Inspection on 08/12/05 for Woodlands

This inspection was carried out on 8th December 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 23/12/09

Woodlands 30/06/09

Woodlands 07/08/08

Woodlands 14/08/07

Woodlands 02/10/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Woodlands 50 High Street Earith, Huntingdon Cambridgeshire PE28 3PP Lead Inspector Matthew Bentley Announced Inspection 8th December 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 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.V273747.R01.S.doc Version 5.0 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 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.V273747.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 Brief Description of the Service: Woodlands provides care accommodation and support for up to 24 older people, some of who have a degree of confusion or a form of dementia. The home is situated in the village of Earith, which is approximately 6 miles from the market town of St. Ives; from the rear of the home are good views across the River Great Ouse. Since the last inspection the previous owner has sold the home. The new provider is Farrington Care Homes Ltd; the registered manager remains in post, Residents’ accommodation is on two floors, the upper floor being accessed via a shaft lift. The home has 18 single, and 3 double rooms. 16 of the single rooms have en-suite toilets, and 4 rooms also have baths, though these are not currently used by the occupants, as they do not have the hoists or other equipment to allow access to people with reduced mobility. There are 4 toilets, one specialist bath, and a level access shower. Communal areas include 2 lounges, a dining area, and a large conservatory, all of which are available for residents’ use. A pleasant garden area leading down to the river is provided outside. Residents are supported by a team of care staff; the premises are looked after by domiciliary staff and a maintenance person. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took 6 hours and took place on 8th December 2005 between 10.30 and 16.30. The inspection was announced so that any changes resulting from the recent change of ownership of the home could be properly, and fully assessed though no significant changes were found to have occurred. The inspection was carried out by one inspector who spoke to a number of service users along with visiting relatives, staff members, the registered manager, and the area manager. The inspection also included reading documents, and a tour of the building; the manager had completed the preinspection questionnaire and 11 people completed the survey of residents/relatives views about the service. Replies to the latter were all very favourable; comments included ‘the home is excellently run and [the residents] are looked after in a very caring and professional manner’ and ‘the care, love, support, and kindness is excellent at Woodlands, both for residents and relatives. I can’t speak highly enough of Pam and her staff; they are wonderful’. One resident wrote ‘The staff are nice to me…. The food is very good. I like it here; the home is very clean’ What the service does well: What has improved since the last inspection? Systems of recording residents’ needs and how they should be met have been improved and care plans have been updated to reflect current needs. The wardrobes which, during the last inspection, were found to be dated and showing signs of wear have been replaced, screens have been provided in the shared room, a call bell has been installed in one of the communal areas in which it was previously lacking, and the system for automatically closing fire doors has been repaired. Hazardous chemicals which, during the last inspection were being stored in an unlocked cupboard, are now kept securely. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Potential and existing residents have access to information about the services they can expect, however the information is not fully up to date, so that they cannot be entirely clear about who runs the home. The home is suitable for the needs of the people living there though specialist training in the needs of people with dementia needs to be arranged so that staff members have sufficient awareness of the likely needs of people with the diagnosis and the implications for how assistance should be given. The home’s contract does not guide people properly about how to contact the Commission if they have a complaint, meaning that people may not be aware that the Commission may be approached for involvement in the process. Sufficient steps are taken to ensure that new residents are properly assessed, so that people whose needs the home cannot meet, are not admitted. EVIDENCE: The home has a statement of purpose which contains the information needed to help people who may be interested in moving in to decide whether it is likely Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 9 to be suitable for them. The document needs to be updated and revised to reflect the fact that the home is now owned by a new provider; a requirement has been made about this. Residents are provided with a contract between themselves and the home; the document needs to be updated to include the address and telephone number of the Commission in the complaints section. A requirement has been made about this, however, the manager said that new provider would be issuing residents with their own contract in due course. Since the last inspection a number of new residents have been admitted to the home; information about their needs has been obtained from care