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Inspection on 01/03/07 for Woodlands Nursing Home

Also see our care home review for Woodlands Nursing Home for more information

This inspection was carried out on 1st March 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff spoken to said the staff group worked well together as a team. The staff were welcoming and presented as a cheerful staff group.

What has improved since the last inspection?

The use of the bain marie has been reviewed and this has now been removed therefore no longer a scald risk to service users. A skill based induction package had been obtained although no staff had yet begun to use this.

What the care home could do better:

Care plans were not always updated to reflect changes in assessed care needs and the format in place did not allow staff to easily update a particular section of the form without having to unnecessarily rewrite others. The training records examined indicated that not all staff had received training in Protection of vulnerable adults. This is an outstanding requirement from previous inspections. Training records also indicated that statutory training in moving and handling and fire safety was out of date. The certificate for the in house moving and handling trainer was also out of date. The servicing of the homes gas appliances and electrical wiring system were out of date which had the potential to increase possible of malfunction and breakdown.The sample of staff recruitment files examined indicated some deficits, this is an outstanding requirement from previous inspections which has not been addressed. The evidence of the quality assurance process in place indicated that this was intermittent and had was poor in recording the findings generally recording no problems. The deficits identified in the servicing of installations and poor staff training had not been identified through the homes own quality audits.

