Inspection on 02/10/06 for Woodlands

This inspection was carried out on 2nd October 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.

Other inspections for this house

Woodlands 23/12/09

Woodlands 30/06/09

Woodlands 07/08/08

Woodlands 14/08/07

Woodlands 08/12/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Woodlands 50 High Street Earith, Huntingdon Cambridgeshire PE28 3PP Lead Inspector Dragan Cvejic 2 nd Unannounced Inspection October 2006 11:30 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 DS0000065969.V296022.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. Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Address 50 High Street Earith, Huntingdon Cambridgeshire PE28 3PP 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) 01487 841404 F/P 01487 841404 Farrington Care Homes Ltd Mrs Pamela Ellis Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (24) of places Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: Woodlands provides care accommodation and support for up to 24 older people, some of who have a degree of confusion or a form of dementia. The home is situated in the village of Earith, which is approximately 6 miles from the market town of St. Ives; from the rear of the home are good views across the River Great Ouse. Since the last inspection the previous owner has sold the home. The new provider is Farrington Care Homes Ltd; the registered manager remains in post. Residents’ accommodation is on two floors, the upper floor being accessed via a shaft lift. The home has 18 single, and 3 double rooms. 16 of the single rooms have en-suite toilets, and 4 rooms also have baths, though these are not currently used by the occupants, as they do not have the hoists or other equipment to allow access to people with reduced mobility. There are 4 toilets, one specialist bath, and a level access shower. Communal areas include 2 lounges, a dining area, and a large conservatory, all of which are available for residents’ use. A pleasant garden area leading down to the river is provided outside. Residents are supported by a team of care staff; the premises are looked after by domiciliary staff and a maintenance person. Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out during the afternoon hours. Most service users were present during lunchtime and met the inspector. Five service users spoke to the inspector about their experience of living in the home. Two service users were chosen for case tracking and their care was focused on. A tour of the building included visiting almost all users’ bedrooms, apart from one that was locked by the user. The home kept two folders for each individual user, and folders for two service users were inspected. Two staff files were inspected and two staff commented on their work, in addition to the information provided by the manager. The new policies manual, introduced by the new proprietors was also inspected. Some of the home’s records were inspected and the results are recorded in the appropriate standards’ group within this report. What the service does well: What has improved since the last inspection? Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 6 The home had responded to some requirements from the previous inspection. The new proprietors prepared and introduced two folders containing new policies and procedures, suggesting different formats for various documents. The statement of purpose and User’s guide were updated with details of the new provider. The complaint procedure was adapted to show the changes. Training was better organised and the staff were, now trained on the Protection of Vulnerable Adults (POVA), on dementia and on mandatory subjects that were due for renewal. The training plan covered mandatory training due at the time of the site visit. New recruitment procedure included improved application forms and the procedure for checking criminal records, references, identification documents and other documents as required by the standards. A new supervision programme was introduced that ensured that staff received a minimum of 6 supervisions a year. The home started collecting users and their relatives’ views on the quality of the service in order to introduce a quality assurance programme. Self closing devices were installed on the doors to improve fire protection within the home and a maintenance man was checking the doors and fittings for improved safety of service users. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodlands DS0000065969.V296022.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 Woodlands DS0000065969.V296022.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): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users could choose the home from information provided to them, from trial visits and from discussion with staff and were reassured that their needs would be met. EVIDENCE: The new provider updated policies and procedures, including the Statement of Purpose and Service user’s Guide to accurately present information about the home. However, the staff in the home still worked on the principle of explaining the home’s provisions verbally; in direct contact with potential users and their relatives, or during the respite stay of service users. This method was still effective for the home, vacancies were filled and users could choose the home. This method worked well in the current market situation, where demand for residential places in the area was relatively high. Many service users were referred to the home by families moving to the region who wanted to have their older relatives close by. The assessment process was carried out by two main methods: one, when the manager visited potential users in their home, and the other when user was Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 9 invited to visit the home and to spend at least one full day in the home, allowing staff to carry out their assessment. The form used for the assessment covered all basic needs. The home also consulted relatives about the appropriateness of the placement for a particular individual. However, the risk assessment did not include all potential risks. It concentrated on moving and handling and on mobility related risks. The staff were aware that with the new format of care plans and users’ records, the expanded risk assessment would need to be carried out. New contracts were produced when the ownership changed and both checked files had appropriate contracts and terms and conditions. Once in the home, users’ needs were met. Five service users spoken to stated that staff were very good, responsive, respectful and helped them with all their needs. Woodlands DS0000065969.V296022.