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Inspection on 12/08/08 for Woodlands Nursing Home

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

This inspection was carried out on 12th August 2008.

CSCI found this care home to be providing an Poor service.

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.

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

Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them.

What has improved since the last inspection?

The toilets and bathrooms have been fitted with suitable locks. The garden has been risk assessed to evaluate potential hazards such as high steps and drop from patio. A handrail has been installed.

What the care home could do better:

A comprehensive needs assessment must be undertaken by the home to ensure that staff are fully aware of the presenting needs of the resident. Furthermore residents` care plans must include all aspects of their health, personal and social care and need to be reviewed on a monthly basis or sooner where required. The administration/non-administration of all medication must be recorded accurately at all times for the health and safety of residents and an accurate record must be made when items of medication are being disposed of. All items of medication must be within their use by date so that residents are not put at risk. The resident`s wishes concerning terminal care and arrangements after death must be discussed and recorded so that staff are aware of them. The service must ensure that all staff within its organisation receives relevant training that is targeted and focused on improving outcomes for residents. This training can be small scale and individualised if necessary in order to promote the delivery of person centred services. Individual supervision sessions must take place regularly for the delivery of good quality services. All records in the home must be kept accurate and up to date at all times to ensure that residents` rights and best interests are being safeguarded. The health, safety and welfare of residents and staff must be promoted and protected.

