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Inspection on 18/09/07 for Woodlands Nursing Home

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

This inspection was carried out on 18th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

The home has safe systems for managing people`s medications. Staff on Calder unit engaged people in activities and interacted well with people during the visit.

What has improved since the last inspection?

The exterior of the home has seen some improvements. The front lawn has been regularly cut and the rubbish has been tidied up from around the building.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Sands Lane Mirfield West Yorkshire WF14 8HJ Lead Inspector Sally McSharry Key Unannounced Inspection 08:30 18 , 19 & 24 September 2007 th th 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 DS0000001100.V342562.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 DS0000001100.V342562.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Nursing Home Address Sands Lane Mirfield West Yorkshire WF14 8HJ 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) 01924 491570 01924 497377 Woodlands.Mirfield@Craegmoor.co.uk Speciality Care (REIT Homes) Limited Vacant post Care Home 87 Category(ies) of Dementia - over 65 years of age (87), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (87) Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can provide accommodation and care for 5 named service users under 65 years of age. 1st May 2007 Date of last inspection Brief Description of the Service: Woodlands Nursing Home is owned by Speciality Care (REIT Homes) Limited which is a wholly owned subsidiary of Craegmoor Healthcare. The home provides nursing and personal care and accommodation for up to 87 older people who suffer from dementia type illnesses and mental disorders. Woodlands is a large, brick built home set within 47 acres of woodland. The home is divided into 4 units over two floors. Access to the first floor is gained via a passenger lift. The home provides single and double room accommodation. Some rooms have en-suite facilities, some rooms have a small cubicle which is fitted with louvre doors; the cubicle contains a toilet. The home is in a secluded position, one mile from public transport but has a minibus available. Woodlands has its own gardens that includes patio areas, seating, an orchard and a pond. Some outside areas are securely fenced to allow freedom to walk or sit in a protected setting. The provider informed the Commission for Social Care Inspection on 18/09/07 that fees range from £335.24 to £767.18 per week. Additional charges include hairdressing, private chiropody, newspapers, special toiletries, tobacco and some clothing. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Woodlands Care Home has a long history of fluctuating care standards. At the last inspection in May 2007, serious concerns were raised by the Commission about the standard of care and accommodation provided at the home. In July 2007 the Commission met with the Craegmoor representative who is responsible for the running of the home. Open discussions were held regarding the Commission’s concerns about the standard of care being delivered to people in the home. Craegmoor produced an action plan to address the seventeen requirements made in the last report and acknowledged that improvements must be made. An unannounced visit was made to the home by two inspectors on 19 September 2007, three inspectors on 20 September and two inspectors on the 24 September. On the first day the inspectors arrived at the home at 08:30 hours and left the home at 19:00 hours, on the second day the inspectors arrived at 10:00 hours and left at 12:00 mid-day and on the third day inspectors arrived at 17.00 hours and left at 18.40 hours. During this visit, the inspectors spoke to some of the people living in the home, two visiting relatives, some of the staff and the home’s management. The inspectors read care records, audited a sample of medications, discussed staff training records, carried out a brief tour of the building and observed breakfast and tea being served. The inspector would like to take this opportunity to thank everyone who participated in the inspection process. Prior to the inspection, relatives’ surveys were sent out to sixty one of the relatives/friends of people living in the home. At the time of writing this report, twenty two had been returned from relatives. Thirty questionnaires were made available to members of staff who work at the home, two were completed and returned. Other information used in the inspection process included notifications from the provider to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider. Surveys returned from relatives of people living in the home were mixed, some people are happy with the care their relatives are receiving and the overall standard of care in the home. However, many identified serious failures to provide basic health and social care. During this visit, the inspectors also identified poor standards of care, lack of social activities and a failure to respect people’s privacy and dignity. What Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 6 they saw also prompted them to refer 9 people to the Social Services Department responsible for co-ordinating services to make sure people are safe. What the service does well: What has improved since the last inspection? 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 DS0000001100.V342562.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 DS0000001100.V342562.