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Inspection on 01/11/05 for Woodlands Care Home

Also see our care home review for Woodlands Care Home for more information

This inspection was carried out on 1st November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Cleanliness was good throughout the home at the time of this inspection. The atmosphere in the home was welcoming and more relaxed than at the previous inspection. Visitors were observed to be welcomed into the home and those spoken to stated they enjoy visits to the home. There is a good choice of food and the menu was on display at this time. Two signatures and the date are clearly recorded when any medication is altered. Staff spoken to at this time displayed an open attitude and were enthusiastic to learn what areas could be improved in the home.Service users stated they feel they are cared for and supported in the home.

What has improved since the last inspection?

The main lounge area is more relaxed and spacious, this has previously been quite full however, this was not the case at this inspection.

What the care home could do better:

Regular storage of medication needs to be checked as the bag of medication to be returned at this time was far too much and an unacceptable quantity. When medication is not given for any reason other than a refusal, the reason must be clearly recorded on the medication administration record. Records are very basic with only physical observations being noted, there is no indication of the actual person, their mood or of any interaction other than care being given. Staff must consider the whole person and the social welfare of those being cared for. More interaction between staff and service users needs to be undertaken. One record stated a service user was wandering during the night, the person was told it was night and the person then went back to bed. Staff did not offer a drink, sit and talk to the person or ask if they could help in any way, or if they did, this was not recorded. Staff must recognise the social needs as well as the medical needs of service users. The home is registered for 5 palliative care beds. An important part of palliative care is spending time with a person and talking with them, particularly during quiet times in the home and the night time period. There was no record of any discussions or time spent sitting with a person in the home. Staff must consider the experience of being pushed in a wheelchair, this can be very uncomfortable and can be a very frightening experience at times. There are very bad marks on walls on the upper corridor area that have been causedby wheelchairs. The corridor is wide and easily accommodates wheelchairs, there is therefore not reason for marks to be on walls. Staff are either rushing too much or leaving foot plates in the incorrect position. Incident reports are to be fully completed, stored in the correct folder and must be the original document with no use of tippex. Incidents are to be regularly reported to the care manager, next of kin and the Commission for Social Care Inspection. All records are official documents and must be completed fully with any errors must be crossed through once. While menus are on display in the dining area, consideration must be given to those with any degree of sight loss. Information on display must be in an appropriate format, large print for example, to support the needs of those in the home.