managers and other sources. The manager has taken appropriate steps to ensure that the home is suitable for meeting the needs of the people concerned, and in one case has turned down a placement due the needs of the person concerned being too great. The manager encourages people to visit the home before making a decision to move in, however, this is not always possible as recent referrals have come from hospitals and timescales have not allowed preadmission visits. Suitable aids and adaptations have been provided around the home, including ramped access from one part of the home to another and handrails to assist residents with their mobility. Access to the rooms upstairs is by stairs or a shaft lift, however, access to two rooms is via a small number of steps, so these rooms are only suitable for people who are able to use stairs. District Nurses are supportive and their input is asked for when necessary. During the last inspection the manager said that a course had been organised regarding caring for people with dementia, however, this has not taken place, and a requirement that staff receive specialist training in the needs of people with dementia has been made. The home does not provide intermediate care therefore standard 6 does not apply. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The system of care planning outlines what help each person needs and how that assistance should be given, so that staff can be clear about what they need to do. Arrangements are in place to ensure each service user receives input from relevant professionals to ensure each person’s health needs are met. Personal care is given sensitively so that individuals’ dignity and privacy are maintained. Procedures for managing service users’ medication are satisfactory and are being properly followed, so that medication is safely administered. EVIDENCE: Care plans relating to 2 residents were seen and showed the action required to meet their assessed health, personal, and social care needs. The plans have been reviewed every month and updated to show any changing needs or goals. Recording of what takes place in relation to each resident during each shift needs to be improved as there are some days when no entries have been made which implied that the people concerned were not involved in anything that took place in the home. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 11 The home is not registered to provide nursing and no nursing tasks are carried out by care staff, however, the manager said that district nurses are very supportive and carry out nursing tasks when they are needed. Staff are provided with equipment such as hoists and mobility aids to ensure that residents are safe when moving around the home. Medication is given to residents by the manager or a senior staff member, all of whom have had training. Records relating to medication were seen and found to be in order, as were the storage arrangements. Care staff were seen talking with service users whilst helping them walk from one place to another and with other tasks including eating lunch; the way they spoke was cheerful, friendly, respectful, and polite. Two residents who were unwell were being cared for in their rooms; care staff were making sure that the person concerned was properly fed and were also making sure they had enough fluids. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Staff provide appropriate support to facilitate contact with family, friends, and relatives, and residents are encouraged to make choices about their lives and are encouraged to maintain their independence. Dietary needs are well catered for, with a balanced and varied selection of food available to meet residents’ individual tastes and choices. EVIDENCE: Residents confirmed that they feel able to get up and go to bed when they choose, and decide for themselves how they spend their days. At the last inspection some people said that they would like more organised activities: the manager said that she has tried to put things in place to keep residents active though the take-up of what is offered is variable. Recent activities include exercises, games, a very well-attended carol service, and singing and dancing. A small library is available and a member of staff comes into the home most days, to sit and chat informally to people and to spend time attending to residents who need a lot of help with tasks such as eating and drinking. Visitors are welcome to visit at any time, and can be received in sitting rooms or, if they wish to have privacy, in bedrooms or outside. One person was being visited by their niece, who said that she, and the rest of the family felt able to visit at any time without making specific arrangements. She said that staff are always well-presented and welcoming and always offer her a drink; this was Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 13 backed up by people who filled in the relatives’ comment cards sent out on behalf of the Commission. Residents are free to move around inside the home and to use either their own rooms or a choice of either large lounge with a television, a large conservatory, or a smaller, quieter lounge. Personal possessions can be brought into the home; however, items of furniture and electrical equipment must meet the relevant safety standards. Residents confirmed that they are encouraged to exercise choice about what they do in the home; after lunch, people were reading newspapers, receiving visitors, and talking to each other and to staff. The main meal on the day of inspection was steak pie with fresh vegetables, followed by a selection of