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Woodlands Nursing Home 38 Smitham Bottom Lane Purley Surrey CR8 3DA Lead Inspector Mohammad Peerbux Key Unannounced Inspection 08:50 12 and 14th August 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands Nursing Home DS0000019048.V366971.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 DS0000019048.V366971.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Nursing Home Address Woodlands Nursing Home 38 Smitham Bottom Lane Purley Surrey CR8 3DA 020 8645 9339 F/P 020 8668 9371 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) Guidebefore Limited Manager post vacant Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified resident with a learning disability to be admitted for as long as the home can continue to meet all of the resident`s assessed needs. 16th May 2007 Date of last inspection Brief Description of the Service: Woodlands is a home registered for up to eighteen residents who, because of their age and general infirmity, require nursing care. Its relatively small size lends itself to the creation of a homely atmosphere not always seen in larger establishments. The home is situated in the pleasant suburb of Purley, within reasonably easy reach of the centre of Croydon and well placed for access to road and rail links. The range of weekly fees is between £550 and £650 and this information was gathered on the day of the inspection (12/08/08). Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is zero stars. This means the people who use this service experience poor quality outcomes. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2008/2009.The inspection was carried out over two days. In writing the report, consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. The head of care, acting manager and area manager facilitated the inspection. Some of the residents were spoken to, however due to their cognitive ability it was difficult to seek their views, though one resident stated, “ Staff are good here”. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. A tour of the building was also carried out. All registered adult services are now required to fill in an annual quality assurance assessment (AQAA) .It is a self-assessment that the provider (owner) must complete every year. The completed assessment is used to show how well the service is delivering good outcomes for the people using it. Some information from this AQAA is included in the report. What the service does well: What has improved since the last inspection? The toilets and bathrooms have been fitted with suitable locks. The garden has been risk assessed to evaluate potential hazards such as high steps and drop from patio. A handrail has been installed. Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 6 What they could do better: 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 DS0000019048.V366971.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 DS0000019048.V366971.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): 1,3 and 6 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home does not always undertake an assessment of the healthcare needs of residents prior to their admission so it would be difficult to ensure that their needs would be met. EVIDENCE: At the time of this inspection, the home did not have an up to date statement of purpose and service user’s guide so it would difficult to ensure that people who moved into the service had sufficient information on which to base their choice of home. An up-to date statement of purpose and service user’s guide Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 9 must be produced, so that prospective residents to have the information they need to make an informed choice about where to live. The service user’s guide and the statement of purpose should be kept under review (by the registered person) and revised when changes are made to the service. We should be notified within 28 days of when the changes were made. The acting manager stated that both documents are being reviewed at present. The home does not always consider the needs assessment for each prospective resident before agreeing admission to the home. Four residents’ files were sampled at random; one resident did not have a pre-admission assessment carried out. All new residents must receive a comprehensive needs assessment before admission to ensure that their needs will be met. The assessment must be considered against the statement of purpose to ensure that the service is able to meet the needs of the new resident. It was also noted that the assessments were not always completed fully. If the assessor is unable to gather information about a resident during the pre admission assessment process, this must be noted on the assessment. Without a comprehensive assessment, an initial care plan would be difficult to develop and without such staff would be unable to provide the care required. It would also impact on the home’s ability to offer a placement, if they were not fully aware of the presenting needs of the resident. It is also recommended that a date is included on the assessments and also the name of the person who carried out the assessments. Evidence suggests that assessments are carried out when the residents are admitted to the home however again these assessments were not fully completed so it would be difficult to develop a comprehensive care plan. Intermediate care for rehabilitation and return to the community is not provided by this home. Woodlands Nursing Home DS0000019048.V366971.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 and 11 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ health, personal and social care needs are not being appropriately met as their care plans do not always identify their needs and are not being reviewed and updated to reflect their changing needs. The practices for administration of medications are inadequate and potentially places residents at risk. EVIDENCE: Four residents’ care plans were sampled at random and it was noted they generally included information necessary to deliver the resident’s care but did not cover all the residents’ needs. For example one resident suffers from high blood pressure and osteoarthritis, these were not covered in her care plan. Another resident suffers from osteoporosis and hypertension and again these were not covered in his plan of care. This was discussed with the acting manager and area manager. Residents’ care plans must include all aspects of Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 11 their health, personal and social care needs to ensure that all their needs are met. The residents’ plan must meet relevant clinical guidelines produced by the relevant professional bodies concerned with the care of older people, and includes a risk assessment, with particular attention to prevention of falls. Residents’ care plans must also be reviewed by care staff in the home at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. This will ensure that all their needs are being met. The home actively promotes the residents’ right of access to the health and remedial services that they need, both within the home and in the community. However as mentioned above not all care needs are being identified and residents’ care plans are not always being reviewed and/or updated so it would difficult for staff to meet residents’ needs fully. There was evidence in the care plans of health care treatment and intervention, and a record of visiting professionals. The medication administration records were audited. There were a very high number of instances where prescribed medication had been omitted or administered but not signed for. In all cases where medication is not given as prescribed, staff must ensure that they record the reason for this. The administration/non-administration of all medication must be recorded accurately at all times for the health and safety of residents. During the inspection it was also noted that three items of medication were out of date. All items of medication must be within their use by date so that residents are not put at risk. There were also six items of medication not labelled. Again all items of medication must be labelled with the residents’ names to avoid any mishandling and to ensure residents are not put at risk. No record of disposal of medication was available. The home must keep a record of disposal of medication to avoid any mishandling of medication. The home is reminded that medicines in the custody of the home must be handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society, the requirements of the Misuse of Drugs Act 1971 and Nursing staff abide by the NMC Standards for the