CARE HOMES FOR OLDER PEOPLE Woodlands Care Home Fairfield Road Broadstairs Kent CT10 2JU Lead Inspector Brenda Pears Announced Inspection 09:30 1 November 2005 st 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 Home DS0000065784.V251317.R02.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 Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodlands Care Home Address Fairfield Road Broadstairs Kent CT10 2JU 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) 01843 860998 01843 862865 Ashbourne (Eton) Limited Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (3), Terminally ill over of places 65 years of age (5) Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 33beds registered for nursing patients 10 are also registered for the admission of residential clients Date of last inspection Brief Description of the Service: Woodlands Care Home is a purpose built two-storey building set in gardens next to Fairfield Manor Care Centre, both of which are owned by the same company. The Home offers personal, nursing and palliative care, it is also registered to care for 3 people with a physical disability. Accommodation comprises of 28 single and one double room all with en-suite facilities. The well-kept garden and patio area are available to service users at the front of the building. The Home stands in extensive grounds, with ample parking facilities and is located in a residential area on the outskirts of Broadstairs. Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection and the inspection consisted of speaking with the newly appointed manager, staff members, service users and visitors. The methods of inspecting the home included checking records, tracking service user care plans, examining staff files, discussions with service users and visitors, observations and a tour of the building. The inspection focussed on the requirements from the last inspection, key standards and particularly the quality of life experienced by service users. As part of the pre-inspection process, residents and relatives were consulted for their views of the home. The service users and families returned their comment cards, providing valuable feedback about the home, which helped in the planning of this inspection. The home was found to be clean and odour free and service users were fully included in this inspection. Visitors were relaxed and welcomed into the home at this time and staff were observed to be undertaking their duties with due consideration for dignity and choice. The home has been without a registered manager for some months during which time, the deputy manager has been overseeing the home. A newly appointed manager is now in place and was present during this inspection. What the service does well: Cleanliness was good throughout the home at the time of this inspection. The atmosphere in the home was welcoming and more relaxed than at the previous inspection. Visitors were observed to be welcomed into the home and those spoken to stated they enjoy visits to the home. There is a good choice of food and the menu was on display at this time. Two signatures and the date are clearly recorded when any medication is altered. Staff spoken to at this time displayed an open attitude and were enthusiastic to learn what areas could be improved in the home. Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 6 Service users stated they feel they are cared for and supported in the home. What has improved since the last inspection? What they could do better: Regular storage of medication needs to be checked as the bag of medication to be returned at this time was far too much and an unacceptable quantity. When medication is not given for any reason other than a refusal, the reason must be clearly recorded on the medication administration record. Records are very basic with only physical observations being noted, there is no indication of the actual person, their mood or of any interaction other than care being given. Staff must consider the whole person and the social welfare of those being cared for. More interaction between staff and service users needs to be undertaken. One record stated a service user was wandering during the night, the person was told it was night and the person then went back to bed. Staff did not offer a drink, sit and talk to the person or ask if they could help in any way, or if they did, this was not recorded. Staff must recognise the social needs as well as the medical needs of service users. The home is registered for 5 palliative care beds. An important part of palliative care is spending time with a person and talking with them, particularly during quiet times in the home and the night time period. There was no record of any discussions or time spent sitting with a person in the home. Staff must consider the experience of being pushed in a wheelchair, this can be very uncomfortable and can be a very frightening experience at times. There are very bad marks on walls on the upper corridor area that have been caused Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 7 by wheelchairs. The corridor is wide and easily accommodates wheelchairs, there is therefore not reason for marks to be on walls. Staff are either rushing too much or leaving foot plates in the incorrect position. Incident reports are to be fully completed, stored in the correct folder and must be the original document with no use of tippex. Incidents are to be regularly reported to the care manager, next of kin and the Commission for Social Care Inspection. All records are official documents and must be completed fully with any errors must be crossed through once. While menus are on display in the dining area, consideration must be given to those with any degree of sight loss. Information on display must be in an appropriate format, large print for example, to support the needs of those in the home. 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 Care Home DS0000065784.V251317.R02.S.doc Version 5.0 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 Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Pre admission assessments are carried out to ensure any decision to move into the home is appropriate. EVIDENCE: The admission process and assessments have been thoroughly carried out and full care plans developed. Files contain information to support service users and to ensure the needs of the individual can be met. Woodlands Care Home DS0000065784.V251317.R02.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 & 11 Care plans clearly set out the health needs of service users and these are being met by staff and through contact with appropriate health care teams. Incidents are not fully completed, contained tippex corrections, are not placed in the appropriate file and the appropriate agencies are not informed, this is not fully protecting service users. Care plans are to be reviewed on a monthly basis and files must evidence this to ensure care needs are appropriate at all times. Service users are treated with respect and privacy is upheld. While care plans do contain all areas of care needs, currently, staff do not fully support the whole person or consider an holistic approach, this is omitting many areas of care and support. Medication is stored appropriately and the medical room was found to be orderly and clean with temperatures being recorded. However, records do not contain complete information and all medication must be controlled more closely to ensure the minimum amount is stored in the home to comply with guidelines set by the Royal Pharmaceutical Society. Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 11 EVIDENCE: Records evidence that residents’ health care needs are identified and responded to appropriately. The involvement of general practitioners, community nurses, dentists, opticians and other relevant health practitioners are all clearly recorded. Care plan assessments are completed and a copy is placed at the front of each service user file, but care plans have not been reviewed on a monthly basis and the information contained in care plans is not being followed. On the day of this inspection a service user had a fall after being left on the commode when this person’s care plan clearly stated they were not to be left on the commode alone. The manager contacted the next of kin and the care manager to undertake a full investigation of this incident. Another record showed a person wandering during the night, this person was told it was night time and so returned to bed. There was no record of any conversation, or offers to make a cup of tea or any mention of staff accompanying this person to their room to ensure they were settled. Records on daily reports contain physical observations but do not give any indication of the mood of the person, how the day was spent or if the person was chatty, quiet or perhaps talking with others. These observations give an idea of the mood of the person and is just as useful and informative when considering appropriate support as the physical signs shown. The home is registered to support up to 5 people who require palliative care. Again, while physical needs are met and recorded, staff need to pay more attention to the whole person and consider all aspects of a person’ s care needs. Terminal illness requires staff to take time to sit and talk to the individual and to ensure regular checks are carried out. Records do not show this is currently being undertaken and this must then bring into question this particular category of registration. Observations, conversations with service users and visitors and questionnaires received prior to this inspection confirm that staff do consider privacy and treat service users with respect. Copies of incident reports were not found in the appropriate file, one report was found to be insufficiently completed with tippex corrections and the appropriate agencies/people are not being informed following an incident. Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 12 While medication is stored appropriately and the medical room was found to be orderly and clean, records are not being fully completed. Records do not have a reason for medication not being administered when the reason is other than a refusal. Medication has also been over prescribed by doctors and this must be monitored more closely to ensure the minimum amount of medication is stored in the home. The manager explained that a meeting is being held with the local pharmacy to ensure good practice are undertaken to enable the home to control the amount of medication received. Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 & 15 Physical needs of service users are met by the home and family, friends or advocates are encouraged to maintain contact, creating an open atmosphere. An activities organiser does undertake group and individual recreational activities and outings are also enjoyed when possible. Service users would benefit from more interaction with staff during their daily routines, this would create a more inclusive environment. A variety of meals are offered at all times and alternative choices are available, but attention must be paid to all cultures. Staff need to talk to service users to ask what is needed to meet individual requirements other than vegetarian and diabetic. EVIDENCE: Care plans, discussions with service users and comments made on the questionnaires received all confirm that service users feel they are supported in the home. Visitors were observed being welcomed into the home during this Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 14 inspection and service users stated that family and friends are always welcomed. Staff were undertaking their duties in a confident manner but there was very little interaction or conversation with service users. Chatting and including people in the inspection process would support those living in the home to enjoy a more interesting atmosphere and break from the regular routines. An activities organiser undertakes some group activities with service users such as bingo, art, a quiz, keyboard, light exercise and outings where possible. The home does not have a vehicle to undertake outings but currently a vehicle is hired for outings. Individual talks and discussions also enable the activities organiser to become aware of what is important to the individual. One service user spoke of the e-mails that are received by the activities organiser from her son abroad and these are then passed to her. Pictures are also taken and then attached to e-mails for family and friends to enjoy. A magazine is produced every 3 months for service users to enjoy information about the home, about new service users and celebrations undertaken in the home. Some people express their worries during individual discussions and the activities person is then able to find activities, books or films to help the person cope with their worries. Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): While not directly inspected at this time, complaints or matters needing attention have been dealt with appropriately and with due consultation being undertaken with those concerned. EVIDENCE: Woodlands Care Home DS0000065784.V251317.R02.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 & 26 The home was found to be clean and, in the main, hygienic at this time. However, some areas do have a stale odour and new carpeting and redecoration is needed throughout the home. Office space in the home is minimal and space does not currently support staff or provide an appropriate area to complete records or undertake confidential discussions. EVIDENCE: The Home is on 2 floors with 2 lounge areas and a dining room. The smaller lounge currently accommodates 2 service users and this area is also used by visitors who wish to talk in private with service users. Corridors are wide and easily accessed by wheelchair users but staff must consider the experience of being pushed in a wheelchair as this can be very uncomfortable and often a very frightening experience. There are very bad Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 17 marks on walls along the upper corridor area that have been caused by wheelchairs. The corridor is wide and easily accommodates wheelchairs, there is therefore no reason for marks to be on walls. Staff are either rushing too much or leaving foot plates in the incorrect position. Radiators are covered in the communal areas, while this ensure safety, the covers are made of wire and do not create a homely atmosphere. Bathrooms and toilet areas do