desserts; the alternative main course was homemade vegetarian quiche. Staff were seen helping residents with their lunch in an appropriate manner, sitting with the person concerned and helping them discretely and at the person’s own pace. The dining room is arranged so that people who need help are at one table, but are still involved in the social aspect of mealtimes. The cook prepares homemade cakes and savoury snacks every day, which are served up in the afternoon. Residents all said that they are very happy with the quality and quantity of the food in the home, and if they didn’t like what was offered, alternatives are available. Pureed food is provided for those who need a soft diet and meals are taken in the dining room in a calm relaxed atmosphere, though two people who were ill were being helped to have their meals in their rooms. Since the last inspection the cook has acted on the advice given, to make sure that food that is pureed or softened is well presented with, for instance, vegetables, potatoes and meat being kept separate rather than being mixed up together; the manager said that this has resulted in the food looking more appetising and being more tasty, which probably helps people eat a full meal. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home’s systems for dealing with complaints are generally satisfactory though some amendments are needed on the written procedures to ensure anyone wishing to make a complaint is given accurate information about who to contact. The arrangements for ensuring the protection of service users from neglect or harm are generally satisfactory, so that service users are protected from abuse or mistreatment; however, the manager needs to have the training that she has organised for her staff. EVIDENCE: The home has a complaints procedure which is included in the contract; the procedure needs to be updated to include the address and phone number of the provider, full contact details of the Commission, and the fact that complainants can contact the Commission at any stage of a complaint. A requirement has been made about this. No complaints have been received in the last 12 months, and a number of letters complementing the home on the service provided have been received by the home. The home has a ‘whistle blowing’ policy aimed at encouraging staff to report bad practice or allegations of abuse. The manager has a copy of the County Council’s Adult Protection Procedures, and staff have been provided with training on the procedures, however, the manager herself has not had the training, a requirement was made about this following the last inspection; failure to comply with this requirement may result in further action being taken against the home. Staff said that they would feel able to talk to Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 15 the manager if they had any concerns about the treatment of residents, and the manager said that she would contact the Commission or the Adult Protection Team if she had any concerns. Files relating to one of the newest staff were seen, and contained two written references, however, it did not have a Criminal Records Bureau (CRB) check nor had a Protection of Vulnerable Adults (POVA) check been carried out. A requirement has been made about this and the area manager said that she was aware that such checks must be made before staff are appointed and would ensure that company policies and procedures are followed in the future. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 The home is suitable for the needs of those living there, and sufficient equipment is provided so that service users’ independence is maximised. Effective systems are in place to ensure that the home is kept clean and hygienic. EVIDENCE: The home is in the village of Earith and is close to shops and pubs. The premises are well-maintained and have a homely and pleasant atmosphere. The gardens are accessible to people with poor mobility and are well kept, however, due to the proximity of the river, supervision would be needed for those residents who are confused. Residents have access to a range of safe and comfortable communal areas including a quiet lounge and a large conservatory. Furnishings and fittings provided, are clean, domestic in scale and design, and appear both comfortable and suitable for their purpose. Residents said that they are very happy with the accommodation provided and two respondents to the Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 17 questionnaire sent out on behalf of the Commission commented that the home is always very clean. In addition to the 16 bedrooms with en-suite facilities, the home has six toilets, a bathroom with a specialist bath, and a level access shower. A number of bedrooms have a bath installed in them; some of them are situated in the bedrooms rather than in an en suite cubicle, and appear rather out of place. The hot water being delivered to these baths is excessively hot (around 600c); the manager said that the baths are never used, however a requirement that a risk assessment be carried out on each of the baths, and action be taken to avoid possible injury, has been made. The building has been adapted to suit the needs of older people, and appropriate aids and adaptations have been provided throughout the home, including hoists and grab rails in bathrooms and toilets, and around the building. Since the last inspection a call-bell has been provided in one of the seating areas which previously lacked the facility. All bedrooms were inspected and were clean and furnished to a high standard; the wardrobes in 3 rooms which