Inspection on 19/09/06 for Woodlands House

This inspection was carried out on 19th September 2006.

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 18/09/07

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 19th September 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands House DS0000034082.V316221.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.V316221.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 020 8332 1044 Central & Cecil Housing Trust Eileen Nartey 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.V316221.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.V316221.R01.S.doc Version 5.2 Page 5 9. 10. 11. Distribution of Staff The number and distribution of nurses, care staff and ancillary staff must be reviewed at regular intervals. If at any time, the evidence indicates that there are insufficient staff of any category available to meet the assessed needs of service users, the NCSC will require additional staffing as appropriate. Assessment The registered provider must demonstrate that each transferred service user has had an in house needs led assessment since 01.02.02 by 31.11.02, that this is recorded on the individual’s file and that it can be demonstrated that individual needs are being met appropriately. To vary the category to allow the home to admit one named service user under the age of sixty-five years, who has learning disabilities. 14th December 2005 Date of last inspection 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-six residents are currently residing at the home with one resident in hospital. 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 of the home is served by a lift. The home 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 between £438.60 and £782.25. Information regarding the CSCI is included in the Statement of Purpose and Service Users Guide. Woodlands House DS0000034082.V316221.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 seven hours on the 19th September 2006 by two regulation inspectors. The inspection included the examination of records, inspection of communal areas of the home and four residents bedrooms, talking to residents, the deputy manager, staff and the registered person. The inspectors spoke with fourteen residents and ten members of staff. Questionnaires were left with residents, staff and visitors and sent to two professionals. Four questionnaires have been received and comments from these are included in the relevant sections of this report. What the service does well: What has improved since the last inspection? What they could do better: Assessments must take into account prospective residents needs and care should be taken to ensure new residents ‘fit’ with current residents. Care plans should be more person centred and include all the care and support needs of individuals. Wound records must include the size and indicate if the wound is healing. Residents must receive appropriate health treatment when required with clear communication systems in place to ensure that this happens. Woodlands House DS0000034082.V316221.R01.S.doc Version 5.2 Page 7 Medication Administration Records Sheets must be signed at the time medication is administered and not signed if medication is not administered for any reason, with the reason clearly specified. Cleaning materials must be securely stored to ensure residents are protected from harm. 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.V316221.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.V316221.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 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have access to information to make an informed choice about moving into the home. Assessments are completed prior to admission. Residents admitted for intermediate care are supported to return home EVIDENCE: The Statement of Purpose and Service Users Guide contain information needed by people to help them decide whether to move into the home. These documents have not changed since the last inspection in December 2005 and detail the services provided, staffing, activities, consultation, religious services and the complaints and fire procedures. Woodlands House DS0000034082.V316221.R01.S.doc Version 5.2 Page 10 Residents comments regarding the home included ‘my room is ok’, ‘I like my room’ and ‘it’s not got as much room as home, but I was able to bring personal items and I have a nice view out of my window’. One relative said ‘the home is nice with a homely environment’. Assessments are completed by the manager or deputy prior to admission, these assessments include information about the individuals needs and the support and assistance they require. One assessment was found to identify the individuals needs, which are more than can be catered for in the residential unit, however the resident was admitted to a residential unit. This placement does not meet the needs of the individual. Care must be taken with admissions to ensure that new residents needs can be met at the home and that new admissions will not have a detrimental affect on the current residents. A separate unit provides dedicated intermediate care for up to twelve residents. This service is well managed and provides appropriate support to people who are recovering from operations or stays in hospital and helps them prepare to return home. Residents made positive comments about the treatment, support, and food they have received while using the intermediate care service. Woodlands House DS0000034082.V316221.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are in place and include information needed to provide support and assistance to individuals, however they could be more person centred. Residents health care needs are recorded and met by staff with the exception of medication which must be signed at the time it is administered. EVIDENCE: Care plans were in place in six case files seen by the inspectors. One file did not contain a care plan, only an assessment which had been completed at the time of admission, four weeks previously. Care plans completed by different staff contained different levels of information, some being more detailed. One care plan identified that the resident sometimes presented ‘aggressive’ behaviour and noted that ‘staff will make them comfortable and calm them down’. The care plan did not suggest what staff would do or how they would Woodlands House DS0000034082.V316221.R01.S.doc Version 5.2 Page 12 ‘calm’ the individual and if this is required, staff should have clear guidelines to follow. One care plan did not include a social history. Daily recording needs to be more factual and detail what care and support has been provided. It is good that staff are able to complete training in basic English as a part of their induction to the home. Communications to staff on one unit indicated that staff should keep residents awake during the day, this was not followed up during the inspection but left with the deputy manager to