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Despite the fact that standards were almost met and would justify an adequate level, the outcomes to service users determined the judgement as good. The home was in the process of transferring users’ details on the new format of care plans. However, the practical care offered to service users was good. EVIDENCE: The existing care plans did not contain all relevant details. Diabetes of one of the case tracked users was not accurately recorded in his care plan, but all staff spoken to knew of his conditions. The existing care plans were not signed by users or their representatives and did not have evidence of users’ involvement in the care planning process. The new owners suggested use of a different format to record care plans. This format required much more detail than the existing plan. The manager envisaged that the home needed approximately 3 months to transfer and establish new care plans for all service users. Risk assessments contained risks associated with the mobility assessment, but did not cover other potential risks that service users were exposed to, such as Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 11 these associated with diabetes, road safety, drinking and alcohol related issues, or other vulnerability resulting from individual users’ conditions. Medication was administered from the boxes and recorded on hand written MAR sheets. This system is considered to be out of date and the pharmacy arrangements now-days include blister packed medication, or, at least use of dose boxes, and MAR sheets need to be either printed or with labelled instructions for administration purposes. The home was in the process of negotiating the modernised way, but for the time being, they ensured that hand written instructions were signed by a GP, they accurately recorded receipts and returns of medication, they kept records of balances for each prescribed medication and ensured the safety of service users. Controlled drugs were recorded according to the requirements, with two signatures for each administration. The deputy manager, responsible for medication issues, was considering obtaining the list of all controlled drugs to ensure that appropriate procedures were followed for each prescribed controlled drug used in the home. Medication records of case tracked service users and two others that were prescribed controlled drugs were inspected and records were appropriate. The lunchtime was observed and service users were treated with respect. The laundry procedure and tidiness of users’ clothes also demonstrated respect and the home’s efforts to promote users’ dignity. A payphone was positioned in a corridor, ensuring better privacy than in the lounges. There were three shared rooms. The home provided screening, but service users chose not to use it in two rooms, while the third room had a built in screening wall. Staff were particularly careful not to compromise on the privacy of users sharing rooms. Woodlands DS0000065969.V296022.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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users benefited from the locality of the home in a small village where activities, community contacts, and a friendly atmosphere in the home were contributing to the users’ complete satisfaction with the organisation of day to day life. The outcomes of this group of standards exceeded minimum standards. EVIDENCE: A service user stated: “I like reading, so I can use the library service when I want, but I get most books from staff.” Another service user sat by the river, at the bottom of the garden and commented how her life had meaning again, since moving into this home. She mentioned about her favourite activities: sewing, knitting, reading, feeding ducks in the river and generally enjoying the similarities with her farm life background. Several service users were visiting the pub next door to the home. All service users took part in a day’s event in the Marina, to the other side of the home. The owner of the Marina invited the entire home to tea and cakes and all service users went. They used the opportunity and enjoyed a boat trip on the river. Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 13 A service user was also going to the Garden centre and the manager was in the process of referring her to a nearby Day-centre. She stated that she had been to the local shop the day before. Autonomy and choice were affected by users’ abilities to do things independently. Although independence was partly promoted within the home, the attitude to protect service users by having the staff present at most of their activities did not directly demonstrate how independence was promoted. This fact affected records rather than outcomes of this standard. The manager stated that service users could have the room keys if they ask for them, but the key was not routinely offered to service users. Not all bedrooms had a lock, but the bedroom of a service user who wanted to keep her room locked was locked during the site visit. A service user stated that her son was handling her money, but that she could ask staff for it if she needed and would get it form the home. The local school regularly invited the service users to join the events organised in the school. Woodlands DS0000065969.V296022.