during the last inspection were found to be dated and showing signs of wear have since been replaced with more up to date furniture. Residents are able to bring personal possessions into the home as long as they meet the relevant safety standards. Two of the three double rooms are currently used as singles, and since the last inspection screens have been provided to promote the privacy of the occupants when personal care is being given. All rooms have central heating, and thermostatic values are fitted to radiators so that service users can control the temperature of their room, with support if needed. The radiators have also been fitted with covers to protect residents from hot surfaces. Pre-set valves are fitted in the specialist bath to ensure that the hot water provided does not exceed 43°C and emergency lighting is provided throughout the home and is tested each month. The home is clean, hygienic and free from offensive odours. Laundry facilities are sited in a separate out-building, therefore soiled articles, clothing and infected linen do not need to be carried through food preparation areas or places where people eat. All of the replies to the questionnaire sent out on behalf of the Commission indicate that residents and visitors find the home to be clean; one person wrote ‘Woodlands is always clean and bright, with comfortable surroundings for residents and visitors, which indicate a well fun facility’. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Sufficient staff are on duty to ensure that residents’ needs are properly met. Staff are clear about their roles and are competent though the specialist training in the needs of people with dementia (for which the home is registered) has not yet taken place, meaning that staff may not be fully aware of the implications of the diagnosis and the approach they should take when providing care. The home’s recruitment procedures need to be revised so that full checks are carried out on potential staff to ensure that unsuitable people are not employed. EVIDENCE: At the time of the inspection, three care staff were on duty, along with the manager, and catering and housekeeping staff. Two waking staff are on duty overnight and an on call system is in place in case management support is needed. Staff are well presented in a uniform, and were courteous, welcoming and helpful. New employees work alongside existing staff until the manager feels that they are competent, however, no formal induction is in place. The manager says that the new providers have a formal system for the induction of new staff and this will be introduced to the home in due course, a requirement has been made about this. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 19 The manager said that the home is still working towards the minimum requirement that 50 of care staff have National Vocational Qualifications (NVQs) by 2005 however only around 30 of staff have, or are working towards the qualification so it is unlikely that the goal will be achieved. Training is reported to have been carried out on health and safety matters such as moving and handling, and fire safety, however, records are difficult to access and it is recommended that the system of recording essential training be revised to make it clearer when updates and refreshers and due. As noted in standard 18, files relating to one of the newer staff were seen; the file contained two written references, however, no Criminal Records Bureau (CRB) check had been made, nor had a Protection of Vulnerable Adults (POVA) check been carried out. The matter was discussed with the manager, and the area manager, nd a requirement has been made that no staff are appointed until all of the necessary checks have been made and all of the required documentation obtained. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 The home is generally well-managed and staff are supported in what they do, however, more office based time would help the manager put in place systems needed to develop the record keeping, supervision and other aspects of the management role that need improving. A number of areas of health and safety have some shortfalls, which may put residents at risk of accidental harm. EVIDENCE: The registered manager, Pam Ellis, has worked at the home since 1986 when she started as a member of the care staff; she has held the post of manager for the past 10 years. Pam Ellis had completed the NVQ level 3 in care and is aware of the requirement to gain level 4 in management and care, however, no progress has been made towards registering on the course and Mrs Ellis plans to discuss the matter with the new provider. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 21 Mrs Ellis has a high presence in the home, often working alongside care staff and has an approachable and open style of management. Communication in the home is effective, and staff members, service users and relatives spoken to said that they were happy with the style of management and would feel able to approach the manager or a senior member of staff if they had any concerns or suggestions. The need for more time to be freed up so that management tasks such as staff supervision and developing quality assurance systems could be done was once again discussed, and a recommendation has been made to this effect. The manager said that she has developed some systems of quality assurance including a service users’ questionnaire however, this is likely to be replaced with the systems used by the new provider in its other homes; the effectiveness of these will be evaluated as part of future inspections. A