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Inspection on 21/08/06 for Woodlands Nursing Home

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

This inspection was carried out on 21st August 2006.

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

Service users spoken were positive regarding the care delivery of personal care. Positive comments were made on how staff deliver personal care. Service users said the food at the home was good despite all service users saying there was a choice routinely given. Service users said they were able to have an alternative if they asked for it.

What has improved since the last inspection?

Some staff spoken to confirmed that they had been on protection of vulnerable adults training courses and reported that this had been thought provoking.

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Wardgate Way Holme Hall Chesterfield Derbyshire S40 4SL Lead Inspector Bridgette Hill Key Unannounced Inspection 21st August 2006 09:15 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.V304819.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.V304819.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 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.V304819.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 9th December 2005 Date of last inspection Brief Description of the Service: The Woodlands is a purpose built two-storey home, which provides residential and nursing care for up to 50 elderly service users. The home is situated on a housing estate and shops and community facilities are close by. The home has a large car park for visitors and is situated in lawned grounds. The home provides forty-four single and three shared rooms. Three rooms have en-suite facilities. The fees charged at the home range from £298.20 - £512.00. There are additional costs for hairdressing, chiropody, and personal newspapers. This information was taken from the Pre Inspection Questionnaire. Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit which focused on assessing compliance to previously listed requirements and on assessing all key standards. As part of the inspection a sample of service users care files and a range of documents were examined. A tour of the building was conducted. During the visit opportunity was taken to have discussions with staff, service users and visitors. One visiting professional contacted the Commission for Social Care Inspection for advice and to share a concern their comments have been included in this report. Discussions were also held after the inspection with a Free Nursing Care Team member. A Pre Inspection Questionnaire was received by the Commission for Social Care Inspection prior to the inspection taking place and some information included in this report is taken from this. Not all service users in the home were able to express themselves and participate in the inspection process. The person in charge at this visit was Ida Needham Deputy Matron What the service does well: What has improved since the last inspection? What they could do better: Since the last inspection the home as successfully applied to register three beds for service users with dementia. Some aspects identified at this visit presented potential risks to service users with dementia/confusion. This included doors through which service users could leave the home without staff being aware, openly accessible areas which Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 6 should be secured, and hazards from hot water and chemical cleansers being found. The recruitment procedures are not being robustly followed before employment and therefore appropriate checks were not completed to ensure staff were suitable to work with vulnerable service users. Training records were found to sporadically kept with some blank forms and information not updated 2003/4. An induction programme was available but examples viewed indicated that nothing had been recorded since staff commenced employment. The medication administration records were examined and a number of requirements have been made on how these must be improved. This includes the recording of administrations, recording of dosages and verifying handwritten records by a second staff member. 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 DS0000002099.V304819.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.V304819.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 at least once during a 12 month period. 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 the service. Procedures were in place and implemented to ensure service users needs were assessed and information sought on service users needs prior to admission. EVIDENCE: A sample of three care files were examined. All of these had assessments completed by staff. Where admissions had been arranged as emergencies written information from Care Managers had been sought and was available in files. An admissions procedure was available which included the accepting of emergency admissions. The home does not offer intermediate care as defined by National Minimum Standards 6. Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Inconsistencies were evident in care plan recording which may adversely affect the care given to service users. Medications records revealed a range of areas where improvements are required to ensure safe administrative practice at all times. EVIDENCE: A sample of three service users care files were examined to assess how standards were being met. The care plans were usually written by nursing staff if service users were assessed as requiring nursing care and by Senior Care staff if assessed as needing personal care only. It was found on one occasion that the care plan had not been updated and reviewed by nurses when care needs had been reassessed. A format was in place for recording care which included a range of headers as prompters for staff. There was some inconsistency found in the quality of care plans with some being specific in how to deliver care and others not. There Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 10 were also inconsistencies in the frequency of reviews with some not being reviewed for above 6 months. The home has recently been registered to accept 3 service users with dementia. One care file examined did detail dementia as an identified need but not specific on how staff should deal with this and deliver care. Another care file noted mental health difficulties and dementia in the medical history but these were not recorded in the plan of care. Another care file recorded that a service user had experienced a cerebral vascular accident (stroke) but this was not specifically recorded in the plan of care on how this affected the service user and could have a bearing on how care was delivered by staff. The content was also inconsistent with actual practice at times with a care plan saying bed rails were not being used when discussion with the Manager after the inspection confirmed they were in place. The storage and administration of medicines was examined at his visit. A monitored dosage system is used at the home. Most medication