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Inspection on 14/08/07 for Woodlands Nursing Home

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

This inspection was carried out on 14th August 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 there was a core of staff at the home who were long serving who worked well together and communicated effectively as a team. Opportunities were routinely offered to service users to go out from the home in small groups to local places of interest or to shop.

What has improved since the last inspection?

The recording of staff training has improved with overviews now being available of what training has been completed. Some overdue training had now been completed including fire safety and Moving and handling. The quality of information provided on the Providers monthly visits had improved and documents viewed indicated that staff and service users were being consulted at these visits to ascertain their views. Staff recruitment standards had been improved and all required documentation and checks were found to be in place to ensure staff were being recruited appropriately. The induction process for staff had also been improved and a skill based induction pack was being used.

What the care home could do better:

There were insufficient levels numbers of staff being provided which was impacting directly on the service users in the home. There were reports from service users and staff regarding low staffing levels and observations made of service users waiting to receive assistance from staff and increased risks to service users was evident. An immediate requirement was issued at the home during the visit to rectify this situation. A range of deficits were identified in the administration of medications. These tended to poor recording by staff. A change of supplying pharmacy had occurred which meant some difficulties in the medication administration records supplied by the pharmacist and staff were having to handwrite medication administration records but were not ensuring these were completed fully. In one circumstance only the name of the drug was recorded on the prescription without doage or frequency instructions.

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Wardgate Way Holme Hall Chesterfield Derbyshire S40 4SL Lead Inspector Bridgette Hill Unannounced Inspection 14th August 2007 09:25 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.V340882.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.V340882.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.V340882.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 1st March 2007 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 service is also registered to accept three service users who have dementia related needs. The home is situated on a housing estate and shops and community facilities are close by. A range of communal areas are available including a small smoking area for service users to use. 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. Bedrooms are located on two floors and a lift is available to provide access to those with mobility difficulties. The fees charged at the home range from £333.85 - £512.00. There are additional costs for hairdressing, chiropody, none urgent escorts to hospital and personal newspapers. This information was given to the inspector at the inspection. Woodlands Nursing Home DS0000002099.V340882.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. 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 partial tour of the building was conducted. During the visit opportunity was taken to have discussions with management, staff, and service users. Prior to the visit an Annual Quality Assurance Assessment form was completed by the home. The Commission for Social care Inspection to 10 service users sent out surveys. 6 of these were returned although 2 were not completed. Discussions were held during the inspection with service users, staff and a visitor. The findings have been included within the body of the report. The person in charge initially at this visit was the Manager Jane Tinsley who had to leave due to prior engagements. The deputy manager Ida Needham was on duty for the remainder of the inspection. What the service does well: What has improved since the last inspection? The recording of staff training has improved with overviews now being available of what training has been completed. Some overdue training had now been completed including fire safety and Moving and handling. The quality of information provided on the Providers monthly visits had improved and documents viewed indicated that staff and service users were being consulted at these visits to ascertain their views. Staff recruitment standards had been improved and all required documentation and checks were found to be in place to ensure staff were being recruited appropriately. The induction process for staff had also been improved and a skill based induction pack was being used. Woodlands Nursing Home DS0000002099.V340882.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 DS0000002099.V340882.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.V340882.