CARE HOMES FOR OLDER PEOPLE
Woodlands 50 High Street Earith, Huntingdon Cambridgeshire PE28 3PP Lead Inspector
Dragan Cvejic Unannounced Inspection 7th August 2008 07:45 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.V369916.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.V369916.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.V369916.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th August 2007 Brief Description of the Service: Woodlands provides care, accommodation and support for up to 24 older people, some 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. Residents’ accommodation is on two floors, the upper floor being accessed via a shaft lift. The home has 18 single and 3 double rooms, but would only be used to accommodate a couple if the need arises. Sixteen of the single rooms have en-suite toilets, and 4 rooms also have baths. 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.V369916.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes.
This was an unannounced inspection of the service. We (the Commission for Social Care Inspection) have followed the service since the last inspection through regular reporting of any significant event, accidents/incidents that occurred at the home. We asked the home to carry out a self-assessment and fill in the AQAA (Annual Quality Assurance Assessment). We also sent questionnaires to people that used the service to their relatives and to staff. We received 3 surveys from residents and 3 from relatives with comments, which are used for this report. We visited the service on 07/08/08 and talked to 8 residents, 2 staff and to the manager. These comments are also incorporated into this report. We checked 3 residents’ files and checked records kept about 2 staff members. We checked some policies, procedures and other records kept in the home. We walked through the home to observe the environment. What the service does well:
Care is provided in a homely way, with passion and patience, from a dedicated and stable staff team helped residents feel at home. Their attitude, behaviour and freedom seen during the site visit showed that they felt that they “possess” the place and feel at home. However, modern principles of care were only making a slow entry into the home and their procedures and practices. Documentation kept in the home was improved from the last inspection, but still was not detailed and precise enough to demonstrate accurately and to evidence the level of care the service offered to the residents. People that talked to us were very complementary about the service. Many of them remembered the inspector from the past inspections and were talking about their private life, about relatives, sons and daughters, wives and husbands. Some comments related to the home and care they received were: “The staff are marvellous. They are always here when we need them.” “We have a musician come in regularly. I can’t sing because I have got asthma, but I like sitting here, in my chair and listening to them and how they all sing.” A resident with a mild form of dementia was singing in a happy voice to us whenever she saw us during the site visit. Visibly happy and comfortably relaxed she demonstrated that the care she received suited her needs and made her happy.
Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 6 All contacts between staff and residents started with a personalised greeting, calling each other by name. They obviously knew each other by name and residents felt friendly with staff in a homely atmosphere, completely free from any signs of a clinical approach. Most residents were from the local area and knew staff, who were also local, even before coming to live in this home. What has improved since the last inspection? What they could do better:
As the deputy manager achieved NVQ (National Vocational Qualification) at level 4, she started applying her knowledge in practice. New residents files introduced, however, still needed to provide clearer information, more related and referenced to the entries made by the staff: for example, records of nurses’ visits did not always match with daily records, as there were no records of a specialist visit even though daily records recorded 4 consecutive days when a resident was not well. An advice for appropriate activities for dementia sufferers should be sought by the new activity organiser and should expand the range of the type of activities suitable for this condition. NVQ’s were given much more importance, both within the home and in the head office and promised progress on the number of trained people, especially
Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 7 with the new plan, that would finally bring the level of trained staff to over 50 , as required by the standards. The manager noted down the contact details for the training providers for the training on Protection Of Vulnerable Adults, intending to call in the trainers and arrange for all staff to receive this training. The manager also suggested the home’s supervision form could be used to record her supervision with the area manager in order to evidence the support she received. New supervision plan was recently introduced and should bring staff supervision to the required level, with the evidence hopefully available in the future. The management also took on the task of explaining to staff how to record particular events, avoiding any doubt of potential abuse, for example connecting potential bruises with events, or recording visits by medical professionals when they are called due to a resident’s health deterioration. This would ensure better evidenced protection of the residents and staff. Control valves were installed on taps in bathrooms, but not in toilets. Without a sign or a recorded risk assessment, this represented a risk to the residents. 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 DS0000065969.V369916.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 DS0000065969.V369916.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): 3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Both the home and the residents did have sufficient information to determine if a placement in the home would work and if needs would be met if the admission was agreed. EVIDENCE: Three residents’ files were checked. Two did not have records of the initial assessment in the files for daily use, as these two people were admitted years ago, while the third file checked, for the recently admitted resident, contained a form filled in on admission. This form addressed all information needed to determine if the assessed needs could be met by the home. The manager stated that she was in a position to refuse an admission, after her assessment indicated that they would not be able to meet the needs if the prospective resident was admitted.
Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 10 The home also relied on respite care residents coming in to become permanent. An example of this was a resident whose husband was bringing her for respite regularly and, consequently, when he died, she became a permanent resident. By this time, the home knew her needs in detail and an informed decision about admission could be made. A resident, currently on respite care, talked a lot about the home, his needs and his decision to come in when he needed admission. He stated that he was confident that the home would meet all his needs and “would not consider going anywhere else.” The home did not offer intermediate care, but respite care worked on similar principles, with the difference that the respite residents were choosing to come in, rather than being sent in by hospitals. Admission procedure, with trial visits of one day and a “probationary” period of one month also allowed both residents and the home to decide if the needs could be met upon admission. Residents spoken to confirmed that the home met their needs. One of them responded to the question of what could be better: “Leave it as it is. They are good.” Woodlands DS0000065969.V369916.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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good personal care offered to residents was not always well recorded and evidenced, but as all residents spoken to confirmed, they were very well looked after, were respected and appreciated the help and support they had in the home. EVIDENCE: A new format of residents’ document were introduced. All information related to day-to-day care was gathered in one folder for each individual. The folder contained daily notes, care plans, risk assessments, various charts, such as a weight or nutrition chart, continence monitoring chart, record of contribution to activities, visits by external medical professionals and the reviews records. The review sheet contained the dates and signatures when reviews with users and/or their relatives took place. Some entries did not have dates recorded, but, generally, records were sufficient to provide the picture of the needs and how they were met.
Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 12 However, some entries in daily records were not properly addressed in the accompanying documents. For example: daily records continually stated that a resident was not well for 4 consecutive days. There were no records of professional medical interventions, although the deputy manager stated that a district nurse attended to the resident, and the resident was seen in a healthier condition, singing to us during the site visit. Redness was recorded as reported for thee days in daily records for another resident, but there were no records of any follow-ups. However, the resident stated to us that this was a result of her “pushing against the arm rest on her chair”, clearing doubts of any potential abuse. Vocabulary used in daily notes was not always appropriate and could lead to potential allegations, such as “pushing fluids”, but the management team stated that they would provide clear instructions to staff on how to record the events without causing any doubts. A letter from the manager asking for a servicing of the hoist demonstrated how the home looked after the equipment that helped them offer appropriate care to the residents. A resident’s file contained a detailed record of her admission to hospital, showing that residents’ healthcare was given important attention. Two residents confirmed that they had their eye tests, one in the home and the other visited an optician in the community. Four medication records checked were accurate, without gaps in signing when the medication was given. Two residents confirmed that they were happy for staff to keep their medication and administer it to them according to the instructions. A staff member went out to collect medication during the site visit and respected the procedure. Another staff member was observed administering medication to a resident just before breakfast, demonstrating that the policy was respected. The manager stated that the new arrangement for medication, whereby the pharmacies were preparing medication in dose boxes, was much better and safer. Privacy and dignity of residents was highly respected. Their preferred name was marked in care plans and used by staff, as observed throughout the site visit. A visitor came to see her mum during the visit and the other staff fully respected their privacy, by leaving them alone for a while. A payphone was next to the entry to the building, available to all residents. The laundry lady stated that she knew most residents’ clothes, but still asked them to mark any new item in order to ensure their clothes do not get mixed. Although the double room was not used at the time of the visit, the manager explained that: …“it is reserved for couples.” She explained that a couple were using it even when only one resident came to the home for respite care, but wanted her husband to stay with her and he agreed.
