Inspection on 17/05/06 for Woodlands

This inspection was carried out on 17th May 2006.

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

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

Other inspections for this house

Woodlands 05/07/07

Woodlands 11/01/06

Woodlands 26/08/05

Woodlands 10/02/05

Woodlands 08/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Woodlands 66 Bridle Road Stourbridge West Midlands DY8 4QE Lead Inspector Mrs Cathy Moore Unannounced Inspection 17th May 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodlands Address 66 Bridle Road Stourbridge West Midlands DY8 4QE 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) 01384 394851 01384 394851 Mrs Siobhan Shroff Mr John Wall Davies Mrs Siobhan Shroff Care Home 19 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (18) of places Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11/01/06 Brief Description of the Service: Woodlands- Care Home comprises of two converted detached properties (Known as Woodlands 1 and 2) which are adjoined by a conservatory. Woodlands is situated in a quiet residential area of Stourbridge. The local village of Wollaston, which has numerous shops, public houses and other amenities, is within walking distance or can be easily accessed by local public transport. Woodlands has a small driveway and car parking facilities off road. It has large well- maintained gardens situated to the front and rear of the property. Ramps are available for access to the home and garden area. The home was initially registered in 1986 by the current owners and provides care for 19 older persons, one of whom at any one time can have a diagnosis of dementia. Resident accommodation is on both the ground and first floors. A passenger lift is available between floors in Woodlands 1 only. Woodlands provides fifteen single and two double bedrooms. Residents’ bedrooms are all pleasantly decorated with good quality furnishings. The home has a number of bathrooms and toilets. One bath provides assisted facilities and a shower is available on the ground floor. The home has two attractive lounges, a dining area and additional dining space in the conservatory. The fees for this home range from £375-£395 per week. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced ’key’ inspection was carried out by two inspectors’ over one day between 08.30 and 15.45 hours. The inspection assessed all of the main key ‘standard’ areas ( National Minimum Standards for Older People and also assessed progress or otherwise concerning past requirements made. Information to aid the inspection process was gained prior to the inspection by asking the manager to complete a pre-inspection questionnaire and by asking residents’ or their relatives’ to complete standardised questionnaires. Fourteen completed questionnaires to date have been received. Three residents’ were chosen to focus on during the inspection. This process included looking at their needs, assessing their care plan, daily notes and other records. These three residents’ were spoken to in order to see if they are satisfied with the home and the care provided. Four other residents, three staff and two relatives were also spoken to during the inspection day. The manager / co-owner was involved in the inspection process. The premises were randomly assessed to include; communal areas, three bedrooms, the laundry, kitchen, one toilet and two bathing facility rooms. The medication systems and administration were assessed. Records concerning health and safety, staff recruitment and training and fire prevention were also examined. What the service does well: One of the Co-owners is also the registered manager having day to day involvement with the running of the home. The home is situated in a pleasant residential area. It has large attractive gardens and is well maintained. The atmosphere of the home was found to be warm, welcoming and friendly. Staff spoken to are very motivated and committed to providing a good service to the people in their care. They were able to demonstrate a good level of awareness of the needs of people in their care. Over 50 of the staff have achieved N.V.Q level 2 or above in care. Visiting times are flexible. Residents’ are encouraged to maintain contact with family and friends. Although menus and meals offered need further exploration- generally there was positive feed back about the meals. A small number of requirements have been made concerning medication management however, generally, medications are managed well. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 6 A number of very positive comments were received from residents’ and relatives; “ Very happy with care and service”. “ We as a family are extremely happy with the care she receives”. “ As a general observation the level of care and associate needs e.g. standards of hygiene are second to none”. “ Staff are always friendly”. “ Staff are always pleasant and helpful- I like it here”. What has improved since the last inspection? What they could do better: The homes’ contract/ terms and conditions document needs to be revised. Care plans require ‘fine tuning’ to ensure that all needs are captured and that they are reviewed adequately. Activity provision needs further exploration to ensure that it meets the needs of each resident. Complaints procedures must be produced in a manner so that they are understandable to all residents’. Local Authority protection systems and processes must be made available to staff it must be evidenced that they have read these. Any incident of violence from resident to resident must be reported. A number of outstanding requirements remain from as far back as 2002 in terms of the staff and office space, the laundry and fittings and fixtures in bedrooms. Recruitment of staff processes to ensure resident protection need to be tightened. Two issues were identified concerning health and safety which require action to prevent risk. The home has a number of outstanding requirements across a number of areas which now need to be addressed in full within the timescales set. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4. Following the assessment of contracts/ terms and condition documents, admission processes and feedback from residents’ it has been determined that this section ’choice of home’ is being ‘ adequately’ met by the home. EVIDENCE: It is positive to identify written evidence to show that residents’ had been given a copy of the homes’ statement of purpose/service user guide. It was pleasing to see that a contract/terms and conditions document was included on each residents’ file viewed. Fourteen of the fourteen completed resident questionnaires received confirmed that they had been issued with a contract. An assessment of need process is in operation within the home and was found to be of a good standard. It is also pleasing that thirteen of the fourteen completed resident questionnaires confirmed that they ‘were given enough information about the home before they moved in to help them make the decision whether or not the home would be the right place for them’. A comment was received from a relative about her experience in choosing the home for her mother; “ I had Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 10 researched the home via relatives of previous residents’, my minister and doctor “. Another commented;” I was invited to visit the home anytime. I was made welcome and able to speak to residents’ for their views”. A written letter is given to each prospective/new resident confirming that the home can meet their needs. It was identified that three residents’ may be accommodated who have a dementia diagnosis, this is to be explored as the home is only registered to take one resident at anyone time who has a primary diagnosis of dementia. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Health and personal care provided by the home has been assessed as being ‘adequate’ as further development is needed in the areas of care planning, nutritional and tissue viability assessment as well as medication and the promotion of privacy and dignity. EVIDENCE: It was positive in that each resident had in place a written care plan. The care plans however, are at the present time produced only in written, standardised print which could make them difficult for some residents’ to read or understand. It was identified that there was a lack of care planning for individual residents’ who at times displayed aggression or other behaviours that may give cause for concern. It was also identified that the care plan review documents are not always being signed and dated as they should for auditing/monitoring purposes. Generally there was good evidence of healthcare input from doctors’, district nurses and others’ for example; chiropody. It was noted however, that at least one resident has not been receiving regular dental checks- it was unclear if she Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 12 had refused these. Weights are monitored regularly and there was evidence to confirm that where a residents’ weight is giving cause for concern then this is reported to their doctor. Tissue viability and nutritional assessment processes are in place. It was noted however, that these are not carried out unless there is a concern preventing the obtaining of a ‘ baseline’ measurement. It was also noted that one resident had gone to hospital following an injury and although this had been reported in accordance with health and safety requirements it had not been reported to the Commission. Positive feedback was obtained about health and personal care from completed resident questionnaires in that twelve residents confirmed that they’ received the care and support they needed’, two felt that they ‘usually’ did. Similarly, Thirteen confirmed that they ‘received the medical support they needed’, one felt that they usually did. Medication systems have improved considerably over the last year. Staff have received medication training, five new staff are commencing on accredited medication training. New secure medication trolleys have been purchased. Good practice was observed concerning medication management in that a Controlled Drug book has been purchased and has been put into use. The senior on duty was very knowledgeable about medications and was helpful and enthusiastic when involved in its assessment. There is a good system for recording in-coming medications. Medications deemed to be high risk are confirmed by two staff before and when administered. Resident photos are attached to their medication record to help ensure medication is administered to the correct person. A number of shortfalls were identified examples being; there was a lack of criteria to inform staff about the administration of ‘ as required’ medication. Although it is being addressed the home has not got a current medication policy in operation. There was a lack of detail on medication records concerning the doctor’s name and allergies. Staff observed during the inspection showed respect to the residents’. It is positive that the home determines and records the preferred form of address for each resident. There was however, no clear records to ascertain if residents’ are asked their preferences regarding opposite gender staff providing their care although, no male staff are presently employed at the home to give this choice. Bathroom and toilet doors were seen to be shut when in use. There was however, a lock missing on a ground floor toilet door. A requirement is outstanding concerning the use of mobile screens in double rooms and the lack of a net curtain at one window in a double room. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The area of ‘ Daily Life and Social Activities’ is assessed as being ‘adequate’. Daily routines and visiting arrangements residents were found to be satisfied with. Activities and methods for meal options however, need further development. EVIDENCE: Residents’ spoken to confirmed that they could choose when they got up and when they went to bed. It is positive in that on two of the three resident files viewed there was evidence to confirm that they had been asked about bath or shower preferences and times. It is also pleasing that an external activities person visits the home once a week to provide activities. However, the feedback from completed resident questionnaires suggests that activity provision is not fully meeting their/everyone’s needs. In response to the question;’ Are there activities arranged by the home that you can take part in?” seven answered ‘sometimes’, four answered ‘usually’ and only three answered ‘always’. Further comments were received concerning activities as follows; “Lacks general stimuli” and “ Can not remember if they take place”. “ There needs to be more activities to improve mobility and more outdoor activities like coach trips”. The home has a ‘visiting and guests’ notice displayed, which includes instruction for visitors’/guests to sign in and out of the home in case of fire. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 14 Residents’ spoken to were satisfied with visiting arrangements. Three residents’ confirmed that they can have visitors when they wanted to and three said that they could receive their visitors in the lounge or their bedroom. During the inspection one relative did in fact visit her mother in her bedroom, others were seen visiting in lounges. One relative spoken to said;” The staff welcome me, they are always pleasant and polite”. Another relative said that she; “visits the home three times a week”. It is positive that information concerning external advocacy services is displayed within the home in the event residents’ wish to access this service/support .It is also positive that there was written notes confirming that those residents who wanted this had been given support to complete their postal voting forms. Residents’ can bring into the home with them their own personal belongings this was confirmed during the random tour of the premises. Items ranged from pictures and ornaments to radios and televisions. One resident had brought into the home with him his own bed. On the inspection day the manager was the ‘cook’ as there is one cook vacancy. The new cook is due to start at the home soon. The manager said;” The meal today will not be as stated on the menu because of the requirements on my time”. She further said that she was going to cook a casserole she knew that the residents’ all liked that. The manager said; “ The residents’ love casseroles, pies and roast meals”. Menus were seen to be available within the home but only in a written printed format. Menus looked interesting and varied with at least three roast meals per week. Sundays offer a choice of two roast meats. The meal of the day looked appetising with good sized portions. The meal consisted of chicken casserole, potatoes and vegetables followed by rice pudding or mint and chocolate chip ice-cream. There was little left on plates after this meal had been eaten. There were differing views/ considerations about the menus and meals in general for instance; the individual meal preference records on residents’ files gave options for cooked breakfast yet a cooked breakfast is only offered on Sunday’s. A comment made by a questionnaire respondent was; “ The home lacks morning and evening choice of meals”. Another comment received was; “ The main meal of the day is lunch. Breakfast is fruit or cereal. Tea soup or sandwiches. No supper”. Ten residents’ answered the question’ Do you like the meals at the home?’ As ‘always’, three ‘usually’ and one’ sometimes’. There were a number of positive comments about the meals as follows; “The food is always good.. does not like sandwiches and they endeavour to provide alternatives”. ”Like the food here –have enough for me. Can have something different if we ask”. “Food is excellent, staff are very, very obliging”. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The area of complaints and protection, in particular protection and reporting requires improvement to prevent risk of harm to residents’ it has therefore been assessed as being ‘poor’. EVIDENCE: The home has a written complaints policy which is on display within the home and is detailed in the service user guide. It however, refers to the former organisation the NCSC rather than the present the CSCI. The complaints policy has been produced in print only which may reduce its meaning to residents’ who have poor eyesight or who are confused. Five complaints have been received by the home in the last 18 months or so which is positive in the sense that it proves that relatives and residents’ are aware of the policy and how to access it. This point is confirmed further by the feedback from completed resident questionnaires in that the majority stated that they did know who to speak to if they were not happy and they know how to make a complaint. One comment was received however, was as follows;” Know can speak to staff, but not able to distinguish who is the senior on duty”. Complaints were seen to have been addressed in the timescale required. One however, was an issue of ‘protection’ not a complaint as such and should have been dealt with by using Dudley MBC Adult Protection reporting mechanisms. It is positive that the majority of staff have received abuse awareness training. Staff spoken to were asked what they would do if an incident of abuse were to occur they said that they would report to the senior, deputy or manager on duty. Concern was identified due to an incident that occurred between two residents as it had not been reported to Dudley MBC or the Commission. This incident occurred on May 2005. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 16 Evidence was not available to demonstrate that the home has clear procedures in place to access if there is an allegation or incident of abuse. The manager did however say that this was being addressed. Similarly, there was no evidence to suggest that staff have read Dudley MBC Adult Protection Procedures. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26. Generally, the home is comfortable and well maintained. Its downfall however, is the size and layout of the laundry giving a potential for cross infection and the lack of dedicated, suitable office and staff room space. The environment has been assessed overall as being ‘adequate’. EVIDENCE: The home has a warm, friendly atmosphere. It has adequate indoor communal space and generous sized attractive gardens to the front and rear. Communal areas comprise of two lounges a dining area and conservatory come dining area. These rooms are attractive and well maintained. The conservatory carpet had been replaced the week of the inspection. The homes’ ‘office’ is the space between the kitchen and the laundry. Although it is positive that lockable facilities are available the area is not suitable for staff supervision or other tasks where non-disturbance and privacy is needed. Similarly, the home does not provide changing facilities for the staff. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 18 The three bedrooms viewed were comfortable and of a good size. They are well maintained in terms of décor and carpets. Lockable facilities/ door locks are not provided although repeated requirements have been made. The laundry is small for the size of the home possibly preventing cross infection. It is positive that it has two sinks, one to use for hand washing purposes. The laundry flooring is in need of re-coating’ Observation of the home showed that it was clean and there were no offensive odours. This confirmed by comments from residents and relatives as follows; “ The home is beautifully clean and tidy”. “ The home is exceptionally clean and fresh. This is one of the reasons I chose it for my mother” There is however, a lack of ‘hand wash’ signs in high risk areas, or where they are provided they are not in a prominent position. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Generally ‘staffing’ issues within the home are well managed in respect of staff numbers, qualifications and training. The major shortfall is that of staff recruitment which has a potential to place residents’ at risk. Due to this factor this section has been assessed as being ‘poor’. EVIDENCE: Generally staffing levels are adequate. Although staffing levels against needs must be monitored. The response to the question “ Are the staff available when you need them?” was answered to as ‘ always’ by 8 of the 14 respondents and ‘usually’ by 6 respondents. Staffing is provided as follows; Am 3 carers and a senior (plus the manager 5 days per week). PM 2 carers and a senior. Night 2 waking care staff. The home generally has a cook everyday. Unfortunately a vacancy exists at the present time which the manager confirmed has been filled. A number of staff have left the home since the last inspection, however it appears that the situation is being dealt with. One senior said;” The new staff that we have are very good”. The home just has one full time care vacancy now which has been advertised. Another aspect that needs to be explored is the resident responses to the question” Do the staff listen and act on what you say?”. 8 responded as “ always”, 6 responded as “ usually”. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 20 51 of the care staff team have achieved N.V.Q level 2 or above in care which is positive. Staff recruitment is concerning. A number of staff employed by POVA first rather than waiting for the full Criminal Record Bureau (CRB) check to be received. Further, although it is positive that the manager has produced risk assessments and has nominated shift ‘supervisors’ for staff who have not got a full CRB these are not being adhered to as the rota confirmed that in a number of instances staff were not on shift with any of their named ‘supervisors’. One of the staff was working on nights which meant that supervision is very limited. There was no evidence available to confirm that the hairdresser has a full CRB as she should. Generally, staff training is being received as it should, new staff are the only ones who are really lacking training and this is being addressed. The home has an overall training matrix. The manager provided documentary evidence of planned training and formal induction packages. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. Management systems within the home require further development, particularly concerning quality assurance. Two health and safety issues require urgent attention. This section management and administration has therefore been assessed as only ‘adequate’. EVIDENCE: The manager who is also a Co-owner has managed the home for the last 19 years. She has recently achieved her N.V.Q level 4 in care and is waiting to commence on the required management component. The manager has day-today involvement with the home and it’s functioning. The manager confirmed that she has secured input from a consultancy company to assist her in the task of implementing a required quality assurance/ monitoring system which is lacking at the present time. The home does however, use a range of satisfaction surveys to gain the views of Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 22 residents’ and relatives. Comments were received alleging that one of the registered owners had displayed ‘rude’ behaviour towards a relative. This conflicts with the principles of ‘ maintaining good relationships ’ and needs resolving. The home holds a considerable number of residents’ money in safekeeping. Three of these were checked balances against amount and were found to be correct. Only two staff at the present time have access to this money. Receipts were available for transactions. It is positive that the hairdresser and chiropodist issue individual receipts to residents’ for their services. The manager was not able to provide an up to date policy concerning the safe keeping of money, but has given an assurance that one will be forwarded to the Commission. The last Environmental Health Inspection was carried out in September 2005 it was pleasing that only one recommendation was made which has been addressed. Assessment of the kitchen revealed that it was clean, with cleaning schedules and records in place. Fridge and freezer temperatures are taken twice daily. It was noted however, that cooked meat temperatures are not always being recorded as they should. Generally health and safety issues are being adhered to. The home has a fire risk assessment in place that has been seen by West Midlands Fire Service. Random assessment of service records showed that the fire alarm system, fire fighting equipment, emergency lighting and hoist services have all been carried out recently. The five year fixed electrical wiring test was carried out in 2003 and was found to be satisfactory. In-house tests of the fire protection systems are carried out as they should be. Concern was raised in that recommendations and a fault was detailed in the passenger lift and gas landlords certificate, it is not clear if these have been dealt with. A further concern was seen in that exposed copper pipe work above the boiler in the conservatory was extremely hot. This requires urgent remedial attention. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 2 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 2 x x x x 2 x 1 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 2 2 3 x 1 Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5(1)(b) Requirement Timescale for action 01/07/06 OP4 2 14(1)(a) The registered persons’ must revise the homes’ contract/terms and conditions document to ensure that no ‘ unfair’ terms are used. It is strongly suggested that the contract/terms and condition document be revised in accordance with The Office of Fair Trading publication;’ Unfair Terms in Care Home Contracts’. The registered persons’ must ask 01/07/06 the following residents’ doctors’ to confirm in writing their primary diagnosis MR. NT. DH. The outcome of this process must be forwarded to the CSCI. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 25 3 OP4 14(1)(a) (d) The registered persons’ must ensure that the residents’ accommodated ( prospective residents’)needs fall within the categories detailed on the homes’ registration certificate. Examples; The one place for dementia should not be allocated to a person with just old age needs. No more than one resident who has dementia as a primary diagnosis can be accommodated at any time. 01/07/06 4 OP7 12(4)(a) (b) 15(1) 5 OP7 15(1) 6 OP7 15(2)(b) 7 OP8 37(1)(c) The registered persons’ must ensure ( where identified as being needed) that the service user plans are reproduced in a format suitable for the service user example; large print. Requirement made and not met since June 2004. The registered persons’ must ensure that there is a risk assessment and care plan in place for all residents’ who behaviours that challenge examples being; verbal/physical aggression. The registered persons’ must ensure that all ‘review and evaluation documents’ are fully completed/ signed and dated. The registered persons’ must inform the CSCI in accordance with Regulation 37 any time that a resident suffers an injury which requires medical/hospital attention. 01/08/06 01/07/06 01/07/06 17/06/06 Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 26 8 OP8 12(1)(a) (b) The registered persons’ must 01/07/06 ensure that all residents’ are offered regular oral screening. Where this is offered and refused this must be recorded. If it is felt that any resident is at particular risk of not being screened then this should be reported to the social worker or discussed at their next review. 