Inspection on 28/08/07 for Woodlands Care GRP Ltd

This inspection was carried out on 28th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodlands Care GRP Ltd 01/03/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodlands Care GRP Ltd 22 Woodlands Drive Atherton Manchester M46 9HH Lead Inspector Judith Stanley Unannounced Inspection 28 August 2007 09:00 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 Care GRP Ltd DS0000067718.V345020.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 Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Care GRP Ltd Address 22 Woodlands Drive Atherton Manchester M46 9HH 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) 01942 875054 F/P 01942 875054 Woodlands Care GRP Ltd Mrs Janet Hope Care Home 30 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (30) of places Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 30 service users to include: up to 30 service users in the category of Older People; up to 10 service users in the category of DE(E) (Dementia over 65 years of age). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The service should at all times employ suitably qualified and experienced members of staff, in sufficient numbers, to meet the assessed needs of the service users with dementia. The service should ensure that all staff receive training in dementia care and ensure refresher training also takes place. 1st March 2007 2. 3. 4. Date of last inspection Brief Description of the Service: Woodlands offers personal care and support for up to 30 residents over the age of 65 years. Included in those numbers the home can offer care to 10 residents with a dementia related illness. Woodlands is on the Bolton and Atherton border and is set back off the main road up an unmade road. Local amenities are a short drive away from the home. The home is a large detached house set in it’s own grounds with wellestablished gardens to the front and the rear of the home. The garden at the rear is private and secure. Limited car parking is available at the front of the home. The home is a two-storey building with bedrooms, bathrooms and toilets on both floors. The home offers 26 single rooms of which 6 have en suite facilities and two double rooms of which 1 has an en-suite facility. There are three lounges and a separate dining room. The current scale of fees per week ranges from £370.00 - £395.00. Additional charges are made for private chiropody, hairdressing, personal toiletries and pet food and pet costs (a resident has brought her cat with her when she moved into the home). Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included a site visit, which the home did not know was going to happen and was conducted over one day. The inspector was assisted during part of this inspection by an “expert by experience”. This is a person who has received some training in what to look for in a care home setting and chats to residents about the care they receive and about for example activities and food. The “expert by experience” completes a written report of the findings of which excerpts will be included in this report. The inspector arrived at the home at 09:00 am and stayed until 16:00 pm. The “expert by experience” arrived at 10:00 and stayed until 14:00. The inspector spoke with the manager and checked information the home holds on residents (care plans) and other records the home needs to keep to ensure the home is being properly run. The “expert by experience looked around the home, checking the environment, the laundry facilities, checked what activities were available, had lunch with the residents and spent time chatting with residents. Prior to the inspection the manager was asked to complete and return to the CSCI an Annual Quality Assurance Assessment (AQAA). This provides the inspector with information on how the home meets the National Minimum Standards, what the home does well and in what areas the home can improve on. To find out more about the home comment cards where sent to residents, relatives and other people who visit the home, such as doctors and district nurses. Six residents, four relatives and two other visitors returned comment cards. One resident said, “I am happy here, if I had any concerns I would speak to Janet (manager)”. No extra comments were made but of the returned comment cards residents seemed happy with the home, staff and the care provided. One relative said, “ The staff at Woodlands are very caring people, my mother loves living there and she was one that always said she would not go into a home. The staff have made her very welcome and this has helped her settle very quickly so I think the home does very well in caring for the residents”. Another said, “ I visit my mother every other day and during the time she has lived at the home she has always been pleasant when I see her. She is obviously happy with the people she is with and with the environment. The home plans a number of activities each day and displays the results of these. Relatives and friends are encouraged to join in. The bedroom is clean like the rest of the home and it feels like ‘mums own space’. The food is nutritional Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 6 and well balanced, plenty of variety and staff are always pleasant and helpful to visitors”. One of the tutors that visits the home to assess for NVQ training has said, “ I have observed several staff on many occasions the staff appears to have adequate training for the service users needs. The home delivers care to a good standard.” The hairdresser that visits the home regularly said, “ I enjoy working at the Woodlands finding it a very pleasant atmosphere, where residents are all looked after well. If there is for example a scalp problem and it is needed to be looked at, the home will act on my request and medication will be provided for their next hair appointment”. There have been four complaints made to the manager of the home since the last inspection, two regarding the security of the home, in that a service user has attempted to leave the premises, this has now been addressed and keypads have now been fitted. Another two complaints refer to the state of the road, which is an un-adopted road and it very uneven. Measures are being