administration of medicines. Staff in the home are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms. Residents who were spoken to stated that they are happy with the way that the staff deliver their care and respect their dignity. One resident stated, “Staff are good here ”. Another resident stated, “I am happy here though I do not go out often”. Observation of the staff team interacting with the residents showed that the carers were Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 12 mindful how they addressed residents, and they were seen to be polite and friendly. There was a requirement made at the last inspection stating that the bedrooms must provide privacy for residents including suitable door locks. The head of care stated that door locks would be installed following risk assessment and consultation from the residents/relatives. Each resident is being provided with a suitable locked cabinet very soon as the providers is in the process of replacing most of the furniture in the bedrooms. The wishes of individuals about terminal care and arrangements after death are not always recorded on their care plans. None of the four care plans sampled at random had the residents’ last wishes recorded. The resident’s wishes concerning terminal care and arrangements after death must be discussed and recorded. This will ensure that the individual’s wishes, choices and decisions if their health deteriorates are respected and known to the staff delivering the care. Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home tries to be flexible and attempts to provide a service, which is as individual as possible. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: People using the service are given the opportunity to take part in a variety of activities within the home. The activity coordinator stated that not all residents are willing to take part in activities however these are recorded. The director of care stated that the activity coordinator would be coming on a daily basis instead of twice a week. Residents that cannot attend services have the choice of being able to have the priest/reverend attend the home. The home has open visiting arrangements and residents know they can entertain their family and friends in their own room. If they prefer they can use communal areas of the home to talk to visitors. Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 14 Maintaining independence and enabling residents to make their own decisions about how they wish to live is a key objective of the home. Residents have the choice to bring personal possessions with them on admission to the home and are encouraged to keep personal items, which are important to them in their own room. The “Personalisation” of individual bedrooms is encouraged. It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. Staff are ready to offer assistance in eating where necessary, discreetly, sensitively and individually, while independent eating is encouraged for as long as possible. The menu is also available in pictorial format to enable residents to choose what they would like to eat. A more varied menu which includes vegetarian dishes has been implemented and when new residents arrive they can add they favourite dish to the menu. Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are generally managed well, which should ensure that residents’ and relatives’ concerns are listened to. EVIDENCE: The home has a complaints procedure that generally meets the national minimum standards and regulations. The director of care stated that there would be a better record of complaints and this would include comprehensive details of the investigation and any actions taken. There are policies and procedures for safeguarding people who use the service. The area manager stated that the staff have not had training on abuse recently. All staff must have refresher training in the prevention of residents from being harmed or suffering abuse or being placed at risk of harm and/or abuse. Their knowledge and understanding in this area must also be constantly checked at team meetings and during supervision sessions. Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 16 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): 19,24 and 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment does not provide a homely atmosphere or always meet the residents’ needs. EVIDENCE: Although there is an on-going maintenance programme in place the environment does not always meet the residents’ needs. A number of the fixtures and fittings need replacing and the décor requires upgrading. The provider is looking into improving and upgrading the furnishings and fittings and involving the residents and families in the improvements, taking their views into consideration. The home is being rearranged to give the residents more social space to enjoy life. The carpets are also been replaced in some Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 17 areas of the home. The bathrooms and toilets now have suitable door locks. This is in line with a requirement made at the last inspection. The home is kept clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a lack of staff training and this would impact on the care residents are receiving. The continued reliance on agency staff does not assure consistency of care for the residents. EVIDENCE: The home does not have enough qualified nurses at present. They are currently recruiting for more nurses and also for a lead nurse. The home is using agency or temporary staff at times when they are short of staff. This could have an impact on the care that people using the service may receive, as there is no continuity of care. The providers need to ensure that staffing levels as far as registered nurses are concerned, meet the dependency needs of the home’s current residents. The continued reliance on agency staff does not assure consistency of care for the residents. From the information forwarded to the Commission following the inspection it was noted that more than 50 of staff have an NVQ level 2 qualification. The service has a recruitment procedure that meets statutory requirements and the NMS.The director of care is presently updating all the staff personnel files to ensure that all relevant documents are in place. Since the new provider Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 19 has taken over only one staff has been recruited and she is the acting manager. We were not able to check her file and it was at the head office of the company. With regards to staff training records the area manager stated that they were not available. There must be a staff training and development programme in place to ensure staff fulfil the aims of the home and meet the changing needs of residents. A training needs assessment must also be carried out for the staff team as a whole, and an impact assessment of all staff development must be undertaken to identify the benefits for residents and to inform future planning. All staff must receive relevant training that is focussed on delivering improved outcomes for residents. The area manager is aware that there are gaps in the training programme and plans to deal with this. Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37 and 38 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are shortfalls in the management of the home and the health, safety and welfare of residents and staff are not being promoted/protected and this potentially places them at risk. EVIDENCE: During the course of this inspection a number of concerns were identified. This reflects on the way the home is being managed and potentially has an impact on the care of the people who are using this service. The acting manager has a learning disability management experience, and does not have the necessary skills/experience to manage a care home with nursing that caters for people Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 21 with dementia. Her lack of general nursing acumen is reflected in the provision of nursing care to the residents. In view of this the registered provider must appoint a full time Lead nurse who has the experience/skills and qualification to be responsible for the provision of nursing care in the home. This would ensure that all residents’ health care needs are appropriately assessed and met. The acting manager must ensure that there are clear lines of accountability within the home and that the home meets its stated purpose, aims and objectives. The director of care stated that she is in the process of recruiting a Lead nurse however she wants to find the right candidate. With regards to effective quality assurance and quality monitoring systems, the director of care stated