CARE HOMES FOR OLDER PEOPLE
Woodlands House 205 Woodlands Road Woodlands Southampton SO40 7GL Lead Inspector
Carole Payne Unannounced 10.05.05 9:00am 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 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 House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Woodlands House Address 205 Woodlands Road, Woodlands, Southampton, SO40 7GL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 023 8029 2213 H W Gropu Ltd Ms M Hemmings CRH 34 Category(ies) of OP - 34 registration, with number of places Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: N/A Date of last inspection 07.02.05 Brief Description of the Service: Woodlands House is a detached property set in extensive grounds in Woodlands on the edge of the New Forest. There is a bus stop outside the service, with links to Southampton, Totton and Lyndhurst. People who live at the service find a local dial-a-ride facility very useful. The nearest railway station is at Ashurst. The home is owned by H W Gropu Ltd, who also own two other residential homes in Winchester and Bristol. Accommodation is arranged on two levels in the main house, with a single story extension called the cottage. Work is currently underway to provide a permanent link from the main house to the cottage. At the moment there is a covered walkway between the two areas of living accommodation. There are nine single rooms in the cottage and twenty five rooms in the main house, two of which can be used for shared occupancy. All rooms benefit from en suite facilities, aside from one room, which has a private bathroom close by. The building work taking place will provide an additional four rooms to be considered for registration. The home benefits from spacious communal areas. There is a lounge and library in the main house and a lounge in the cottage. Both living areas have a dining room. There is also a small garden room off the main lounge with delightful views across the homes gardens.
Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The home’s first inspection for this year took place on Tuesday 10th and Wednesday 11th May 2005. The visit was unannounced. During the inspection discussions took place with seven of the seventeen people living in the home. The inspector also met with Jo Gavin, the responsible individual, the human resources manager, three carers and the home’s laundry assistant. At the time of the inspection Mrs Sandra Whale was acting as a temporary manager, with the support of the responsible individual. Care records were seen for three people living in the home and the home’s policies and procedures were sampled. The inspector toured the building and observed the daily routine in the home. What the service does well:
The home welcomes people who wish to come and look around and spend time at the home, prior to making a decision about moving in. Service users said that they felt reassured that their needs would be met at Woodlands House. Staff members involve service users in planning their care. A district nurse visiting the service said that staff members work hard to meet service users’ healthcare needs. Staff members provide sensitive and caring support and companionship to service users. People living at the home feel confident in staff members. Seven members of staff are undertaking a National Vocational Qualification [NVQ] in care. Some basic training has taken place; further training is arranged to take place in the coming months. Service users’ interests are recorded and a varied programme of social opportunities is made available to service users wishing to participate. Family and friends are made welcome to share time with their relative at the service. People living at the service enjoy meals provided. People living at the home enjoy an independent lifestyle. Service users are offered choices about the way they would like to live and have the opportunity to have their say about the day-to-day running of the home. People feel confident that if they raise an issue it will be listened and responded to. Senior management and staff members understand the importance of protecting vulnerable adults. Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 Page 6 A particular feature of the home is the well-tended gardens, which provide delightful views from many of the windows of the home and the most pleasant surroundings to enjoy a stroll. What has improved since the last inspection? What they could do better:
A pre-admission assessment had not been carried out for a service user living in the home. Assessments must be carried out for all service users considering moving into the home. Care records did not reflect all of the service users’ current and changing needs. Records kept must support service users needing care. There were shortfalls in the procedures for the safe administration of medicines. Reasons for the omission of medications must be recorded and risk assessments must be carried out for service users wishing to self-administer medication. The inspector advised the home to obtain a copy of the Royal Pharmaceutical Society’s The Administration and Control of Medicines in Care Homes. The responsible individual has confirmed since the visit that a copy of the guidelines has been obtained. Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 Page 7 Two service users commented that on occasion meals taken at the cottage were not hot. The responsible individual said that this was an isolated occurrence and that the arrangements for the serving of meals would prevent reoccurrence. Recruitment records did not show that staff members working in the home have been suitably vetted. The human resources manager has assessed recruitment files and the responsible individual has confirmed that those members of staff who do not have a Criminal Records Bureau check are not working until a POVAFirst [Protection of Vulnerable Adults] check is received. The home must utilise rigorous recruitment procedures. Records did not demonstrate that all staff members working in the home have received appropriate training. A programme of updating staff members in all areas of mandatory training including fire training and drill, adult protection, infection control, manual handling and food hygiene has been arranged and some training has already taken place. All staff must receive training. The responsible individual is reviewing the suitability of the induction programme. On occasion staff members have used inappropriate techniques to help move service users and accidents have not been recorded and followed up to prevent reoccurrence. A safe system of moving and handling service users and recording and auditing accidents must be developed. The team have themselves identified those things that they could, and must, do better. The senior management team must set up a way of looking at the way the home is run on a continuing basis so that the shortfalls that they have recently identified are not allowed to reoccur in the future. 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 House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 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 standard(s) 3 4 5 The home had failed to carry out an assessment for one service user who had recently moved into the home and did not have an appropriate way of assessing that the service is able to meet prospective service users’ needs. The service has acted properly to respond to a situation where service users’ needs cannot be met. The home now has in place a suitable assessment of service users considering moving into the home. Sensitive preparations are made to reassure service users moving into the home that their needs can be met. The home is supportive in welcoming people who wish to look around and spend time at the home prior to making a decision about moving in. EVIDENCE: There was no pre-admission assessment available for a service user who had recently moved in to the home. The responsible individual was unable to confirm, therefore, that an appropriate assessment of the service user’s needs had been carried out. The responsible individual developed a document for recording assessment prior to admission during the inspection. Both herself, and a senior member of care staff, were planning to visit a person in their own home, who was considering moving in. She confirmed arrangements to visit to carry out an assessment.
Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 Page 10 Three service users praised the welcoming environment of the home when they, or their relatives, had visited. One service user said that she had been able to enter the home for a trial period before making a decision regarding moving in on a permanent basis. One of the empty rooms visited contained a checklist in preparation for a new resident moving in. The list referred to the meeting of the specific needs and wishes of the service user, to ensure that the room is prepared and suitable for residency. A member of care staff said that fresh flowers are placed in the room to greet the new service user on arrival. Two service users said that they felt reassured when they moved into the home that they would be well cared for at Woodlands House. The responsible individual had identified that the home is not suitable to meet the care needs of two service users. This was supported by information seen in care records for one service user who was still living at the home. The records outlined needs of care, which fall outside the home’s categories of registration. The responsible individual was appropriately supporting the service user, a relative and care staff to ensure that care needs could be safely met, in the short term. The responsible individual has confirmed that a suitable alternative placement has been found for the service user, following the inspection visit. Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 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 standard(s) 7 8 9 10 The home has supportive means of planning service users’ care, meeting their healthcare needs and treating service users with respect and dignity. Some records do not adequately support service users’ changing needs for care. There are some shortfalls in procedures for the safe administration of medicines. EVIDENCE: Three plans of care for service users living at the home were seen. A detailed assessment is carried out. Each month a dependency profile is carried out which assesses all aspects of daily living. If a risk is identified in relation to skin condition or eating and dietary requirements a pressure sore risk assessment or nutritional risk assessment is completed. The care plans seen reflected most aspects of care needs and are reviewed regularly and include reference to consultation with service users. One service user said that she had been having problems eating and had been experiencing some discomfort. There were details of this within the daily records and the service user had been loosing weight. There was no plan as to how care was to be provided. A district nurse visiting the service said that the home appropriately refers healthcare issues when necessary and follows guidelines appropriately. She
Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 Page 12 spoke with a member of the care staff on duty and the member of staff said that she would update the care plan appropriately. On the day of the visit a member of staff had been out with a service user to visit the doctor. One service user described how the home supports her to access the support of the General Practitioner, dental and optical services. Care records have space for detailing contacts with the General Practitioner. These had not been completed, although there was evidence that the GP had been contacted. The home cares for people who are mainly independent and needing minimal support with health problems. The responsible individual is starting to look at this in terms of providing appropriate support to service users whose health has deteriorated but do not require nursing care. It was noted during the tour of the environment that there is no locked storage provided for service users who are self-administering medicines and medications were left out on shelves in two rooms. The responsible individual went out and bought lockable boxes, during the inspection. These were confirmed as in place prior to the end of the inspection. There were no written risk assessments for service users who have chosen to administer their own medication, involving discussion and consent of the service user, or their representative and the General Practitioner as appropriate. Three omissions were seen on records of medication administration, where the member of care staff had not signed to say that the medicine had been given or the reason why, on that occasion, it had had not been administered. Staff members provided sensitive and caring support during the visit. Staff members knocked on service users’ door, provided gentle support with mobilising and asked service users their wishes. In the cottage the carer on duty sits with service users to have a mid morning drink and a chat. Two service users present said how much they enjoy this shared time. One member of staff described how she works to preserve the dignity of a service user who needs some help with personal care. She gives the service user time, encouragement and respects wishes, enabling her to retain independence. Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 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 standard(s) 12 13 14 15 The home provides excellent opportunities for service users to enjoy a varied quality of life; supporting people to make decisions, choices and have control over their lives. Families and friends are made to feel welcome to be a part of the home. People living at the home receive a good standard of meals, which reflect a balanced diet, enjoyed in pleasing surroundings. EVIDENCE: The home benefits from an activities coordinator. Service users interests and hobbies were recorded on care plans seen and in individual records of participation in the social life of the home. Records included reference to sherry parties and shopping trips and service users said that these were pastimes that they particularly enjoyed. Two service users commented on the varied and independent lifestyle at the home. During the visit service users were seen sitting quietly in the lounge, enjoying a doze, reading newspapers and having a cup of tea with friends in the home and a staff member. One service user said that the lady from the mobile library visits her in her own room and brings a range of books for her to choose from. The home also supports service users to continue to practise in accordance with religious beliefs. Two service users said how much they feel that staff members contribute to the quality of life offered by the home and just wish that they had ‘more time to talk.’ Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 Page 14 One service user said that her family had recently visited and she had enjoyed a private family lunch with them in the library. She told how her family had been ‘waited upon’ and had been made to feel ‘at home.’ Some people living at the home use dial-a-ride for getting about in the local area. One person expressed the view of many of the service users living at the home that the gardens ‘could not be bettered.’ It is a source of great pleasure to watch the colours changing in the gardens, enjoy a stroll, and see the birds and squirrels, which were busy raiding the bird feeders on the day of the visit. One person said that she had had to move over to the cottage due to the building work taking place and now would not move back as she has a window on the wildlife in the garden. One service user living at the home was busy organising a hospital appointment during the visit, others were awaiting a visit from a business advisor. One service user explained that she is chairwoman of the residents’ committee, another said that he sits on the committee, which is an opportunity to share views and take forward issues and comments to the management team at the home. The chairwoman said that she feels that their views are listened and responded to, enabling people at the home to have control over their lives. Service users make choices about daily life. ‘I do what I like’ said one service user. Choices were evident in the home’s menu; curry or fish for the main meal on the first day of the inspection. At the time of the visit the home was not catering for any special diets. The service user who had enjoyed a meal with her family said they had been treated to smoked salmon ‘ you could not ask for more. A staff member described how she enables a service user to make choices about where she would like to eat. Most people eat in the home’s main dining room for lunch, and people living the cottage sometimes take supper at the cottage, which is prepared in their separate kitchen facilities. Meals seen reflected a well-balanced and nutritious diet. One service user commented that on occasion meals had been prepared in the main kitchen and brought over to the cottage and the bacon and eggs, for example, had been cold. Two service users said that the choice of some dishes such as curry or a flavoured mushroom dish had not been to their taste. The responsible individual said that meal preparation has now been organised to make sure that all meals are provided at an appropriate temperature and service users views are being sought as part of an audit to improve the service provided. Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 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 standard(s) 16 18 Service users at the home are confident that their complaints will be listened and responded to. A suitable policy and method of recording complaints is now in place. Staff members have a good awareness of what they must do if a service user is at risk of harm. Training in the protection of service users from abuse is not currently adequate. EVIDENCE: The home has a complaints procedure. During the visit the document was amended to include timescale for responding to complaints received and the opportunity to consult with the Commission for Social Care Inspection at any stage. A service user said that she felt able to raise issues through the residents’ committee and was confident of a response. The responsible individual has recently devised a questionnaire in which service users have the opportunity to raise complaints or issues of concern. The home did not have a book for recording any complaints received. Sheets were present which set out details of a complaint and then went on to refer to action in relation to incidents. The responsible individual produced a log for recording complaints at the time of the visit. The home has a copy of the local guidance from Hampshire County Council for Adult Protection and has a policy for responding to allegations of abuse. The home has demonstrated since the last inspection that the senior management have an understanding of the referral procedures in a case of suspected abuse and that appropriate action is taken in relation to any issue arising in respect of suspected adult protection.
Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 Page 16 A staff member said that if she felt that a service user was at risk of harm she would report it to the supervisor on duty. She said that if she was asked by the service user to keep an issue which may compromise safety a secret, she would explain that she had a responsibility to report it, so that the person at risk of harm could be protected. The staff member said that she had not had formal training in adult protection. Some of the staff have had training in relation to responding to an allegation of suspected abuse as part of their NVQ studies. The responsible individual intends to implement a training programme. Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not assessed on this occasion. EVIDENCE: Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 28 29 30 The numbers of staff working satisfactorily meets service users needs. The service has a good record of attendance on the National Vocational Qualification in care award. There are major shortfalls in the home’s vetting of people who apply to work at the home. The human resources manager is putting in place good recruitment methods to ensure that people wishing to work at the home in the future are properly screened. There has been a failure to update all staff in basic training. Progress is being made with devising an appropriate training programme. EVIDENCE: On the day of the visit the staff member who was due to be in charge was absent. The supervisor took over and organised staff members to cover for the day, an informative handover was given and staff on duty supported service users with care, taking time and attention to meet their needs. One service user said ‘staff are very caring.’ Two services users did say that they would like more time to chat with staff members, but all service users spoken to who live in the home felt that staff members had time to give good care. The home has a short induction programme. The responsible individual is reviewing the programme and looking at that adopted by other homes in the group to ensure that the training provided meets with the requirements of the National Training Organisation. At the time of the inspection seven members of staff were undertaking a National Vocational Qualification in care [NVQ]. Training sessions for infection control, the control of hazardous substances, COSSH and manual handling
Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 Page 19 have been arranged. At the time of the visit staff had not stored hazardous substances and medicines safely and inappropriate manual handling techniques had been used in the past to help move service users. The human resources manager has been going through staff recruitment files and has highlighted shortfalls in the recruitment practices of the home. These issues are being responded to as a matter of priority by the service. The manager has confirmed in writing with the Commission for Social Care Inspection that staff members who had commenced work without a Criminal Records Bureau check will not work in the home until a POVAFirst [Protection of Vulnerable Adults] check has been received. Three recruitment files seen showed failure to follow up in a gap in employment history, one reference only on one file, which was not from the most recent employer and no proof of identity held on two of the files seen. Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 38 The home does not have a monitoring system for ensuring that the home is run in the best interests of service users. The home is working to put in place good working practices to ensure that shortfalls in protecting service users and staff members are addressed. EVIDENCE: At the time of the visit three doors in the cottage were wedged open. The wedges were removed. The responsible individual discussed this with service users at a residents meeting following the inspection. The responsible individual confirmed that discussion would take place with the Fire Officer regarding arranging to hold open the doors so that they will close in the event of fire, according to the wishes of service users. The home’s accident record book does not meet with current guidance regarding Data Protection of records. The responsible individual intended to make contact with the Health and Safety Executive to obtain an appropriate record book. From records seen there had been two occasions when staff had
Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 Page 21 ‘lifted’ service users who had fallen and had hurt themselves. Although the responsible individual has indicated that an appropriate procedure would be followed in the case of such an incident, and that staff members receive training in manual handling, there was no written record to indicate that this had been followed up and that the carer had been confirmed as fit to work following the incidents. There is currently no audit process in place to look at trends in accidents occurring and steps taken to prevent reoccurrence. The responsible individual had noted that some service users had had a number of falls and was following this up. Discussion took place regarding appropriate referral when there were concerns. Two accidents had occurred when a member of staff had slipped on the temporary ramp from the main house to the walkway to the cottage and the responsible individual had taken appropriate action to make the ramp safe. Cleaning substances and ant killer were found in open cupboard in the cottage and the main house. The responsible individual took prompt action to arrange for the substances to be locked away. One of the rooms in the cottage has trees near the window, which blocks out some of the light entering the room. The responsible individual said that this was being looked at as part of the work being carried out to complete the building works to the home. The toilet in this room had a problem with flushing. The service user also said that her door is very heavy to open. The responsible individual has looked into this issue since the inspection and has found that there is little that can be done due to fire regulations. It was agreed, therefore, that a risk assessment and care plan reflect support for the service user, who has difficulty in using this door. The responsible individual undertook to give these issues immediate attention. The responsible individual had already responded to a comment regarding doors being slammed during the night. She had drawn up a schedule of work for staff members working at night to include the need for quiet. She intended to monitor this to ensure that service users had a good nights rest. Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x 1 x x x x 1 Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 3 78 9 Regulation 14 15 13 Requirement No service user must move into the home without having his/her needs assessed. Care plans must reflect service users current and changing needs. Reasons for the omission of medications must be recorded. There must be risk assessments in place for service users who wish to administer their own medication. Service users must be supported and protected by the homes recruitment practices. Two written references, CRB and proof of identity must be sought and held on file as part of the recruitment process for new staff members working in the home. Staff members must be trained to do their jobs. The programme of updating staff members in all areas of mandatory training including adult protection, health and safety, infection control and food hygiene must be completed. A system for regularly reviewing and improving the quality of care provided at the home must be Timescale for action 31 May 2005 31 May 2005 31 May 2005 4. 29 19 31 May 2005 5. 30 18 13 30 September 2005 6. 33 24 15 June 2005
Page 24 Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 established. 7. 38 23 All members of staff working in the home must receive fire training and drill practice, ensuring that the safety of service users is maintained. The safety of service users and staff must be protected and promoted by providing a safe system of moving and handling service users and for recording and auditing accidents in the home. 15 June 2005 8. 38 14 15 June 2005 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 Good Practice Recommendations Woodlands House H54 S12161 Woodlands House V225195 100505.doc Version 1.30 Page 25 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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