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 were assessed prior to admission to ensure that their needs would be met at the home. EVIDENCE: The admission process was discussed and the file of a recently admitted service user was examined. The care file examined indicated that pre admission assessments were documented. Information had also been sought from Care Managers, previous placements or Nurse Assessors where these were involved. A Statement of Purpose and Service User Guide was available which contained the majority of information required. The fees range was not included and a blank space was available for this to be completed with the fees charged for the individual service user. Woodlands Nursing Home DS0000002099.V340882.R01.S.doc Version 5.2 Page 9 Reasons given for choosing the home were given on questionnaires as it being close to previous address. Service users also recorded that they used the home for respite before deciding to move in permanently. Views were given from service users that they were generally happy with the choice of home they had made. Questionnaires returned indicated that some service users were unsure if they had signed a terms and conditions contract. The home does not offer intermediate care as defined by National Minimum Standards 6. Woodlands Nursing Home DS0000002099.V340882.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 poor. This judgement has been made using available evidence including a visit to this service. Service users personal care needs and personal choices were being adversely affected by poor staffing levels which was placing service users at risk. Poor recording relating to medication was evident which could adversely affect service users. EVIDENCE: A sample of three service users care files were examined to assess how standards were being met. Since the last inspection a new format for recording care plans had been introduced. Staff spoken to said that whilst these had taken a little getting used to they found them easy to update and use. The information contained in the care plans was found to be personalised and descriptive of the service user as an individual. They consistently described any Woodlands Nursing Home DS0000002099.V340882.R01.S.doc Version 5.2 Page 11 equipment in place when this was checked against what was being used and described how staff were to approach service users and deliver care. Reviews of care plans were documented and log entries for each service user were written twice daily. These appeared to be informative and were signed, timed and dated. The care plans in place contained a range of risk assessments including Moving and handling, tissue viability and nutrition. These had recorded monthly reviews and appeared consistent with the recorded needs identified in the care plans. Service users were weighed on a monthly basis and records of visits from healthcare professionals were recorded. A private chiropodist visits the home on a regular basis. The homes service users are registered with the community dental service and a private optician visits the home who was reported as offering a responsive and regular service. Some additional healthcare input was accessed by service users on a needs basis this included speech and language therapy, community psychiatric nurses and other out patients services. The provision of staffing at the home was reported by service user questionnaires, discussions with service users and staff at the home to be low. There were reports from service users of delays in care needs being met. This included a service user being left on the commode for a long period of time. Observations of care delivery also indicated that service users were not being supervised and requests for assistance with care needs were not met quickly. This was observed to be distressing to one service user. The was also an increased risk to safety as service users with poor mobility were unsupervised and were observed to be agitated and moving towards the edge of the chair they were sat on. When observations of the unsupervised lounge were discussed all the service users in this lounge were moved to another lounge. Whilst this improved safety for service users in the short term it adversely affects the choices and freedom of service users to access all parts of the home as they wish. Service users reported delays in receiving medication when it was requested, this was also observed by the inspector, and delays in receiving assistance with service users saying that staff say ‘just a minute’ and state they ‘are short staffed’ if requests are made. Some service users reported that they were able to mainly care for themselves and needed only assistance in certain areas and reported positively that staff respected and supported their independence. Woodlands Nursing Home DS0000002099.V340882.R01.S.doc Version 5.2 Page 12 The storage and administration of medicines was examined at his visit. In the past 5 weeks a new supplying pharmacist had been contracted by the home. It was evident from the records viewed that this had not run smoothly with large numbers of medication administration records being handwritten. Poor record keeping from staff was evident with entries not on the prescription boxes not being signed by staff. One prescription did not have any dosage of frequency instructions records – only the name of the drug. Inconstant records were being kept of drugs received into the home. Records of disposal were available and appeared to be comprehensive although an audit trail was not possible due to poor recording of drugs received in. Where prescription dosage had changed part way through the medication administration record the old prescription had been amended. Some controlled drugs were stored appropriately and balances correlated with the records held. Staff spoken to said that some drugs were still in the home despite the service user not residing there anymore. The reason given was that there was not a suitable disposal vessel available to safely dispose of the controlled drugs. The storage of medications was considered appropriate. Woodlands Nursing Home DS0000002099.V340882.