Inspection on 23/01/07 for Woodlands

This inspection was carried out on 23rd January 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

Woodlands 24/01/06

Woodlands 07/07/05

Woodlands 13/12/04

Woodlands 01/07/04

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 Woodlands Grimston Road Kings Lynn Norfolk PE30 3HH Lead Inspector Mrs Jacky Vugler Key Unannounced 23rd January 2007 09:50 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 DS0000034240.V328512.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 DS0000034240.V328512.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Address Woodlands Grimston Road Kings Lynn Norfolk PE30 3HH 01553 672076 01553 670744 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) www.norfolk.gov.uk Norfolk County Council-Community Care Carole Ann Heley Care Home 40 Category(ies) of Dementia (13), Old age, not falling within any registration, with number other category (27) of places Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home can accommodate up to 27 Service Users who are Older People not falling in any other category. The home can accommodate up to 13 Service Users who are elderly and have dementia. The home is to accommodate up to 40 Older People. Date of last inspection 24th January 2006 Brief Description of the Service: The home is a two-storey care home that is owned and managed by Norfolk County Council and is situated in South Wootton on the outskirts of Kings Lynn. It is set beside Crossroads, a large day centre for older people, which is also owned by Norfolk County Council. The home is within easy reach of Kings Lynn and is on a bus route that serves the South Wootton area from the town centre. Nearby are local shops and other facilities, for example, a post office and public house. The home was first built in 1963 as a residential home for older people. In 1998 an extensive refurbishment programme was completed. As part of this programme a 13-bedded unit for the elderly mentally frail was developed within the home, known as the Heather Unit. There are lounges and reception rooms for service users in the main building offering a facility for quiet space or company and activity. There is a large dining room, which serves the twenty-seven service users in the main unit. Heather unit has its own dining room and lounge. The home offers both permanent and short-term care as well as two places for day-care. The home has thirty-nine single bedrooms and one double room on the ground and first floors, although these are all used as single rooms. There is a passenger lift and a stair lift. The home has a ramp to the front entrance, which provides good access for wheelchair users. There are large grounds to the front and the rear and there is a secure garden area for service users from Heather Unit The current fees as stated in the pre-inspection information January 2007 are Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 Page 5 368.72 a week. In addition, residents are expected to pay for hairdressing at £5 - £15, Chiropody at £10 - £15, some activities, newspapers, magazines, toiletries, clothes and sweets at varying costs. Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection taking place over nine hours on a weekday. Mrs Carole Heley, the Manager, was present throughout the inspection. Thirty-five residents were accommodated on the day, twenty-three in the main unit and twelve in Heather unit. Many records were viewed and a tour of the building was undertaken. Seven residents were spoke to, one privately, three members of staff in the Heather unit and three in the main unit were spoken to. Twelve comment cards were received from relatives and friends and three from GPs. All indicated a high level of satisfaction with the care provided. However, one relative said that she would expect introduction literature. Many areas of good practice have been highlighted throughout the report. What the service does well: What has improved since the last inspection? The care plans have been upgraded to a new format and are very well completed, giving sufficient information to staff regarding the residents personal and healthcare needs. Medication practices have improved since the last inspection and there are many areas of good practice. Each resident using external preparations now has a locked box in their room for storing these and the relevant records. Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 Page 7 A programme of redecoration is being undertaken and the wheelchair scuffs in the main unit have been repaired and redecorated, although there is still work to do in the Heather unit, and the whole home would benefit from some redecoration. The draughty windows have had the layers of old paint scraped off and been repainted, thus making many of them easier to close. However, some still remain difficult to close and draughty, causing some discomfort and loss of independence to the residents concerned. The Manager said that twenty locks have been changed on bedside cabinets to enable safe storage for resident valuables. On the day of inspection electronic door closures were being fitted to bedrooms doors so that those who wish to may safely leave their bedroom door open. 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. The summary of this inspection report can be made available in other formats on request. Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 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 DS0000034240.V328512.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about where to live. No resident moves into the home without having his or her needs assessed and being assured that these needs will be met. Prospective residents and their families or representatives have the opportunity to visit the home to assess its suitability. The home does not provide intermediate care. EVIDENCE: The manager said that prior to admission information about the home is given to the prospective resident or their family and this was confirmed by those Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 Page 10 spoken to. The statement of purpose and service users guide were displayed in the lobby and the reception areas, as well as six copies on a table for people to help themselves to. All residents are given a welcome pack, which includes the above, the complaints procedure, How are we Doing? and a residents agreement. A returned questionnaire from the relative of a new resident said she would expect introduction literature………. The manager or a care co-ordinator visits the prospective resident wherever they are and conducts an assessment so they can be sure they can meet this persons needs. Assessments were also seen to be in place from the social workers and these written assessments then form the basis of the care plan. Prospective residents and their families or representatives are encouraged to look around the home whenever they want to. Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents health, personal and social care needs are set out very clearly in an individual plan of care, which is regularly reviewed. The residents health care needs are fully met. Residents are protected by the homes policies and procedures for dealing with medicines and some good practices are in place. Residents feel they are treated with respect and their right to privacy is upheld. EVIDENCE: All care plans have now been upgraded to the new format and in the front of each care plan folder is a list of all residents and their key workers, instructions for writing care plans and reviews, the role of the key worker, Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 Page 12 contact sheets and a record of any medical contacts. This is good practice as it is very helpful to the staff. Two care plans were looked at in detail and six others generally. The care plans are clear and comprehensive and based on the pre-admission assessment of the resident. They include a photograph and description of the resident, a good social history, details of health and personal care needs and a night care plan. Personal preferences are recorded, for example, bathing, food, what help is needed, in one case, to cut food up, activities. A record is also kept of the residents individual objectives and another, of discussion between the resident and key worker about his or her care. All these records were seen to be signed by the resident and regularly reviewed. A falls assessment and a Malnutrition Universal Screening Tool was completed in each care plan viewed. Risk assessments are in place where necessary and these are regularly reviewed. Visits from other healthcare professionals are recorded in the care plans. Residents are able to choose their GP from five surgeries, providing they have a vacancy. Some residents use their own dentist, opticians and chiropodist, whilst others visit an outside practice or use those that visit the home. The dietician visits when necessary and the District Nurses regularly visit and give advice regarding skin care. From observation and conversations with residents it is evident that the staff treat the residents with respect and that they are mindful of their privacy and dignity. The home uses the Norfolk County Council policies and procedures for medication. The medication administration records are well recorded and the codes are used appropriately with a clear explanation where necessary. This is good practice. The home currently uses a monitored dosage system for storing medications and those not in the cassettes are counted in with a brought forward figure to aid the auditing process. This is also good practice. A separate record is kept for external preparations and this is kept in the residents room with the preparations in a locked facility. Each resident has an individual homely remedies list, which has a space for not allowed to have. No residents currently wish to self medicate. All the controlled drugs were correct and appropriately recorded. The room an fridge temperatures are recorded daily. Regular audits take place and these include medications to be taken when necessary and liquid medicines. Weekly audits observing staff administering medicines also take place. This is good practice. Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The comprehensive programme of activities both within and outside the home provides the residents with varied interests. Residents are able to maintain ties with the local community and visitors are encouraged and made welcome at the home. Residents are able to exercise choice and control over their lives. Residents have a varied choice of nutritious food which they eat in a pleasant dining room. EVIDENCE: The home provides two carers who are dedicated to organising and conducting various activities and outings, and one attends the residents meetings. Each resident has a photograph in a profile which is dedicated to their preferences, interests and hobbies, likes and dislikes, personality, family and important values and beliefs. It contains details and comments on activities undertaken including trips out and is signed by the resident. Activities include one to one sessions, for example, hair and manicures and group activities, for example, Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 Page 14 darts, Bingo. Carpet bowls. The many outings are open to all residents and these include Thursford, pantomime, drives to the coast and in the warmer months these are almost daily. Some residents had been taken back to where they used to live for a look around. A blackboard in the reception area highlights the activities for that day. A reminiscence book is in use which indicates the topic discussed and those attended. There are three other folders in the reception area for people to view. One is for trips out, one for events held and the other for activities held. All contain photographs, who attended and comments made, also included are thank you letters and cards regarding activities, from residents and their families. In the Heather unit the activities are ongoing with the staff as seen on the day and the name plates on the bedroom doors were decorated by the residents. The home operates an open visiting policy and visitors were seen to come and go during the day, one resident said, we can see visitors where we like. Some residents like to attend their local church and some enjoy the in-house Communion. Schools sometimes visit for a concert and some residents like to go to the school for Harvest Festival and Carols. The activities organisers take residents to their appointments, for example, to the opticians or to their hairdressers and this is commended. From observation and conversations with residents it was evident that they are able to exercise choice and control over their lives. They spoke of being able to get up and go to bed when they liked, choosing their own clothes, whether or not to take part in the activity or outing being offered. A good variety of nutritious meals are offered with a choice, which was confirmed by the residents. One resident said, the food is lovely, there is a choice and you can have as much as you want. The meals are taken in a pleasant dining room and seemed to be unrushed. Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 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. 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. Residents are confident that there complaints will be taken seriously and acted upon. Residents are protected from abuse. EVIDENCE: There is a clear complaints procedure and every resident and their family or representative receive a copy in their welcome pack on admission to the home. All the residents spoken with said they would complain if the need arose and were clear about how to do this. The majority of comment cards received from relatives indicated they were aware of the complaints procedure. Complaints were recorded on individual sheets and all were appropriately dealt with. The action taken and the outcome of the investigation were recorded. All criminal record bureau checks were seen for staff except one who has been on long term sick, and on her recent return to work was missed. The Residential Services Manager is aware, a risk assessment has been completed and the member of staff does not currently work in Heather unit. Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 Page 16 Since the last inspection an allegation of verbal abuse has been made against a member of staff, who was immediately suspended. All the correct procedures were followed and investigations are still ongoing. All staff have received training in abuse awareness as part of their induction, and from an outside agency. This was verified by those spoken to and the files seen confirmed that it is regularly updated. Staff spoken to were aware of the whistle-blowing procedure and all felt able to report any suspicions of abuse if necessary. Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The main unit is safe and well maintained, however, the Heather unit needs some repair to doorways. Residents in the main unit have access to safe and comfortable indoor and outdoor facilities, and the residents in the Heather unit have access to a safe garden, however, the communal space indoors needs to be made larger. Bedrooms in both units were personalised with the residents own possessions. However, some residents have their independence and comfort compromised by windows which are difficult to close and ill fitting. The home is clean, pleasant and hygienic. EVIDENCE: Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 Page 18 The home is very pleasant, clean and hygienic. The reception area is welcoming and displays photographs of the staff and lots of information about the home with copies of the service users guide available for visitors to take. There are three activities folders which are able to be viewed and an ideas/complaints box on a table. There is an aquarium and in a small recess where there used to be seating, there is now a half size snooker table, which the Manager said some residents enjoy. There are several sitting areas in the main unit and the dining room overlooks an attractive courtyard with a water feature and potted plants. In addition there is an activities room a hairdressing room and a training room for staff. The residents rooms are personalised with soft toys, ornaments, photographs and one displayed lots of tapestries. The bedroom door plates showed the room number, name and a photograph of the resident. On the day of inspection automatic door closures were being fitted. A passenger lift or a stair lift were available for access to the first floor. Although the home does not employ a handyman, they have borrowed one from another home and in the main unit most of the wheel chair scuffs have been repaired and redecorated. However, it is recommended that the décor continues to be upgraded. The Manager said that a representative from Norfolk Property Service would be visiting the home on 29th January to plan redecoration. The Heather unit was clean tidy and odour free. The residents had helped to make their door plates which were personalised, for example, one resident used to be a pilot and pictures of planes were on his door. The bathroom and toilets had pictorial signs and were nicely decorated. There is a large, enclosed garden with a summer house for the residents in this unit. There is some damage to the door frame to the linen room and there are also wheelchair scuffs which need repairing. Recommendation. As mentioned in previous reports, the communal space is this unit is very limited for thirteen residents, three staff and visitors. The Manager said that plans are currently being discussed to increase this space, but work has not yet started. This requirement is repeated. The two wings at the back of the home have UPVC windows, however the old metal style windows remain in the rest of the home. Manager said that in general the windows have improved as work has been completed which rubbed off all the excess paint on the hinges before repainting them. This has meant that some of the windows now close well and are draught free, however, there do remain some windows which are difficult for the residents to close independently and some of these are draughty. In 2005 it was agreed that the provider was mindful of the need for the unsuitable windows to be replace, however, we still have not received a plan. This requirement is repeated. Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 Page 19 The residents said it is very nice to live here, its nice and clean. A returned questionnaire from a relative said that more could be done with the gardens although they had improved a bit recently. Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 Page 20 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): 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. Residents needs are met by the numbers and skill mix of staff and residents are in safe hands at all times. Residents are protected by the homes recruitment practices. Staff are trained and competent to do their jobs. EVIDENCE: On the day of inspection twenty-three residents were accommodated in the main unit and twelve in Heather unit. A care co-ordinator works from 6.45 am until 9.45 pm with an hours overlap at lunchtime for a handover. Three carers work in the main unit throughout the day and two work at night. Three carers work in the Heather unit throughout the day and one at night. These numbers usually include a senior carer. In addition, another carer is employed as a relief to cover sickness and holidays and two carers are employed part-time to organise and conduct activities and this is good practice. The majority of questionnaires returned by relatives and visitors indicated that these staffing levels were satisfactory. The Manager regularly monitors the Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 Page 21 residents dependency levels and this was seen for January 2007. The staff did not seem rushed and those in Heather unit were sitting with the residents. Comments from residents included, staff are excellent…………they come quickly at night, staff are respectful, we have a laugh, staff do the little things I want. Three care co-ordinators have achieved the NVQ level 3 and three senior care assistants are currently undertaking it. A further sixteen carers have achieved NVQ level 2. This equates to 57 of carers having achieved NVQ level 2 or above. The home follows the Norfolk County Council policies and procedures for the recruitment of staff. Two staff files were looked at in detail and others were viewed more generally. All were seen to have the relevant documents in place, including the criminal records bureau disclosure. The training opportunities at this home are good. Each member of staff has an Evidence of Learning file, which contains evidence of training undertaken including induction and mandatory training. Other training undertaken includes, vulnerable adults at risk, dementia, falls, effective communication, risk management, medication management, diversity and rights and many more. All staff have completed training for the Malnutrition Universal Screening Tool and all those working in Heather unit have completed training in dementia. Questionnaires and certificates were seen where necessary. Staff said that training opportunities are good, the people in the office keep a list and make sure the training is kept up to date. Woodlands DS0000034240.V328512.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): 31, 32, 33, 35 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a well run home, which is managed by a person who is experienced and qualified, and able to discharge her responsibilities fully. The home is run in the best interests of its residents. Residents financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: Woodlands DS0000034240.V328512.R01.S.doc Version 5.2 Page 23 Mrs Heley has been the Manager at Woodlands for thirteen years and holds the CSS and PQS certificates in addition to the Registered Managers Award and the NVQ assessor’s award. She has also completed many training courses to update her knowledge and skills. From observation and conversations with residents and staff it is evident that this home is run in an open and inclusive manner. Staff said that the Manager is fair, approachable and supportive. The Commission has received responses to recent quality assurance questionnaires sent by the home to staff, residents, relatives and friends. They showed the questions asked with a percentage score, an analysis and an action plan to address the areas which scored lower. Overall the results showed a good level of satisfaction of the service provided. Monthly audits are also carried out in order to monitor the quality of the service provided. These include, medications, care plans, health and safety, the building and Legionella. Regular staff meetings are held and the minutes are displayed in the staff room. Regular residents meeting are held and this was confirmed by those spoken to. The financial records for the residents were appropriately recorded and the latest monthly audit was seen. They recorded the income and expenditure and the receipts were kept and numbered. The monies for fifteen residents were checked and found to be correct. A number of health and safety records were viewed including the fire records, service certificates for the passenger lift and the various hoists. A monthly audit of the building is undertaken in addition to monthly safety inspection forms. The accident records were well completed and included the action taken and outcome. Woodlands DS0000034240.V328512.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 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 8 9 10 11 2 2 x x x 2 X 3 4 3 3 3 x STAFFING Standard No Score 27 3 28 3 29 3 30 4 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 4 x 3 x x 3 Woodlands DS0000034240.V328512.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 OP20 Regulation 23(2)(h) Requirement The Registered Person should submit to the Commission a plan to ensure that the communal space provided for residents in the Heather Unit is extended to give choice to residents appropriate to their circumstances. The Registered Person must submit to the Commission a more detailed plan for replacing the windows causing the most discomfort. Timescale for action 30/04/07 2. OP24 23 (2) 30/04/07 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 OP19 Good Practice Recommendations It is recommended that the current work continues to repair wheelchair damage in the Heather unit and redecoration where necessary throughout the home. DS0000034240.V328512.R01.S.doc Version 5.2 Page 26 Woodlands Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Woodlands DS0000034240.V328512.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. 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