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had improved their complaints procedure and continued providing effective protection procedure for service users. EVIDENCE: The new proprietors introduced a new complaints procedure that was clear: with a time scale and with information about the potential recipients of the phased complaints. Three service users stated that they would know how to complain if they wished. The home reacted to an allegation and the company arranged a full investigation of the allegation, concluding that the allegation was not substantiated. However, carrying out the procedure, while the alleged staff member was suspended, demonstrated the company’s determination to fully protect service users. All staff but one were trained on Protection of Vulnerable Adults. (POVA). The home’s policy was to encourage service users to arrange for either family members or external professionals to help them with their finances. Woodlands DS0000065969.V296022.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): 19,20,21,22,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was suitable for service users conditions and provided a pleasant and safe environment where they could exercise their independence and autonomy in a supported atmosphere. EVIDENCE: The home was nicely located in the high street in the village and on the banks of the river. This location was very attractive to service users who benefited from the calm, relatively quiet location, but still within easy access to the local community amenities. The well-maintained, beautifully landscaped garden was improved by installing a wooden fence protecting the service users from the potential risk of falling at the bottom of the garden. The maintenance man was dealing with all reported faults within the home, when they were reported by staff. Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 16 However, the fire door adjustment lasted only for a certain period of time and the doors needed readjustment. Two fire doors did not close properly on the day of the site visit. The tour of the premises took place and demonstrated that the standards that were met previously remained met, unchanged. The home was clean and infection control measures were in place. Staff used protective equipment. The manager stated and two service users confirmed that they preferred the bath to the shower. The home provided both facilities. Service users’ rooms were individualised with their private pieces of furniture and with ornaments and pictures they brought in. Some bedrooms had locks and the manager stated that locks would be installed on requirement from service users or their families. Radiators were covered by appropriate guards, protecting service users. However, the hot water taps delivered water above the safe range of temperatures. The company had obtained quotes for the mixing valves in order to install them to respond to the requirement set on the previous inspection. Woodlands DS0000065969.V296022.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team were competent, skilled and experienced, and were able to meet the needs of service users. EVIDENCE: Three staff members were working the morning shift, with the manager and the deputy present in the home. The afternoon shifts were also covered by 3 care staff and the home engaged an extra staff member between 2pm and 6pm to talk with service users in order to meet their social needs. The home was recruiting to fill the post for one senior staff for weekends. Two service users stated that the staff responded appropriately to their needs and that they felt that there were enough staff per shift and that they were well trained, knowledgeable and caring. The home employed carers, domestic staff and a maintenance man. Regular visits by the responsible individual, an area manager from the company, also was seen as an extra support, by manager, by the staff and even by service users. The home and the company promoted NVQ training, but the total percentage of trained staff was below the required 50 , at around 25 . Recruitment was carried out appropriately, according the new proprietor’s policy. This included checking CRB and POVA disclosures before staff could start working unsupervised in the home. All checked files contained CRB certificates. Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 18 Some staff files did not have two references, but all new staff had two references in their files. Staff training was also improved since the last inspection. All staff attended POVA training. The manager and the deputy had their certificates displayed in the hall. Fifteen staff attended training on Dementia. The mandatory subjects were closely monitored so that refresher training was organised appropriately, on time and ensured staff kept their knowledge up to date. New proprietors had also introduced a new induction check list that replaced the old induction training book. Woodlands DS0000065969.V296022.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): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The safety of service users was ensured, but there was an evidenced lack of appropriately kept records and planned improvements to respond to future challenges. The change of ownership initiated positive changes within the home that were just introduced and needed time to show positive effects on the outcomes for service users. EVIDENCE: The manager had 20 years experience and managed the home successfully. Her style contained elements of older community care principles, whereby the service users were accompanied when going out, for better safety, but the written risk assessments did not address what kind of risks would they be exposed to if allowed to leave the home unaccompanied. However, several Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 20 service users enjoyed this extra safety support and pampering where promoting independence was limited by the specific environment, internally within the home, or in other very safe environments such as day centres and similar. The friendly attitude of staff minimised the effects of limited independence and service users did not object being supervised most of the time. Another element illustrating these principle could be seen in home’s practical arrangements for daily life, where service users were offered a healthy and nutritious diet with a choice between two main courses. The cook knew some users’ dislikes and respected those when preparing and planning the meals. However, the challenge of innovative thinking and stimulated ideas for service users was not widely promoted. The home was a nice place for service users that wanted extra attention. The home started work