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 and 6. People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. People moving into the home cannot be sure their health, personal and social care needs will be met. EVIDENCE: This home does not provide intermediate care. Written evidence of pre-admission assessments could not be found for two people recently admitted to the home. The purpose of the assessment is to make sure that the home will be able to meet the person’s needs before they are admitted. A community care assessment (an assessment carried out usually by a social worker identifying the person’s care needs before admission to the home) was available for one of the people but this referred to care at home not in a care home setting. Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 9 The inspectors saw a person who had been admitted to the home the previous day in a very distressed state, agitated, breathless and confused. The person was constantly seeking reassurance and help from the inspectors and staff on the unit. As only two members of staff were working on the unit, and both were busy, this person’s needs were not being met and inspectors observed an increase in the person’s distress and breathlessness. People must not be admitted to the home unless the home has sufficient staff to meet their needs. A requirement has been made about this in this report. Woodlands Nursing Home DS0000001100.V342562.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 and 10. People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health, personal, social and dignity needs are not being met. EVIDENCE: Work has been carried out on care plans and a new person centred care plan implemented. Person centred care plans should be developed from the point of view of the person receiving care and be individual and specific to that person. However, not all care plans at Woodlands do this. Some care plans also fail to identify significant health care needs. The care plan of a person with diabetes did not mention their diabetes or the need for a special diet. One person’s daily record referred to “prescribed cream applied”. When staff were asked what cream was prescribed, and where it was being applied, they advised “aqueous cream on the buttocks”. There was no mention of this in the Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 11 care plan, however two later entries one in the record of doctor’s visit said the doctor had visited on the 6/09/07 and cream had been prescribed for an itchy wrist and sore face. Another entry said cavalon cream was being applied to a red area on the sacrum. Staff could not be clear what cream was being applied. This is not safe practice. During the visit, the inspectors saw a person living in the home who had clearly been incontinent of urine. Despite this, staff proceeded to walk this person into the dining room, give them their breakfast and take them back to the lounge afterward without changing this person. This person was sitting in wet clothes for at least two hours before a member of staff changed them. Four people’s medications were audited. Medications held at the home corresponded with records and were found to be stored safely. The privacy and dignity of people living in the home is not being maintained. Relatives spoke to the inspectors, and wrote in surveys about people not being dressed in their own clothes. There had been a recent incident in the home where a carer changed the blouse of a person whilst in the lounge and in front of other people living in the home with no regard of their privacy or dignity. People in the home, being nursed in bed, were seen dressed only in vest and underpants with no nightclothes. Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 12 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 who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s social, cultural, religious and recreational needs are not being met. EVIDENCE: Since the last inspection in May 2007 some attempts have been made on some units to provide some social activities. Some people were seen taking part and enjoying activities. However, not all people have access to adequate activities. Relatives in verbal feedback, at the time of the visit and in surveys, confirmed this. Care records showed people’s religions but there was little evidence that people are supported to practice their beliefs. No restrictions are made on visiting times to Woodlands, however the home is located approximately a mile from the main road and the nearest bus stop. Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 13 Unless visitors have their own transport, visiting could be difficult, although Woodlands does offer some support with transport to the home. Where family and friends are unable to visit Woodlands, relatives indicated in surveys that they would appreciate someone from the home contacting them monthly to give a detailed update on their relatives’ conditions and progress. Some of the people living in the home are able to make limited choices, for example what time they get up or go to bed and some choices at some meals. However, this is not always the case. When morning drinks were offered there was only juice available on the drinks trolley. Members of staff were willing to make cups of tea on request but this was not routinely offered. However, it is more appropriate to offer people with dementia type illnesses an immediate visual choice and, by failing to do this, they restrict people’s options. In the lounge, there were no tables to put a cup of tea or a glass of juice on. Not all people were given a mid morning drink. Those who had a drink had to hold onto their glass of juice. On one unit people were seen not to be offered any choice at the teatime meal. Meals generally are appetising and plenty of food is available. However, on some units there were insufficient members of staff available to support and supervise people with their meal. People were touching other people’s food and generally causing disruptions, which unsettled and upset some of those trying to eat. Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 14 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 who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are not confident that their complaints will be dealt with appropriately, not all people in the home are being protected from harm or abuse. EVIDENCE: The regional manager said that he was still dealing with a six month backlog of complaints. Relatives said, in conversations with the inspectors, that they had raised concerns but had not yet received a full response. During the visit, examples of care that compromised the welfare of individuals was seen. Following this, the inspectors made nine safeguarding referrals to the Local Authority for them to investigate. Staff working at the home do not recognise practice that puts the welfare of people at risk. Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 26. People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. The comfort and wellbeing of people living at the home is not promoted due to poor standards of maintenance, infection control and cleaning. EVIDENCE: The Commission has been informed that major refurbishment work is to commence very shortly. This is to include new windows, refurbishment of bathrooms and development of shower rooms. There is also planned renewal of floor coverings in corridors and lounges and refurbishment of every bedroom. Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 16 However, minor maintenance problems highlighted at the last inspection had not been attended to. This included issues such as handles missing from toilet doors and plaster missing from walls in bedrooms. Observations were that standards of basic hygiene and infection control were poor. Soap was not available in at least two communal toilets and chairs were not being cleaned after people had been incontinent in them. A member of cleaning staff was observed to go into a toilet on two occasions but neither time cleaned the faeces off the door handle. There was a lack of occasional tables in lounges for people to rest their drinks on and the lack of cushions for supporting people to sit comfortably. Relatives commented that beds were not always made. Insufficient supplies of bed linen were highlighted as a concern at the last inspection and, despite the acting manager saying that more had been bought, observations during the visit were that this is still a problem. Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 17 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 who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. Appropriately trained staff are not available in sufficient number to meet the needs of the people living at the home. EVIDENCE: Observations made during this visit identified a shortfall in staffing. This was particularly evident during the breakfast time on Thornhill unit where people’s needs in relation to eating and drinking were not being met, and on Hopton unit where a lack of appropriate staffing resulted in people being placed at risk of abuse and others not having their needs met. Rotas show that staffing has been decreased on Hopton unit since the last inspection to only two staff during the day. This means that when people who need two staff to meet their needs are being attended to, there is nobody available to observe and support other people on the unit. The regional manager said that changes had been made to ensure that a qualified nurse was available on each unit at all times during the day but this should not have resulted in a reduction in staffing levels. The acting manager said that she would look into the situation. Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 18 The staffing rota given to the inspectors for the week of the visit was not correct. For instance, the rota showed that a nurse who was seen on duty, was on sick leave. Several relatives of people living in the home have expressed their concerns about poor staffing levels in the home and some relatives spoken to during the visit said that there are not enough staff to maintain people’s safety. Personnel files for the the four most recently recruited staff were examined. Three of the four files did not contain a health declaration. One file did not contain evidence that the individual concerned had been interviewed about a number of convictions that were shown on their Criminal Records Bureau check and the employment history of this person had not been fully explored. The acting manager said that a staff training matrix was available but that neither this document nor individual staff records could be verified, as there was evidence that training records had been falsified by a previous manager. The regional manager said that the company were looking into this and would ask for verification of all external training that had been delivered to staff. It was therefore not possible to ascertain, on this occasion, the competence of staff in the home to deliver care. The home does not meet the national minimum standard of 50 of care staff being trained to National Vocational Qualification level two in care. Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 19 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 and 38. People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. Management processes regarding health and safety of people at the home are not sufficient and could put people at risk. EVIDENCE: The home does not have a permanent manager. Since the last inspection, a period of five months, there have been three different people acting in the role of manager. The person in this role on the day of the visit had only been at the home for three weeks. Some relatives said that they found this situation Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 20 confusing in that they did not know who is in charge and therefore did not know who to approach with any problems. Senior management from within Craegmoor had given their assurances to the Commission that they are doing all they can to address this issue and to support the acting manager. Senior management were aware of the serious concerns about the home and the care provided following the last inspection. They have not yet effected significant improvement to the quality of care provided to some people living in the home. Matters relating to the finances of people living at the home were not inspected on this occasion, however there have been no concerns raised relating to finances and outcomes from the previous inspection were that this was being managed safely. During this visit issues were identified which directly affected the health and safety of people living living in the home. Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 21 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X 2 X X X X 1 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 22 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. 2. Standard OP3 Regulation 14 (1) (d) 15(1) Requirement People must not be admitted to the home unless their needs can be met. All people using the service must have an up to date, detailed care plan. This will ensure that they receive person centred support that meets their needs. Timescale of 30/06/07 not met. Staff must be trained, supervised and monitored to ensure people living in the home have their privacy maintained and their dignity upheld. Timescale of 30/06/07 not met. All people living in the home must have access to daily activities which meet their individual needs. Timescale of 13/11/06, 30/06/07 and 30/06/07 not met. The staff must make suitable arrangements to help people maintain their religious beliefs and cultural needs. Timescale of 30/06/07 not met. DS0000001100.V342562.R01.S.doc Timescale for action 01/10/07 01/10/07 OP7 3. OP10 12(4) 01/10/07 4. OP12 16(2)(n)( m) 01/10/07 5. OP12 12 (4) 01/10/07 Woodlands Nursing Home Version 5.2 Page 23 6. OP15 12(1) 7. OP16 17(2), schedule 4. 13 (6) 13(4) 8. 9. OP18 OP19 10. OP19 23 (2) 11. OP21 23(2)(n) 12. OP24 16 (2) (c) 13. OP27 OP28 OP30 18 (1) 14. OP30 18 (1) Action must be taken to ensure staff support and assist people properly with their meals and dietary intake. Timescale of 30/06/07 not met. A record of all complaints must be maintained and action taken by the registered person. Timescale of 30/06/07 not met. The registered person must ensure people are not put at risk of abuse, harm or neglect. The registered person must ensure that the action plan to improve the home’s environment is implemented to provide a pleasant and safe place to live. Timescale of 31/11/06 and 30/07/07 not met. The registered person must ensure that all areas of the home are maintained to exclude draughts and leaks and maintain a comfortable and safe temperature. Toilet and bathing facilities must be clean, well maintained and adequately equipped, to ensure people can bathe in pleasant and hygienic facilities. Timescale of 31/07/06, 28/02/07 and 28/07/07 not met. New suitable bed linen must be provided. Timescale of 30/11/06 and 31/07/07not met. The registered person must, ensure that there are sufficient numbers of skilled, experienced and competent staff to meet the needs of the people living in the home. Timescale of 31/07/07 not met. The registered person must ensure that training is satisfactory and staff become DS0000001100.V342562.R01.S.doc 22/10/07 01/10/07 01/10/07 31/12/07 30/09/07 01/10/07 01/10/07 01/10/07 31/12/07 Woodlands Nursing Home Version 5.2 Page 24 15. OP33 12, 15 and 24. OP38 16. 12(1) 13 (2-4) 16 (2) 23(4-5) and remain competent to do their job. Effective quality audit systems must be implemented to maintain and monitor standards in the care home. Timescale of 30/11/06 and 31/07/07 not met. A competent person must carry out a full and detailed health and safety audit of the building. Issues identified must be acted upon and made safe. Timescale of 31/07/07 not met. 22/10/07 01/10/07 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. 5. Refer to Standard OP10 OP19 OP26 OP28 OP31 Good Practice Recommendations It is recommended that further training and supervision be provided to staff to ensure that, at all times, service users’ privacy and dignity is maintained. The redecoration programme should be continued and address all bedrooms and bathrooms. All parts of the home should be free from unpleasant odours. Training should continue with the aim being for the home to have 50 of its staff trained to NVQ level 2 or above. The registered provider should put forward a suitably qualified and skilled person of good character to manage the care home. Woodlands Nursing Home DS0000001100.V342562.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 DS0000001100.V342562.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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