not have radiator covers. One particular radiator is positioned very close to a toilet, creating a risk to service users should the radiator be hot or if legs hit the rough edges of the radiator. Some internal redecoration has been undertaken but there are still many areas needing attention. The external structure of the home is to be redecorated commencing in February 2006 but the inside of the home is greatly in need of upgrading. A new conservatory is to be constructed and will be attaché to the front lounge area. This will provide additional lounge space, allow more light into the home and will give service users an uninterrupted view of the front garden area. Consideration will need to be given to a smoking area for service users as the area to the front of the building is currently used for this purpose. The construction of a conservatory will eliminate this space and as there are still some smokers in the home, this will need some attention. A walk-in shower is also to be created on the ground floor of the home to offer a choice to service users when bathing. Office space in the home is minimal and this does not currently support staff or provide an appropriate area to complete records or undertake confidential discussions. During this inspection, the manager was forced to leave the building and undertake private conversations in the front garden area. This will certainly not be possible during winter months and does not support staff when needing to speak with the manger in private. Service user reviews, meetings with families or advocates, supervision are all compromised by this total lack of adequate space. Some rooms have doors open for those who are confined to bed, this is not ensuring full safety for service users, although this does create an inclusive atmosphere. Sonic alerts were discussed with the manager at this time, as these are easily installed, are cheaper than most fire alerts and automatically close doors when the fire alarm sounds. Woodlands Care Home DS0000065784.V251317.R02.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): 28,29 & 30 Service users stated in questionnaires and in discussions at this time that they feel safe in the home, but particular attention must be paid to care plans to ensure the full safety of service users is maintained at all times. The recruitment process is thorough with staff demonstrating an enthusiastic and open manner when discussing their roles. There is a training matrix in place to ensure refresher and core training is up to date at all times, however, support for the needs of individual service users must be incorporated in the training programme to fully support every person living in the home. EVIDENCE: Staff only commence work after the appropriate checks and references are obtained to ensure the safety of service users at all times and a sampling of staff files evidenced this. A training matrix is in place to monitor refresher courses and core training but some training in areas that support the needs of individual service users must be incorporated in the training programme. Individual needs must be supported such as those service users who are visually impaired or blind, those with any degree of hearing loss or training with regard to being guided or sitting in a wheelchair. These areas of awareness fully support individual Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 19 needs and enable staff to fully appreciate how a person experiences daily routines and how staff can make life easier and more comfortable. The staff group has at least one person with a visual loss and again, attention must be paid to specific needs with regard to the correct size of print and appropriate consideration around the home itself. Woodlands Care Home DS0000065784.V251317.R02.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 & 38 The manager is a fit person to undertake full responsibilities in the home. While there are some areas needing attention and action, the manager and staff group, in the main, do consider the health, welfare and safety of service users. EVIDENCE: Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 21 The newly appointed manager has been in nursing since 1980 in a variety of settings including elderly care, psychiatric and mental health and with experience in a local hospital working with stroke victims. Meetings have been undertaken with service users, family members and the staff group. Although induction is currently being undertaken, the manager is aware of areas needing addressing and is prepared to deal with these matters immediately. While there are requirements regarding some areas in the body of this report, in the main, staff do try to ensure the safety and well being of service users. This was confirmed in questionnaires received and through discussions with service users and visitors at this inspection. There are clear signs for emergency and fire exits, fire extinguishers are appropriately placed, clearly signed and serviced. There were no COSHH items in evidence, and cupboards/areas posing a risk were appropriately locked at this time. The fire alarm is tested regularly but must be regularly recorded in the appropriate fire log book. However, the full well being and safety of service users is only achieved when recording is correctly completed to ensure information is shared, when incidents are recorded in all appropriate areas and when the details set out in care plans are known to staff and fully carried out at all times. Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X 2 STAFFING Standard No Score 27 X 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 2 Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 14 & 17 Timescale for action Incidents are to be fully recorded 02/11/05 and reported to appropriate agencies Care plans are to be reviewed on a monthly basis and staff must be familiar with all service user needs Care plans must be more detailed and evidence the full care given. Medication stores must comply with guidelines set by the Royal Pharmaceutical Society Risk assessments must be completed for all uncovered radiators and all risks minimised. Staff must interact with service users at all levels to fully assess and meet needs 18/11/05 Requirement 2 OP37OP7 14 & 17 3 OP37OP7 14 & 17 02/11/05 OP9 4 OP38 5 OP12 6 OP30 7 13 02/11/05 12,13,16 & 23 12 & 16 02/12/05 02/11/05 16 & 19 All training to be undertaken that 14/11/05 fully supports individual service user routines and needs Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 24 8 09 OP38 OP38 12 & 13 12,13,16 & 23 12,13,16 & 23 The fire log must be in good order and up to date. All open doors are to be risk assessed and appropriate fire safety installations obtained. Risk assessments to contain appropriate information to support outcomes at all times. 02/11/05 02/12/05 10 OP38 18/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP26OP19 Good Practice Recommendations 16 & 23 The internal redecoration programme to continue to improve the environment for the comfort and well being of service users. Woodlands Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Care Home DS0000065784.V251317.R02.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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