address to ensure that residents needs are met and that residents receive the appropriate care and support from staff. Records of wounds include details of the wound and treatment given. One wound plan had photographs taken monthly. One wound plan noted the size of the wound in July 2006 with no further record of size. Case files included weight records. One residents weight had been recorded in May then not until August, when a large drop was noted, it was not clear if advice was sought regarding the weight loss. The nurse and care staff reported that they seek medical advice if significant weight loss is noted. The daily record for one resident noted that they had broken a tooth, this was reported to a senior member of staff but there was no record of an appointment being made with the dentist. This is very poor practice and does not meet residents health needs. The nurse on duty during the inspection visit contacted the dentist and an appointment was made for the following week. Medication was examined on all units and a number of issues regarding recording and administration were noted. Generally gaps were noted in the signing of fourteen residents Medication Administration Record Sheets. Also on two residents MARS, staff had signed that the medication had been administered, when it was still in the blister pack. Some old medication had not been disposed of. On one unit, a member of staff had completed a monthly audit of medication and not noted any issues, when some of the gaps in signing had occurred and some medication remained in the blister packs. Clear systems need to be in place to ensure any medication audits identify issues and address them with staff training to ensure issues do not occur in the future. Woodlands House DS0000034082.V316221.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to a range of activities during the week in addition to watching the television and listening to music. Visitors are made welcome which supports residents in maintaining contact with family and friends. A varied menu is provided which caters for residents cultural, religious and medical requirements as well as offering a choice of meals. EVIDENCE: An activities schedule was displayed on the ground floor which included a variety of activities for residents to participate in including: conversations; ball games; aromatherapy; hand care; reminiscence; karaoke; newspaper discussions; art and music sing-a-longs. Staff also reported that they have access to a selection of puzzles and card games to use with residents. Residents can borrow books and videos from a library at the home. Representatives from the Church of England visit every month and staff reported that people from other faiths can be invited into the home for residents if requested. Residents comments about activities included: ‘I really Woodlands House DS0000034082.V316221.R01.S.doc Version 5.2 Page 14 enjoy the artists visit’; ‘I like the film shows’; ‘there’s not much going on here’ and ‘I’m not doing much’. Visiting entertainers are invited to the home to offer different forms of entertainment for residents to watch if they wish. Residents and relatives confirmed that visitors are made welcome by staff and offered drinks and can have a meal if they ring the day before to arrange. One residents case file did not include a social profile of the individual and did not have any care plan around occupation or how they wish to spend their time. A separate record is maintained of activities, however these could include more detail of the activities offered and how often they are accessed by residents. This information could then be used to review the care plan in place. The menu for the day was displayed on all units, three choices of main meal, including a meat, fish and vegetarian meal are provided. The home operates a four weekly repeating menu which caters for residents dietary requirements. Residents comments about the food included: ‘the food is alright’; ‘the food is ok’; ‘nice food’; ‘beautiful food’ and ‘nice lunch’. A mealtime was observed to be well managed, allowing individuals time to eat their main course and pudding. Woodlands House DS0000034082.V316221.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate policies are in place to deal with complaints and to protect residents from harm, however recording practices do not fully acknowledge complaints raised by residents. EVIDENCE: The complaints procedure is included in the Service Users Guide and is displayed at the home, accessible to residents and their representatives. Questionnaires indicated that residents were aware of how to complain and residents said that they would ‘speak to staff’ or ‘speak to the manager’. Two residents and two relatives also said that they have had no reason to complain. The minutes from a residents meeting identified a concern raised by a resident which was not in the complaints record. The deputy reported that the matter was being addressed. A copy of the local authorities protection of vulnerable adults policy is available at the home. Some staff have completed training in the protection of vulnerable adults. This training should be provided to all staff. A resident raised an issue relating to protection, which was reported to the local authority who carried out an appropriate investigation. The CSCI was informed of the outcome of the investigation. Woodlands House DS0000034082.V316221.R01.S.doc Version 5.2 Page 16 Woodlands House DS0000034082.V316221.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, 23, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was purpose built to meet the needs of current residents. The home is maintained to a good standard of décor and cleanliness with the exception of a few shower rooms, particularly on the ground floor. Bedrooms are single with an ensuite toilet with bath and shower rooms available on each unit. EVIDENCE: The home was purpose built as a care home with aids and adaptations fitted to meet residents needs. The home is separated into five units, each with a lounge, dining room, bedrooms and bathrooms. Bedrooms are single and have a bed, wardrobe, chest of drawers and armchair. Staff reported that residents can bring small items of furniture on admission to the home. Three residents confirmed that they brought some items which are important to them. The Woodlands House DS0000034082.V316221.R01.S.doc Version 5.2 Page 18 bedrooms in the intermediate care unit were noted to be less personalised than other bedrooms, this is due to the short-term nature of the service. Residents made positive comments about the home and their bedrooms one resident said ‘my room is fine’ with some commenting that ‘it’s not like home’. Residents have access to a library of books and videos. The shower room on the ground floor has a number of tiles which have fallen off the wall and another shower room on the ground floor has a broken shower screen. A shower on the second floor has a damaged hose. The second lounge on the second floor was found to have a broken cabinet. These issues must be addressed to keep the home at a good standard for residents. Residents have access to two small gardens which have benches, both raised and ground level flowerbeds, bird tables and a patio area. Residents said ‘I like spending time in the garden’, ‘I like the roses and flowers’ and ‘they keep the garden nice’. One resident also said they liked looking at the garden from their bedroom. Appropriate systems are in place for infection control and staff are aware of issues and how to protect residents. All areas of the home were found to be clean, with the exception of one lounge on the second floor, which appeared to be used by staff and needed cleaning and rubbish thrown away. A number of cleaning products were found to be stored in bathrooms and bedrooms, not locked away. This practice does not protect residents and cleaning materials must be securely stored at all times. Woodlands House DS0000034082.V316221.