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Inspection on 19/10/05 for Woodlands Nursing Home

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

This inspection was carried out on 19th October 2005.

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

Woodlands Nursing Home assesses all prospective service users prior to admission to the home.

What has improved since the last inspection?

Although there are many requirements and recommendations identified in this report, improvements have been made at the home. The overall standard of care planning and recording in the home has improved. The management of medications is better than on the last three visits. Staff were seen to be interacting with service users appropriately and activities are now being offered to service users. Some service users have limited choice due to their mental and physical frailty, however there is evidence that choice is available in the home and staff respect choices made. Training in general has increased and the majority of staff have received training in the protection of vulnerable adults and movement and handling . The provision of specialist equipment has improved with some profiling beds provided in the home.

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Sands Lane Mirfield West Yorkshire WF14 8HJ Lead Inspector Sally McSharry Announced Inspection 19th October 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 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.V250588.R01.S.doc Version 5.0 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 Speciality Care (REIT Homes) Limited Mrs Angela Gillard 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.V250588.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 named persons under 60 years of age Date of last inspection 29th April 2005 Brief Description of the Service: Woodlands Nursing Home provides nursing, 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 ancient 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 louver doors the cubicle contains a toilet. The home is in a secluded position, one mile from public transport but the home has a minibus available. The home has its own gardens that include patio areas, seating, an orchard and a fishpond. Some outside areas are securely fenced to allow freedom to walk, or sit in a protected setting. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an announced visit carried out on 19th October 2005. Four inspectors attended the inspection, which included a brief tour of the building, an audit of some care plans and service user records, including medications on each unit. Staff recruitment and training records, the kitchen facilities, quality assurance, service users finances and health and safety records were also inspected. The inspectors spoke with some service users, some staff and the managers of the home. A selection of the National Minimum Standards was assessed during this visit and the progress made to address requirements and recommendations made in previous reports was assessed. Woodlands Nursing Home was inspected on 29 April 2005 and standards found to be unsatisfactory. The Commission met with Craegmoor Healthcare Limited and Craegmoor voluntarily stopped admissions to the home. The Commission requiring the standard of care and protection of service users to be improved two statutory enforcement notices were issued to Craegmoor Healthcare Ltd. The Commission also required the level of training, supervision and competence of staff to be improved. Two further monitoring visits took place during the summer and Craegmoor Healthcare Ltd have taken steps to improve standards, training and the level of competence of staff. Efforts have been made by the Commission and Craegmoor Healthcare Ltd to raise the standard of care. To date, admissions have only occurred on one specific unit, admissions to the remaining units will not occur until a sustained improvement has occurred. Craegmoor Healthcare Ltd have shown a commitment to improve standards at Woodlands Nursing Home and the Commission continues to monitor the home. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 6 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. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 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.V250588.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Information is available about the home, however this is not in a format, which is appropriate to prospective service users. Prospective service users are assessed prior to admission to the home to ensure their needs can be met. EVIDENCE: The home’s statement of purpose and service user guide is not in an accessible format and does not provide service users with the required information. There have been few admissions since the last inspection as Craegmoor Healthcare Ltd agreed voluntarily to stop admission to the home until standards of care had been improved and sustained. This agreement was partially lifted and since August 2005 some admissions have taken place on to one unit. An audit of service user plans on this unit showed that prior to admission prospective service users are being assessed to ensure the home can meet the service user’s health and welfare needs. Woodlands does not provide intermediate care. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Service user’s health, personal and social needs are included in care plans. Service users health care needs are being met. The management of medications is generally satisfactory, however the way staff dispose of some medications must be reviewed. Not all service users are being respected and their privacy and dignity upheld. EVIDENCE: The standard of care planning has improved. Generally care plans identified service users’ health and welfare needs and how these were to be met in the home, however some care plans did not give specific or detailed advice, for example there was reference to a service user being given “enough” fluids. It was not clear what enough fluids was. Risk assessments are carried out and a care plan produced, however on Calder unit both the nutritional assessment and risk of developing pressure assessment indicated a high level of risk for one service user but a care plan had not been developed to advise staff how to manage the risk. Assessments and documentation is reviewed monthly. Care staff were aware of the care plans and service users’ needs. Some issues were identified when looking at care plans and five recommendations have been made in this report. Care planning appeared to address the needs of service users and there was evidence in care plans to indicate where staff in the home were able to manage Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 10 a service user’s needs other health care professionals were contacted to support staff and provide specialist advice. Accidents occurring in the home are audited in an effort to identify any particular patterns or issues. The management of medications have improved and generally medications audited were reconciled against records. One issue was identified regarding the manner in which some staff are disposing of some medication. Some staff are maintaining the privacy and dignity of some service users, service users who were able to express their opinions confirmed this. However the inspectors did witness practice, which would indicate that this is not always the case. One inspector noted communal hairbrushes in use in bathrooms. There was also an incident where a service user interfered with another service user’s breakfast, staff acted appropriately to distract the service user and remove them from the situation and attend to hygiene needs, unfortunately the second service user was not provided with a new breakfast. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Efforts are being made to try to ensure lifestyle experience in the home meets service users’ expectations and although the standard has improved more work is still required. Service users are able to maintain contacts with their family and friends. Service users are helped to exercise some choice with in the home. Service users received a varied diet. EVIDENCE: Activities are offered in the home. There is one activities organiser and the manager of the home advised that a second activities organiser has been employed. The manager also advised that both activity staff are to attend a special training course. On some units care staff were providing activities and it was very pleasing to see a carer reading to service users on Hopton Unit whilst they had their morning coffee. Service users confirmed that they enjoyed this very much. There was evidence of other activities taking place on other units. Staff were also seen taking some service users out in the grounds. Service users are able to maintain contact with their families and there are no restrictions imposed by the home on visiting. Service users said that they did have choice with in the home. Choices are available around where and with whom they spend their time, choices around activities offered and meals and menus provided. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 12 Choices are offered at meal times. The main meal of the day is offered at teatime. Special diets are catered for and staff were seen to be assisting service users who required help with feeding. Those service users who were able, said that they enjoyed the meals provided. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Complaints are acted upon by the provider and are taken seriously. Service users are protected from abuse, however further steps must be taken to ensure all adult protection issues are reported to the local authority. EVIDENCE: A detailed record of complaints is maintained in the home. On arrival at the home two conflicting complaints procedures were displayed in the entrance of the home, neither contained the information required by the Care Homes Regulations 2001, this was rectified during the visit with one amended procedure being placed in the entrance of the home. The majority of staff have received adult protection training this year, accidents are analysed to identify any trends. At the inspection it was evident that the home had not been reporting possible incidents of abuse to the local authority when the incident involved two service users. The home’s adult protection procedure does not include the local authority procedure and this should be added. The inspectors advised of the need to refer all incident of abuse even when it may involve two service users. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 23, 25 and 26. Some parts of the home are better maintained than others. Bathroom and toilet facilities are available, however some repairs were identified and some require cleaning. Some service user’s rooms are homely and meet their needs. Not all areas of the home were clean or odour free. Clinical waste management must be improved. EVIDENCE: Woodlands is a large home and some redecoration and maintenance of communal areas and some bedrooms has taken place, however other areas such as some bedrooms, bathrooms and dining areas are showing signs of wear, the shower on Mirfield Unit needs repairing and some bathrooms were dirty (Thornhill and Calder Units). There was an unpleasant odour on Thornhill Unit. All these issues should be addressed. Some bare wires from an old door locking system are exposed and accessible, these should be removed. External window frames are very weathered and some appear rotten, a programme to replace these must be commenced. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 15 Some crockery such as plastic/ melamine beakers are heavily stained and worn and must be replaced. It was noted on Thornhill unit that when staff are in the dinning area, they are unable to hear the nurse call system and therefore a service user in their room calling for assistance was not attended to until the inspectors alerted a member of staff. The nurse call bell must be audible throughout the unit. Clinical waste storage is insufficient at the home and the external clinical waste bins were over flowing. Clinical waste bins were not locked or kept in a secure area. This must be addressed. It is recommended that staff be provided with alcohol hand gel as an extra infection control precaution. Laundry staff expressed some concern about how they launder the personal clothes of service users who may have an infection. Advice should be sought from the local infection control nurse. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Service users’ needs are not always being met, where and how staff are deployed should be reviewed. The registered provider is taking steps to ensure service users are in safe hands. The recruitment policy and practice does not currently protect service users. Staff training has increased. EVIDENCE: The home is adequately staffed considering the number of service users currently resident in the home. During this visit the inspectors identified some issues regarding where staff are deployed with in some units. During meal times all staff on one unit were assisting service users with meals, however some service users were sat in the lounge area. The service users in the lounge area became distressed and were unable to attract staff’s attention, staff were not supervising these service users and had the inspectors not alerted staff, service users could have been distressed for sometime. Staff should be deployed on units so as to ensure all service users are supervised. NVQ training is ongoing in the home. There is some work required to meet the target of 50 staff with NVQ level 2 by 31st of December 2005. The level of staff training provided since the last inspection is good. Craegmoor Healthcare Ltd have worked hard to ensure a varied training programme is accessible to all staff. Current staff recruitment policies and practice is unclear and neither the manager nor her deputy was able to explain the current practice and procedure. Staff records were incomplete and do not protect service users. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 17 Action must be taken to review the current company recruitment practices and procedures. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, and 38. The home now has an experienced registered manager. Quality assurance measures need to be improved to ensure the home is run in the best interests of the service users. It was not altogether clear in the home how service users’ finances are safe guarded. Staff are not receiving formal supervision. The health, safety and welfare of service users’ and staff are not being promoted or protected adequately. EVIDENCE: Angela Gillard is the registered manager for the home. Ms Gillard is a first level registered nurse with care home management experience. Company quality assurance policies and procedures are available, however the manager was not able to locate the current quality assurance audit or the previous audit. The company’s policy states that this should be available in the home at all times. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 19 Regular visits done under Regulation 26 of the Care Homes Regulations 2001 have not been received by the CSCI as required, in recent months. Craegmoor Healthcare Ltd holds service users’ finances centrally. It is a pooled account with individual balances records. The records of individual’s balance were not readily available at the time of the visit and staff at the home were not familiar with the system for holding service users’ finances. The manager advised that little formal supervision has taken place since the last inspection; therefore it remains a recommendation of this report that staff receive formal supervision. Some health, safety and routine maintenance is carried out in the home, however several issues were identified that require action. The issues are identified in the requirements and recommendation section of this report. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 20 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 1 1 X 2 1 X 2 X 1 STAFFING Standard No Score 27 1 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 2 X 1 Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 21 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 OP1 Regulation 4&5 Requirement Timescale for action 31/12/05 2 OP9 13 3 OP10 12 (4) 4 OP18 13 The registered person produces and makes available to service users an up-to-date statement of purpose setting out the aims, objectives, philosophy of care, service and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. Time scale of 01.04.05 and 01.07.05 not met. The home’s policy for the 30/11/05 disposal of medications must be reviewed. It is not acceptable for staff to be washing medications, which have been declined, down the sink. Further staff training and 31/12/05 supervision must be given to ensure service users’ privacy and dignity is maintained at all times. All incidents of possible abuse 31/12/05 must be reported under adult protection procedures. The local authority adult protection procedures must be included in the home’s adult protection policy. DS0000001100.V250588.R01.S.doc Version 5.0 Woodlands Nursing Home Page 22 5 6 7 8 OP19 OP19 OP22 OP26 23 (2) 13 (4) 16 (c) 13(3) & 16 (2) (j) Window frames must be repaired and /or replaced where required. Wires from the old door locking system must be removed. The nurse call system must be audible throughout the units. Further clinical waste bins must be provided and external clinical waste bins must be locked or held in a secure area. Staff must be deployed throughout the units to ensure all service users are supervised. Action must be taken to review the current company recruitment practices and procedures, to ensure service users are adequately protected. Effective quality assurance measures must be in place. Regular visits and reports must be produced in relation to Regulation 26 of the Care Homes regulations 2001. At the inspection no valid passenger lift certificate was available. A copy of the current certificate must be forwarded with the action plan required for this inspection. The most recent electrical report states “fixed wiring not safe” evidence must be provided to the CSCI that this has been addressed. A warning notice was issued 10.06.05 on one of the home’s boilers. Evidence is required that the necessary work has been carried out. Some care plans (Thornhill and Calder unit) failed to provide specific movement and handling advice. Movement and handling plans must be clear and provide specific information. Door closers must be maintained DS0000001100.V250588.R01.S.doc 30/04/06 30/11/05 31/12/05 30/11/05 9 10 OP27 OP29 18 19 30/11/05 31/12/05 11 12 OP33 OP33 24 26 30/06/06 30/11/05 13 OP38 13 16/12/05 14 OP38 13 16/12/05 15 OP38 13 16/12/05 16 OP38 13 (5) 31/12/05 17 OP38 13 31/12/05 Page 23 Woodlands Nursing Home Version 5.0 18 19 OP38 OP38 23 23 to ensure they are closing appropriately and dinning room doors should not be wedged open Time scale of 01.04.05 and 09.05.05 not met. All staff must receive fire training. An action plan must be produced and a copy forwarded to the CSCI identifying how and when the issues raise in the West Yorkshire Fire authority’s schedule 1 and 2 report will be addressed. 31/12/05 18/11/05 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 6 7 8 9 10 11 12 Refer to Standard OP7 OP7 OP7 OP7 OP7 OP19 OP21 OP21 OP24 OP26 OP26 OP26 Good Practice Recommendations Where risk assessments identified a risk a care plan must be produced to minimise or eliminate the risk. Advice given in care plans should be specific. Use of the words “enough” or “regularly” should be avoided. All care plan entries should be dated and signed. All care plan documentation must be completed. Daily record entries are sometimes brief, they should reflect the care given that day and any outcomes to that care. The redecoration programme should be continued and address all bedrooms and bathrooms. The shower on Mirfield Unit should be repaired. The toilet and bath facilities on Thornhill and Calder Unit should be maintained and thoroughly cleaned. The stained and worn plastic/ melamine cups should be replaced. All parts of the home should be free from unpleasant odours. Alcohol gel should be provided to all staff as an extra infection control procedure. The infection control nurse should be consulted for advice regarding the washing of service users personal clothes. DS0000001100.V250588.R01.S.doc Version 5.0 Page 24 Woodlands Nursing Home 13 14 15 16 17 18 19 20 21 OP28 OP36 OP38 OP38 OP38 OP38 OP38 OP38 OP38 The registered manager must work toward having 50 of staff trained to NVQ level 2 or equivalent by 31.12.05 Staff should receive formal supervision. Showerheads should be disinfected as a precaution against the Legionella bacteria. Cold water should be checked to ensure it is below 20 degrees centigrade as recommended by the independent water company. Hot water should be monitored weekly as per the company’s policy, not monthly which is the current practice in the home. Only one accident book per unit should be used to record service user accidents. Full detailed and up to date COSHH details should be available in the home. A more reliable way of testing the hot water temperature of baths should be introduced. (Current practice reported to be the elbow test). The freezer handle should be repaired/replaced. Woodlands Nursing Home DS0000001100.V250588.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 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.V250588.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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