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 are a range of regular activities offered with dedicated staff employed which allow service users to have choices and variety within the lives at the home. EVIDENCE: An activities coordinator is employed by the home for 20 hours per week typically working 4 afternoons. Some records were available to record what activities were offered however these did not appear to do justice as to what was offered as no records for August had been completed. Service users confirmed that social activities were offered. A planner of activities was located in the lounge and activities were viewed to be happening during the visit. The care plans viewed considered and recorded service users social interests and included details of how these were to be met. Discussions with a visitor confirmed staff were knowledgeable regarding their relatives preferences. Woodlands Nursing Home DS0000002099.V340882.R01.S.doc Version 5.2 Page 14 The range of activities available included, bingo, memory days, skittles and some craftwork. Service users said they also went out to local shops with staff. During the summer the home had access to a wheelchair accessible bus and a few times each small groups of service users were offered the opportunity to go out to local places of interest. One service user said they particularly enjoyed having tea and cake out of the home. A hairdresser visits the home and was present during the inspection. One visitor spoken to said they were able to visit their relative in private and were happy that they were informed of any significant health changes that occurred. Observation was made of the serving of the lunchtime meal which was the main hot meal of the day. One meal was cooked and served with options said to be offered if service users did not like this. This was confirmed by service users spoken with who gave examples of their dietary needs and how the home met these. Varying portion sizes of meals were served to service users and aids to help maintain independence were observed to be used for example plate guards. The meal of steak and kidney pie with 3 vegetables and potatoes appeared to be well balanced. One service user was observed to have a different option. Generally positive responses were given regarding the quality of the food with one service user saying it was ‘quite nice’. Two dining areas were used with service users being able to choose a smaller quieter dining room if they wished. Training records indicated that all kitchen staff had been trained in basic food hygiene. Woodlands Nursing Home DS0000002099.V340882.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. Procedures in place are not robust and clear enough to safely ensure allegations of abuse are handled appropriately possibly placing service users at risk. Some staff have had training in Safeguarding Adults but other have had limited in house training which is poorly documented and may not adequately ensure service users are protected from harm. EVIDENCE: The Annual Quality Assurance Assessment received by Commission for Social Care Inspection recorded that two complaints had been received at the home in the past 12 months. Records at the home were available for only one complaint and staff spoken to could not recall if there had been another complaint. The records relating to the complaint had been examined at a previous inspection. Action had been taken to ensure that the concerns were acknowledged and responded to. The Commission for Social care Inspection had not received any complaints or concerns regarding the home. Woodlands Nursing Home DS0000002099.V340882.R01.S.doc Version 5.2 Page 16 The complaints procedure was on display in the home and one service user spoken to said they would approach staff if they had worries and gave an example of where they had done this. There have not been any investigations relating to safeguarding adult concerns since the last inspection. Staff spoken to said they had received training in Safeguarding Adults and said they would approach the Manager or Nurse in charge if they had concerns. The staff training records available indicated that the majority of staff had received training in Safeguarding Adults. Some newer staff had no recorded training documented. The Manager stated that these staff had received some in house training as part of the induction process though no documentary evidence of this was available. The Safeguarding Adults procedure was examined. In the policy file there were three different procedures available for handling allegations of abuse after it had been reported. This was potentially confusing for staff. Woodlands Nursing Home DS0000002099.V340882.