considered by the owners of the home to address this. No complaints have been made to the CSCI since the last inspection. The home is currently undergoing major building works. A new extension on the rear of the home will offer six more en suite bedrooms with access to a terraced area. At the front of the home, work on the grounds and car-parking facilities is ongoing. The workmen and noise from the machinery is not conducive to offering a relaxed environment, however residents did not seem to be to disturbed and work should hopefully be completed by February 2008. What the service does well: The home is a well-managed and well run home ensuring a good standard of care for the people living there. Residents have everything they might need to live a comfortable life. If something is needed, relevant to a person’s health and well - being, arrangements are made for it to be obtained. The premises are clean and safe and the standard of the accommodation is good. Several of the staff had worked at the home for a long time, so residents are cared for by people they know and trust. Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 7 The home offers different communal areas so residents have a choice of where they sit and with whom they wish to spend time with. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodlands Care GRP Ltd DS0000067718.V345020.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 Care GRP Ltd DS0000067718.V345020.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): 2 and 3 were assessed. Standard 6 does not apply as the home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A full pre admission assessment is carried out to ensure that the home can fully meet the needs of the individual. EVIDENCE: All residents were provided with a written contract/ statement of terms and conditions regardless if the local authority funds them or they are self funded. Contracts detail information about the overall care and services, including food covered by the fee and any additional charges, who is responsible for the payment of fees, and the terms and conditions of occupancy. Three care plans were chosen for inspection. On examination all contained pre admission assessments to ensure that the resident’s health, personal and Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 10 social care needs could be met. Assessments are carried out at the most convenient place for the prospective resident, either at their own home, hospital or if preferred at Woodlands. The assessment is detailed and covers the residents well being, weight, hearing, vision, speech, skin condition, feet and oral care, mobility, what they need help with, medication and diet. The assessment provides staff with the information they need to ensure the individuals care needs can be met and provides the base line for the drawing up of the care plan. Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are clear and provide staff with the information they need to meet the needs of the residents. Personal support was offered in such a way to as to promote and protect resident’s dignity. EVIDENCE: Three care plans were chosen for inspection. The information contained in the care plans gave staff detailed information about the care each resident required. One care plan looked at was that of a resident who had only just moved in to the home. There was sufficient information for staff to offer the appropriate care to the resident. Other information in the care plan includes risk assessments, for example, moving and handling, mobility around the home, bathing, and individual risk assessments in the event of fire. Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 12 There was evidence to demonstrate in the care plans that outside agencies, such as doctors, district nurses and the chiropodist are contacted and visit the home as required. Observation throughout the inspection showed that the personal care needs of the residents were being met. Attention was given to personal grooming and residents were seen to be clean and their clothes were nicely washed. This was also confirmed by the “expert by experience”, who said, “ The residents appeared to be well dressed and clean in appearance. One staff member spilled juice on to the back of a ladies cardigan accidentally. This was changed immediately and a fresh garment put on”. Staff were seen knocking on doors and waiting for a response before entering the room. Staff were heard speaking with residents in a respectful and friendly manner and it was evident that staff had a good understanding of the needs of the residents and that good relationships had been formed. The senior on duty gives out the medication. Staff have received training in the safe storage, administration and in the recording of medication. Residents were given medication in an appropriate manner and offered water to help them swallow them. Medication was then recorded on the individual’s drug sheet. Woodlands Care GRP Ltd DS0000067718.V345020.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 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a range of activities to meet their needs and expectations. EVIDENCE: There has been a noted improvement in the range of activities provided. On the day of the inspection a member of staff was sat with residents in the main lounge and they were having a quiz. Residents appeared to be enjoying themselves and the member of staff made it light hearted and fun. Other residents were seen playing a ball game. The “expert by experience” spent time observing and talking with the residents and staff about the activities provided and was told that baking was normal on Tuesdays and the products are usually eaten for lunch. This activity was sadly cancelled this week due to a member of the kitchen staff being off sick. Some staff had been on a ‘Moving More Often’ course, which they found useful in understanding how the bone structure and its degeneration can affect movement. The “expert by experience” checked the activity file and saw evidence of recorded activities as Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 14 the file contained details of work being done by residents. There were details of what residents preferred to do such as