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by a group of staff who have considerable experience working with older people. Staff have access to training through the organisation. Some staff have received regular supervision since the last inspection ion December 2005. EVIDENCE: Most staff have been at the home for a number of years and are aware of residents needs and how to meet them. Staff demonstrated good knowledge and understanding of residents needs. The relationships between residents and staff was positive with staff offering support in appropriate ways Residents comments regarding staff included ‘staff are polite’, ‘staff are alright’, very nice people here’, ‘the staff are very very good’ and ‘staff do a good job’. The staff rota identified staffing levels in line with those set at the time the home was registered. The deputy reported that two senior staff had been off for a while and that they were due to return to work soon. Woodlands House DS0000034082.V316221.R01.S.doc Version 5.2 Page 20 Staff have access to appropriate training through the organisation and staff reported that they have sufficient training to carry out their role fully. Six staff files were looked at which included references, application forms and records of training courses completed. Evidence was not in place confirming that a Criminal Records Bureau check had been completed. The registered person reported that recruitment information is held at the head office and the organisation has a new list of information to be completed for all staff which will identify which recruitment checks have been completed and where the information is held. This list must be completed for all staff. The file for one nurse had a copy of their registration with the Nursing and Midwifery Council (NMC), which was due to expire in a few days. A process must be in place to ensure that when nurses renew their registration with the NMC, this information is held on their staff details. Woodlands House DS0000034082.V316221.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, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed to meet resident’s needs. All staff must receive regular supervision to ensure they are able to fulfil their role fully. Good health and safety policies, procedures and systems are in place to protect residents, visitors and staff from harm. EVIDENCE: The manager and senior staff have significant experience working with older people. Regular residents meetings are held with residents involved in planning outings and activities. Woodlands House DS0000034082.V316221.R01.S.doc Version 5.2 Page 22 Some staff confirmed that they have received supervision, however this has not been happening for all staff on a regular basis. The deputy reported that this was due to some senior staff being off work, but they were now due to return to work and supervision would take place again. All staff who spoke with inspectors and who completed questionnaires confirmed that receive the support they require to do their job and that they have senior staff to report to if necessary. The gas, electrical supply and hoists have all been checked and serviced at the required intervals. The fire alarm system has been tested weekly with the exception of two weeks in March and August 2006. The portable electrical appliances were tested in August 2005 and are due to be tested again. Records of bath and shower temperatures were found to be sporadic with a number of records in bathrooms seen to be from March 2006, staff reported that this is now put on case files with resident’s personal care details. It is not clear how often the contents of first aid boxes are checked and this must be clearly recorded. Woodlands House DS0000034082.V316221.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 3 X X 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 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 2 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Woodlands House DS0000034082.V316221.R01.S.doc Version 5.2 Page 24 YES 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. Standard OP7 Regulation 15(1)& (2) Requirement The registered person must ensure that care plans include details so staff can meet residents assessed needs. (previous timescale of 30/06/05 not met) The registered person must ensure that records of wounds include the size. The registered person must ensure that medication is signed for at the time it is administered. The registered person must ensure that all complaints and concerns are recorded with clear details on the actions taken and the outcome. The registered person must ensure that the tiles and broken shower door in the ground floor shower rooms are repaired or replaced. The registered person must ensure that all staff complete training in dementia care and for senior staff to complete training in supervision. (previous timescale of 06/02/06 not met) DS0000034082.V316221.R01.S.doc Timescale for action 24/11/06 2. 3. 4. OP8 OP9 OP16 12 (1) a 13 (2) 22 (3) 14/11/06 24/11/06 14/11/06 5. OP19 23 (2) b 24/11/06 6. OP30 18 (1) 24/11/06 Woodlands House Version 5.2 Page 25 7. OP30 18 (1) c 8. OP30 13 (6) 9. OP36 18 (2) The registered person must ensure that nurses receive appropriate training. (previous timescales of 30/06/05 & 06/02/06 not met) The registered person must ensure that all staff complete training in the protection of vulnerable adults. The registered person must ensure that all staff receive supervision at least six times a year from a senior member of staff at the home. (previous timescales of 30/06/05 & 06/02/06 not met) 24/11/06 24/11/06 24/11/06 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 OP19 Good Practice Recommendations The broken cabinet in the lounge on the top floor should be removed and general rubbish thrown away. Woodlands House DS0000034082.V316221.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. 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