requirement that quality assurance systems and developed and expanded has been made. No monies are held on residents’ behalf; relatives or other representatives are asked to assist residents with their finances if this is needed. Informal supervision takes place involving the manager working alongside care staff, however, only a limited number of staff have had formal supervision. A requirement that all staff receive formal supervision at least 6 times a year has been made. Staff records, and those relating to residents, do not contain all of the information required by legislation; the manager agreed that she would ensure that all of the documents and other items required would be obtained and copies kept on the relevant files. A requirement has been made about this. Staff spoken to during the inspection confirmed that they had been provided with the training necessary for them to carry out their duties safely, including training in moving and handling, and fire safety. During the last inspection, a number of potentially dangerous chemicals were found unattended in a room next to the sitting room; at the time of this inspection chemicals such as cleaning materials were locked safely away. Since the last inspection a number of automatic closers have been repaired, however, the closing device on one room is faulty and a wedge is being used to keep the door open. In addition a number of fire doors do not close properly, meaning that fire and smoke would not be properly contained in the event of a fire; requirements have been made about these matters. Records of tests of the fire alarms and emergency lighting were satisfactory. Since the last inspection the upstairs windows have been fitted with restrictors to prevent residents from falling. The hot water to the sinks in residents’ bedrooms is being delivered at a very high temperature (in excess of 590c); a requirement that corrective action is taken has been made to prevent risk of scalding. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 22 The manager has sent notification to the Commission of any incidents adversely affecting the welfare of residents as is required under Regulation 37, and the area manager is carrying out monthly inspections and providing a report to the home and to the Commission, as is required under Regulation 26. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 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 2 2 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 2 2 Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 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 OP1 Regulation 4& Sched. 1 18(1)(c) 22 Requirement The home’s statement of purpose must be updated to reflect the recent change to the registered provider Staff must be provided with specialist training in the needs of people with dementia The home’s complaints procedures must be updated to include full details of the local office on the Commission The registered manager must undertake training in the County Councils adult protection procedures. This was a requirement resulting from the last inspection; failure to comply with this requirement may result in further action being taken against the service. Staff must not be appointed until all the information required in the relevant Regulations and schedules have been obtained A risk assessment must be carried out on all of the baths, and measures must be taken to ensure that any identified risk is DS0000065969.V273747.R01.S.doc Timescale for action 15/01/06 2 3 OP4&OP30 OP16 28/02/06 15/01/06 4 OP18 13((6) 31/01/06 5 OP18& OP29 OP21 19 & Sch 2 & 4.6 13(4)(a) 08/12/05 6 31/12/05 Woodlands Version 5.0 Page 25 7 OP30 18(1)(c) 8 OP33 24 9 OP36 18(2) 10 OP38 4(c)(i) 11 OP38 4(c)(i) 12 OP38 13(4)(a) minimised or eradicated Arrangements must be put in place to ensure that new staff receive induction training in line with NTO specifications. This was a requirement resulting from the last inspection; failure to comply with this requirement may result in further action being taken against the service. The home must put in place effective quality assurance and monitoring systems based on seeking the views of service users. This was a requirement resulting from the last inspection; failure to comply with this requirement may result in further action being taken against the service. Measures must be put in place to ensure that staff receive formal supervision at least 6 times a year. This was a requirement resulting from the last inspection; failure to comply with this requirement may result in further action being taken against the service. The fire doors referred to must be adjusted to that they close properly on their intumescent strips Wedges must not be used to hold open fire doors. This was a requirement resulting from the last inspection; failure to comply with this requirement may result in legal action being taken against the service. Measures must be taken to ensure that hot water in residents’ bedrooms is delivered at a safe temperature. 28/02/06 28/02/06 31/01/06 31/12/05 08/12/05 15/01/06 Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP30 OP31 Good Practice Recommendations It is recommended that the home’s systems for recording statutory training be revised to make clearer when renewal or updated training is due. Consideration should be given to increasing management time when administrative, supervisory, and other tasks can be carried out. Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodlands DS0000065969.V273747.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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