Inspection on 01/08/07 for Woodlands Nursing Home

This inspection was carried out on 1st August 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodlands Nursing Home 25/10/06

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Butterley Hill Ripley Derbyshire DE5 3LW Lead Inspector Steve Smith Key Unannounced Inspection 1st August 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands Nursing Home DS0000066012.V341303.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 Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Nursing Home Address Butterley Hill Ripley Derbyshire DE5 3LW 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) 01773 744919 woodlandsch@aol.com Westwood Care Homes Limited Mollie Ann Hardy Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (4) of places Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The condition of registration is that the kitchen area be refurbished. Date of last inspection 28th February 2007 Brief Description of the Service: The Woodlands Care Home has been purpose built and is registered for the care of 40 elderly Residents. The Home is registered to permit the admission of Residents with nursing and personal care needs. A condition of registration allows the Home to admit up to four younger adult Residents (50 - 65 years) with physical disability needs. The home is situated close to the town centre of Ripley. The Woodlands Care Home provides a pleasant environment for the Residents and accommodation is provided on two floors. There is a passenger lift and staircase access to the first floor facilities. There are two main lounge/dining areas and a mix of single and double bedrooms are provided. Five of the single bedrooms are provided with en-suite facilities. The home has adequate provision of assisted bath/shower facilities throughout. All bedrooms are fitted with TV points and the call/alert system operates in all areas of the home accessed by Residents. The attractive grounds of the home are accessible to the Residents. Support services are in place with a choice of General Practitioners, and chiropody, dental, optician and other services arranged as appropriate. The charges made for a room at The Woodlands range from £324.05 to £498.30 a week, dependent on the size of room, the facilities provided, whether the room is a double or single room, and whether residential or nursing care is required. The current charge made for disabled Residents was £545.15. A copy of the Commission’s inspection report is available from within the Home. Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of just over 6 hours. Discussion was held with two Residents, and the records of four Residents were ‘case tracked’. Discussion was also held with the Manager and with one member of the care staff. A number of records were examined, and the bedrooms of four Residents were examined, and all public areas of the Home were looked at. The Commission’s Annual Quality Assurance Assessment questionnaire, sent to the Manager, was examined. The Commission’s Residents questionnaire was also sent to a selection of Residents, and 4 were returned at the time of this inspection. They all commented favourably on the Home. What the service does well: What has improved since the last inspection? Since the last inspection, in October 2006, the Registered Provider and Manager have updated the Residents Guide to ensure it complied with the new requirements that came into force in September 2006. In addition, the Home’s terms and conditions of residency was made available to all Residents supported by Social Services Depts. The Registered Provider had also provided information in the statement of purpose and Residents Guide on the physical environment Standard provided within the Home. Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 6 The records of care provided for Residents had been improved, which included the record of medication and the record of meals provided within the Home. Minor improvements had been made to the physical appearance of the Home. At the time of this inspection the Home had more than 50 of care staff holding at least an NVQ level 2 qualification in Care. The Registered Provider and Manager had ensured that the majority of the Quality Assurance issues have been addressed in the Home. What they could do better: The Manager needed to ensure that the Residents Guide contained information on Residents views of life in the Home. The Residents plans of care needed additional items addressing to ensure they met appropriate standards. There was also an issue that needed improvement in the record of medication kept by the Home. The work begun by the Manager to recruit a new Activities Coordinator needed to be completed. The staff team needed to be made aware of those Residents at whose doors they should knock and await an invitation to come in, and those Residents whose dementia meant that staff should knock, pause and enter. A real choice of meal needed to be provided at all meals offered in the Home. Residents needing assistance to take a meal, needed to be provided with both their dinner and sweet all at one time. A small number of improvements were needed to the physical environment of the Home. When employing new staff the Manager needed to ensure that she received an additional reference from adult homes/children’s homes, as necessary, to ensure that potential new staff had not been dismissed as a result of inappropriate behaviour towards Residents/children. The Manager needed to publish all information she held, in relation to the quality assurance information, resulting from questionnaires carried out with Residents, relatives and friends of Residents, and with GPs, District Nurses, Chiropodists etc. A large number of staff needed to receive training in Infection Control. Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 7 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 Nursing Home DS0000066012.V341303.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 Nursing Home DS0000066012.V341303.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): Standards 1, 2, 3 & 6. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. All new Residents moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Providers had provided a detailed statement of purpose for the Home together with a Resident’s Guide, which was available in each Residents bedroom. The Guide was well completed, although did not provide the opinions of Residents on what life was like in the Home. The Residents Guide did contained information on how contact could be made with the Commission, the local Social Services Dept and the local Health Authority. The records of four Residents were examined during this inspection and a copy of the statement of terms and conditions of residency or a contract, if purchasing their care privately, was found in each file. Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 10 When new Residents were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident, copies of which were seen. The Manager also assessed all Residents sponsored by Social Services Depts. If the Residents were self-funding from the outset, the Manager completed her own summary of needs, which were also seen during the inspection. Standard 6 does not apply to this Home. Woodlands Nursing Home DS0000066012.V341303.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): Standards 7, 8, 9, 10 & 11. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents’ health and personal care needs were being well met, as demonstrated within care plans, and medication was administered appropriately to meet Residents needs. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of four Residents were examined, for the purpose of case tracking. All of the basic information, concerning each Resident, was found to be in the files examined. That was, their name and date of birth, their preferred name, their next of kin, their GP, Care Manager and their date of entry to the Home. Records of the Manager’s initial assessment of each Resident were found in each file, together with completed Individual Plans of care for each Resident, which were all found to be up to date. Records of the risk assessment on each Resident were also available. Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 12 However, the Manager had not completed her planned improvements to the records for those Residents suffering with dementia. As a result, in the two of the four files examined there were no records of the Resident’s possible limitations of choice, freedom and decision making, despite these Residents suffering with dementia. The Manager was found to be only recording in a minimal way the 6 monthly reviews of care of each Resident. The Resident, their relatives or formal representative, should all be invited to these formal reviews. However, it was found that the local Social Services Depts undertook formal reviews of care on an annual basis. All of the files were easy to read and good entries had been made by the nursing staff. The Manager said that she reviewed the records of each Resident at regular intervals, but she had not signed the records to indicate that this had taken place. The files were well organised, with different sections, although a confidential records section was not found in any of the files examined. Staff were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents was examined, and a good system was found to be in use. However, the following issue needed to be addressed. A review of some of the MAR sheets was undertaken and a number of signature gaps were found on the MAR sheets. Discussion was held with Residents about life in the Home. They said that staff were generally very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They also said that their care needs were, again in general, always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being – ‘I am very satisfied with the care provided’. However, one Resident spoken with was not so satisfied – ‘Staff don’t always think, for example, I have had to ask staff to leave the bathroom when I needed the toilet. On one occasion, while taking a shower, the two staff helping me began to talk about me as though I wasn’t there, which was very thoughtless.’ Discussion was also held with Staff, and very positive ways were described of assisting Residents within the Home. Woodlands Nursing Home DS0000066012.V341303.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): Standards 12, 13, 14 & 15. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents preferred lifestyles were respected by the Home, although attention was needed to the activities provided. Residents were given a wholesome and appealing diet in pleasant surroundings, although improvements were needed to ensure that Residents well-being was appropriately supported. EVIDENCE: Residents were asked about the activities provided in the Home. Those spoken with said that the Home used to have an Activities Coordinator, who was described as being very good, doing group activities and individual activities, but that he had not attended for a number of weeks, and as a result the number of activities had significantly reduced. Staff were asked about this and they confirmed that the Activities Coordinator had possibly left, and so staff provided activities. However, the Manager said that another Coordinator was now being looked for. A relative was spoken with who also said that activities provided had recently declined. Residents said that they decided when they got up and went to bed – ‘Yes, I choose the getting up time and going to bed time.’ Another Residents said Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 14 that ‘I bath on Sunday and Wednesday, I would like to bath every day, but the Home cannot provide me with the amount of help I need do this.’ Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘I always see my visitors in private in my bedroom.’ The staff spoken with also said that relatives could visit at anytime. It was said that Residents could chose where they wanted to see their relatives, in one of the lounges, or in their bedrooms. The relative spoken with also confirmed this. Residents had a mixed response when asked how staff entered their bedrooms. One said that ‘Staff knock and wait for me to say ‘come in’ before doing so.’ But another said that ‘Staff always knock, but always just walk in.’ Residents said that the Home provided a choice of meals, but that this was mainly at breakfast time. At dinner time a fixed meal was provided, and the choice was offered only if the meal was actively disliked by the Resident. At teatime, the meal was always sandwiches. Residents said that some staff offered a choice of sandwiches, while other staff did not. Staff, and a relative, confirmed this. Staff also said that drinks and snacks were always provided between meals for Residents, which was witnessed during this visit to the Home. Staff said that when Residents needed to be fed by the staff, that, for example, all of these Residents were fed with their dinner, and then all Residents would be feed with their sweet/pudding. The result of this was a long period of time between each part of the meal. Woodlands Nursing Home DS0000066012.V341303.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): Standards 16 & 18. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints made to the Manager were addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: One Resident said that she had had to complain about a member of staff, and she had done this with a staff member that she liked. The Resident said that the outcome was that the member of staff had been dismissed. Another Resident said that she had complained to the Manager/Matron about the actions of some staff, and that the matter had been appropriately resolved. However, she would not be keen to make a similar complaint again, as the response of staff, at the time, had been difficult for her to deal with. The Commission had not received any notice of complaint since the last visit to the Home, in October 2006. Since that visit, the Manager had recorded one verbal complaint, reported above. This was reviewed and was found to have been satisfactorily dealt with. Good procedures were seen for both written and verbal complaints. The Registered Provider’s complaints procedure detailed that all complaints would be responded to by the Registered Provider or Manager within at least 28 days. Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 16 The Registered Provider had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. The Manager said that a copy of the Public Interest Disclosure Act of 1998, and of the Dept of Health’s policy called ‘No Secrets’ were available in the Home. The Manager also confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. This had been done, as described by the Resident at the start of this section of the report. The policies and practices laid down by the Registered Provider ensured that all staff understood physical and verbal aggression by Residents. The Manager said that a policy was available to staff stating that they could not benefit from Residents wills, which was also understood by the staff, with whom discussions were held. Woodlands Nursing Home DS0000066012.V341303.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): Standards 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was very well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the public areas of the Home, and included the four bedrooms of the Residents whose care was reviewed at the time of this visit. The Home was attractively decorated throughout, and the lounges and dining rooms were pleasant to sit in, and were provided with appropriate items for the Residents. The bedrooms seen provided appropriate space and provision for each Resident. The Registered Provider had provided most of the appropriate furnishings in all locations seen during this visit. Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 18 Toilets were easily available to all Residents, were clearly marked, and were provided with handrails where necessary. A call system was also available throughout the Home. All bedroom doors were provided with locks, which Residents could chose to use. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. However, the following issues needed attention: In two of the bedrooms seen a chest of drawers was not provided for the Residents, although each wardrobe was provided with clothing shelves. In double bedrooms separate wardrobe and drawer space needed to be provided for each Resident in the bedroom. Each bedroom was provided with a ceiling night light, but this night light was not provided with a light shade. The toilet by the lift, on the first floor, was found not to lock. In the above toilet the staff call line was found to hang extremely close to the toilet and could not be reached from the floor, should a Resident had fallen. Woodlands Nursing Home DS0000066012.V341303.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): Standards 27, 28, 29 & 30. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Care staffing was provided to meet the needs of Residents, and appropriate recruitment practices were always followed when recruiting new staff, so that Residents welfare was always safeguarded. EVIDENCE: A satisfactory level of staffing was found to be provided in the Home to meet the needs of Residents. At the time of this inspection it was found that more than 50 of care staff had a qualification of at least NVQ level 2 in Care. The records of two new staff employed during the past 12 months were examined to see whether the Manager had obtained all relevant information about them. It was found that almost all information had been obtained. However, the history of employment of one of the staff had only been taken over the previous 10 years, and not back to when they had left school. This was needed to allow the Manager to check whether the potential member of staff had worked in care in the past, to allow an additional reference to be obtained. All other information was found to be satisfactory. The Manager said that new staff would be provided with induction and foundation training, which was confirmed by staff. She also said that all care Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 20 staff were provided with at least three paid days training a year. A member of the care staff said that much more than three days was provided, often as many as 5 days paid training was provided. The records of some of this training was seen. All staff also had an individual training and development assessment and profile. Woodlands Nursing Home DS0000066012.V341303.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): Standards 31, 33, 35, 36 & 38. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Management arrangements at the Home were in place to ensure that Residents care was maintained at a positive standard. EVIDENCE: The Manager was appropriately qualified to manage the Home, having an NVQ level 4 qualification in Management and a Nursing qualification. The records of the monthly ‘inspections’ of the Home, carried out by a senior manager, were examined and found to be in good order. The Manager was able to show the extensive annual development plan for the Home, completed in conjunction with a senior manager, that reflected the aims and outcomes for Residents had been completed. Surveys had been undertaken of Residents opinions of the operation of the Home, but these had Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 22 not been published at the time of this visit to the Home. The Manager also said that she discussed with Residents the operation of the Home at Residents meetings, the minutes of which were posted on one of the Home’s notice boards. She also stated that she and the staff would be able to demonstrate the Home’s commitment to lifelong learning and development of each Resident in the Home, which was confirmed by staff spoken with during the visit to the Home. The opinions of Residents families and friends or of GPs and District Nurses were obtained on how well they thought the Home was achieving goals for Residents, during reviews of the care provided for each Resident. However, these had again not as yet been published. The Manager was able to show that the personal money of Residents, held by the Home, was maintained satisfactorily. While reviewing Residents personal money a number were found to need revising to a more suitable amount to be kept in the Home. A staff member was asked about the supervision she received from the Manager or other senior staff in the Home. She said that this was done on approximately a 2 or 3 monthly basis, when her own needs and the needs of the Residents, were discussed. The Manager confirmed that supervision was provided by herself or senior staff, for all care staff working in the Home. The training required by the Regulations was examined. This showed that Moving and Handling training, Fire Safety training, and Food Hygiene training had been provided for all appropriate staff in the Home. All staff needing training in First Aid were booked to receive this training in September 2007. Twelve staff were in need of Infection Control training. However, the Manager said that she was having difficulty finding an appropriate course for staff to attend within a reasonable distance of the Home. Staff spoken with said they were up to date with all their training, and in addition had received training in Continence Awareness, Dementia, Safeguarding Adults procedure, Health and Safety, Diabetes, and Swallowing Difficulties. From copies of the Home’s maintenance schedule, forwarded to the Commission prior to the inspection, it was found that all necessary maintenance and repairs were being appropriately addressed. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Manager was able to show that the Home had complied with the majority of legislation applicable to its operation, although she said she did not have information on the Management of Health and Safety at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations of 1992 or the Provision and Use of Work Equipment Regulations of 1992. Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 23 The Manager was not able to show that she had provided risk assessments on all safe working practices of staff; that is for care staff, catering staff and domestic staff. However, the Registered Provider had provided a written statement of the policy, organisation and arrangements for maintaining these safe working practices. Finally, the Manager was able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 24 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 2 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 25 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 17(1)(a) & Sch. 3 3(q) Requirement The Manager must ensure that each Resident, or their representative, has the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome must be recorded in each Resident’s records. Signature gaps on the MAR sheet must be followed up by the Manager. She should indicate on the back of the relevant MAR sheet why the gap occurred and her action when following this up. The Manager must ensure, when appointing new staff, that all the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as amended during 2004, are obtained. Of two staff’s records examined, it was found that a full history of employment had not been obtained, dating back to when the member of staff had left school. DS0000066012.V341303.R01.S.doc Timescale for action 26/09/07 2. OP9 13(2) 26/09/07 3. OP29 19 26/09/07 Woodlands Nursing Home Version 5.2 Page 26 4. OP33 24 The Manager must ensure that the results of all of her questionnaires of Residents, and of relatives, friends and of GPs and District Nurses etc are published, and made available to Residents, relatives and, when asked for, the Commission. The 12 staff identified during this visit to the Home must be trained in Infection Control. (This issue is outstanding from the inspection report dated 25 October 2006) 26/09/07 5. OP38 13(3) & 18(1)(c) 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP1 OP7 No. 1. 2. Good Practice Recommendations The Residents Guide should contain the views of Residents on what it is like to live in the Home. The Manager should complete formal 6 monthly reviews of care with Residents. Those attending the review should include the Resident, their relatives and representative, and staff from the home. Where Social Services Depts carry out annual reviews of care this could be one of the 6 monthly reviews. (This issue is outstanding from the inspection report dated 25 October 2006) The Manager should review each Resident’s file on at least a monthly basis. She could indicate that this has been done by signing the record with a red or green pen. Each Resident’s file should contain a ‘confidential’ section. This section should be used for records made by staff that the Resident should not see and for information passed to the Home by professionals to which the Resident had not been made party. Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 27 3. OP10 Staff should be reminded of the privacy needs of Residents, and to make sure that their conversation, in the presence of Residents, is always appropriate and inclusive of the Resident. Activities should be provided regularly in the Home, and an Activities Coordinator should eventually be employed. Staff should be made aware of those Residents who should be encouraged, following staff knocking on their bedroom door, to invite staff into their bedrooms and those Residents who can no longer do this. (This issue is outstanding from the inspection report dated 25 October 2006) 4. OP12 5. OP15 A real choice of meal should be provided at all meals offered within the Home. At teatime, meals other than sandwiches should be provided, with sandwiches, of whatever type, being just one of the choices. Residents who needed assistance with eating should, for example, be given both their dinner and sweet/pudding together, to avoid a long period of time elapsing between each part of the meal. Residents waiting to be assisted with their meal should be left in the lounge, until staff could assist them with all their meal. Where these Residents were slow to eat, the meal should be reheated at least twice before accepting that the Resident does not want to complete the meal. 6. OP16 When Residents complain about the actions of staff, the manager needs to make sure that staff do not make things difficult for Residents making the complaint. If this is not done, Residents will not make further complaints, and the manager will not therefore know that Residents have concerns about staff. All toilets and bathrooms should be provided with an operating lock that can be opened from the outside with appropriate equipment. Staff call lines in toilets and bathrooms should be hung at an appropriate distance from the toilet or bath. The line should be long enough to ensure the line can be access by a Resident who may have fallen to the floor. In double bedrooms Residents need to be provided with DS0000066012.V341303.R01.S.doc Version 5.2 Page 28 7. OP21 8. OP22 9. OP24 Woodlands Nursing Home their own wardrobe and drawer space. (This issue is outstanding from the inspection report dated 25 October 2006) In single bedrooms each Resident should be provided with their own chest of drawers, as well as wardrobe space. 10. OP25 The ceiling night light provided in each bedroom should be provided with a light shade, rather than the bare bulb currently provided. The amounts of Residents personal allowance kept within the Home should be reduced to the amounts suggested during the visit made by the Inspector. The Registered Provider should ensure the Home complies with the Management of Health and Safety at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations 1992 and the Provision and Use of Work Equipment Regulations 1992. The Manager should provide risk assessments, for all staff, on all working practice topics in order to ensure that significant findings are recorded and that all staff are safeguarded. 11. OP35 12. OP38 Woodlands Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Nursing Home DS0000066012.V341303.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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