Woodlands DS0000065969.V369916.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although residents enjoyed daily life in the home, the evidence collected showed huge potential for improving activities, to include more residents and to expand on the range of activities already provided. EVIDENCE: “We have a choice”, stated several residents when they were asked. One of them related the answer to the choice of food: “We can choose what we want to eat from the menu. If we choose something different, they make it for us.” Another resident related his answer to his freedom: “I can get up when I want, or go to bed when I want. I can, I go out to the local shop, they do not stop me.” A resident explained why she did not join others when the guest musician performed in the home: “You see, they all sing with him, but I can’t sing, as I have asthma. So I stay away, but I love listening to them.” Residents’ visitors were coming almost on a daily basis. The homes’ location in a small local community created the atmosphere of regular visitors who knew not only their relatives, but most residents too. One of the regular visitors
Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 14 played music for several residents, although he was visiting his relative. Several residents and he himself enjoyed these visits. The local school was sending children regularly to sing in the home. A neighbouring marina offered a free boat trip to residents once a year. The last barbeque organised in the home attracted about a hundred visitors. Residents benefited from the location of the home in the local community and developed excellent relationships with neighbours. Residents could choose who they wanted to see. Several residents used a day centre next door and expanded on activities. Creating the new post of activity organiser was a measure the home introduced to improve activities. However, the person in the post did not have the training that would help her organise appropriate activities for residents suffering from dementia. One of the residents’ files contained the entry: “Does not want to take part in activities.” When the resident in question was spoken to she said: “”I don’t like these activities. I prefer reading and watching TV”. The record of activities showed individual entries made on average every fourth day, indicating the huge potential to improve conditions for the residents. All questioned residents stated that they were very happy with food. During the visit, a resident knocked at the kitchen door to order what he wanted for his breakfast directly from the cook. The cook kept the records of food consumed by individuals that was not from the menu, to ensure better protection for residents. The environmental health inspection was carried out a few weeks before the site visit and the inspectors were pleased with the findings. The providers intend to replace the kitchen in the forthcoming period. Woodlands DS0000065969.V369916.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 adequate. This judgement has been made using available evidence including a visit to this service. Although much improved, protection was still not fully achieved, with some outstanding training and necessary changes in wording of some residents’ documents. EVIDENCE: There were no formal complaints either to the home or to the Commission for Social Care Inspection. The complaints procedure was available to residents and visitors and was clearly presented. Several residents confirmed that they knew how to complain if they wished. The manager presented records of the meeting she attended, showing an external investigation for the resident with bruises on the heel while in hospital. This showed the homes’ determination to be involved and offer protection to residents even when they were not in the home. The home did not keep residents’ money. Mainly relatives dealt with it, as confirmed by 4 residents spoken to. Two residents proudly stated that they always had small amounts of money with them, as they wanted to and no one in the home prevented them from doing that, or insisted on controlling their money. Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 16 Although policies and procedures for protecting residents were in place, two staff did not have POVA (Protection of Vulnerable Adults) training. The home used a DVD for this training, resulting in a lack of training certificates for staff. In discussion with the manager it was agreed that she would organise this training for all staff with the Protection team from social services and then use the DVD for refresher training. Also, improvement in residents’ documentation must be improved to ensure protection for them and to distinguish between accidents/incidents and potential cases of abuse, as described in the Health Care section of this report. The head office was conducting staff checks before employment was offered. There were three new job applicants at the time of the site visit who had not started due to awaiting their POVA and CRB (Criminal Records) checks. Another missing element of protection was related to hot water taps in toilets that were not marked, or properly risk assessed. This requirement was addressed in the environment section. Woodlands DS0000065969.V369916.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): 19,22,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Safety for residents in the otherwise nice environment was not completely achieved, as hot water from certain taps could present a danger to the residents as it was not fully controlled or warned about. EVIDENCE: The home offered a very comfortable and homely environment. New carpets in the lounges and bedrooms improved the look of the home and all residents spoken to were very happy with the homely arrangement and feeling in the home. The home employed a maintenance man who ensured that faults were dealt with almost immediately. The providers invested in the home and planned to further improve environment by replacing the kitchen.
Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 18 The garden overlooking the river Great Ouse was very attractive, well maintained and usually attracted many residents to come out and spend time feeding ducks or simply enjoying the river. The local fire service and environmental health visited the home recently without raising any requirements regarding their area of expertise. Toilets, washing and bathing facilities were appropriate, although the hot water taps in the toilets were still awaiting the installation of mixing valves. This was considered to cause a risk to the residents, as there were no appropriate risk assessments or warning signs to ensure better protection. This uncompleted task was also against the Water Supply regulations from 1999. The old hoist was hard to maintain due to the age and lack of spare parts and the manager showed the letter asking for a new one, to ensure that residents could be supported all the time. The manager was considering how to improve the natural lighting in some bedrooms on the third floor that faced trees, shadowing the nearby public pathway and incidentally a few bedroom windows, although the residents did not spend much of the daylight hours in their bedrooms. New infection control training attended by all staff and other measures ensured better protection for residents. The home was free from offensive odours and hygienically clean. The laundry room was located in an additional building and offered a good way of infection control by physical separation from the areas used by the residents. Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 stable and dedicated staff team was a real asset to the home and ensured that residents were respected and helped in the way they wanted. EVIDENCE: “Staff are marvellous. They are always here when we need them”, “Staff always find the time to talk to us”, “They have a good and enough staff”, are some of the comments from residents. Two staff files were checked and all required documents were there. The training certificates showed that not all staff received certified POVA training as mentioned in the protection section of this report. The home responded to residents’ needs by employing sufficient and dedicated staff at all times. The main advantage of this home was the staff’s attitude and the respect they showed to residents. The home still did not achieve 50 of the NVQ (National Vocational Qualifications) training, but the plan and latest improvement demonstrated their determination to achieve and even exceed this standard. Recruitment was conducted by the head office. Although the home conducted interviews, the check for new staff was carried out at the head office. Staff files consequently contained the number of the CRB (Criminal Records) and POVA that were checked at the head-office first and then sent to the home.
Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 20 Identification documents were also in staff files, as well as references; at least two and in one file 3 references were present. Head office also checked the right to work for foreign nationals. Files checked did not show all training certificates, for example the POVA certificates were missing in two checked files. However, staff spoken to were happy with the training received. The deputy manager was in particular proud of her achievement: NVQ (National Vocational Qualifications) level 4, usually obtained by managers. The progress demonstrated that the providers encouraged staff to attend training. Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Necessary improvements in administration and acting on identified risks to protect residents were still to be achieved to ensure full protection of residents. EVIDENCE: The experienced and dedicated manager managed the home successfully with the help from her deputy and the rest of the dedicated staff team. The ethos created in the home exceeded minimum standards. All residents spoken to felt free to talk, praised staff and other elements they individually considered as excellent. Several comments with the message: “Do not change anything” demonstrated that the care for residents was really good. However,
Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 22 a little more attention to the issues of protection and how things were written in evidence should be the aim for the home in the forthcoming period and would move the home into a better rating. Staff knew their roles and had clear goals not only for the home as a whole, but for individual residents in it. Packs from the General Social Care Council were now given to all new starters. The openness and transparent way of running the home exceeded minimum standards. The manager stated that quality assurance questionnaires were just sent out and was preparing the quality assurance review for when they come back. The manager’s intention to improve both processes and environment and create a safe, comfortable, open and progressive place for residents, demonstrated how quality assurance could be used to improve the entire service for residents. Staff supervision started to provide evidence of its regularity: all three checked files contained the recorded documents of supervision for these staff members. The manager stated that the regularity of supervision was improving. However, the home still did not have evidence that the manager received regular supervision, despite her statement that she felt quite supported by the monthly visits of her line manager. It was agreed with the manager that the staff supervision form is also used for her supervision. At the time of the visit, this evidence was still not sufficient to confirm regularity, but based on the plan, the requirement set on the previous inspection seemed to be answered. The home did not have all records of visits by the responsible individual, showing that visits take place monthly and discuss relevant issues regarding the running of the home and the safety of residents. Records, especially safeguarding records for residents needed to be improved, as explained in the part of this report addressing protection of residents. Safe working practices regarding the care process were in place. However, the hot water temperature on taps in toilets, the outstanding manager’s request for the new hoist, installation of new kitchen and lack of accurate records of accidents/incidents with actions to prevent reoccurrence, determined the adequate rating on this group of standards. Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 3 X X 2 2 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X X 2 2 2 Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation Schedule 3 (3. j and k) Requirement Timescale for action 15/09/08 2. OP18 13(6); 13 (4)(a)(b)( c) 3. OP25 13,16,23 The records in care plans, daily notes and other documents kept in individual files must contain related entries showing what is done and how to help and support residents and to ensure their full protection. 30/10/08 The residents must be fully protected by arranging for all staff to attend certificated POVA training, to ensure that daily records do not cause doubts of potential abuse, and, the physical protection of residents from hot water that still has not been regulated by adding mixing valves to certain taps must be ensured. While waiting for the work on hot 15/09/08 water mixing valves, the home must carry out a risk assessment and introduce measures to minimise the risk to which service users are exposed. This was an outstanding requirement not met by the previous time scale(20/11/06). The hot water taps must be marked with warning signs while
DS0000065969.V369916.R01.S.doc Version 5.2 Woodlands Page 25 4. OP37 17 13(6) the home is awaiting the installation of mixing valves. The records kept in the home 15/09/08 must be developed and set as planned, with elements to demonstrate users involvement and access. Once set the records must be kept up to date by the introduction of regular and recorded reviews. This was a requirement set previously with the time scale 31/12/06. This inspection identified the need for improving vocabulary, recording dates and making clear and connected entries in residents’ files and must be achieved by the new set time scale to ensure full protection of residents. Water temperature above the safe range must be addressed in risk assessments and measures must be in place to protect residents. Safe working practices must include accurate and appropriate records that would protect residents, be dealt with when risks are identified and ensure safety and welfare of residents. 15/09/08 5. OP38 13(c) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodlands DS0000065969.V369916.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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
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