card making using foam cut out stick-ons and drawing and colouring. The “expert by experience” said, “There appeared to be a great interest in the new musical instruments purchased by the home. There was hesitancy at first by some residents but inclusion very quickly when they realised that the experience can be enjoyable, for example tambourine, maracas, desk bell board and drum. These instruments can create music very effectively; I tried”. There was evidence that residents have had clothes parties, Easter egg raffle. On Sunday afternoon residents can enjoy a glass of wine and cakes. Music is offered in different forms such as Mood Music. The home have recently purchased a fabric parachute, this is a good way to encourage upper body exercise and residents confirmed they enjoyed the activity. The “expert by experience” said, “Activities are planned not just if possible and when staff have time”. She went on to say, “ I felt that great effort was made to give pleasure and enjoyment to the residents. The programme was inclusive of all abilities. I did not ask whether there was a named person responsible for the planning and delivery of the activities but it was obvious that the manager was very involved. There is a good budget annually allowed for activities. This was obviously spent when looking at games provided and baskets full of art materials. Activities are listed and graded – Intensity Key: High, Medium and Low. This is to include everyone and looks at people who are chair bound rather than by pass them. In conclusion not all residents will join in the activities on offer but I really feel that they had a choice”. Visitors are welcome to visit the home at any time; there are no restrictions on visiting times. Residents can meet with visitors in one the lounges or in the privacy of their own rooms. Visitors spoken with during the inspection expressed to the inspector their satisfaction of the home, the staff and the care provided. The manager and her staff welcome and encourage links with the local community. Relatives and friends are welcome to take part in events that are taking place. The menus were available for inspection. These were in a rough draft as they were being reviewed. The menus offered a nutritious and well balanced diet with a variety of food offered. The home has reverted back to having two sittings at lunchtime so that staff are available to assist residents that need more help eating their meals. The “expert by experience” joined residents for lunch on the second sitting, she said, “ The dining room has apparently undergone improvements with the Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 15 kitchen adjoining the dining room with a serving hatch. The kitchen units were all new. There is a hand washbasin in the dining room with disposable hand towels and waste bin. The tables had fresh flowers on them, tablecloths, glasses for water or juice and serviettes. I noticed that the staff did not go into the kitchen. The cook served from the hatch. I sat with a group of five residents. One lady came to the table in a wheelchair and was asked whether she wanted to stay in the chair or not. Corned beef hash arrived with beetroot. The hash was nice but not very warm, the plates were cold. The sweet was mincemeat meringue, fresh fruit, or a strawberry mousse. Plates were promptly cleared. Hot drinks were offered. Most has a cup or beaker of tea. I received a half cup of tea without a saucer as did others”. A lighter afternoon tea is served with choices available. The day’s menus are written on a board in the lounge. Suppers are available before residents retire. Hot and cold drinks and snacks are served during the day. Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 16 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 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be confident that residents will be protected from abuse and have their rights, including the right to complain, protected by staff training and procedures. EVIDENCE: A complaints procedure exists and records of complaints are kept and properly recorded, along with the outcome. The manager said there had been four complaints made since the last inspection. Two are indirectly out of the manager hands as they are about the state of the un-adopted road leading to the home. The owners of the home are giving this consideration of how is the best way to address this. The other complaints are regarding a resident trying to leave the premises and grounds. This matter has been addressed suitably and safeguards have been put in place. The CSCI have not received any complaints about the home since the last inspection. Most staff had now undertaken training in the protection of vulnerable adults. There have been no safeguarding referrals made since the last inspection. Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 17 Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 18 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 and 26 were assessed Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home in maintained to a good standard making it a homely, comfortable, clean and pleasant home for residents to live in. EVIDENCE: Despite the huge amount of building work in progress to the rear and front of the home, the staff have kept the running of the home as smooth as possible and tried to ensure that the building work has not impinged on the day to day life of the residents. Some residents said they enjoyed watching what was going on and that it would all be very nice when finished. The interior of the home was clean and tidy and no odours were detected. The lounges and dining room were found to be comfortable and fit for purpose. Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 19 There are proposed plans for refurbishment inside the home when the extension is completed. The “expert by experience” looked around the home and found that rooms were comfortable and clean and contained peoples personal belongings including pieces of furniture and TVs. In one room is a married couple and they had brought with them their own bed, embroidered pictures and table lamps. They are waiting for a new suite to be delivered. Systems are in place to control the risk of cross infection. Staff were observed wearing different aprons for different tasks. The laundry is sited in the cellar away from food storage and food preparation and does not intrude on the residents. In the proposed plans the laundry is to move upstairs. Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be sure that their needs can be met with appropriate staffing levels and with a competent staff team. EVIDENCE: The staff rota showed that there were enough staff on duty to meet the needs of the residents. The ratio of staff to residents takes into account the needs of the residents. Domestic and kitchen staff are employed in sufficient numbers to cater for the needs of the residents and to support care staff. Several of the staff had worked at Woodlands for a number of years and from discussions, staff showed they know the residents needs well. Staff were clear about their work they were employed to do and that they were happy to help one another out. From the inspectors’ observations staff morale appeared to be good and the staff seemed happy to be working at the home. Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 21 The home’s manager is well supported by the head of care who, has recently achieved NVQ level 4 in care and is now working to complete the registered managers award. Three staff employment files were chosen for inspection. The files contained written application forms and CRB disclosures. One file had two written references, another of a long - standing member of staff had one written reference and another had none. This was discussed with the manager and the explanation given was that the member of staff with no references had come to work at the home and had had no other job and that the manager was her referee. If this is the case the manager should submit a reference and ensure that a character reference is obtained. There were no individual job descriptions on files, the manager told the inspector that a job description for each role was kept in the office and that staff all are given a copy of commencement of employment. Training is progressing well and staff files evidenced that staff had completed mandatory training and other training for example in dementia. Staff undertakes a full induction programme on commencement of work. There was evidence in one new starters file of the induction programme being worked through as required. Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Woodlands is well run by a well qualified and suitably experienced manager whose main concern is to ensure a high standard of care for the residents living at the home. EVIDENCE: The home’s manager has a significant number of years experience in working with elderly people and is qualified to NVQ level 4 in care and had the Registered Manager’s Award. Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 23 The manager is committed to her own training and that of her staff team and sees this as essential element to delivering good quality care for the residents. There are clear lines of accountability and seniors are encouraged to expand their skills, for example some supervision of some staff. The way in, which the home is managed, is open and transparent. The home’s manager operates an ‘open door’ policy so that she may be approached at any time by staff or residents or their families. During the inspection this practice was observed when the manager spent time with a relative looking at the new plans. The office is organised so that staff have access to all the paperwork and contact information they need during a shift. There are additional systems in place to check that everything is recorded when it should be and kept up to date. There is a system of continuous self-monitoring in the home, which includes satisfaction and quality surveys. There is internal auditing of the records and weekly/monthly audit checks within the home. It was noted that there were gaps in the monthly reports that must be carried out under regulation by the company or a director of the company or an appointee. Since November 2006 to June 2007 there were only four reports available for inspection. Some residents living at Woodlands have handed over the responsibility of their financial affairs to their families but keep a small amount of money with the manager for safekeeping. A sample of residents’ monies was checked and found to be in order and matching the written records. The manager describes the process of staff supervision, which ensures accountability and support for staff at all levels. Staff are now being supervised at regular intervals throughout the year. Records kept and required by regulation were seen to be in good order and up to date, all records are kept securely as required. Equipment and systems used in the home are serviced and maintained, and records are well kept and easily accessible. The following checks have taken place and certificates were available to verify that: Gas: 27/02/07 Electrics: 22/07/07 Lift: 26/06/07 Fire inspection: 21/02/07 PAT (electrical equipment) 06/08/07 Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 24 The home’s fire risk assessment had recently been reviewed and checked by the fire officer during his visit to the home in February 2007 and has taken in to account the building work in progress. Accident, injuries and incidents are recorded properly and reported to the CSCI as required. Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 25 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 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 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 x 2 x 3 x x 3 Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP29 Regulation Schedule 2. 3 Regs 7,9 19 26 Requirement You must ensure that two written references, including, where applicable a reference relating to the person’s last period of employment. The responsible individual or one of the partners or an appointee must visit the home monthly and provide a written report of their findings. These must be on site and available for inspection. Timescale for action 26/10/07 2 OP33 26/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodlands Care GRP Ltd DS0000067718.V345020.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!