9 OP8 12(1)(a) (b)13(4) 10 OP9 13(2) The registered persons’ must ensure that a tissue viability assessment with accompanying documentation is undertaken for all residents at least on admission to gain a ‘baseline’ measurement for future monitoring. The registered persons’ must ensure that the criteria for the administration of ‘ as required’ medication be medically provided and must be recorded. Timescale of 31/01/06 not fully met. 01/07/06 17/06/06 11 OP9 13(2) The registered persons’ must formulate a policy and procedures document for the handling of medicines which describes every aspect of medication handling within the home. Once developed the home must ensure that the staff are fully aware of the contents and adhere to them. A copy of the medication policy/procedures must be forwarded to the CSCI. 30/06/06 Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 27 12 OP9 13(2) 13 OP9 13(2) The registered persons’ must ensure that handwritten changes or entries to medication records are signed, witnessed and dated. The registered persons must ensure that medication records are completed with full details of the resident’s date of birth, doctor and any known allergies. 17/06/06 17/06/06 14 OP10 12(4)(a) 23(2)(b) 15 OP10 12(4)(a) 16(1)(c) The registered persons’ must ensure that a suitable and safe lock is provided on the toilet door- ground floor – that was highlighted during the inspection. The registered persons’ must provide new screening ( as an alternative to the current ‘ mobile’ provision in shared rooms). Timescale of 31/03/06 not met. 10/06/06 01/07/06 16 OP10 12(4)(a) 16(1)(c) The registered persons’ must ask all residents’ residing present and future in the ground floor double bedroom facing the drive if they want a net curtain. If anyone does then this must be provided. Written evidence must be available at all times to demonstrate that this is being done. 01/07/06 Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 28 17 OP12 16(2)(n) (m) 18 OP12 16(2)(n) (m) The registered persons’ must ensure that a programme of / and activities to suit group and individual needs are available at all times to provide required recreational pursuits and stimulation. The registered persons’ must ensure that the leisure goals of each resident are documented in their care plans . Requirement first made June 2004. Not fully met May 2006. The registered persons’ must explore on a regular basis the food requirements/preferences/needs of each resident and provide to meet needs. The registered persons’ must ensure that menus are produced in formats appropriate for the residents’. The registered persons’ must determine and record the milk preferences/needs of each resident – future and new residents’ in terms of taste and nutrition. Where milk other than semi-skimmed UHT milk is required then this must be provided. The registered persons’ must ensure that information posted (concerning complaints procedures) is in an accessible format for service users’. Timescales of 08/05 and 31/01/06 not fully met. The registered persons’ must ensure that the complaints procedure is amended to detail CSCI not NCSC. 01/07/06 17/07/06 19 OP15 16(4) 17/06/06 20 OP15 12(4)(b) 01/07/06 21 OP15 12(2) 16(2(i) 16(4) 17/06/06 22 OP16 22(2) 01/08/06 23 OP16 22(7)(a) 01/07/06 Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 29 24 OP18 13(6) The registered persons’ must devise an in-house policy that reflects the Local Authorities ( Dudley) multi-agency policy on safeguarding adults. This requirement supersedes previous requirement no 13 in inspection report dated 11 January 2006. The registered persons’ must ensure that all incidents of physical aggression between residents’ an example being where any resident is ‘hit’ is reported in accordance with Dudley MBC Adult Protection Proceedings and Regulation 37. 01/08/06 25 OP18 13(6) 17/05/06 26 OP18 13(6) The registered persons’ must ensure that a flow chart ‘ easy reference tool’ is produced concerning allegations or incidence of abuse complete with agency contact names and telephone numbers. All staff must be asked to read the flow chart and Dudley MBC adult protection procedures then sign and date. 17/06/06 Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 30 27 OP18 13(6) 37(1)(d) The registered persons’ must amend the homes’ ‘missing persons’ procedure to ensure that it instructs staff that if an incident occurs it must be reported to the CSCI in accordance with Regulation 37. 17/06/06 28 OP19 23(3)(a) The registered persons’ must 30/06/06 provide a staff room with storage facilities. ( i.e suitable facilities and accommodation, other than sleeping accommodation, including(i) facilities for the purpose of changing. (ii) Storage facilities. Requirement first made August 2002. Not met May 2006 29 OP19 23(2)(a) The registered persons’ must provide an office space for the manager in order to carry out administrative tasks, individual staff supervision, staff disciplinaries in a private and confidential area. Requirement first made August 2002. Not met May 2006 01/08/06 Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 31 30 OP19 23(2)(b) The registered persons ’must refit floorboards in W2 adjacent to bedroom 11 which have become loose under the carpet. Requirement first made August 2002. 