CARE HOMES FOR OLDER PEOPLE
Woodlands Care Home Fairfield Road Broadstairs Kent CT10 2JU Lead Inspector
Christine Grafton Unannounced Inspection 20th August 2007 09:25 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.V346046.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 Home DS0000065784.V346046.R01.S.doc Version 5.2 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 www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Mrs Andrea Callow Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing only - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 33. Date of last inspection 30th September 2006 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. Ashbourne (Eton) Ltd is the registered company, which is a subsidiary of Southern Cross Healthcare. Accommodation comprises of thirty bedrooms that are all currently used as singles, but this number includes three larger rooms that can be used as doubles. All bedrooms have en-suite toilet facilities. There is a lift to the first floor and ample bathroom and toilet facilities. Communal areas consist of the main lounge, a very small lounge and dining room. There is a well-kept garden to the side and patio area at the front of the building for residents’ use. Shared parking facilities are available to the front and the home is located in a residential area on the outskirts of Broadstairs. The home offers personal and nursing care. There is always at least one registered nurse on duty, with a team of carers and ancillary staff that deal with cooking, cleaning, laundry, administration and maintenance. The fees for support from the home are set during the assessment period and are very individual to the needs of the individual, depending on the level of support required and the staffing numbers provided. The manager stated that the average fee levels at this time are from £580.00 to £680.00 per week. Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report takes account of information received since the last inspection, including a visit to the home. An unannounced visit took place on 20th August 2007 between 09.25 hours and 17.05 hours. The visit included talking to the manager, four staff members, twelve residents and one visitor, looking at some records and undertaking a tour of the home. Observations of the home routines, activities and staff practices have also informed judgements made in this report. The manager submitted an annual quality assurance assessment prior to the visit that has also been used in the assessment of this service. At the time of the visit there were twenty-eight residents living at the home. What the service does well: What has improved since the last inspection?
Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 6 The quality of care provided to residents has been enhanced by improvements in the home’s care planning system. Care plans have been developed to make sure they consider the whole person, rather than just their physical and health care needs. Things that are important to a person’s psychological and social well-being are recognised and action taken to make sure that such needs are fulfilled. The redecoration and refurbishment programme has continued and has improved the quality of environment for residents, making it feel homely and welcoming. A number of bedrooms have been redecorated, some have new furnishings and some new profiling beds have been provided. The new beds are electrically adjustable to a variety of positions and provide extra comfort and support for those needing to spend a long time in bed. A new sensory garden has been created in the grounds with raised beds of bright coloured and scented plants and wind chimes. This garden is still in its infancy, but it provides a pleasant area that can be reached by a pathway that people in wheelchairs, or those just getting mobile, can use for exercise, fresh air and to stimulate the senses. Fire safety installations have been added to a number of bedroom doors where residents wish them to be kept open, so that they will close automatically in the event of a fire. This provides added fire protection and is a better safeguard for them. What they could do better:
The home’s statement of purpose and service users’ guide need some minor amendments so that residents and people considering moving into the home can be confident about their accuracy. The manager has recognised that a special chair is needed to meet a resident’s changing needs and she indicated that one would be provided for the resident’s safety and comfort. The medication room temperature is monitored and there is an air conditioning unit. However, at the time of the visit the room temperature was excessively low. There needs to be a method of monitoring and maintaining the room temperature to ensure that medicines are stored at the temperature recommended by the manufacturers. Training on abuse and the protection of vulnerable adults needs to be provided to make sure that all care staff know what to do to safeguard residents from being placed at risk of harm. Recruitment practices need strengthening to ensure that robust checks are always completed prior to new staff commencing work at the home to fully ensure residents’ safety.
Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 7 The provision of additional communal space would be of benefit to residents to ensure they have enough communal seating and recreational space, other than in their bedrooms. This is important to support their activities, to meet individual needs and specifically relates to the planned conservatory identified at the last two inspections that has been put on hold. A review of staffing levels needs to be carried out and any necessary action taken to ensure there are always enough staff on duty to meet the diverse needs of residents being cared for, taking account of the layout of the home. Better recording of staff induction training would not only confirm that this is being properly completed, but would also provide a basis for staff future development and training. Staff do receive supervision from senior staff, but their one to one meetings could be better planned to ensure regularity. This provides dedicated time to consider all aspects of practice and career development. The manager has already recognised most of these things as areas for improvement and indicated her commitment to addressing the matters that she has control over. Senior management need to ensure that the improvements identified are appropriately resourced, implemented and maintained. 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 Home DS0000065784.V346046.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 Home DS0000065784.V346046.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): 1, 3, 4, 5 & 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People moving into the home can be confident that they will be given the information they need to make an informed choice. The home’s admission procedure ensures that any decision to move in is appropriate and that the home can meet the person’s needs. Intermediate care is undertaken with appropriate support to maximise independence and facilitate a speedy return home. EVIDENCE: The home’s statement of purpose and service users’ guide are kept readily available for visitors to see in the entrance hall. A copy of the service users’ guide is placed in each bedroom for residents and their relatives to read. Copies of the documents were seen to contain all the necessary information. It
Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 10 was discussed with the manager that the date should be added to each document so that it can be seen when they have been reviewed. Another amendment needed is to ensure the correct details for the local office of the Commission. Both documents state that the home is owned by Southern Cross Healthcare. As the registered provider for the home is Ashbourne (Eton) Limited, this needs to be made clear in the documentation that the registered company is a subsidiary of Southern Cross Healthcare. From the case tracking, it was seen that the home undertakes a very thorough assessment prior to agreeing to admit a person to the home. Care plan files seen contained the pre-admission assessments, full admission assessments and detailed care plans. The manager stated that either she, or her deputy, visit prospective residents to assess their needs to make sure that the placement is appropriate. In the home’s annual quality assurance assessment, the manager has indicated that if appropriate, potential residents are offered the chance to spend a day at the home prior to admission, or if a bed is available, they are invited for a short stay first to assess the home’s suitability for themselves. Intermediate care and rehabilitation is undertaken using appropriate equipment, plus assessed support from care staff and healthcare professionals. Care is provided to enable a full recovery and to ensure independence is achieved and maintained. A resident and their relative both commented how much they appreciated the intermediate care service provided that had helped in the resident’s recovery. The person was looking forward to returning to an independent lifestyle in their own home and stated that this was thanks to the good care received at Woodlands. Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Improvements to the care planning system have made sure that staff have all the information they need to provide consistent care. Residents receive good health care support and they are protected by the home’s procedures for managing their medication. EVIDENCE: Detailed care plans have been drawn up for each resident with their involvement and that of their relatives where possible. Care plans are holistic and cover a wide range of needs in line with current clinical guidance. Appropriate risk assessments are recorded where there are high dependency needs, such as: nutrition, skin integrity, tissue viability, risk of falls and intervention plans are in place. Since the last inspection, work has continued to develop and improve the care planning system. Care plans now include informative life histories with social, psychological and spiritual needs
Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 12 identified. Personal and healthcare needs are well recorded and regularly reviewed. Contacts with healthcare professionals are clearly referenced. From the case tracking it was possible to follow an audit trail and cross reference the various sections of the care plans to follow up healthcare issues and see how risks are being managed. Falls and wound care are closely monitored and where necessary referrals are made to other health care professionals for advice, such as the tissue viability nurse. Information about an unusual medical condition had been researched and put in one care plan, so that all staff would be able to recognise symptoms of deterioration. Care plans are being regularly reviewed by nursing staff on a monthly basis and relatives are invited to six monthly review meetings. Care plans ensure that the uniqueness of the individual is recognised and that any specific needs such as: race, disability, age, religion and belief are identified and the appropriate care promoted. An example of good practice in this respect was evidenced in the case tracking. Equipment necessary for the prevention or treatment of pressure ulcers is provided. The manager has identified that one person’s changing needs now require a special chair to ensure comfort and safety. Although the manager stated that she was looking into this, it had not been recorded in the care plan. One care plan record regarding a chest infection risk could have been more clearly evaluated and this was discussed with the manager. Medications are mainly supplied in a monitored dosage system and a medication trolley is used when administering them. Medication records contain photographs and other information regarding each resident to support the correct administration of medication. Medication administration (MAR) sheets had mainly been appropriately signed. There were a couple of gaps in the MAR sheets that were discussed with the deputy manager, who was able to ascertain who had administered the medications and indicated they would look into it. The ordering and stock control of medication is regularly checked by an allocated member of staff. The medication room temperature reading was not much higher than the normal range for cold storage in a refrigerator. It was discussed with the manager that the air conditioning unit might need adjusting to maintain a more appropriate room temperature. Staff spoken to had good understanding of residents’ needs and residents felt that they receive good care. From observations, it was clear that care staff have established a good rapport with residents and were demonstrating good attitudes towards them. Conversations with residents confirm that staff treat them with respect and consider privacy. Residents said that staff are caring and always ready to help and assist when needed. Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported and encouraged to have control over their own routines and lifestyles, benefiting from the opportunities for social contacts within the home. Planned improvements around activities should enhance residents’ choice. Residents’ dietary needs are well catered for, with a varied, balanced selection of food available that meets their tastes and choices. EVIDENCE: Discussions with residents confirmed that their daily routines are flexible and suit their needs. Several residents expressed that staff in the home always make their visitors feel welcome and a visitor also confirmed this. Information is passed to family members to ensure that they are fully aware of current events. Any matters needing attention are brought to the staff directly and residents stated they are confident to approach staff. Care plans ensure that residents’ religious and spiritual needs are met.
Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 14 An activities organiser works during the week and follows an activities plan that includes room visits to those residents who are unable to, or do not wish to join in with group activities in lounge areas. The manager has identified a need to improve the range of activities offered within the home and is working with the activities organiser to extend the group activities offered. There is a large dining room that is used by those choosing to eat in this area and those wishing to eat in their rooms are supported to do so. Comments from residents again indicated that the food is good and they have plenty to eat, with good choices. The four-week menu plan indicates that a varied nutritious diet is offered and staff confirmed that regular drinks are offered and snacks are available in between meals if requested. Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be listened to and acted on. Arrangements in place for protecting residents from abuse need strengthening to ensure residents’ best interests are fully protected. EVIDENCE: The home has a formal complaints procedure, which is conveyed to residents and their visitors in the service users’ guide and notices in the entrance hall. Residents and relatives are reminded of this at residents’ meetings and the manager holds weekly ‘surgeries’ when people know she will be on duty and available to speak to them if they have any issues of concern. The manager stated she also operates an ‘open door policy’ and several of the residents spoken to were appreciative of this. Since the last inspection, there has been one adult protection referral and the Commission has received one complaint that was investigated by the home. Recruitment procedures include criminal record bureau checks (CRB) and checks of the protection of vulnerable adults (POVA) register. However, analysis of information received since the last inspection between January and
Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 16 April this year, indicated an area of weakness in recruitment practice and protection procedures that was not sufficiently robust to safeguard residents. The manager now has access to a legal help line and has worked hard to improve both her own and staff knowledge on protection issues. However, this is being imparted verbally and has not been formalised. For example, only six out of a care staff team of twenty-two staff have attended any formal training on abuse and the protection of vulnerable adults, and their training was not recent. One staff file checked contained evidence of a CRB check but the POVA check had not been requested and there were no induction records. Formal staff supervision meetings are not held at the frequency specified in the national minimum standards, although the manager has already recognised this as an area for improvement. Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 16 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, comfortable well-maintained environment. Recent improvements have helped to create a more homely environment for residents. EVIDENCE: Redecoration and refurbishment has continued since the last inspection, with over half of the home redecorated and some new furnishings, including some new profiling beds. Several residents spoken to were very pleased with their rooms. All bedrooms have an ensuite toilet and a number have been highly personalised with the resident’s own possessions making them look especially homely. Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 18 There are currently two lounge areas available for residents, one is a very small room that offers quiet time and cannot accommodate many more than three people in armchairs. Many residents use specialist chairs and additional space is needed to comfortably accommodate everyone and support chosen activities. At the last two inspections the organisation had indicated their intention to add a conservatory that would have provided a valuable area to enable activities to be undertaken and free up some much needed seating space. Unfortunately this plan has not yet reached fruition. The manager said she hopes it will be in the home’s annual development plan for the coming year. The external grounds have been developed to include a sensory garden with raised flowerbeds, wind chimes and a pathway for those in wheelchairs, or just getting mobile. The manager stated that several residents enjoy this walk and benefit by becoming more mobile from this exercise. A canopy has been added to the seating area to the front of the building, where residents may smoke if they wish. A maintenance person works at the home and also does the decorating and gardens. The manager confirmed there is a programme for the routine maintenance of the home. The home has appropriate sluicing and clinical waste facilities and procedures in place. There is alcohol hand scrub throughout the building to control infection and provide a hygienic environment for those living in the home. A number of staff have attended training on infection control this year. Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from living in a home where there is a stable staff team who work positively with residents to improve their quality of life. However, a review of the numbers and skill mix of staff on duty is necessary to ensure that all residents’ needs are consistently met. Adequate recruitment procedures are in place to protect residents but some aspects would benefit from strengthening. EVIDENCE: Staff on duty at the time of the visit consisted of: the manager, one registered nurse, six carers, the activities organiser, a laundry assistant, two domestics, two kitchen staff, an administrator and the maintenance person. The case tracking and discussion with the manager and care staff indicated that a large proportion of the residents have high dependency needs, some with complex nursing care needs. A number of residents are nursed in bed and/or in their bedrooms all of the time and require two staff to provide personal assistance and transfer them. Staff spoken to said there are times
Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 20 when they feel there should be more staff on duty and that they sometimes feel pressured to complete care tasks in a rush. The complaint received by the commission in April concerned staffing levels and although the allegation was not substantiated at the time, evidence at this inspection indicates that staffing numbers need to be reviewed to ensure they are sufficient to meet residents’ needs at all times taking account of the layout of the building and numbers of residents cared for in their rooms. The manager stated that the weekly nursing staff hours have recently been reduced and there is only one nurse on shift at any time now (not including the manager). Also all of the activities person’s hours are now included in the weekly care hours provided, which the manager indicated is another change that has also affected the number care hours provided since the last inspection. Therefore there has been a significant reduction in the overall number of care hours provided. The manager monitors residents’ dependencies and stated her intention to organise a ‘twilight shift’ covering the tea time and evening periods between 16.00 hours and 21.00 or 22.00 hours, dependent upon budget allowances. Whilst this would be of benefit to residents, the weekly nursing hours may also need some adjustment as well. For instance account should be taken of the time taken to administer the morning medications, which can take up to two and a half hours to complete now, since the reduction in nursing hours, with only one nurse on duty at that time. Information provided by the manager indicates that the home has a stable workforce and six staff have their National Vocational Qualification in care level 2, with a further eight staff working towards it. The staff-training matrix indicates that staff are encouraged to attend a range of courses to develop their knowledge and skills. Sampling of staff files indicates that adequate recruitment procedures are followed, including obtaining two references and CRB checks. As previously indicated under the Complaints and Protection section, the manager must ensure that POVA checks are completed prior to appointment and that staff induction training is properly recorded. Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is being run in residents’ best interests. The manager has a good understanding of what needs to improve in the home and there is some planning in place to achieve the changes identified. EVIDENCE: At the last inspection, the manager had not long been promoted from an acting manager role. Since then she has been registered as manager with the Commission and has completed a management qualification. Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 22 Staff and residents were observed to be relaxed and confident in their interactions with the manager. The home’s quality monitoring systems include: satisfaction questionnaires, occasional residents’ meetings, staff meetings and monthly visits from the owning organisation’s operations manager. In the annual quality assurance assessment completed by the manager, she indicated that staff supervision is completed, but these formal meetings with staff have not all been completed at two monthly intervals as specified in the standards. Previous inspections have confirmed that procedures are in place to ensure that any monies held on behalf of residents are appropriately stored and records maintained of all transactions made on their behalf. The manager confirmed that the home’s equipment has been serviced and all maintenance and safety checks are up to date. Since the last inspection a number of sound activated closures have been added to bedroom doors to keep them open safely and provide protection in the event of a fire. Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 3 3 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 2 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 2 x 3 Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 24 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 OP27 Regulation 18 Requirement Make sure that there are enough nursing staff and other suitably qualified, competent care staff on duty at all times, taking account of the numbers and assessed needs of residents and the layout of the building. A review of staffing levels to be carried out and any identified adjustments made to staff rotas, with improvements implemented and evidence submitted. Timescale for action 15/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP20 Good Practice Recommendations That additional communal space is provided to ensure
DS0000065784.V346046.R01.S.doc Version 5.2 Page 25 Woodlands Care Home residents have enough communal seating and recreational space, other than in their bedrooms, to support the provision of a selection of activities, to meet individual needs. (This relates to the planned conservatory identified at the last 2 inspections that has been put on hold). Woodlands Care Home DS0000065784.V346046.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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