Inspection on 18/09/07 for Woodlands House

This inspection was carried out on 18th September 2007.

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 House 19/09/06

Woodlands House 14/12/05

Woodlands House 10/05/05

Woodlands House 12/10/04

Woodlands House 29/06/04

Woodlands House 20/01/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Woodlands House 118 Cavendish Road London SW19 2HJ Lead Inspector Emma Dove Unannounced Inspection 11:30 18 September and 12 and 16th October th th 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 House DS0000034082.V349020.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 House DS0000034082.V349020.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands House Address 118 Cavendish Road London SW19 2HJ 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) 020 8408 8552 0208 543 9067 Central & Cecil Housing Trust Post vacant Care Home 64 Category(ies) of Dementia - over 65 years of age (36), Old age, registration, with number not falling within any other category (28) of places Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Nursing Places To include no more than twenty service users requiring nursing care at any one time. Dementia Care Comprising of three units of twelve service users on each floor. There must be two members of staff on each unit between the hours of 7.30am and 9.30pm. One member of staff must be available to cover night duty for each unit between the hours of 9.00pm and 7.45am. Residential and Nursing Care On the first floor there must be two care staff available on the unit 7.30am to 9.30pm and one care staff to cover night duty between 9.00pm and 7.45am. On the second floor there must be two care staff available on the unit from 7.30am to 9.30pm and one care staff to cover night duty between 9.00pm and 7.45am. In addition a qualified 1st level nurse must be available to cover both nursing units twenty four hours a day. This nurse must not have any management responsibilities for the home other than within the nursing and residential provision where based. Additional Staff An additional member of the care staff team must be available between 9.00pm and 7.45am to offer assistance and cover breaks throughout the home. Management One full time Manager 40 hours per week One Deputy Manager 40 hours per week Senior Staff The registered provider must ensure that a named person designated as the senior person, in charge of the home is available at all times. Ancillary Staff Cook 105 hours per week Kitchen assistants 164.5 hours Housekeeper 35 hours per week Domestic staff 136.5 hours per week between the hours of 9am and 5pm Laundry staff 91 hours per week Administrative staff 37.5 hours per week Reviews The organisation must ensure that the above minimum staffing levels remain under review and that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health and welfare of service users. 3. 4. 5. 6. 7. 8. Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 5 Date of last inspection 19/09/06 Brief Description of the Service: Woodlands House is a purpose built care home which has the capacity to provide nursing care for twenty older people, residential care for twenty-four older people who may have dementia and twenty older people. Within these numbers, twelve beds have been designated to provide intermediate care. Fifty-two people are currently living there. The home is owned and managed by Central and Cecil, a charitable organisation who own and manage two other similar services in the local area. Accommodation is provided over three floors. A lounge, dining room, kitchenette, bathrooms and single bedrooms are available on each floor. Residents have access to enclosed gardens to the rear and side of the home. Each floor is served by a lift. Woodlands House is situated in a residential area of Colliers Wood, within a ten to fifteen minute walk of local shops, public transport systems and churches of a number of denominations. The home is staffed twenty-four hours a day by trained nursing staff, care assistants and domestic staff. Three meals are provided daily with drinks and snacks available between mealtimes. The weekly fees are from £438.60. Information regarding the CSCI is included in the Statement of Purpose and Service Users Guide. Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over five hours on the 18th September 2007 by two regulation inspectors and five hours on the 12th and 16th October 2007 by one inspector. The inspection included talking with people who use the service, visitors, staff, the temporary manager and new manager, looking at records, communal areas and six bedrooms. Questionnaires were sent to people who use the service, their relatives, health and social work professionals. We have received three completed questionnaires, comments from these are included throughout this report. An Annual Quality Assurance Assessment was returned in good time to be included in this report. We have received appropriate notifications but have not had copies of the monthly visits carried out by the organisation. What the service does well: What has improved since the last inspection? What they could do better: All people must have a care plan, detailing their needs and how they should be met. Generally recording around care planning, reviews of care plans, medication administration and health care should be improved to ensure people’s needs are noted and can be met by staff. Better systems to check the administration of medication, the quality of care received and to welcome visitors to the home would improve these areas. Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 7 The interaction between staff and people using the service should be reviewed to ensure people receive good quality care. Mealtimes should be reviewed, to ensure they offer people a good experience while eating. The activities provided should be looked at to ensure that people have access to a range of activities to meet their needs. Some people said ‘there’s not much to do’. Staff files must contain evidence that the appropriate checks have been completed to ensure people using the service are protected from harm. Staff should wear name badges, to follow the companys’ procedure and ensure people using the service and visitors are aware who staff are. The staff training spreadsheet should be updated to include all sessions staff have attended. Staff must complete training in the protection of vulnerable adults and caring for people with dementia, to ensure staff can meet peoples needs and provide a good quality of care. The staff rota must be up to date with the staff on duty. 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 House DS0000034082.V349020.