Inspection on 26/08/05 for Woodlands

This inspection was carried out on 26th August 2005.

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 17/05/06

Woodlands 11/01/06

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 Debbie Sharman Unannounced 26 August 2005 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 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 E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodlands Address 66 Bridle Road, Stourbridge, West Midlands DY8 4QE 01384 394851 01384 394851 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Siobhan Shroff Mr John Wall Davies Mrs Siobhan Shroff Care Home 19 Category(ies) of OP Old Age (19) registration, with number of places Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2005 Brief Description of the Service: Woodlands consists of two converted detached properties, (known as woodlands 1 & 2) which are adjoined by a conservatory. The care home 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 easily accessed by local public transport. The Home has a small drive way and car parking facilities off road. There is a large wellmaintained gardens situated to the front and rear of the property. There are ramps for access to the Home and garden area. The Home was initially registered in 1986 by the current owners and provides care for nineteen older persons, one of whom may have a mental illness. Service user accommodation is on the first and ground floor. The Home has a shaft lift for access to the first floor in Woodlands 1. There are fifteen single bedrooms and two double bedrooms. Residents’ bedrooms are all pleasantly decorated and generally furnished to a high standard. The Home has three bathrooms and one shower room. One bath has been fitted with a mechanical hoist. There are also numerous toilets located on both floors. There are two lounges and two dining areas. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced meaning that neither the proprietors nor manager had prior notice. Two Inspectors who divided the assessment of the home between them carried out the inspection that began at 9.30am and finished at 4.00pm. One Inspector case tracked two residents care and spoke to two residents. This Inspector also checked four staff files (two not yet employed) assessed menus and undertook a limited tour of the premises. The other Inspector assessed complaints, protection, the premises, staff training, infection control and safety including assessment of maintenance records. Progress made towards previous requirements issued to ensure improvement was also assessed by both Inspectors. What the service does well: There is a calm and orderly atmosphere at the Woodlands. Staff were observed to be polite and respectful. The premises are warm, homely and fresh smelling. Residents spoke highly of the meals and portions were seen to be generous, well presented and the desert was home baked. Staff training is valued within the home and staff are able to undertake a range of training courses which supports them to carry out their role and meet the needs of service users. A service user said that the home is ‘wonderful’. The gardens are landscaped and maintained to a very high standard providing service users with a pleasant outlook. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Some areas where recruitment info could be better Gas appliances had not been serviced since 2002 compromising the safety of service users and staff. Whilst fire equipment is well maintained a fire risk assessment which identifies any risks so they can be minimised and is legally required has not been carried out again compromising the safety of service users and staff. It has long been accepted that the home needs larger staff, office and laundry facilities. The provider continues to state that there are plans to extend but there continues to be no progress. An immediate requirement notice issued at the last inspection in February 2005 to assess the risk of cross contamination in the small laundry has also not been complied with risking further legal action and the safety of service users. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 7 Whilst the number of outstanding requirements for improvement has substantially reduced as a result of improvements assessed at this inspection the momentum for improvement must be maintained. Activity provision and recording could improve and whilst care plans have improved they would better guide staff if there was greater clarity. The manager must also ensure that individuals resident risk assessments are accurate. Staff competency to use blood glucose monitoring devise must be assessed and confirmed. 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 E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 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 standard(s) 3 The manager ensures that service users needs are assessed prior to moving in to the home but is not assuring new service users in writing that their needs can be met. EVIDENCE: Examination of two case files for recently admitted residents evidenced that the home had obtained assessments from the funding authority and also carried out its own assessment of need that built on this information. The information available was sufficient for the home to have a clear picture of the needs of these residents prior to their admission. Information about the home in the form of the statement of purpose and service users guide had been provided by the homes manager, this evidenced through a record of the relatives signature. The only omission by the home was to provide the residents with written confirmation, based on the assessments carried out pre admission, that the home was able to fully meet the services users needs. The home was seen to have a standardised format of a letter for use for this purpose, these not used on this occasion. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 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 standard(s) 7, 8, 10 Health care needs are monitored and responded to appropriately supported by care plans that adequately guide staff. Service users are treated with respect. EVIDENCE: Examination of two care plans provided clear evidence of improvement in the recording of these documents by staff at the home. Needs were clearly recorded, these drawn from the pre admission assessments that were present. Case tracking confirmed through a variety of sources (discussion with staff, residents and examination of other records) that the care plans were overall consistent with the practices carried out at the home. There were numerous risk assessments that supported the care plans although it was noted that some information within a minority of these had not been updated or did not carry detail of where the home had taken action to lessen identified risk. The care plans were seen to have been agreed by the residents relatives, this evidenced by their signature. Plans were consistently reviewed on a monthly basis. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 11 Whilst the information available was judged acceptable, and an improvement over what had been seen previously it was felt that the care plans could be more concise so as to allow easier access to information (for example use of a core record of all up to date information that at present is spread `throughout the case file. There was clear records seen that showed that health care needs were monitored and responded to appropriately, with involvement of community health professionals as was necessary dependent of residents needs. There were copies of tissue viability and nutritional assessments available, these seen to influence the care instructions within the case files. On of the residents was a diabetic, and staff were checking their blood sugar through the use of an electronic blood glucose-monitoring machine. This process involved breaking the residents skin to obtain a drop of blood, this essentially invasive practice. This was discussed with the manager who stated that staff had received guidance from the district nurse, this not however confirmed in writing, as should be the case. The home needs evidence of which staff have been given guidance, with confirmation from the district nurse that they are competent to carry out these ‘prick’ tests. Records of medication documented with assessments and case files were found to be consistent with those recorded on the homes medical administration records. Discussion with a resident evidenced that they felt the staff at the home respected their privacy and dignity. It was said that the staff treated them well and they were encouraged to retain their independence as far as this was possible, an example of this in that they were encouraged to dress themselves. The was evidence of regular hairdressing, manicures this important in assisting residents to maintain self-esteem. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 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 standard(s) 12, 15 Group activity is provided that does not reflect individually preferences and interests which are largely not known. Service users are provided with a wholesome appealing balanced diet that meets individuals’ needs. EVIDENCE: Resident’s choices as to some of their preferred daily routines (such as time to get up, go to bed) were seen to be recorded in their case files, with one resident confirming that the records were accurate. The home was seen to have an activity programme that detailed the one group activity offered by staff each day this including TV, films, knitting (some residents seen to be doing this), bingo, games, music and exercise. Detail of individuals preferences in respect of social activity was however limited and there was very little documentation to show what sort of stimulation individual residents received on a day to day basis. The comment from the resident spoken to was that they never got bored as there was plenty to do at the home. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 13 The homes menus indicated that there was a balanced and nutritious variety of meals available to residents, these throughout the day. Breakfast is usually a light meal, but residents do have the choice of a full cooked morning meal on Sundays. Information in those case files examined showed that information documented in respect of residents dietary requirements was detailed with some evidence in daily records that these were met. The menu was seen to be on display in the dining room and indicated that choice were available. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 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 standard(s) 16, 18. Systems do not currently support residents to know how to make a complaint but responses to complaints that are made is now appropriate Systems are generally in place to protect residents but some improvement is required to ensure their greater protection. EVIDENCE: The complaints procedure now includes the details of agencies to refer to in the event of dissatisfaction although this needs to be updated from the ‘National Care Standards Commission’ to the Commission for Social Care Inspection. Advice about how to make a complaint is not publicly available within the home. The manager must ensure that this information is provided including in an accessible format for residents. However there have been significant improvements in the management of complaints and comments. Practice is now more accountable and improvements arising from one service users comments was evidenced. There are a range of policies and procedures in place to protect residents. The Inspector sampled the following: • Restraint policy • Managing Violence policy • Making Wills policy • Whistle blowing • Management of service user finances • Accepting gifts • Sexuality • Dudley Local Authority Adult Protection policy • Homes policy in relation to Adult protection and abuse. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 15 Many of the policies are brief but adequate. The home’s policy in relation to adult protection was reviewed with Social Services in July 2005. One minor amendment was suggested by the Inspector to ensure clarity in relation to the home’s role in the investigation process following any allegation. Training for staff in Adult Protection has been rebooked for September 2005. Records indicate that the home has obtained medical advice and Social Services reassessment of need following aggressive behaviour from one service user whose health is deteriorating to ensure that his and others needs are met. Inventories are in place to protect residents’ possessions and the management of service user finances have benefited from some improved to systems since the last inspection. Receipts are now kept and numbered, financial records audited by the manager and handover and storage facilities have been improved. The sexuality policy acknowledges the right of residents to engage in consenting sexual relationships but does not detail what action should be taken in the event of none consent or the lack of ability to consent. Improved guidance for staff would ensure the better protection of residents in this respect. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 26 The premises provide a pleasant environment for residents with evidenced improvements. The environment is generally safe with some omissions that may compromise safety. Sufficient action has not been taken to reduce the risk of cross contamination EVIDENCE: The location and layout of the home is accessible and suitable for its stated purpose. It is clean, fresh smelling, uncluttered well furnished and decorated. There is a lift and a hoist available to support service users with limited mobility. Some areas of maintenance require improvement and are detailed under Standard 38. The grounds are exceptionally tidy, safe, attractive and well maintained and enhance the premises and residents enjoyment. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 17 Historically compliance in relation to improvement of the premises has been slow but this inspection has seen some improvement and some long outstanding requirements have been deleted e.g. provision of dishwasher, removal of plastic dining tables replaced by wooden ones, replacement of broken glass, securing electricity meter that was exposed in a residents bedroom. Other improvements have been agreed by the provider but are still awaited e.g. window restrictors, creation of an office area to support the management of the home. Further improvement is required which will only be achieved through extending the home. The laundry is clean but in need of refurbishment and it is small and this compromises infection control. Some action has been taken to reduce risk to service users (clean laundry now removed from laundry, paper hand towels are available and a hand wash basin has been fitted) but more is required. A risk assessment to reduce the risk of cross contamination which was immediately required at the last inspection has not been carried out. This has affected outcomes, which have not consequently been addressed. The following was observed. Risk assessment would have identified the need for the removal of fabric hand towels from the laundry and staff toilet, removal of the nailbrush from the laundry, removal of the ironing board from the laundry and the provision of a paper towel dispenser in the staff toilet to avoid paper towels sitting on the toilet cistern. Paper towels are not being used in the staff toilet as there is nowhere to dispose of them and this must be addressed. The proprietor has not been able to secure evidenced advice from the infection control nurse. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29, 30 The Registered Manager ensures that there is a staff training and development programme in place to support staff to meet the needs of service users. Service users are supported and protected by the home’s staff recruitment practice. EVIDENCE: The staff files for the two most recently employed staff at the home were examined and showed that all the necessary and required checks were carried out before they commenced work. Both staff commenced employment prior to receipt of an enhanced disclosure but after a POVA 1st check. This was discussed with CSCI (prior to their employment) and a risk assessment was completed by the home identifying how any potential concerns in respect of staff for which a full disclosure was not available would be managed (namely their working with a named and experienced member of the existing staff team. These risk assessments could however be improved to detail all the steps the home had and does take to reduce the risk of recruiting unsuitable staff. The manager was however advise that it would be useful for the reference request form to have a space for the referee to write the date they completed it, and that all staff sign a statement in respect of criminal convictions declaration at the point or before employment. Obtaining Staff signatures on applications forms are also advised Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 19 There is now in place a training matrix, which helps to plan training required. Training records for two members of long standing staff were assessed. One staff member has in the last 12 months undertaken six appropriate training courses. The second staff member has in the last 12 months undertaken four courses. Both had achieved their NVQ 2 in Care. Fire training, risk assessment training and Adult Protection training are booked for September 2005. Staff are therefore being offered a minimum of three days paid training. Notices were seen posted in the home requiring staff attendance at training courses booked. New staff had not completed induction training within the required six weeks but an induction system is in place to support staff to the required level. The Inspector saw a member of staff’s induction workbook and a staff member was heard to ask the Manager for her workbook to work on. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Some omissions in routine maintenance are compromising the health, safety and welfare of service users. EVIDENCE: Assessment of service and maintenance records for the premises showed most to be present, appropriate and up to date with the exception of servicing for gas appliances which was last carried out in 2002 and a fire risk assessment compromising the safety of residents and staff. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 21 A Food Safety inspection was carried out in April 2004 by the Environmental Health Department and the letter sent refers to no progress since the prior inspection of 2nd January 2002. This inspection showed fly screens to have been provided in the kitchen and a dishwasher has been provided too both which will promote better infection control reducing any risk to residents. A further visit by Environmental Health was carried out on 22 March 2005 and focussed upon slips trips and falls. Action was required of the home to reduce risk to residents. There have been 9 minor accidents recorded since April 2005. There is evidence that the manager is reviewing these and taking action accordingly. Two falls have been recorded both prior to 7am and the manager has increased staffing hours to appoint an extra staff member for the 6am shift to increase the level of supervision of residents at this time. The first aid box is well stocked. The previous requirement to fit window restrictors has not been met held up the Inspector was informed by the contractor. There are some risk assessments available. The manager however will benefit from the provision of risk assessment training which following previous requirement has now been booked for September 2005. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x x x 2 Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 23 yes 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 Op3 Regulation 14 Requirement To ensure that all prospective residents are given, in writing , confirmation that the home is able to meet their needs, this based on any assessments that have been carried out. Requirement originally made August 2002.New Requirement at August 2005 To gain written confirmation from the distrct nurse that the staff that use the blood gluciose monitoing machine are judged by them as competent to do so. New Requirement at August 2005 To ensure that all individual residents risk assessments are up to date and reflect the current practice of the staff at the home (in respect of the appropraite resident) New Requirement at August 2005 Care plans must include residents’ financial management arrangements.Care plans must include plans to meet the assessed social/ leisure/ community access needs of residents.Requirement first made and not met since February 2005 Timescale for action Next Admission 2. Op4,8 13, 18 30.9.05 3. Op7 15 31.10.05 4. OP7 1512(3) Not Met 31.10.05 Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 24 5. OP8 14 6. OP8 15(1)(2) 7. OP9 13(2) Where the registered manager cannot gain access to copies of continence assessments carried out by the district nurse then a full record of the outcome of the assessment must be documented in the residents case file with detail of the services users views of the outcome.Requirement first made and not met since June 2004. The registered manager must ensure the following is included in every service user care plan:· The service user plans must also be reproduced in a format suitable for the service user for example large print, audiotape and so on.Requirement first made and not met since June 2004. The Medication Policy must be reviewed and updated to cover all required areas. (first required and not met since August 2002)Medications received and returned must be documented upon the Medication Administration Record Sheet.The manager must seek the written approval of the contracted pharmacist in respect of storage cupboard