that there is a system in place based on seeking the views of residents to measure success in meeting the aims, objectives and statement of purpose of the home. This is normally done in August of each year. We will check this standard in more depth at the next key inspection. The AQAA was completed and forwarded to us. An annual quality assurance assessment (AQAA) is a self assessment and a dataset that is filled in once a year by the providers. It is one of the main ways that we get information from providers about how they are meeting outcomes for people using their service. The AQAA received was is some areas very brief and gave little information about the service. It did not give us a reliable picture of the service, as some parts were not completed at all so it was difficult to ascertain that the home is meeting the outcomes for people using the service. The acting manager informed that the home does not look after any resident’s money. The area manager stated that staff are not up to date with their supervision sessions. All care staff must receive formal supervision at least 6 times a year for the delivery of good quality services. Checks show that records keeping in the home could be improved, as medication administration records are not being completed accurately when staff is administering items of medication. There are also concerns around care planning, reviews and care needs not being recorded. All records in the home must be kept accurate and up to date at all times to ensure that residents’ rights and best interests are being safeguarded. A number of health and safety issues arose during this inspection and they are as follows: -One fire door was wedged open and one fire door was not closing fully. Both situations were rectified on the day of the inspection itself. Fire doors must not be wedged open unless held open by a magnetic door holder that responds to the fire warning system for the safety of staff and residents. Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 22 -It was noted that the hot water cylinder, which is in an unlocked cupboard in a resident’s bedroom, had electrical live and neutral wires uncovered. This is very dangerous and could cause harm to the resident. The wiring of the hot water cylinder must be made safe and the cupboard must be kept locked at all times for the safety of residents. -The radiator pipes in room 6 must be covered to prevent residents from scalding. It is also recommended that the home carry out a risk assessment on all uncovered hot pipes in the building for the safety of residents. -It was noted that the windows in one bedroom on the first floor did not had any restrictors. Window restrictors should be fitted as standard to upper floor windows, unless a risk assessment, based around the individuals that use the service, indicates how windows are otherwise safe. The bedroom was vacant at the time of inspection. -The electrical periodic test was out date. There must be an up to date electrical periodic test carried out to ensure the safety of residents and staff. -There were no risk assessments available for all safe working practice topics. There must be a comprehensive risk assessment carried out for all safe working practice topics and the significant findings must be recorded for the health and safety of the people using the service. Risk assessment information must be appropriately communicated to all staff. It is recommended that a visual inspection be carried out on a regular basis as this will help to identify any potential risks and hazards within the environment that may pose a risk to residents. Certificates relating to health and safety were up to date servicing certificates. These included gas safety, fire safety and lift maintenance. Woodlands Nursing Home DS0000019048.V366971.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 1 X X 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 1 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 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X N/A 1 2 1 Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No. 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 OP1 Regulation 4 and 5 Requirement An up-to date statement of purpose and service user’s guide must be produced, so that prospective residents to have the information they need to make an informed choice about where to live. All new residents must receive a comprehensive needs assessment before admission to ensure that their needs will be met. Residents’ care plans must include all aspects of their health, personal and social care needs to ensure that all their needs are met. Residents’ care plans must also be reviewed by care staff in the home at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. Timescale for action 14/10/08 2. OP3 14 Schedule 3 1(a) 14/10/08 3. OP7 15(1) 14/10/08 4. OP7 15 (2)(b)(c) 14/10/08 Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 25 5. OP9 13(2) The administration/nonadministration of all medication must be recorded accurately at all times for the health and safety of residents. All items of medication must be within their use by date so that residents are not put at risk. All items of medication must be labelled with the residents’ names to avoid any mishandling and to ensure residents are not put at risk. The home must keep a record of disposal of medication to avoid any mishandling of medication. The resident’s wishes concerning terminal care and arrangements after death must be discussed and recorded. All staff must have refresher training in the prevention of residents from being harmed or suffering abuse or being placed at risk of harm and/or abuse. There must be a staff training and development programme in place to ensure staff fulfil the aims of the home and meet the changing needs of residents. A training needs assessment must also be carried out for the staff team as a whole, and an impact assessment of all staff development must be undertaken to identify the benefits for residents and to inform future planning. 23/09/08 6. OP9 13(2) 23/09/08 7. OP9 13(2) 23/09/08 8. OP9 13(2) 23/09/08 9. OP11 12(2) 14/10/08 10. OP18 13(6) 14/11/08 11. OP30 18(1) 14/11/08 12. OP30 18(1) 14/11/08 Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 26 13. OP31 9(2) A full time Lead nurse who has 14/11/08 the experience/skills and qualification to be responsible for the provision of nursing care in the home must be appointed. This would ensure that all residents’ health care needs are appropriately assessed and met. All care staff must receive formal supervision at least 6 times a year for the delivery of good quality services. All records in the home must be kept accurate and up to date at all times to ensure that residents’ rights and best interests are being safeguarded. 14/11/08 14. OP36 18(2) 15. OP37 17(1)-(3) 14/11/08 16. OP38 13(4) Fire doors must not be wedged 14/09/08 open unless held open by a magnetic door holder that responds to the fire warning system for the safety of staff and residents. The wiring of the hot water cylinder must be made safe and the cupboard must be kept locked at all times for the safety of residents. The radiator pipes in room 6 must be covered to prevent residents from scalding. Window restrictors should be fitted as standard to upper floor windows, unless a risk assessment, based around the individuals that use the service, indicates how windows are otherwise safe. 14/09/08 17. OP38 13(4) 18. OP38 13(4) 14/09/08 19. OP38 13(4) 14/09/08 20. OP38 13(4) There must be an up to date 14/09/08 electrical periodic test carried out to ensure the safety of residents DS0000019048.V366971.R01.S.doc Version 5.2 Page 27 Woodlands Nursing Home and staff. 21. OP38 13(4) There must be a comprehensive risk assessment carried out for all safe working practice topics and the significant findings must be recorded for the health and safety of the people using the service. 14/09/08 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 OP3 Good Practice Recommendations It is recommended that a date is included on the assessments and also the name of the person who carried out the assessments. It is also recommended that the home carry out a risk assessment on all uncovered hot pipes in the building for the safety of residents. It is recommended that a visual inspection be carried out on a regular basis as this will help to identify any potential risks and hazards within the environment that may pose a risk to residents. 2. OP38 3. OP38 Woodlands Nursing Home DS0000019048.V366971.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 DS0000019048.V366971.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. 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