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 House DS0000034082.V349020.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 and 6 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home understands the importance of having sufficient information when choosing a care home. It has developed clear information to help people understand the services provided. This information is given to all people and their relatives or representatives. Assessments are usually completed before admission. EVIDENCE: A Statement of Purpose and Service Users Guide have been developed which include information about the services provided and facilities available. The acting manager reported that they are in the process of updating the Service Users Guide to include photographs to assist people in understanding the services provided. Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 10 One person said that they have a contract of residence and ‘we’re lucky to get a place in Woodlands’. Two people did not have a contract of residence but had received enough information to help them decide to move in. One person noted that their relative had ‘settled in very well’. The temporary manager reported that pre-admission assessments are completed and people who are considering moving in have been invited to visit for a meal to spend time with staff and other people using the service to help them decide if the home is right for them. People are encouraged to bring personal items with them, to help them feel at home. One case file did not contain a pre-admission assessment. Other files had an assessment from the placing social worker and an assessment completed by a senior member of staff. A twelve-bedded unit for intermediate care is available with input from the Primary Care Trust (PCT). A weekly meeting is held with all professionals involved to note progress and agree the individuals care plan and programme of support. Social workers reported that they no longer attend this meeting. A quarterly meeting is held with the PCT to update on the service provided. People using the intermediate care service made positive comments about the environment, staff and support they receive. Woodlands House DS0000034082.V349020.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 People who use the service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Most people using the service have a care plan, but the practice of involving people who use the service in developing and reviewing the plan is variable. Care plans vary in the amount of detail they include, some include basic information about peoples needs but are not detailed with how these needs should be met. Care plans are not person centred. People’s health needs are generally noted, although with some gaps in records. Medication is generally well managed with some gaps in recording of medications administered and some discrepancies with the amount of medication received and the amount administered for some people. EVIDENCE: Care plans were seen to be in place for most people. One person who had been at the home for one month did not have a care plan. Care plans contained different levels of information and some did not include enough information for staff to be able to meet the individual’s needs in the way they Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 12 prefer. Some care plans contained good detailed information about people’s life history and what they had done during their life, while others contained very little information. Care plans had mainly been reviewed every month by staff, however a number of care plans had not changed for a few years. One person’s care plan noted that they ‘have difficulty speaking English’. The family visit regularly and that one member of staff speaks the person’s language. This level of detail does not demonstrate that the home can meet this person’s needs. Two questionnaires noted that the people ‘always’ and one person ‘generally’ get the care and support they need, with an additional comment ‘if permanent staff are on duty’ The temporary manager noted that they could improve the daily records, although there was no plan of how this is to be addressed. The property lists for some people receiving intermediate care were not completed, dated or signed, this could lead to confusion when people are discharged from Woodlands. Records seen noted that people are not all weighed on a regular basis and it is not clear when someone has a significant change in weight, particularly a loss, that this is followed up with a referral to the GP or a dietician. Three questionnaires noted that the people ‘always’ get the medical support they need’. Records indicated that some people have not been having a bath every week. This should be discussed with people who use the service and people should be offered more regular baths or showers. The temporary manager noted that they have improved staff levels to ensure when people have to go to hospital for a routine appointment, if family members are not able to attend, a member of staff is available to escort them. Medication is appropriately stored and labelled, however some gaps were noted in the recording of medication administered to four people. A count of one person’s medication noted a difference in the amount of medication received and the amount administered of three different medications. One person’s medication profile noted that they are not taking any medication, however one medication was being administered on a daily basis and another medication had been given for one week. A number of medication profiles did not include a photograph of the individual. Medication audits had not been completed since April 2007 in one unit but had been done monthly in other units. The temporary manager noted that they could improve the medication processes but again, there were no details of how this is to be achieved. Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People using the service are given the opportunity to take part in a variety of activities. Visitors are welcome. The menu is varied and caters for people’s dietary and cultural needs. EVIDENCE: The television was on in all units and people who use the service were seen to be watching television, listening to music, reading the paper and talking amongst themselves. Some regular activities are arranged every week and information is displayed around the home for people who use the service and visitors. An aromatherapist visits once a week and spends time with individuals, people said that they continue to enjoy this. An artist visits every week and again people spoke positively about having the opportunity to do painting. A church service is held every month. The temporary manager noted that they could improve the service by seeking feedback from people using the service about activities provided. One person said ‘no activities at present, but maybe in the future’. One person said that there are ‘usually’ and one person said ‘sometimes’ activities are Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 14 available but they are not keen to join in. One person confirmed that they have a newspaper delivered and are able to sit and read it during the day. Visitors are welcome and can visit in communal areas or in private in the persons bedroom. The days menu is displayed on a board as you enter the lounge. Most people were not aware of what was for lunch, but they were not worried about not knowing. Peoples comments about the food included ‘lunch was quite nice’ ‘food is fine’ and ‘get fish and chips too often’. Two people said that they ‘usually’ like the meals. Meal times could be managed better and be a nicer experience for people who use the service. The use of ‘bibs’ should be reviewed, so that people’s dignity is maintained. Meals could be served at the table and more discussion about meals served could be had with people. The new manager reported that the use of ‘bibs’ will be reviewed and that mealtimes will be observed and suggestions to improve them discussed with people who use the service. Meeting minutes indicated that people have asked for meals to meet their cultural needs, the new manager confirmed that meals are planned to meet peoples cultural and religious needs. Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure which is available in written format and is displayed. People are aware of who to speak to if they have any concerns. Complaint records must include the outcome for the complainant and people should not feel repercussions for making a complaint. Staff have completed or are due to complete training in the protection of vulnerable adults. EVIDENCE: The complaints procedure is included in the Statement of Purpose and Service Users Guide and displayed for people who use the service and their visitors to access. The temporary manager reported that complaints are taken seriously and responded to. People we spoke to are aware of who to speak to if they had a complaint or concern, most people said that they would ‘go to the office’. Three questionnaires noted that the people know who to speak to and how to make a complaint. Care must be taken to ensure when people make a complaint that they do not feel victimised. Records are kept of complaints and actions taken. Sixteen complaints have been received since the last inspection. There was not a clear outcome for the Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 16 people using the service in some of the complaints made. Three complaints had been received recently about the quality of care provided. Staff meeting minutes confirmed that these complaints were being taken seriously with discussions around quality and how to meet people’s needs. A clear action plan had been put in place in one instance and the complainant felt that things were improving. Actions from one complaint included staff being given name badges, with a written directive from the company confirming that all staff must wear name badges. Staff did not have name badges and people using the service made comments about not knowing the names of staff. The temporary manager reported that the number of name badges had been noted and that an order was due to be made, when information had been received from other homes within the organisation. Policies are in place for the protection of vulnerable adults. The temporary manager demonstrated knowledge and understanding of the policies and her responsibilities. Some staff have completed training in the protection of vulnerable adults with other staff booked to attend this training. Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23 and 26 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home was purpose built and provides an environment that is appropriate to the needs of people who live there. The home is generally well maintained with a few areas needing attention. Specialist aids and adaptations are in place to meet individual’s needs. Bedrooms are single and people are encouraged to personalise their rooms. EVIDENCE: The home is separated into five units, one on the ground floor with two units on the first and second floor. Each unit has a lounge/dining area, single bedrooms, toilets, shower room, assisted bathrooms and a small kitchen to prepare drinks, snacks, breakfast and serve meals. Two enclosed gardens are available to the rear of the home, with seating areas, flowerbeds and bird Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 18 tables. People who use the service made positive comments about looking out over the garden. Staff have separate rest and toilet/changing areas. The main kitchen and laundry are on the ground floor. A large purpose built day centre is next door to the home, they share car park and front entrance. Some people who live at Woodlands attend the day centre. Some areas are starting to look worn and are in need of redecorating to keep the home maintained to a good standard. One lounge on the second floor has some water damage to the ceiling, which requires repairing. One lounge had some old furniture in, which should be moved to ensure people have access to this area. Staff reported that they are starting to use the second lounge on the ground and second floor for activities and have started to buy some board games and cards, this will be good for people who use the service. Bedrooms are single, have an ensuite toilet and wash hand basin and are furnished with a bed, wardrobe and chest of drawers. Some people have bought small items of furniture and other personal possessions, which make their rooms their own and as one person said ‘makes it mine’. However some bedrooms are very bare, have not been personalised and did not have peoples personal possessions. Three people noted that the home is ‘always’ clean and fresh with ‘high standards maintained’. All areas of the home were clean and fresh. Appropriate policies are in place for infection control. Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People using the service are generally satisfied with the care they receive to meet their needs. Appropriate recruitment policies and procedures are in place, although records do not always confirm that appropriate checks have been completed on new staff. Staff have access to training and development sessions to support them in their role. EVIDENCE: The staff rota did not include the staff on duty during our first visit. Two staff are on duty on each unit every day with one nurse on the first floor, some days a second nurse is available. At night, one member of staff is on the ground and second floor, with two members of staff and a nurse on the first floor. The manager, domestic, administrative and catering staff are available in addition to these staff. Staff levels were seen to be sufficient during our visits with the exception of a lack of senior staff during one visit due to staff training. The only issue raised about staff levels was how having the second nurse was good for the service. One member of staff had worked eleven days without a break. People using the service noted that there had been a number of staff changes Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 20 over recent months. The temporary and new manager confirmed that a number of senior staff had left over the last year and that new staff were being recruited to cover the vacancies. People using the service comments about the staff included ‘generally ok, although some new staff are not well trained’. Three people said that staff ‘always’ listen and act on what they are asked to do. One person said that staff are ‘always’ available and two people said that staff are ‘usually’ available. The organisation has a recruitment process which includes the appropriate checks being completed before someone starts work. Four staff files seen included a copy of the application form. Only two staff files contained confirmation that a clear Criminal Records Bureau check had been completed and contained proof of the persons identity. One staff file contained one written reference. Staff files do not contain information to confirm that people using the service are protected from harm by the recruitment process. Records indicated that staff have been doing more training in the last six months with more training booked to cover the specialist areas the service provides. This should give people using the service a better quality of care. Five members of staff have completed training in medication administration, three members of staff have completed training in the protection of vulnerable adults, three staff have completed a one day course in dementia care and one staff has completed training on the Mental Capacity Act and working with people with a visual impairment. The staff training record should be updated to include the training staff have attended recently. Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The manager has been at the home for a few weeks and is in the process of learning about the organisation and the people who use the service. The manager is aware of the need to promote safeguarding and is developing a plan to improve the services provided. Health and safety systems are generally good with required checks up to date with one exception. EVIDENCE: The registered manager left in July 2007, a temporary manager was put in place two and a half weeks later and a new manager started early September 2007. The deputy left the home on a temporary basis in June 2007 and a number of senior staff have left for various reasons since the last inspection. Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 22 This has had an effect on the way the home has been running and will take a while for new staff to be appointed and for the manager and acting deputy to work together to start improving the service. The new manager demonstrated a commitment to working with staff to improve the services provided. A representative from the organisation visits the home every month to check on the quality of care. A report is available at the home but a copy is not sent to us. One staff meeting has been held to introduce the new manager with further staff meetings planned. Pages have been torn out of the communication book in one unit. The home looks after some money for some people using the service. This was not looked at in detail during this visit, but will be at the next inspection. Appropriate health and safety policies and procedures are in place. Records confirm that checks are up to date and completed at the required intervals with the exception of the gas safety check, which was completed in May 2006. This check must be done every year. Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 3 3 X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 24 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 15(1)& (2) Requirement Care plans must include details so staff can meet peoples assessed needs. (previous timescales of 30/06/05 24/11/06 and 20/04/07 not met) The provision of activities should be reviewed to ensure people have access to a range of activities and outings to meet their needs. (previous timescale of 30/05/07 not met) Medication must be signed for at the time of administration. The staff rota must be up to date with the staff on duty. Staff files must contain evidence that the appropriate checks have been completed to ensure people using the service are protected from harm. All staff must complete training in the protection of vulnerable adults, to ensure they are aware of their responsibilities. (previous timescales of 24/11/06 and 27/04/07 not met) All staff must complete training in dementia care to ensure that DS0000034082.V349020.R01.S.doc Timescale for action 06/12/07 2. OP12 16 (2) m 31/12/07 3. 4. 5. OP9 OP27 OP29 13 (2) 17 (2) Sch 4 (7) 18 ( 28/11/07 28/11/07 28/11/07 6. OP30 13 (6) 05/12/07 7. OP30 18 (1) 31/12/07 Woodlands House Version 5.2 Page 25 they can meet the needs of people who use the service. (previous timescales of 06/02/06, 24/11/06 and 27/04/07 not met) 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. 2. 3. 4. 5. 6. Refer to Standard OP7 OP7 OP15 OP27 OP30 OP31 Good Practice Recommendations The bath routine should be reviewed with people offered the chance to have a bath at least once a week, and more often if they wish. Clothing lists should be completed, dated and signed on admission to ensure peoples belongings can be packed when they are discharged. Mealtimes should be reviewed to ensure they are a pleasant experience for people who use the service and the use of ‘bibs’ should be reconsidered. Staff must wear name badges, to follow the companys policy and ensure people using the service and visitors are able to identify and address staff. The interaction between staff and people who use the service should be reviewed to ensure people receive good quality care. Better systems should be put in place to monitor medication administration, the quality of care provided on a day to day basis and to welcome visitors to the home Woodlands House DS0000034082.V349020.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 House DS0000034082.V349020.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!