used to store medication.Documentation must be held to evidence reasons for changes made to Medication Administration Records e.g. photocopies of prescriptionsThe Manager must obtain an up to date British National Formulary. Reasons for residents’ medication refusals must be documented.Medication Administration Records must be signed after administration of the drug (not before administration) The manager must ensure that the administration of prescribed Not Met 31.10.05 Not Met 31.10.05 Not Assessed 31.8.05 Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 25 8. OP9 13(2) 9. OP12 16(2) m & n 10. OP15 13(2) creams is evidenced in the medication administration records.When medication is administered as PRN or ‘as required’ the time of administration must be recorded.Advice must be sought from the GP to clarify confusion over whether drugs prescribed as ‘take 2 x 3 daily when required are to be regularly administered or administered as ‘as required’. This is required in relation to ES, DP, MBCriteria for the administration of ‘as required’ must be medically provided and must be recorded.The advice of the GP must be sought and must be recorded in respect of any homely remedy provided by the home, any resident or relative of any resident e.g. FL and Cod Liver Oil.Requirements first made February 2005. The manager must seek the advice of the pharmacist in relation to the storage of eye drops.A labelled container must be provided within which to store drugs held in the domestic fridge.Requirement first made February 2005. The registered manager must ensure that there is better documentation of resident’s wishes and preferences in respect of social activity, following which there must be better documentation of the home addressing these choices. At Feb 05 - Good documentation in resident meeting minutes. Leisure goals not included in care plansRequirement first made and not met since June 2004. The registered manager must ensure that where supplements Not Assessed 31.8.05 Not met 31.10.05 Not Met 31.8.05 Page 26 Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 11. Op16 22 12. Op18 13(6) (such as thickening agents) are added to a resident’s foods following medical advice, that this is fully documented when administered. Requirement first made and not met since June 2004. Information as to how to make a complaint must be posted throughout the home for visitors to easily access. Information posted must also be in an accessible format for service users.New Requirements at August 2005. The Adult Protection Policy must provide clarity about the home’s role in the investigation process following an allegation. (Requirement originally made August 2002) The home’s Sexuality Policy must include action required in the event of none consent or inability to consent to sexual activity.New Requirements at August 2005 The registered manager must ensure that staff do not use under lifting to lift or move residents at any time. Requirement first made June 2004. To refit floorboards on first floor landing in W2 adjacent to bedroom 11 which have become loose under carpet. Requirement first made and not met since August 2002 To provide a staff room with storage facilities, and a staff toiletRequirement first made and not met since August 2002. To provide an office space for the Manager in order to carry out administrative tasks, individual 31.10.05 31.10.05 31.10.05 13. OP18 13(5) 14. Op19 23(2)(b) Not Observed at inspection– to be kept under review Not Met 31.9.05 15. Op19 23(3)(a) 16. Op 19 23(2)(a) Not Met – to provide CSCI with target date Not Met – to provide CSCI with Page 27 Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 17. OP19 23(2) b 18. Op23 24 16(2)(l) staff supervision, staff disciplinaries in a private and confidential area. Requirement first made and not met since August 2002. To replace the double-glazed window unit in conservatory that is compromised and misting up.Requirement first made and not met since February 2004. To provide a lockable space in all service users’ bedrooms.Requirement first made and not met since August 2002. target date Not Met – 3 months 19. OP24 16(2)(c) Sch 3(q) 20. Op26 12(1)(a)1 3(3) 21. OP29 19 22. OP29 10, 19 To 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. To fit bedroom door locks upon rooms becoming vacant.Requirement first made and not met since August 2002. To resite and enlarge the laundry area so that it is not in proximity to the kitchen and to provide separate hand washing facilities for staff, separate areas for drying, ironing, and storage of clean linen away from soiled linen.Requirement first made and not met since August 2002. Staff must sign a statement re criminal convictions and the application form prior to employment.New Requirement at August 2005 To revise the homes risk assessment format for employment of staff without Not Assessed – 3 months where it is a resident express wish to have this facility. Not Assessed30.9.05 Not Met – To provide CSCI with a target date. Next appointme nt Next staff appointment Page 28 Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 23. OP29 24. Op30 25. OP33 26. OP34 27. OP35 28. OP36 disclosures to evidence all the checks the home is carrying out prior to employment that contribution to reduction of the risk presented by new staff. This risk assessment should also identify why there is a need to employ the staff without disclosuresNew Requirement at August 2005 19(4) b An Enhanced Disclosure (through the Criminal Records Bureau) must be obtained prior to staff commencing work at the home.Requirement first made February 2004. 