on quality assurance. The questionnaires from families were distributed in June and a few comments were returned. However, the quality assurance programme needed further development and implementation. The new owners had also introduced new policies and procedures that would need to be reviewed within the home as a part of the quality assurance programme. At the time of site visits there were no published results from any quality assurance review, but this new initiative and questionnaire demonstrated that this aspect for monitoring quality was given serious thought. The home did not keep service users’ money. These needs were mainly referred to families and external organisations and professionals. The programme for staff supervision was now set and started rolling, ensuring that staff receive at least six supervisions per year. Staff spoken to confirmed that they felt very well supported, listened to and respected. Record were not up to date and many records were insufficient; and in many cases were just brief comments without records of planned or implemented action. Many records were missing users’ signatures and there was no evidence that users were involved, or consulted about records kept on them. With the introduction of new policies and procedures, safe working practices were also improved. The new induction programme was an example. The planned training programme that included specialist training subjects, such as dementia, diabetes or other training related to users’ conditions, had started taking place. This demonstrated how the home was moving towards new principles of care and started implementing modernisation in care practices. Current working practices protected service users. An example was the action on the requirement to regulate hot water temperatures, whereby now all taps, including those in service users’ bedrooms, were included in a quote for fixing mixing valves. Another example was a sloping wall in a corridor that was a feature of the building, but was considered to be included in generic risk assessment, as it could realistically present a risk. The planned check and maintenance of fire doors, as addressed previously, was the best response to the ongoing problem with doors not closing fully. The doors were adjusted when requested, but after a few months the problems re- Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 21 occurred. The response to check them on a regular basis was the appropriate action in current circumstances. Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 X 3 1 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 1 2 Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 23 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 OP19 OP38 Regulation 23 Requirement Timescale for action 15/12/06 2 OP25 13,16,23 3 OP28 18 The fire doors referred to must be adjusted so that they close properly on their intumescent strips. This was a requirement set on the previous inspection with the time scale set for 31/12/05. Despite the maintenance work done, the site visit identified two of these doors not to close appropriately again and the home must devise a check up programme with clearly identified periodical routine based deadlines, and address this issue in their generic risk assessment. While waiting for the work on hot 20/11/06 water mixing valves, the home must carry out a risk assessment and introduce measures to minimise the risk to which service users are exposed. The company and the home 01/02/07 must further promote and emphasise the importance of the NVQ training and arrange further enrolments to ensure that 50 of staff are NVQ trained. DS0000065969.V296022.R01.S.doc Version 5.2 Woodlands Page 24 4 OP33 24 The home must put in place 31/12/06 effective quality assurance and monitoring systems based on seeking the views of service users. This was a requirement resulting from the last inspection; failure to comply with this requirement may result in further action being taken against the service. This was a requirement set previously with a deadline of 28/02/06. The home now must ensure that the initiated survey and review are completed, analysed and acted upon, creating a successful resource for quality assurance review. This step was given a new deadline to ensure continuous development of the required quality assurance programme. The records kept in the home must be developed and set as planned, with the elements to demonstrate users involvement and access. Once set the records must be kept up to date by introduction of regular and recorded reviews. The fire doors referred to must be adjusted to that they close properly on their intumescent strips. This was requirement set previously and was responded to by the set deadline of 31/12/05. However, as the problem reoccurred, the new requirement relates to a planned effective maintenance programme that would require action prior to the problem re-occurring. 31/12/06 5 OP37 17 6 OP38 4(c)(i) 31/12/06 Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 25 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 OP7 OP7 Good Practice Recommendations The home should transfer information about individuals onto the new format for care plans that contain all necessary sections to cover all care needs. The home should expand the risk assessment to cover all potential risks to service users and not only those related to mobility. These should be recorded when new the care plan format is established. The home should consider modernising medication procedures and start using pre-packed medication and printed sheets for recording the administering of medication. The home should clearly identify medication classified as controlled drugs and establish an appropriate recording system for this specific group of medication. The home should ensure that service users possessions brought into the home are properly recorded and signed by service users or their representatives and include pieces of furniture etc in addition to valuables and money that are already recorded. 3 OP9 4 5 OP9 OP14 Woodlands DS0000065969.V296022.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 DS0000065969.V296022.R01.S.doc Version 5.2 Page 27 - 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!