Inspection on 12/10/05 for Woodlands (Colchester) Ltd

This inspection was carried out on 12th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodlands (Colchester) Ltd 27/02/09

Woodlands (Colchester) Ltd 28/02/07

Woodlands (Colchester) Ltd 23/02/06

Woodlands (Colchester) Ltd 23/03/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Woodlands (Colchester) Ltd 76 Lexden Road Colchester Essex CO3 3SP Lead Inspector Pauline Dean Final Unannounced Inspection 12th October 09:15 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 (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodlands (Colchester) Ltd Address 76 Lexden Road Colchester Essex CO3 3SP 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) 01206 571200 01206 505450 Woodlands (Colchester) Limited Ms Julie Wells Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Twenty three female service users, aged 65 years and over, who require care by reason of old age only 24th March 2005 Date of last inspection Brief Description of the Service: Woodlands is located within the Lexden area of Colchester, an established residential area to the west of the town centre. There is approximately a ten minute walk between the home and the town centre. Public transport, passing to the front of the home, is frequent. The nearest train station is Colchester Town, approximately half a mile distant. The early 1900’s property was a former large family dwelling and has been developed to present the current accommodation. The home is solely for women. The accommodation is arranged on two floors, the upper floor is accessed via a passenger lift. Single and shared bedrooms are available and there are various communal rooms. There is a rear garden incorporating a sun terrace and lawn. The front of the property, enclosed by trees and shrubs, includes parking and seating areas. The garden also extends along one side of the home. Mrs Julie Wells is the registered manager. Miss Samantha Racey, the responsible individual of the company, is also involved in the day to day running of the care home. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one day in October 2005. This was the first inspection of the inspection year 2005 to 2006. Throughout the day there was discussion with the registered manager, care staff, residents and visitors. Two care staff, three residents and two visitors were interviewed. There were twenty-three female residents on the day of inspection. A tour of the premises was conducted and both residents’ and staff records were sampled and inspected at this inspection. Policies and procedures were also sampled and inspected. Twenty-two of the thirty-eight standards were inspected; of these thirteen were met, with eight standards almost met. One standard was not applicable. Overall, there has been an improvement in meeting requirements. However, some shortfalls are still to be found in care planning and record keeping, the adult protection policy and procedure, premises issues, hot water temperatures and quality assurance monitoring and review. What the service does well: What has improved since the last inspection? Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 6 Mrs Wells said that further training opportunities have been offered to care staff since the last inspection. Training materials, in the format of DVDs and workbooks, have been purchased for the home. Topics covered include Challenging Behaviour, Fire Safety, Health and Safety in a Care Home and Protection from Abuse. In addition, both the registered manager and a senior carer have completed an Immediate Aid Emergency Response First Aid course. A further two senior care staff are to complete this course in November 2005. Basic Food Hygiene courses for both catering and care staff are being pursued. Previuosly identified requirements and shortfalls relating to the home’s premises are being progressed. Double electrical sockets have been fitted into bedroom accommodation where shortfalls had been identified. On the day of the inspection radiator covers were being fitted and it is anticipated that radiator covers and hot water pipes will have been covered and made safe by the following day. In addition, the ground floor bathroom has been refitted, with a new bath and fixed hoist in place and there was evidence of ongoing maintenance and decoration both inside and outside the care home. What they could do better: Mrs Wells said that a training and development programme had been introduced, in addition to the in-house basic training courses introduced, further National Vocational Qualification (NVQ) training is being progressed. The need to continually review training and staff skills and expertise was acknowledged. Two care staff interviewed spoke positively regarding training opportunities offered and were looking forward to commencing NVQ level 2 training. Whilst it is acknowledged that consideration and attention is given to the accommodation and the premises at Woodlands, further work is required to help ensure the safety and welfare of residents at the home with regard to hot water temperatures from hot water taps accessed by residents. Further work is required in the care planning documentation, in respect of detail and clarification, as to the actions to be taken to meet indentified needs. Mrs Wells spoke of introducing a new activity display board. Although some effort had been made to ensure that all residents are aware of planned activities and social events, it was acknowledged that a greater emphasis on this aspect of care should be progressed. A relative also raised this during this inspection. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 7 The need to review arrangements around the hairdressing facility was highlighted at this inspection. The need to more fully respect both privacy and dignity, with regard to the current arrangements around the use of occupied double bedroom and bathroom facilities, needs to be reviewed. 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 (Colchester) Ltd DS0000061910.V258209.R01.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 (Colchester) Ltd DS0000061910.V258209.R01.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): 1, 3 & 6. Clear detailed information is provided to prospective service users and their families to help enable them to make a choice as to the suitability of the home. Woodlands operates a thorough and responsible pre-admission assessment, with care and attention given to ensuring that the home can meet the service users individual needs. Intermediate care is not offered at Woodlands. EVIDENCE: Both the Statement of Purpose and the Service Users’ Guide are in place and continue to meet requirements. Prospective residents are provided with these documents to help enable them and their relatives to make an informed choice of whether they wish to live at Woodlands. Two residents and two relatives were spoken with and they confirmed that they were happy with the way the admissions had been managed. All confirmed that they were happy with the way in which the home was meeting Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 10 their or their relative’s individual needs. The files of three new service users were sampled and inspected and clear evidence of a completed pre-admission assessment was seen. Woodlands do not offer intermediate care. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. A plan of care has been generated from a comprehensive assessment. This did not fully detail all the action that needs to be taken by care staff to help ensure that all aspects of the health, personal and social care needs of the resident are met. Residents’ health care needs and medication requirements are met within the home. Woodlands have an established staff team with a good understanding of residents’ individual needs. Staff treated residents with respect and actively supported them to maintain control of their care and health needs, as appropriate. EVIDENCE: Whilst it was acknowledged that there have been changes and some improvement in care planning documentation, the need to develop care planning objectives further was highlighted. Care planning objectives were found to be brief, without detail of how these needs are to be met. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 12 From speaking with two relatives it was clear that, whilst they were aware of their relative’s care plan and they said that they were informed of any change, they were not involved in the development and review of care plan objectives. This needs to be considered in future care planning reviews. Residents and relatives spoken with were complimentary regarding the way in which personal and health care needs were being met. They said that they felt staff treated them in an appropriate way, respecting their privacy and dignity. Two care staff interviewed gave examples of ways in which they help ensure residents’ privacy and dignity was respected. Records seen showed that health care needs were monitored and appropriate referrals to medical professionals were noted. Medication receipt, administration and storage were sampled and inspected. Record keeping and stock control were found to be in good order, with recommendations made at the last inspection complied with. ‘Controlled Drugs’ medication and administration was not inspected on this occasion. Current arrangements for hairdressing within the home need to be reviewed. The current use of an occupied double bedroom and bathroom facility needs to be reviewed, for whilst the accommodation meets physical requirements, it does not respect the privacy and security of the residents occupying this private room. This concern was highlighted at the inspection and the care homes needs to review current arrangements and propose alternative arrangements. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.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, & 14. The daily routine in the home was flexible, with residents being encouraged to maintain contact with family and friends. Residents spoke of some social and leisure activities in the home and being able to exercise choice over what they wished to do. EVIDENCE: From discussion with residents, care staff and management, the inspector understands that residents are able to choose how they wish to spend their leisure time. Mrs Wells spoke of wishing to promote the activities available at Woodlands. She spoke of having an activity sheet/programme on a separate display board and ensuring that residents receive up-to-date information promoting activities available in the home. Two residents spoken with commented on recent activities, highlighting a ‘Line Dancing’ demonstration as very enjoyable. One resident said that they enjoyed the quizzes and board games on offer, whilst another resident said that, when they had been able, they had enjoyed walking into Colchester town centre. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 14 Two residents spoken with said that they enjoyed watching television in their rooms. One was enjoying snooker and another said that they like watching football. This was confirmed on the day of the inspection by a relative visiting. The two relatives interviewed on the day of the inspection said that they regularly visit Woodlands and on arrival refreshments are offered. Both said that they were able to see their relative in private, but often visits take place in the main lounge or dining room. Mrs Wells said that the care home does not hold monies and valuables for any of the current resident group. Families and legal representatives are invoiced for purchases and payment is made this way. None of the current resident group uses the services of an independent advocacy agent. Mrs Wells said that residents, family and friends are made aware of these services should they require them. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.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): 16 & 18. The home’s complaints procedure is made available to residents and their representatives to help enable them to progress complaints as they wish. An Adult Protection Procedure is in place to help ensure that residents are protected from abuse. This requires further development to ensure there is reference to the local authority guidance on the Protection of Vulnerable Adults (POVA). EVIDENCE: The home’s complaints procedure is referred to in the Statement of Purpose and meets requirements. Copies of this procedure were available in the home. All three residents said that should they have any concerns they would raise the matter with the registered manager, Mrs Julie Wells, or the responsible individual, Miss Samantha Racey. Both relatives spoken with confirmed that this was the action they would take. There have been no complaints since the last inspection. As at the last inspection the adult protection policies and procedures were inspected and, whilst they were found to detail the action to be taken, there was no reference to local guidance issued by Essex County Council. The two care staff interviewed were aware of the adult protection procedure in the home and confirmed that they had copies of the local authority guidance. The inspector was informed that three care staff have completed a local authority adult protection workshop and further training on Adult Abuse Awareness is being promoted in the care home via a DVD. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 & 26. Woodlands is a clean and well-maintained property. There were, however, some shortfalls in the home’s environment that present issues for the welfare and safety of the residents. EVIDENCE: A tour of the premises was conducted on the day of inspection. Records relating to premises issues were also inspected. Woodlands was found to be clean, warm and homely. This is managed by ongoing maintenance and decoration. Since the last inspection, both internal and external decoration has taken place and new French doors have been fitted in the dining room. Mrs Wells said that the home plans to re-surface the area immediately outside this room allowing easy access to the rear garden. Mrs Wells said that additional double electrical sockets have been fitted to meet the shortfall identified and now all rooms have sufficient sockets to meet requirements. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 17 As at the last two inspections, there is a shortfall regarding the provision of all service users having the option of a lockable facility in their rooms and, unless otherwise determined and recorded, a key to their doors. Of the three care plans sampled, there was some evidence of consideration for keys to bedroom doors and nothing relating to a lockable storage facility. Detailed care planning and risk assessments need to be implemented to cover this aspect of care. On the day of inspection radiator covers were being fitted. The remaining covers and hot water pipe covers were to be fitted the following day. Confirmation of completion, that all pipe work and radiators are guarded, is required within the action plan of this inspection. Any outstanding work needs to have clearly detailed risk assessments in place, with timescales for completion of the work. In addition, completion of the planned work regarding the fitting of fail safe devices on all remaining hot water taps accessed by residents is required. Mrs Wells said that a plumber is booked to complete this work by November 2005. Woodlands offers an in-house laundry service, with day and night care staff undertaking these duties. Two residents spoken with complimented the home of the service they received and a relative spoke of a good service that their relative receives. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30. Staffing levels and skills are appropriate to the needs of the residents. Staff recruitment processes were found to meet requirements. All new staff are trained and competent to do their work, supported by a comprehensive induction and basic training programme. EVIDENCE: Staff rotas were inspected for the month of October 2005. These records detailed day and night care staff, voluntary staff, chefs, domestic and maintenance staff. Care staffing levels were seen to be four carers on the morning shift; three carers on the afternoon/evening shift, with two awake night care staff. Mrs Wells confirmed that staffing levels had been determined according to the assessed needs of residents and in accordance with the Residential Forum Guidance issued by the Department of Health. She said that staffing levels are continually reviewed as dependency needs change. Staff recruitment documentation, for a new staff member, was sampled and found to meet requirements. The practice of processing and obtaining two written references is now adhered to. Staff were said to have copies of the General Social Care Council (GSCC) code of conduct and practice. A new care staff member that was interviewed confirmed this and detailed the recruitment process they had gone through. Mrs Wells said that all new staff now complete ‘Skills for Care’ induction training. In addition, an in-house staff induction training record sheet is Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 19 completed, with areas such as moving and handling, tour of the premises, emergency procedures and fire safety covered. National Vocational Qualification (NVQ) training is also being progressed with eight care staff to enrol on NVQ level 2 in October 2005. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 & 38. There is a need to introduce an effective quality assurance and quality monitoring system to help ensure that the home is run in the best interests of the residents. Woodlands does not hold money and valuables for residents. The health and safety of service users and staff are protected through the renewal and updating of health and safety certifications. EVIDENCE: Mrs Wells said that the home has introduced a quality assurance audit. This was seen and related principally to the premises and services of the home through completion of a quality and procedure manual. In addition, a quality assurance questionnaire had been developed. Reference to obtaining the views of the residents is found within the Service Users’ Guide. The home needs, however, to develop an annual development plan for the home, based on a systematic cycle of planning – action – review, reflecting the aims and Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 21 outcomes for residents. The results of residents’ surveys should be published and made available to current and prospective users of the service. Woodlands does not hold money and valuables for residents. furniture and belongings brought into the home are held on file. Records of Records required for the protection of residents, sampled and inspected at this inspection, included staff rotas, staff recruitment records, initial assessments, care plans and daily care records. Comments have already been made regarding this record keeping under the relevant standards. Health and safety certification was sampled and found to be in good order for the Euro-Fire inspection and the installation of the new fixed bath hoist. The management of risk relating to hot water/surfaces temperatures and the regulation of water temperatures has already been commented on under the relevant standards. Regulation 26 visits by the registered provider are completed and copies of these monthly reports are sent to Commission for Social Care Inspection (CSCI). Mrs Wells said that copies are also held in the home. Copies of these visits are, however, sent in batches and the most recent visit report received was for August 2005. The registered provider is reminded of the need to visit and report on a regular monthly basis, with copies sent to the Commission on completion. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 2 2 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 14, 15 Requirement Timescale for action 25/11/05 2 OP10 10, 12 3 OP18 13 The registered manager must review and revise the current residents’ plans of care to ensure that all aspects of the health, personal and social care needs of the resident are met, with detailed care plan objectives and action plans. (This is a repeat requirement from the last inspection. Previous timescale of 23/05/04 not met.) The registered manager must 25/11/05 ensure that arrangements for personal care needs i.e. hairdressing arrangements, ensure that residents’ privacy and dignity are respected at all times, with regard to the provision of accommodation for hairdressing. 25/11/05 The registered manager must ensure that all residents are safeguarded from all forms of abuse in accordance with written policies and procedures. Reference to local authority guidance and procedures must be included. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 24 4 OP24 5 OP25 6 OP33 7 OP38 14, 16, 23 The registered person must provide private accommodation for each resident, which is equipped to assure comfort and privacy, and meets the assessed needs of the resident; specifically, lockable facilities and a key to the bedroom door, unless in the case of the latter there is are reasons for not doing so detailed in the care plan. (This is a repeat requirement from the last two inspections. Previous timescale of 23/05/04 not met.) 16, 23 The registered person must ensure that the heating and water supply meet relevant environmental health and safety requirements and the needs of the individual residents. This is with regard to radiator covers and hot water pipe covers and hot water temperatures. (This is a repeat requirement from the last inspection. Previous timescale of 23/05/04 not met.) 21 The registered person must develop effective quality assurance and quality monitoring systems, based on seeking the views of service users, to measure the homes’ success in meeting aims, objectives and it’s statement of purpose. (This is a repeat requirement from the last inspection. Previous timescale of 23/05/04 not met.) 26 The registered person must ensure that the monthly visits as detailed under The Care Homes Regulations 2001 – Regulation 26 are completed and reports sent to Commission for Social Care Inspection (CSCI) monthly. 25/11/05 25/11/05 25/11/05 25/11/05 Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 25 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 OP12 Good Practice Recommendations The registered manager should ensure that all residents have up to date information of the activities available in the home. Woodlands (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 (Colchester) Ltd DS0000061910.V258209.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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