18(1)(c) To provide staff with the following training: incontinence awareness, dementia awareness, vulnerable adult abuse, palliative care awareness, and accredited medication training.Requirement first made and not met since August 2002. 24 The Home must establish an effective quality assurance system.Requirement first made and not met since August 2002. 25(1)(2)S To ensure that a business and hed. 4 financial plan is held at the Home and is available for inspection. Requirement first made August 2002. 16(2)(l)17 Receipts held in respect of (2) Sch’ residents’ expenditure must be 4(9)13(6) numbered and logged against record of expenditure.The manager must ensure that the policy in respect to the management of residents finances is reviewed and updated to cover storage, access, receipts, checking and verifying prior to recording in.Requirement first made and not met since February 2005. 18(2) The registered manager must ensure that records in respect of E55 S24980 Woodlands V246975 260805 Stage4.doc Not Met Next Admission PART MET – in progress 31.12.05 PART MET – no progress 31.12.05 Not Assessed – next inspection Not Met 30.9.05 Not AssessedPage 29 Woodlands Version 1.40 29. OP 38 30. Op 38 31. OP38 32. Op 38 staff supervision are consistently and accurately documented so as to evidence the actual supervisory practices within the home.Requirement first made June 2004. 13(4) To ensure that all gas appliances 23(2)(b)(c are serviced without delay. A ) Gas Landlord’s certificate must be forwarded to the Commission for Social Care Inspection by no later than 12 September 2005. New Requirement at August 2005 13(4) To seek advice from the West 23(4)(a) Midlands Fire Service to undertake a detailed written Fire Risk Assessment taking action to minimise any risk identified. This assessment must be kept under regular review. A copy of the completed fire risk assessment must be forwarded to the Commission for Social Care Inspection by 12 September 2005.New Requirement at August 2005 16(2)(j), To undertake a detailed risk 13(3), assessment and to implement 23(2)(k) control measures to reduce any risks of cross contamination identified within the laundry, seeking the advice of the infection control nurse. The risk assessment (copy of) must be supplied to the Commission for Social Care Inspection by Thursday 17th February 2005 at 5pm.Immediate Requirement first made and not met February 2005. 16(2)(j) To comply with the immediate 13(3) requirement issued in February 23(2)(k). 2005 and to undertake a risk assessment to identify and minimise any risk of cross contamination within the laundry. A copy of this risk E55 S24980 Woodlands V246975 260805 Stage4.doc ongoing 12.9.05 12.9.05 Immediate Requment not met31.8.0 5 12.9.05 Woodlands Version 1.40 Page 30 33. OP38 18(1)(c)9 (2)(b)(i)1 3(4) assessment must be forwarded to the Commission for Social care Inspection by 12 September 2005. New Requirement at August 2005. The manager and Deputy Not Met 31.10.05 Managers must attend an appropriately accredited risk assessment course (advice to be sought from the Environmental Health Dept). The training must be booked by the date given.Requirement first made and not met since February 2005.At August 2005 – training for 3 booked for September 2005. 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 OP1 Good Practice Recommendations The Statement of Purpose should include a statement that sets out the physical environmental standards met by the home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 23.3 and 23.10. (This due to the amendment of the National Minimum Standards). A summary of this information should appear in the Service User Guide. The home’s Statement of Terms and Conditions should state that residents are entitled to three months trial period at the home as opposed to a month. The home should develop a policy on as to how the home would maintain relatives and friends involvement with the service user, a copy of this to be given to the representative at the time of the service users admission to the home. Contact numbers for advocates should be made readily available to all service users. To provide a third assisted bathing facility To consult with the existing service users who share double rooms and who may be disturbed by fellow occupants who are continuously restless. To offer a single bedroom at the earliest opportunity with written records E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 31 2. 3. OP2 OP13 4. 5. 6. OP14 OP21 OP23 Woodlands 7. OP24 8. 9. 10. Op29 Op29 OP31 kept of the consultation process. The home should ensure that where double wardrobes are used by users in shared rooms, that there should be some dividing section in order that clothes do not become mixed up. To add space on the homes standardised refernce reuest form for a date of completion. To document on the staff file the date staff commence employment. The Registered Manager should submit an action plan to the CSCI as to how she intends to ensure the home has a manager with NVQ level 4 in care and management by 2005. 11. Woodlands E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 32 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. 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 E55 S24980 Woodlands V246975 260805 Stage4.doc Version 1.40 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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