Inspection on 05/07/07 for Woodlands Care Home

This inspection was carried out on 5th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Home 30/05/06

Woodlands Care Home 19/10/05

Woodlands Care Home 18/05/05

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Woodlands Care Home Woodlands Care Home Great North Road Wideopen Newcastle Upon Tyne NE13 6PL Lead Inspector Elaine Charlton Key Unannounced Inspection 5th July 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands Care Home DS0000062615.V343452.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 DS0000062615.V343452.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Care Home Address Woodlands Care Home Great North Road Wideopen Newcastle Upon Tyne NE13 6PL 0191 217 0090 0191 2364165 Linda@woodlandsc.plus.com 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) North East Care Homes Ltd Mrs Linda Elizabeth Gallon Care Home 40 Category(ies) of Dementia - over 65 years of age (29), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (10) Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Once the resident in the MD(E) category leaves the home, the CSCI must be notified immediately. This place will then revert to category DE(E). 29 November 2006 Date of last inspection Brief Description of the Service: Woodlands is a purpose built home that provides personal care and support for 40 elderly people. The home is in a residential area of Wideopen close to shops, churches and local amenities. There is a bus route that passes the home. Residents who need care because of age, physical frailty and/or memory loss including dementia type illnesses are supported by good levels of staff. As well as the registered manager, administrator and care team the home has three activities co-ordinators, six kitchen staff, a housekeeper and laundry assistant. One of the care team is a qualified hairdresser who runs the home’s hairdressing salon. There are bedrooms at first and second floor levels. A passenger lift helps residents to get around the home. The home is undergoing an extensive improvement programme at the moment that will provide 34 bedrooms with en-suite facilities. Fees range from £361 to £395 per week. The fees do not include charges for hairdressing, private chiropody, toiletries, transport and costs for outings. Information about the service, including inspection reports, are available. The home also produces a monthly newsletter to keep people up to date with what is going on. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit was made on date the 5 July 2007, and lasted for 9 ¼ hours. The manager was present throughout the inspection. Before the visit we looked at: Information we have received since the last visit on 29 November 2006; How the service dealt with any complaints and concerns since the last visit; Any changes to how the home is run; The provider’s view of how well they care for people; The views of people who use the service, their relatives, staff and other professionals who visit the service. During the visit we: Talked with nine people who use the service, seven staff, and the manager; Looked at information about the people who use the service and how well their needs are met; Looked at other records which must be kept; Checked that staff had the knowledge, skills and training to meet the needs of the people they care for; Looked around the building/parts of the building to make sure it was clean, safe and comfortable; Checked what improvements had been made since the last visit; We told the manager what we found. What the service does well: Good assessment information is obtained to make sure that prospective residents needs can be met. Residents are supported to regain skills and confidence to make their daily life enjoyable. A high level of co-operation exists between the manager, staff and healthcare professionals to support the care and support residents’ need. There are excellent levels of activities and social opportunities for residents to join in. People who live in the home, have contact with the home or visit are kept up to date with what is going on. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 6 The home maintains good relationships and levels of contact with the local community and associations that benefit the well being of residents. The manager shares inspection reports with a wide range of people and invites their feedback. The manager, staff and residents all played an active part in the inspection, making the process relaxed and informative. During a recent review a relative said: “Our relative is like a new person since arriving at Woodlands”. “It is a relief to see them cheerful and happy”. A reviewing officer said: “The resident’s life has improved for the better. This is due to the attention and attitude of the manager and staff”. A resident said about their Life History Book: “I enjoyed doing this, spending one to one time with staff”. What has improved since the last inspection? The programme of improvements to the home has started. Residents will benefit from en-suite bedrooms and a more homely environment. The quality and content of care plans has improved. They record the support and care residents’ need. Medication recording systems and the attention staff pay to these records has improved protecting the safety of residents. Audit checks are carried on controlled drugs at handover time protecting the safety of residents. Life History Books are being introduced giving residents a chance to talk about their family, what they used to do, and make a record of it. Inspection records are shared with residents, staff, relatives and a wide range of healthcare professionals to keep them informed. The manager has been nominated by the Care Alliance for an Outstanding Achievers Award. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 7 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 Home DS0000062615.V343452.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 DS0000062615.V343452.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are given good information to help them decide about moving into the home. Their needs and wishes are assessed before they are given the chance to move in. EVIDENCE: The assessment for a new resident admitted to the home was seen. Two Local Authority assessments had been received that gave excellent information about the new resident’s needs. A relative had signed the home’s statement that records whether or not they wish to be included in the preparation of care plans. The involvement of relatives is helpful where resident’s have memory problems and may not be able to give staff all the information they want, or express their wishes clearly. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 10 During the home’s pre-admission assessment process staff take time to record the preferred gender of carer and complete assessments for nutrition, continence, skin care and memory. A social assessment is also completed to give staff information about the resident’s family history, where they have lived, where they worked and what they like to do. The home does not provide intermediate care. Woodlands Care Home DS0000062615.V343452.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are asked how they wish their personal care to be provided, and by whom. They are supported and helped to be independent with medication and can see health care professionals as their health needs dictate. EVIDENCE: The service user plans for three residents were seen. These are kept in a standard way and an index is provided. Staff are not keeping some records in the correct section making it difficult to access information quickly. During a recent review for one of the residents relatives said: “Our relative is like a new person since arriving at Woodlands”. “It is a relief to see them cheerful and happy”. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 12 The reviewing officer said: “The residents’s life has improved for the better. This is due to the attention and attitude of the manager and staff”. Staff have worked closely with the Challenging Behaviour Outreach Service to reduce anxiety levels for some residents and reduce behaviours that preoccupy their day. Care plans have improved. Each resident has a number of plans in place. New care plans need to be introduced to widen the area of care that staff are supporting. Not all staff had signed the record in residents service user plans to show that they had read the care plans. Moving and handling plans and guidance setting out how transfers should be carried out were seen. Assessments had been carried out for each of the residents to support nutrition, skin care, continence and memory/behaviour. Throughout the inspection staff were seen knocking on bedroom doors before they entered promoting privacy and dignity for residents. Nice, sensitive, recordings were seen reminding staff about protecting the dignity of a resident who was shy about their body following surgery. The quality of daily recordings and evaluations were varied. These need to become more outcome focused reflecting the affect care and support has had on the residents’ lifestyle. There were some good examples of out come based recordings in the activity organiser’s monthly reports for the manager. All bedroom doors are lockable and residents can have a key if they wish and are able to look after it. A lockable facility is also available in each bedroom so that residents can keep personal items or medication safely. A simple risk assessment is in place to record a resident’s ability to look after their keys. Records of food intake, continence checks or monitoring done on behalf of other healthcare professionals are kept separate to service user plans. These were easily accessed for the inspector. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 13 Records gave good evidence that residents were receiving support and/or care from a range of healthcare professionals. Review meeting records were seen. The manager knows she needs to set up a schedule for these to continue when social work or care manager input ceases and for privately funded residents. Staff have started to prepare Life History books with residents. This is good practice. One resident said they had enjoyed doing this, spending one to one time with staff. The home is contracting with a new pharmacist. They have been given a mobile contact number that means that they can get medication delivered at short notice. The team leader is responsible for checking, ordering and returning mediation. The second most senior member of staff on duty double checks medication where necessary. A carbonised record book is used for returning medication. The pharmacist signs this record. Most medication is contained in blister packs. A random check of medication and medication administration records (MAR) was carried out. No problems were identified. Controlled drugs and recording systems were also checked. These were up to date and correct. The senior on duty said that staff coming on duty each morning audit the controlled drugs with the night staff and sign the register. This is very good practice. Medication is safely stored in the home. An additional locked and alarmed cupboard has been provided for the controlled drugs. Staff have access to up to date reference books on medication. The new pharmacist is also going to do medication checks. . The registered manager carries out in-house medication competency checks for senior staff. Staff who administer medication have received training to support this. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home are encouraged to be as independent as they wish. They access social opportunities within the home and the wider community. Choice and rights are promoted as well as healthy living. EVIDENCE: Policies promote and welcome the involvement of family and friends. People can visit the home when they wish. Evidence was also seen of staff supporting a resident who did not wish to see particular visitors. The home and residents have strong links with the local community, church and outside organisations. Three activities organisers share a full time post. One of them is a qualified aromatherapist and another is a qualified, practising occupational therapist. One of the activities organisers is responsible for providing the registered manager with monthly reports, and does all the paperwork to support the other two. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 15 Activity input is recorded in care plans as the person being an active participant or observer. This is good practice. A monthly evaluation for each resident is done rather than the activities that have been carried out. Recordings were outcome based, personal and sensitive. One resident is thinking about having a short break holiday supported by two carers. The activities co-ordinators work in the home six days per week. Saturdays are covered by care staff who are left with activities to carry out. On the day of the inspection residents were seen taking part in activities and helping prepare napkins for lunch. In the afternoon fresh flower arrangements were made for the dining tables. Recent events have included the Balliol Operatic Society, dog agility display, and Majestic Movies event. Residents have been out to the Alzhiemers Society tea dance, local church coffee morning and lunch club, walks in the local community and one resident goes swimming. Another resident is an accomplished pianist and has their own piano that they play for sing a longs. The local library service recently gifted jig saws to the home. A local milliner gives end of season hats to the home that are used for events such as making Easter bonnets. A group of residents went to a local garden centre to buy an aquarium for the home. Two more aquariums are going to be purchased once the alterations to the large lounge/dining room have been completed. Entertainers come into the home. Residents also enjoy going to the Whitley Bay playhouse. Newsletters go out monthly. Tthe format is friendly, chatty and informative. People are encouraged to put items forward for inclusion. Residents receive a personal copy that is put in their bedroom, copies are also posted to relatives. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 16 One family in Australia receive their newsletter by email. They were also sent pictures via email of their Mum’s birthday party. A nice thank you letter from this family was seen. The home has it’s own hairdressing salon. This is an excellent facility that is decorated and equipped to look like a high street salon. Residents can have their hair done in comfort, enjoy a cup of tea or coffee and have a manicure. The hairdresser is qualified and competent and a member of the care team so he knows the residents well. A nutritionist is working with the residents and chef to produce new menus. Each resident has been consulted about meals they enjoy/don’t enjoy, what they would like included, portion size, dietary needs, and food allergies. There have been some good responses. Families have also been consulted. Residents can choose from items such as cereals, toast, bacon, eggs and beans at breakfast. There are two hot meal choices at lunchtime and teatime. Supper time is usually a selection of sandwiches. On the day of the inspection fresh fruit was being served as a teatime pudding. It was very nicely presented on individual tea plates, looked attractive and appetising. Alternatives are available if a resident does not like the menu choices. A range of products were available to provide suitable meals for a resident who needs a gluten free diet. The chef spoke knowledgeably about individual residents likes and dislikes. He does the cash and carry shopping and butchers meat is delivered weekly. Refrigerator, freezer and food temperature recordings were available. Records of residents’ menu choices are kept for one month. The kitchen was seen to be well organised, clean, tidy. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of people who live in the home are listened to. They are protected from harm through policies, procedures and staff training. EVIDENCE: Policies and procedures support residents to raise concerns or make complaints if they need to. No complaints had been received by the home or CSCI since the last inspection. The registered manager is applying to do the next North Tyneside Council, Training the Trainers POVA course so that she can keep staff training up to date. All care staff have completed POVA training. This is now being arranged for non-care staff. Some nice compliments have been made by healthcare professionals and relatives about the care and support the manager and staff have given people living in the home. The manager is working closely with staff from North Tyneside Council to try and maintain an acceptable level of contact for a resident with their family. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 18 This has included arranging for the resident to be able to see family outside the home supported by a carer. This is good practice. Policies and procedures include staff not accepting gifts or being involved in the making of, or benefiting from, a resident’s will. A random check on personal allowances held for residents was carried out. Staff are required to advise their employer of any new cautions or convictions received following the start of their period of employment. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely environment that promotes their independence and the chance to spend time privately. Everywhere is clean and tidy and hygiene routines are good. EVIDENCE: Major alterations are currently being carried out in the home. Each resident will have a bedroom with en-suite facilities. There will be access to disabled toilets in communal areas and assisted bathing and shower facilities. The large lounge/dining room on the ground floor is being divided into three smaller areas and an additional quiet area is being provided on the ground floor. There are also plans to provide a snoozelene room. This will be equipped from money donated by a late residents family. It is planned to have a memory plaque in this area. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 20 The project is being well managed and disruption is at a minimum. Three bedrooms are being converted in each phase. Residents move to a temporary bedroom and then back to their own. The manager is using this as an opportunity to replace beds, mattresses and furnishings as necessary. Discrete looking, upholstered, commodes have been purchased. These promote the privacy and dignity of residents. Residents have a framed photograph of themselves along with their room number on their bedroom door. They can choose not to display their photograph if they wish. All bedroom doors are lockable. Inside each bedroom a picture and introduction about their key worker is displayed. The housekeeper controls the budget for cleaning products used throughout the home. She carries out stock checks and operates a “booking out” system from the store. All areas of the home were seen to be clean, tidy and free from odours even though a number of workmen were coming and going. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 21 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. People living in the home are protected by recruitment and selection procedures that are properly followed. Staff are supported through training and supervision to provide care to people in a way that meets their individual needs. EVIDENCE: The records for four new members of staff were seen. Files are kept in a standard way and an index makes it easy to find information. A separate file is kept for certificates and training records. Each person had completed an application form and health questionnaire. The rehabilitation of offenders statement on the application form is not clear. During the inspection the manager identified an application form with a clear rehabilitation of offenders statement for future use. Interview notes were seen. The interviewer had not signed and dated these. The manager carries out interviews on her own. This does not meet current recruitment and selection best advice. Checks had been carried out to establish a person identity and that they had the relevant permits to work in this country. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 22 Criminal Records Bureau (CRB) checks had been carried out. All staff sign to acknowledge receipt of company handbook and are employed in accordance with the General Social Care Council (GSCC) Code of Conduct. The extension of a member of staff’s probation period and details of extra support given was well documented. Staff training has included supporting continence, food hygiene, first aid, communication, risk management, health and safety awareness, POVA, in house care planning, infection control, moving and handling, in house medication, and fire prevention. Nurses who qualified outside the United Kingdom and who are working on the care team have done the SKILLS induction programme. A supervision schedule has been drawn up for the year 2007/08. The manager and key staff have an identified group of people to supervise. Everyone has had one supervision session since February. The format for recording supervision meetings is nice, simple and effective. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 23 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run which benefits the people who live there. They are consulted about what goes on in the home through surveys and meetings. Both people living in the home and staff are protected through good health and safety procedures, systems and training. EVIDENCE: The manager is qualified and well experienced to carry out her role. She has been nominated by the Care Alliance for an Outstanding Achievers Award for achieving her qualification against all odds and for using it. She is to be congratulated for this. Staff have easy access to policies and procedures that support all areas of work. The manager intends to up date these section by section. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 24 The manager knows the residents well and was seen taking time to talk to them and make sure they were happy and comfortable. A random check on personal allowances held for residents was carried out. The manager and administrator are the only people who have access to “pocket monies”. Outside of normal office hours, staff have access to a cash float. The manager carries out random audits of financial records. All entries in the financial records were double signed. Money is kept in individual packets, in locked boxes in a locked cupboard. Four residents packets were checked. All were in order and records up to date. Quality assurance survey results from March 2006 available. Computer generated, coloured charts, had been put together to show people the outcome of survey. Good levels of satisfaction recorded from professionals, relatives and residents. The manager is changing the questionnaires used in last years survey as a result of comments received from healthcare professionals. She intends to carry out the next survey once the alterations are complete. Copies of quality assurance results and inspection reports are shared with residents, staff and relatives. The manager also sends copies to GP surgeries, the chiropodist and dentist and other visitors to the home. This is very good practice. The manager has a plan for auditing areas of service – care plans, food hygiene, equal opportunities, accidents, medications, personal allowances, residents questionnaires, outside agencies, staff questionnaires, and the activity fund. Staff meetings are held at least six times per year. Staff attendance is noted and minutes are available. The last meeting was held in June this year. Staff were reminder about confidentiality and the manager thanked them for the cover and support given whilst she had been on holiday. Meetings are also used to identify and discuss practice issues, feedback from inspections and new requirements, for example the CSCI Annual Quality Assurance Assessment. Separate meetings are held with team leaders. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 25 Residents and relatives meetings are held bi-monthly. New staff are introduced at these meetings. Relatives had been shown a memory book that had been completed as an example of work it is intended to do with all residents if they wish. A copy of the inspection report had been handed out at one meeting and everyone had been invited to make comments. A senior member of staff is responsible for carrying out fire checks monthly. These are well recorded. There is also a separate record of fire instruction and drills. Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 26 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 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 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 Requirement The range of care plans must be increased. This will ensure that every residents’ care and support needs are met. Recordings must become more out come based. This will make sure that the benefits of the care and support residents receive are properly reflected. Timescale for action 30/12/07 2. OP7 15 30/12/07 3. OP7 15 The need for individual risk 30/08/07 assessments on smoking must be reviewed. This will make sure that all residents are protected and kept safe. Staff supervision levels must meet the recommended minimum level. This will make sure that residents are support ed by staff who know how to do their job. 30/01/08 4. OP30 18 Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 28 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 OP7 Good Practice Recommendations Records in the home should be kept in the same order as the index provided for that file. This will make sure that information is easy to find. Replacement of the call system, that gives off a loud, intrusive noise, should be reviewed. This will improve the environment for all residents, and particularly those with a dementia type illness. Interviews for new staff should be carried out by at least two people. This makes sure that recruitment and selection best practice is met. 2. OP22 3. OP29 Woodlands Care Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Home DS0000062615.V343452.R01.S.doc Version 5.2 Page 30 - 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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