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Wardgate Way Holme Hall Chesterfield Derbyshire S40 4SL Lead Inspector Bridgette Hill Key Unannounced Inspection 09:30 1st March 2007 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 DS0000002099.V330023.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 DS0000002099.V330023.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Nursing Home Address Wardgate Way Holme Hall Chesterfield Derbyshire S40 4SL 01246 231191 01246 231193 jane.tinsley@tesco.net 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) Midland Healthcare Ltd Mrs B Tinsley Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. To allow one service user under category PD to be accommodated for the period of their stay in Woodlands Nursing Home on a named person basis No one falling within category OP to be admitted into Woodlands Nursing Home when there are already 50 persons already accommodated within the home No one falling within category DE(E) to be admitted into Woodlands Nursing Home when there are already 3 persons under category DE(E) accommodated in the home The maximum number of persons to be accommodated at Woodlands Nursing Home is 50 21st August 2006 Date of last inspection Brief Description of the Service: The Woodlands is a purpose built two-storey home, which provides residential and nursing care for up to 50 elderly service users. The home is situated on a housing estate and shops and community facilities are close by. The home has a large car park for visitors and is situated in lawned grounds. The home provides forty-four single and three shared rooms. Three rooms have en-suite facilities. The fees charged at the home range from £298.20 - £512.00. There are additional costs for hairdressing, chiropody, and personal newspapers. This information was taken from the Pre Inspection Questionnaire. Some activities also incur additional charges. Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit which took place over one and a half days. The inspection focused on assessing compliance to previously listed requirements and on assessing all key standards. As part of the inspection a sample of service users care files and a range of documents were examined. A tour of the building was conducted. During the visit opportunity was taken to have discussions with management, 2 staff, and 2 service users. The person in charge at this visit was Ida Needham on the first day of inspection and the Manager Jane Tinsley on the second visit. What the service does well: What has improved since the last inspection? What they could do better: Care plans were not always updated to reflect changes in assessed care needs and the format in place did not allow staff to easily update a particular section of the form without having to unnecessarily rewrite others. The training records examined indicated that not all staff had received training in Protection of vulnerable adults. This is an outstanding requirement from previous inspections. Training records also indicated that statutory training in moving and handling and fire safety was out of date. The certificate for the in house moving and handling trainer was also out of date. The servicing of the homes gas appliances and electrical wiring system were out of date which had the potential to increase possible of malfunction and breakdown. Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 6 The sample of staff recruitment files examined indicated some deficits, this is an outstanding requirement from previous inspections which has not been addressed. The evidence of the quality assurance process in place indicated that this was intermittent and had was poor in recording the findings generally recording no problems. The deficits identified in the servicing of installations and poor staff training had not been identified through the homes own quality audits. 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 DS0000002099.V330023.R01.S.doc Version 5.2 Page 7 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 DS0000002099.V330023.R01.S.doc Version 5.2 Page 8 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): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed and recorded prior to admission to ensure their needs can be met. EVIDENCE: The file of a recently admitted service user was examined to establish the admission procedure being implemented. The admission assessed was an emergency and it was evident that the home had sought to gain information as soon a s possible after the admission had commenced. This included an assessment from Social services. The form relating to the homes assessment had been completed. A medical examination was also arranged promptly at the home by a GP. A care plan had been drawn up based on the information known. Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 9 Discussions too place regarding planned admissions and it was stated that the Manager or staff from the home always assessed service users prior to admission to ensure the home could meet their needs. The home does not offer intermediate care as defined by National Minimum Standards 6. Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 10 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. Some deficits were identified in the care plans and administration of medications which had the potential to adversely affect the care of service users. EVIDENCE: A sample of three service users care files were examined at this visit. Assessments of service users needs were recorded and the care plans based on these assessments. There were examples in the care plans where identified needs for example the condition Alzheimer’s had not been included in the plan of care nor considered as part of the communication care plan. The care plan format was a continuous form and did not lend itself well to updating particular sections and examples where needs had changed but the care plan was not updated were seen. Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 11 Generally the care plans written were descriptive of how care was to be delivered to the service user. Ongoing log records were written for each shift and these were generally informative of any issues. One log however was considered to be negative in the approach to the service user recording that staff had said to a service user to discuss any issues with the owner or manager but ‘if it was making him so unhappy he should find somewhere else’. Reviews of care plans were documented on an approximately bi monthly basis. A range of risk assessments were included in files and were reviewed. These included moving and handling , tissue viability and nutritional risk assessments. Where tissue viability risks were evident the care plans included the use of special equipment which was observed to be in use in service users bedrooms. Staff spoken to had a good knowledge of service users and their needs. Healthcare needs were met by a number of local GP’s and district nurses visited some service users who were assessed as requiring personal care only from staff at the home. There were regular arrangements in place to provide chiropody and optician services to service users. Extra costs were payable for these. The storage and administration of medicines was examined at this visit. The storage arrangements appeared to be acceptable with a fridge being available and secure facilities being used for medications. Internal and external preparations were stored separately. In many toilet and bathroom areas creams and lotions were found without a name of the service user or the date of opening. Some of these were removed during the inspection. Some gaps were evident on the medication administration records with no codes to indicate if medications had been omitted. This is an outstanding requirement from previous inspections that medication administration records must be fully completed to ensure a complete record of treatments are recorded. Where variable dosages were prescribed staff were not documenting the actual dosage administered. This is an outstanding requirement from previous inspections. Records of medications received at the home as where records of medications disposed of. The controlled drug register was appropriately kept and a sample of balances when checked against actual stock correlated. Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 12 Positive and jovial interactions were observed between staff and service users. There was also good support demonstrated to one service user who was upset do to a recent loss. Service users preferred names were recorded within care files. Woodlands Nursing Home DS0000002099.V330023.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. There is a structured programme in place to ensure regular activities in and outside of the home are offered to service users. EVIDENCE: A dedicated activities coordinator is employed at the home and a regular plan of activities was placed on the notice board in one of the lounges. Individual records were kept of what service users had participated in thought the records were not available for every service user and staff spoken to said that some service users chose not to take part. Typical activities organised by the coordinator included, bingo, skittles, quizzes, memory sessions, and arts and crafts. Staff and service users spoken to said that some dates were celebrated such as Valentines day, Halloween with the home being decorated and special teas held. Holy communion is held in the home approximately monthly. Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 14 The home has access to a shared minibus which is used for occasional outings to local places of interest such as Bakewell shopping trips and garden centres. Some service users go out accompanied by staff to the local shops. The lunchtime mealtime was observed. Two dining areas were available. Service users said that they did not routinely get a choice of meal at lunchtime but that the cook generally knew their dislikes well and accommodated these. The meal was attractively served at lunchtime with gravy served separately in a jug. At teatime a choice of meal was given with a hot and cold choice being available. The small lounge area contained a range of books including some large print books. A portable loop system to aid hearing aid users was available in the home. Woodlands Nursing Home DS0000002099.V330023.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. All staff have not been trained in Protection of vulnerable adults which has the potential to place service users at risk. EVIDENCE: The Commission for Social Care Inspection has not received any complaints regarding the home since the last visit on 6th November 2006. The complaints records at the home indicated that there had been one complaint received in writing since the last inspection. The details of the investigation and outcome could not be located. This was discussed with the Manager who said that this was regarding service users being able to leave the building. It was stated that a keypad type door exit system had been installed as a result of this. Some service users who had the capacity to use the door safely knew the number to this. The complaints procedure was displayed in the entrance hall of the home. The Protection of vulnerable adults procedure was examined. This did not refer to locally agreed procedures and advocated internal investigation. The Manager said that this was a company policy and that it did not refer to the local procedures used in the home which was to refer to Derbyshire County Councils safeguarding adult procedures. One referral regarding the Protection of vulnerable adults has been made since the last visit. This did not relate to any allegation against staff from the home. Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 16 Some staff had received training in Protection of vulnerable adults but not all. Some progress had been made at the last visit but this has not been carried through. This is an outstanding requirement from previous inspections. Staff spoken to said they would discus any concerns they had regarding allegations of abuse with the Manager. Woodlands Nursing Home DS0000002099.V330023.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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The interior of the home was generally well maintained and provided a homely environment for service users EVIDENCE: The home is a purpose built one with 44 single bedrooms and 3 double rooms. A range of lounge areas are available and service users spoke had their preferences. At this visit the key standards and any previous requirements and recommendation were checked. A partial tour of the building was conducted. The home was generally found to be clean and tidy. Some carpets had been cleaned since the last visit and some were being done on the day of the visit. General maintenance was completed by an onsite handyman. Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 18 The records relating to fire safety were examined. These confirmed that equipment had been serviced and regular checks of the fire alarm took place and were documented. The Manager said that they had recently undertook some fire training n order to ensure a fire risk assessment was in place. The last fire drill was held on 18th July 2006. Deficits were identified in the fire safety training received by staff with the last documented training being completed on 8th December 2005. The laundry area was tidy and had 2 working washers and 2 dryers. Some equipment was out of use however the needs of the current occupancy levels of the home were considered to be met. The flooring of the laundry was damaged in places and presented a possible trip hazard to staff. There appears to be some documented problems with the laundry service with items going missing. Derbyshire County Council has compensated one service user for some losses. Other service users said they had not experienced any problems with the laundry service. The staff said that aprons and gloves were readily available and they were observed to be using these during the visit. The home generally appeared to be clean and without odour. Woodlands Nursing Home DS0000002099.V330023.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 poor. This judgement has been made using available evidence including a visit to this service. Staff are not receiving mandatory or job specific training to ensure they are able to meet the needs of service users. EVIDENCE: The occupancy of the home on the day of the visit was 31 service users, 14 service users required nursing care, and 17 service users required personal care only. Some service users were residing in the home on a respite basis only. Typical staffing levels in place were: 1 nurse on duty for all shifts with 5 care staff for morning shifts, 3 care staff in the afternoons. The activities coordinator also worked 4 afternoons per week. At nights there was one qualified nurse and 3 care staff. There were 15 care staff employed at the home of whom 7 had completed and achieved NVQ (National Vocational Qualification) qualifications or other relevant qualifications. An example of this was overseas nurses who were completing adaptation training in the home. Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 20 A sample of staff personnel files were examined to assess if robust recruitment procedures were being implemented. The most recent employees file indicated that all pre recruitment checks had been completed. This included references, Protection of vulnerable adults first and Criminal Records Bureau check. Two further files indicated that for one staff member the second reference arrived at the home one day after employment had commenced. Some minor deficits were evident in files mainly proof of identity. A comprehensive skill based induction package had been obtained but no completed examples of this were seen and the Manager said that there had not been any recent care staff employed yet. Staff training records were examined these indicated that a range of mandatory training was out of date this included: • • • • • Fire safety which was last completed on 8th December 2005 Moving and handling which was last completed in 17th January 2006 The moving and handling trainers certificate was out of date in October 2005. There were staff who had completed first aid training but certificates were out of date. Not all staff who had responsibility for handling and preparing food had completed Basic Food Hygiene training. Some staff training had been completed in 2005 & 2006 such as medications, health and safety and some staff, but not all had completed dementia training. Some staff had received training in Protection of vulnerable adults but not all. For some staff there were no recorded dates of training or certificates available. The manager said that some of these staff worked only occasionally at the home and their training was received at their primary job but there was no evidence of the training they were supposed to have completed. There was not a system in place to ensure that updates were completed in a timely manner and the recording of staff training was poor. Woodlands Nursing Home DS0000002099.V330023.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): 31,33,34,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are ineffective quality assurance and management systems in place to ensure that statutory matters related to health and safety and staff training are dealt with promptly. This has the potential to place service users at risk. EVIDENCE: The Manager of the home is formally registered with the Commission for Social Care Inspection and has been in post since 1997. The Manager was in the process of completing a managerial qualification and was approximately half way through this. The Manager has just completed a one week health and safety facilitated by Derbyshire County Council. Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 22 A deputy Manager who has been in post since the home opened supports the Manager. A valid public liability certificate was on display. Records for establishing financial liability were not requested at this visit. Sampling of records relating to the small amounts of money stored safely on service users behalf were examined. Some small amount of monies were held securely in the home with some monies being held in bank accounts. Some monies were stored for service user who were no longer residing in the home. The Manager was unaware of this. One staff member was not familiar with some of the service users names and could not identify when they had left the home. There were no records to evidence that attempts had been made to return money to service users or their families. Transactions were recorded but these were not always signed. Receipts were retained for any purchases made. There were some documented visits made on the Providers behalf however the visit forms available indicated that these did not meet the standard of being completed at least monthly. The content recorded on the forms was brief lacking detail as to who was spoken to the content of the conversations and the findings relating to the range of records examined. The effectiveness of the quality assurance checks was also questionable as they had not identified the major deficits relating to staff training or lack of servicing of the gas and electrical system in the home. There are also outstanding requirements from previous inspection reports which have not been actioned some of these relating to care plans and medications. Where deficits were identified there was action taken during the visit to organise servicing and staff training however there was no proactive action prior to the inspection to ensure that where there were deficits these were dealt with promptly. There was not a current annual development or training plan in place for the home and the one offered was dated 2004. Some meetings were held in the home for staff, service users and relatives. Minutes of these were kept. A file was in the reception area to invite service users and relatives to leave comments although none were recorded. No formal individual surveys had been completed. The gas appliances in the home have not been serviced since 11th January 20056 and was overdue. This was organised during the inspection to be undertaken the following week. Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 23 The 5 yearly electrical system was last completed in and was overdue having last being checked on 14th September 2001. The water system had been bacterially checked for legionella on 19/12/06. The portable electrical appliances had been checked in May 2006 Accident forms were completed where these had occurred. Woodlands Nursing Home DS0000002099.V330023.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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 3 2 x x 2 Woodlands Nursing Home DS0000002099.V330023.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 15 Requirement All care plans must be reviewed and updated to reflect changing needs Previous timescale 30/10/06 & 31/12/06 2 OP9 13,17, Schedule 3 Where medications are prescribed on a regular basis these must be administered or a record maintained of the reason for omissions Previous timescale 30/09/06 & 31/12/06 3 OP9 13,17, Schedule 3 A record must be kept of the dose of medication administered to a service user where a variable dose is possible. Previous timescale 30/09/06& 31/12/06 4 OP9 13,17 Schedule 3 All topical preparations must be dated on opening and used only for the service user for whom they are prescribed DS0000002099.V330023.R01.S.doc Timescale for action 30/03/07 30/03/07 30/03/07 30/03/07 Woodlands Nursing Home Version 5.2 Page 26 5 OP18 13(6) The registered manager must ensure that all staff receives training on the protection of vulnerable adults. Previous timescales 31/05/06 & 31/12/06 30/05/07 6 OP19 18 7 8 OP26 OP30 23 18 This has been partially met as it was confirmed that some but not all staff have received training The Provider must ensure that all 30/03/07 staff receive fire safety training at intervals suited to the posts held The flooring in the laundry 30/04/07 requires repair to ensure it does not pose a trip hazard to staff Training records must be 30/06/07 available to evidence that staff are receiving all mandatory/role specific training and are fully supported to undertake the role for which they are employed Previous timescale 30/10/06 The provider must ensure that staff receive training in moving and handling by persons who qualified to train others The provider must ensure that there are staff in the home who have received first aid training The home must ensure robust recruitment procedures are adhered to which includes all the checks as required by Schedule 2 being completed prior to staff commencing employment Previous timescale 30/10/06 & 31/12/06 30/04/07 9 OP30 18 10 11 OP30 OP34 18 19 30/06/07 30/03/07 12 OP33 24 The registered person must ensure that the home has a quality assurance system in place which is comprehensive and responsive to the findings DS0000002099.V330023.R01.S.doc 30/04/07 Woodlands Nursing Home Version 5.2 Page 27 13 OP35 23 14 OP38 13,23 15 OP38 23 Where monies are being stored in the home for service users who are no longer resident these must be returned to service users or their next of kin The Provider must ensure the gas installations at the home are serviced by suitably trained persons and are safe to use The Provider must ensure that the electrical installation system is checked by persons who are suitably trained and are safe to use 30/04/07 31/03/07 31/03/07 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 Refer to Standard OP16 OP18 OP35 Good Practice Recommendations The complaints records should be maintained to demonstrate the actions and timescales taken in response to complaints received The Protection of vulnerable adults policy and procedure in the home should be updated to reflect and describe the procedure being followed The records for financial transactions should be doubly signed. Woodlands Nursing Home DS0000002099.V330023.R01.S.doc Version 5.2 Page 28 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 DS0000002099.V330023.R01.S.doc Version 5.2 Page 29 - 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!