01/08/06 31 OP19 23(2)(b) Not met May 2006. The registered persons’ must replace the double-glazed window unit in the conservatory that is compromised and misting up. Requirement first made August 2002. It is very positive to learn that this requirement is at the present time in the process of being addressed. 01/07/06 32 OP24 16(2)(l) The registered persons’ must provide a lockable space in all service users’ bedrooms. Requirement first made August 2002. Not met May 2006. 01/08/06 Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 32 33 OP24 16(2)(c) Sch3 (q) The registered persons’ must ensure that restrictions on residents’ choices are negotiated, included in service user plans and reviewed regularly; decision to not provide bedroom door locks and keys , certain items of furniture, personal care given by opposite gender staff etc. Requirement first made August 2002. 01/08/06 34 OP26 23(2) 13(3) Not fully met May 2006. The registered persons’ must resite and enlarge the laundry area so that it is not in proximity to the kitchen – separate areas for drying and ironing. Requirement first made and not met since August 2002. Not met May 2006. To provide an action plan to CSCI with timescales to meet the timescale set. 01/09/06 35 OP26 13(3) The registered persons’ must ensure that; The sealant around the bath in the ‘pink bathroom’ is replaced. That ‘towelling’ towels are not used in communal bathrooms or toilets unless used for an individual ( then returned to their room afterwards). That ‘ hand wash’ signs are placed in a prominent position in all toilet, bathroom and other high risk areas. 17/05/06 Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 33 36 37 OP26 OP29 13(3) 13(6) 19(4) The registered persons’ must ensure that the laundry floor is re-coated. The registered persons’ must where they make the decision to employ staff without firstly receiving a full enhanced CRB strictly adhere to their risk assessments for example ensuring that they are put on shift with their named supervisors. The registered persons’ must not allow staff members to work on nights unless they have received full clearance for example; a full enhanced CRB. The registered persons’ must ensure that an enhanced Disclosure( through the Criminal Records Bureau ) is obtained prior to staff commencing work at the home. Requirement first made February 2004. Not fully met in May 2006. 01/07/06 17/05/06 38 OP29 13(6) 19(4) 17/05/06 39 OP29 19(4) 17/05/06 40 OP29 13(6) 19(4) 41 OP29 19(4) The registered persons’ must 01/07/06 ensure that the homes’ hairdresser has a full CRB. In the interim a written risk assessment must be carried out. 01/07/06 The registered persons’ must ensure that the commencement date for each staff member employed is clearly detailed on their staff file. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 34 42 OP30 18(1)(c) The registered persons’ must provide staff with the following training; Dementia awareness. Palliative care awareness. Requirement first made February 2004. Not Met May 2006. 01/08/06 43 OP33 12(5)(a) 44 OP33 24 The registered persons’ must both ensure that good relationships are maintained at all times between themselves and relatives. The registered persons’ must establish an effective quality assurance system. Requirement first made August 2002. Not met May 2006. 01/06/06 01/08/06 45 OP33 12(5)(a) 24 The registered persons’ must ensure that regular resident meetings are held to discuss issues such as activities and meals. 01/08/06 Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 35 46 OP34 25(1)(2) Sch 4 The registered persons’ must ensure that a business plan is held at the home and is available for inspection. Requirement first made August 2002. 01/07/06 47 OP35 16(2(l) 17(2Sch 4(9) No business plan was available at the home in May 2006. The manager must ensure that 01/08/06 the policy in respect of the management of residents’ finances is reviewed and updated to cover storage, access, receipts, checking and verifying prior to recording. Requirement first made February 2005. Not met May 2005. A copy of this document must be forwarded to the CSCI by the set timescale. 48 OP35 17(2) 49 OP38 13(4) The registered persons’ must ensure that residents’ property lists are signed and dated by the resident and a home representative. The registered persons’ must ensure that the hot pipe work above the boiler in the conservatory is suitably and permanently guarded. In the interim period suitable, safe, lagging must be used to prevent the possibility of burning to residents’ or other persons’ within the care home. An immediate requirement and serious concern letter have been issued to this effect. 17/06/06 22/05/06 Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 36 50 OP38 13(4) 23(2)(c) The registered persons must seek written clarification from the lift service company and the gas engineer that ‘faults’ ‘recommendations’ detailed on their reports have been satisfactorily addressed. Written documents to evidence this must be forwarded to the CSCI. 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP9 Good Practice Recommendations It is recommended that a Controlled Drugs cabinet is obtained and securely fixed to a solid wall using rag bolts. It is recommended that carried forward balances – where the situation is ‘ non-supplied this month’ occurs on medication records. Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 37 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Woodlands DS0000024980.V292918.R01.S.doc Version 5.1 Page 38 - 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. 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