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. Whilst the home was found to be clean with an ongoing maintenance plan being delivered areas of the home were beginning to appear tired and some aspects identified required attention to ensure the home maintained to a suitable standard to service users to live in. EVIDENCE: The home is a purpose built one and has two large lounge/diners available and a smaller more private lounge. Some of the décor of the home was in places tired with peeling paper in some areas including the lounge and one bathroom. The furniture in some bedrooms had some chipping of edgings and appeared dated. Woodlands Nursing Home DS0000002099.V340882.R01.S.doc Version 5.2 Page 18 Some redecorating of bedrooms was in place during the visit. In the main lounge staff training certificates were framed on the walls which did not contribute to the otherwise homely setting. One very small room has been set aside in the home a smoking area for service users. This was found to be very smoky with the smell permeating into the adjacent corridor near service users bedrooms. A small ceiling extraction system was fitted but was switched off. Observation of service users in this area was not possible without staff having to sit a very smoky atmosphere. An outdoor garden area was available which had some seating for service users to use, one service user spoken said they did like to sit outside in fine weather. Staff spoken to said there were plans to develop the garden area and provide a sensory garden. A partial tour of the building was conducted to include the communal areas, laundry and some bedrooms. Service users spoken with said they had a range of personal possessions in their rooms to help them feel homely. Service users also said they were able to spend time in private in their room if they wished. The home was found to be largely clean and domestic staff were in evidence during the visit cleaning most areas. Service users spoken with said they were happy with the cleanliness of the home and there were ‘no smells’. The extraction fans in the majority of toilets of and bathrooms were not working. These were also found to require cleaning. The restrictor on the window in the staff room on the first floor was found to be broken. The door to the staff room was unlocked rendering it potentially accessible to service users. This was reported to the handyman who later said he had repaired this. The fire records indicated that checks of the alarm and equipment were regularly completed. Water temperatures were also routinely checked to ensure service users were not placed at risks of scalding. The flooring in the laundry area was split as at previous visits. Taping over the split had been made to temporarily repair to this. This had lifted in places and again presented a trip hazard to staff. Two washers and dryers were functioning in the laundry. Service users gave mixed opinions on the quality of the laundry service. Some service users being happy, others reported items going missing. Staff reported that aprons and gloves were readily available to them. Hand gels were also located in some communal areas in wall dispensers to aid hand hygiene. An infection control audit of the home had been completed by the Woodlands Nursing Home DS0000002099.V340882.R01.S.doc Version 5.2 Page 19 Manager and while the findings appeared initially good with some areas of improvement identified a feedback report had yet to be compiled. Woodlands Nursing Home DS0000002099.V340882.R01.S.doc Version 5.2 Page 20 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. The provision of insufficient numbers of staff is adversely affecting the care delivered to service users and potentially places them at risk. The recording and provision of staff training has improved ensuring staff are sufficiently skilled to provide care to service users. EVIDENCE: The occupancy of the home on the day of the visit was 37 service users. 12 service users required nursing care, 25 service users required personal care only. The typical staffing levels at the home were 1 nurse on duty for all shifts with 4 care staff for morning shifts, 3 care staff in the afternoons. At nights there was one qualified nurse and 2 care staff. It is evident that from the last inspection the occupancy level of the home has increased however staffing levels have decreased particularly in the mornings. Woodlands Nursing Home DS0000002099.V340882.R01.S.doc Version 5.2 Page 21 The Manager stated that adverts were being placed to try to recruit staff. It was reported by the Manager that some staff had been recruited but they had not remained in post for very long. Some current staff were also working on a short term basis in the home and were due to leave in the next month. One questionnaire received back reported that they regarded there to be a ‘real staff shortage’ with staff having little time to have one to one chats with service users. This was the opinion also conveyed by the majority of service users spoken to at the home with. Staff spoken with said they were doing their best to ensure standards of care were being maintained despite reporting shortages. From the Annual Quality Assurance Assessment it was recorded that there were 16 care staff employed at the home of which 8 held NVQ (National Vocational Qualification) level 2 in care qualifications. A further 2 staff 5 had begun NVQ (National Vocational Qualification) courses. Some Senior care staff had achieved National Vocational Qualification level 3 in care. Samples of staff personnel files were examined. These confirmed that application forms had been completed and all required checks, including POVA First and Criminal records Bureau checks had been completed prior to staff commencing in post. Staff files also contained contracts of employment and job descriptions for the role in which staff were employed. Samples of the staff training files were examined. Staff training was recorded clearly and supported by files containing the certificates of completion. Staff spoken to said they had received the mandatory training updates in the past year including Moving and handling, Safeguarding Adults and fire safety. Some role specific training had been completed by the nurses at the home including Parkinson’s training and tissue viability. Some staff had completed first aid training in the past year. A skill based induction