairdresser every Tuesday. Her prices commenced at just £4.50 and the ladies who were in the salon all said how happy they were with the way that the hairdresser did their hair. Woodland Villa DS0000064463.V330170.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a good approach to responding to complaints that is clearly demonstrated in the complaints book. Administrative recruitment tasks are not completed to a satisfactory stage, this demonstrates that the home is not fully safeguarding the service users from abuse. EVIDENCE: The home has an up to date complaints procedure displayed that has time scales and the contact details of the Commission for Social Care Inspection office in Ashburton. The home can also demonstrated that they do acknowledge complaints and address them in a positive way. A complaints book is used to record the complaint and how it is progressed to a conclusion by the management of the home. The inspector spoke to six service users and they were able to tell him who they would speak to if they had a complaint to make. The inspector saw evidence that some staff has attended the Adult Protection training carried out by Plymouth City Council and that this is an ongoing arrangement. Staff who have their National Vocational Qualification at level 2 have also been introduced to issues of recognising abuse. Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 15 The home has clear policies and procedures for addressing any allegations of abuse that were made available to the inspector. There are still issues within the recruitment process that have not been satisfactorily addressed with regard to safeguarding the service users from abuse. See also Standard 29 regarding recruitment. Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 19, 20, 21, 24 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is suitable for the purpose of providing personal and nursing care. The total refurbishment has resulted in a more attractive and functional home. EVIDENCE: The home is located close to Plymouth City and on the main bus route. It is on the level with a main road passing in front of it and ample parking to its rear that is entered via the one-way system that operates in the area. The doctors surgery is in close proximity to the home and can be accessed by ambulant clients if they so wish. The home has been developed from a terrace of houses that have been adapted over nearly two decades for its present use. It is large and has several Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 17 communal spaces. At the present time the home has operated as “Residential care” on one side and “Nursing care” on the other. This situation is still under review. The home is well adapted to provide either level of care in any part of it with suitable bathing facilities, toilet facilities and call system. New hi-low baths and wet rooms have been provided for service users. There is improved lighting on the centrally located stairwell. Toilets outside of en-suites are of good proportion and have raised seating and handrails. The tour of the home showed it to be clean, tidy and odour free. There are now suitable sluicing facilities well located in the nursing wing of the home. There are several communal areas that each offer there own particular atmosphere. There is a small seating area with floor to ceiling glass offering a view to the front of the home and the busy street. The dining rooms are more tranquil and there is a library that has wooden panelled walls and comfortable lighting and seating. Service users bedrooms have been decorated to a very high standard and to their own choice of paint and paper. The service users expressed a high degree of satisfaction with the environment. They are also provided with good furnishings supplied by the home if the service users has not provided their own. Some service users also have their own private telephone lines whilst others do have a public pay phone that they can use in the home. There was evidence that general maintenance does take place and the inspector saw evidence of regular servicing of such items as the 2 shaft lifts, hoists and the fire systems whilst carrying out the administrative portion of the inspection. All the radiators are guarded to prevent contact with a hot surface and the new standard that the home is choosing to achieve is for all wash hand basins to have a thermostatic mixer valve fitted. There is a new nurse call system in place and the home has been rewired. The inspectors view is that the standard of redecoration is excellent and that the attention to Health & Safety issues (total rewiring, radiator guards and thermostatic mixer valves) has improved the environment that the clients live in. The service users that were spoken to during this inspection shared this view. The home has its own laundry that is suitably fitted out and includes a washing machine with a sluicing cycle. There is a commercial dryer in the laundry and each client has there own named laundry basket to assist in the delivery of cloths back to the right person. Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 18 Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 27, 28, 29, 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staff appear to be sufficiently experienced and trained to meet the assessed needs of the clients although the evidence of some training was not accessible do to poor filing arrangements. Staff recruitment procedure has not been followed to a satisfactory conclusion. EVIDENCE: The home is managed by a Registered Manager whop is also a 1st level Registered Nurse. Each day shift is staffed by at least two Registered Nurses with current pin numbers who are supported by Social Care Staff some of which have a National Vocational Qualification in care at level 2 or above. This information was verified by the inspector using rota’s and staff files and also through interview with a random selection of the staff during the inspection. The duty rosters provided evidence of the numbers, and skill mix, of staff who are on duty over the 24-hour day. The clients felt that staffing was at an adequate level as their needs are met and should they use the call system the response time was acceptable to them. One visitor commented that generally the staffing appears to be adequate although occasionally the staffing levels could be better. Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 20 The care staff are supported by the rest of the home staff team, domestics, catering and laundry staff who are in adequate numbers to maintain a clean home and good food. The Registered Manager provided evidence that showed staff employed at the home have induction training that prepares them for the duties that are encompassed within their role. The induction package is managed by an external training organisation who provide staff with fire, manual handling and later, National Vocational Qualification training. Staff have a “Training record of instruction and Competence in Care” booklet. This provided some evidence of the areas of induction training that are undertaken with signatures by the staff members mentor when they have shown that they have been instructed and are competent in each area. Staff carry the booklet with them whilst at work. The inspector spoke to one Registered Nurse who had worked in the home for just two months. She felt that the induction she had received was suitably tailored to her needs and included an orientation to the building, fire instruction, manual handling and medication. This staff member’s file provided evidence that an application form had been completed, pin number had been verified, Criminal Records Bureau check undertaken, photographic and other identification information gathered and references obtained. A member of the ancillary staff who was interviewed recalled that she had fire training as part of her induction. She has worked at the home for two years. Her file provided evidence that she had completed an application form, a Criminal Records Bureau check was carried out, and a contract was given. She said she likes working at the home and has seen some very positive improvements during the time she has worked there. One care staff member was also spoken to who provided a view on the general routine and changes in staff attitude that, in his view, would benefit the service users. The staff member drew comparisons with other care work they had experienced as a basis for their view. The staff members file provided information on their career history and included also the documents required by the Regulations. The present staff team is made up of a multicultural group who have different skills and experiences that they bring to the home. Although the home does have a robust recruitment procedure there was evidence that this had not been followed. A general random sampling of the staff files showed that references for several recently employed staff had not been returned and this had not been followed up. This has been an on going issue that has still not been resolved satisfactorily. It was also not clear who had completed adult protection training, as not all of the certificates of attendance were filed in staff folders. There are 36 care assistants employed at the home who are contracted to work for different numbers of hours, some full time and others work part time. There are 13 care staff who presently hold an National Vocational Qualification Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 21 at level 2 or above. This equates to 36 of care staff holding an National Vocational Qualification. There are care staff involved in National Vocational Qualification level 2 training with an external organisation at present. Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 31, 33, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager has made some good changes to working practices. The priorities in recruitment practices have not been met which could affect the welfare of the service users. EVIDENCE: The home manager is a 1st level Registered Nurse and has now completed the process of registration with the Commission for Social Care Inspection. She has been the Registered Manager for several months and has made some significant changes to the way the home functions both in its records and the delivery of care to the service users. She has also enrolled onto the Registered Managers Award training and has begun the training. She said that this might Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 23 be a long process due to the day-to-day challenges of managing the home. Some more focused activity must be undertaken by her to lead her administration duties to fulfil the priorities specifically in the area of recruitment. The Registered Manager was able to provide the inspector with completed survey forms that were sent to service users or their advocates as part of the homes quality assurance exercise. The results were being analysed. The Registered Individual also attends the home at least weekly to look at any issues that might affect its performance. However the home fails to have suitable quality assurance measures that will identify short falls in the staff recruitment process and therefore the Regulations. The home does not manage the financial affairs of any of the service users. They do have robust procedures for handling any monies held for clients and have secure facilities for its storage and good records are kept. There was good evidence seen by the inspector that showed the home has been well maintained and that equipment had been serviced as required by legislation and the manufactures guidance. New equipment has been provided to enhance the service and provide safer environment of the staff to work in and the service users to live in. This includes thermostatic valves on hot water outlets, hi-low baths and wet rooms for showers using safe seating. Staff did have good care plans to direct them and they had been prepared for the tasks through training. Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 3 3 X X 4 X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 3 Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19(1)(5) Schedule 2 Timescale for action The Registered Person shall not 30/03/07 employ a person to work at the home unless he has obtained in respect of that person the information and documents specified in Paragraphs 1 to 7 of Schedule 2. The staff files seen did not hold this level of information. The Registered Person shall 01/04/07 establish and maintain a quality assurance system that will identify shortfalls in meeting the Regulations. Requirement 3. OP33 24 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 OP18 Good Practice Recommendations The staff should continue with Adult Protection training DS0000064463.V330170.R01.S.doc Version 5.2 Page 26 Woodland Villa until all the care/nursing staff have attended. 3. OP28 The home should be able to provide clear evidence of any training undertaken that will include those who have achieved a National Vocational Qualification in care. Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodland Villa DS0000064463.V330170.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!