pack was available and a completed example of this was available to demonstrate that staff were receiving appropriate inductions. Woodlands Nursing Home DS0000002099.V340882.R01.S.doc Version 5.2 Page 22 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): 31,32,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some improvements have been made in some areas however the home is not being managed effectively to ensure staffing numbers are being provided in order to meet all of the service users needs therefore the best interests of service users are not being safeguarded. EVIDENCE: The Manager of the home has been in post since 1997 and is supported by a long serving Deputy Manager. Woodlands Nursing Home DS0000002099.V340882.R01.S.doc Version 5.2 Page 23 The Manager had certificates available to demonstrate ongoing development and learning including having completed courses in fire risk assessment and Health and Safety. The main issue at this inspection relates to staffing levels which are not sufficient to meet the needs of needs of service users. The Management procedures in place at the home have not addressed this to ensure that staffing levels are improved. The home is therefore not being run in the best interests of service users. The quality assurance processes in place were examined. Monthly visits made on behalf of the Provider were documented and the Manager said there had been discussions following the last inspection on how to improve these. Examples of these viewed included documented discussions with staff and service users and some records were examined. Some infrequent staff and service user/relatives were held and minuted. A development plan had been drawn up to cover a range of topics with dates for completion recorded. Recently it was reported that surveys had been sent out to relatives to establish their views on the quality of the service. So far one of these had been returned. This recorded a generally positive opinion of the home with one suggestion for replacing the very large television with a few smaller ones in different areas of the home. Accidents that occurred were recorded and an audit of these over the past months had been completed. Small amounts of service users monies were stored safely on behalf of service users. Balances of a sample of monies were checked which were found to be accurate. Not all transactions were signed by the person completing them. Some service users monies were held in a service users bank account and records indicated how much was retained there. The Annual Quality Assurance Assessment received from the home indicated that all equipment had bee serviced within acceptable timescales. This included the gas and electrical systems which had been overdue at the last visit. These records had also been checked as part of one monthly visit made on behalf of the provider. Woodlands Nursing Home DS0000002099.V340882.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 3 8 3 9 1 10 1 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 3 17 x 18 2 2 x 2 x x x x 2 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 1 x x 3 x x 3 Woodlands Nursing Home DS0000002099.V340882.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 OP9 Regulation 13(2) Requirement When handwritten medication administration records are completed they should be signed and dated by the completing staff member When a GP authorises a change of medication the GP’s name must be recorded on the MAR sheet entry, together with the date from which the change is to start. Accurate records must be kept of all medication received, administered and disposed of to ensure that medication is used safely, correctly and as prescribed. There must be suitable disposal arrangements and facilities in place to dispose of all medications that are no longer required by the service user The Safeguarding Adults procedure must be clear and robust to ensure allegations of abuse to service users are handled appropriately The smoking lounge must have adequate ventilation/extraction DS0000002099.V340882.R01.S.doc Timescale for action 30/08/07 2 OP9 13(2) 30/08/07 3 OP9 13(2) 30/09/07 4 OP9 13(2) 30/09/07 5 OP18 13(6) 30/09/07 6 OP19 23(2)(p) 30/09/07 Woodlands Nursing Home Version 5.2 Page 26 7 8 OP21 OP26 23(2)(p) 23 in place to ensure non smoking service users are not affected by smoke Extraction systems in toilets in toilets and bathrooms must be operational and kept clean The flooring in the laundry requires repair to ensure it does not pose a trip hazard to staff Previous timescale 30/04/07 30/09/07 30/09/07 9 OP27 18 Staffing rota’s must be provided to the Commission for Social care Inspection which demonstrate staff are being provided in sufficient numbers as are appropriate to ensure the health and welfare needs of service users will be met Immediate requirement issued at time of inspection 18/08/07 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 4 Refer to Standard OP9 OP18 OP19 OP19 Good Practice Recommendations When medication administration records are handwritten they should be checked and signed by a second staff member who is competent to do so Where in house Safeguarding Adults training takes place whilst awaiting accredited courses this should be recorded Consideration should be given as to how service users using the smoking lounge are supervised Consideration should be given to redecorating the communal area and bathrooms in the home Woodlands Nursing Home DS0000002099.V340882.R01.S.doc Version 5.2 Page 27 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. 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