administration records were typed, however some were handwritten where changes had occurred during the monthly cycle of the record. Some gaps were evident on the medication administration records where administration was prescribed with no records to evidence if the medication had been omitted. Not all handwritten entries had been signed, checked or verified by a second staff member. Where dosages had changed prescription instructions had been amended where a new instruction must be written. Where a variable dosage of a drug was prescribed the actual dosage administered was not being recorded therefore a detailed record of treatment was not being recorded. The drug trolley on the first floor was found being used to securely store a staff member’s purse this is not acceptable. On discussing the provision of secure storage for staff valuables it was confirmed that lockers were made available. Service user spoken to said that staff protected their dignity and one service user said they did not like being in the home in a dressing gown after showering and this was respected. At the time of inspection there were 5 out of 32 service users who had pressure areas. Discussions with staff revealed that whilst some of these had occurred outside of the home some had occurred within in. Feedback from one visiting professional relayed concerns that service users were not always cared for using appropriate equipment. Subsequent discussions were held after the inspection with the Free Nursing Care Assessor Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 11 who confirmed that they had provided the appropriate equipment required for the service user. Discussions with staff confirmed that some staff had completed training in tissue viability. It was stated that whilst the home could access specialist tissue viability advice this was not routinely done. In one care file a very high risk assessment score for tissue viability was evident. This tool had not reviewed since January 2006 and the care plan had not been reviewed since the same date despite external review of care being completed and the needs assessment being changed. Healthcare from GP’s was accessed from 8 local surgeries. A chiropodist visited the home regularly on a private basis. The services of a regular dentist and optician were in place but staff were aware that some service users chose to access different opticians and dentists of their own choosing. Some service users attended outpatient services including memory clinics. The services of the Speech and language therapist and physiotherapist were on an individual referral basis. Woodlands Nursing Home DS0000002099.V304819.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 at least once during a 12 month period. 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 the service. Service users are offered activities on a regular basis in the home with some periodic outings organised. EVIDENCE: An activities coordinator is employed at the home for four afternoons per week. A schedule of activities was displayed and the planned activity for the day, bingo was observed to take place albeit with few participants. A social assessment form was available to establish likes and dislikes of service users and document social history. Some visits out from the home were currently being organised. This included picnics, trips on a boat and to Bakewell. The home had access periodically to a minibus which was shared with other homes owned by the Provider. Staff spoken to said that some service users declined to take part in activities preferring their own company or own interests such as knitting or word searches. Service users were seen during the visit reading newspapers which they purchased for themselves. Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 13 A payphone was available in a small quiet lounge. This was found to be sited a eye level and was not suitable for wheelchair users to access independently. A library of books was available for service users to access in the quiet lounge. All service users spoken said that there was not a choice of meal available. Generally comments about the food and quality of the Cooks cooking were positive. Some service users dietary preferences were recorded within care files along with any known food allergies. Woodlands Nursing Home DS0000002099.V304819.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Complaints procedures were in place and records evident to demonstrate that complaints were appropriately investigated. Progress was being made to ensure staff had received safeguarding adults training and this was ongoing. EVIDENCE: No complaints have been received about the home at the Commission for Social Care Inspection. The complaints procedure was displayed in the entrance hall of the home. The pre inspection questionnaire indicated that one complaint had been received at the home. Records for this were examined. The complaint concerned the loss of property and the service user was reimbursed by the home after an investigation that was completed within the 28-day timescale. A safeguarding adults policy and procedure was available. This referred to making other agencies aware of allegations of abuse but did not specifically refer to locally agreed Social services procedures. Staff spoken to were conversant with the locally agreed procedures and gave examples of where this has been used in years past. Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 15 Training records available did not verify that all staff had received training on the Protection of vulnerable adults even though it was confirmed some staff had. This is an outstanding requirement from previous inspections and remains listed on this report. Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Aspects of the environment required some work to ensure they were safe for service users with dementia. EVIDENCE: The home is a purpose built one with 44 single bedrooms and 3 double rooms. A partial tour of the building was completed at this visit with all communal areas and the laundry being viewed. A garden area was available with some seating however this was not a secure area and was not found to suitable for service users who may wander. A risk was also evident as patio doors leading to the garden was open throughout the period of the visit. Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 17 Some signage was evident in the home to direct service users to lounges and names were on bedroom doors. A portable loop system was available to aid those service users who used a hearing aid. Aspects of the home were found to be un-homely. This included a vending machine in one dining room reportedly used mainly by staff and visitors. Staff certificates were also displayed on a different dining room wall. The furniture and carpets in the lounge are were beginning to show signs of wear/age and were somewhat tired looking in place with worn edgings.. The front door was found to be accessible by pressing a button which had the potential for service users who may be confused to leave the home without staff being aware of this. The wiring on the fire door was also loose which would render the alarm useless if a service user was to exit the door. The laundry area was viewed. The flooring in the laundry area was damaged in place. It was observed that 3 washers/dryers were out of order. This was discussed with the Manager after the inspection who stated that the capacity of working appliances met the needs of the 32 service users currently in the home. The home was generally found to be clean with no unpleasant odours present. Staff were observed to have access to gloves and aprons and were viewed using them for personal care and the serving of meals. Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There was poor recruitment practice evident and poor recording of staff training which may potentially put service users at risk. EVIDENCE: The occupancy of the home on the day of the visit was 32 service users. 18 service users required nursing care, 14 service users required personal care only. The typical staffing levels at the home were 1 nurse on duty for all shifts with 5 care staff for morning shifts, 3 care staff in the afternoons. The activities coordinator also worked 4 afternoons per week. Additional staff employed included a receptionist, administrator and a handyman. At nights there was one qualified nurse and 2 care staff. From the pre inspection questionnaire there were 16 care staff employed at the home of which 10 held NVQ (National Vocational Qualification) level 2 in care qualifications. A sample of staff personnel files were examined this included recently recruited staff who had begun work at the home. The files examined indicated that staff had been confirmed in post and started work without references being in place, Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 19 Criminal Records Bureau checks being obtained and proof of identity being verified. Two Protection of Vulnerable Adults First checks were seen however both of these were dated after the date of employment commencing. Training records viewed were inconsistently and poorly maintained. Some forms were blank and some had not been updated since 2003/4. It was not possible to ascertain clearly who had completed what training when. As the Manager was not on duty this was discussed with them by telephone the day after the inspection. The Manager said they were in the process of updating training records. A skills based induction package was available however viewed examples were not completed. Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is stable management at the home with views from service users being sought. There was a lack of development of services for service uses with dementia, as there were aspects relating to health and safety and care planning that may potentially adverse the health and welfare of service users. EVIDENCE: The Manager was not on duty at the time of the inspection. Verbal feedback was given by telephone the day after the inspection. Staff on duty at the home aid the Manager was currently in the process of completing a managerial qualification. The Manager had been employed at the home since 1997 according to staff on duty. Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 21 A valid public liability certificate was on display in the entrance hallway. Records for establishing financial liability were not requested at this visit. The Manager was not on duty during the visit and some staff on duty were not fully conversant with the quality assurance systems. Visits were being recorded on a monthly basis on the Providers behalf. Whilst these detailed that some records had been viewed and discussions held with service users the contents of the forms were generally brief. A quality assurance survey was in the process of being completed. Some completed forms were viewed but the findings had not yet been collated. Staff meeting minutes revealed an irregular approach to staff consultation/communication. The last meeting held was in November 2005. Staff spoken to said that there was no meetings held for service users/relatives. Generally service users spoke positively of the staff at the home. Some monies are stored safely in the home on service users behalf. Records of these were examined. Some monies are held in a safe in cash and some monies were held within a service users bank account in the homes name. The financial records in the home did not correctly record what proportion of monies was held in the home and what proportion in the bank. This amount was recorded but on a post it note and not on the main record. Whilst the main care files were stored securely some records relating to individual service users were being openly at the nurses station. On one occasion during the inspection a care file was openly left on top of the nurses station with no staff being around. The method of recording some information was also inconsistent with data protection principles as information on a range of individuals was recorded within one record. Personal information on service users care needs was also displayed on the dining room wall breaching the confidentiality of service users. Information taken from the Pre Inspection Questionnaire confirmed that all service checks were in date this included fire equipment, hoists, lift, gas and electrical checks. The handyman checked the water temperatures of the boiler but evidence of routine checks of temperatures at sinks and bathing outlets could not be located. It was observed at the visit that the Bain Marie food-serving unit in the dining room was hot with the serving dishes removed and extremely hot water exposed. An accident of scalding of staff or service user was possible. Discussions were held with staff to establish if the use of this equipment had been risk assessed, no information could be located to evidence that it had. Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 22 A number of areas in the home were marked with signs to say that doors should be locked when not in use. This included the plant room for the lift and a storage area. these were found to be open with no staff being in the vicinity. In one of these areas chemical cleansers were viewed. Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 2 3 x 2 2 Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Care plans must be drawn up and descriptive of all service users assessed needs and how staff are to deliver care to service users All care plans must be reviewed and updated to reflect changing needs Where assessed risks and needs are identified these must be supported by a plan of care to describe how needs are to be met Where medications are prescribed on a regular basis these must be administered or a record maintained of the reason for omissions A record must be kept of the dose of medication administered to a service user where a variable dose is possible. Where a prescription for a medication is changed a new box must be written on the medication administration record and verified by a second staff member The registered manager must DS0000002099.V304819.R01.S.doc Timescale for action 30/10/06 2 3 OP7 OP7 15 15 30/10/06 30/09/06 4 OP9 13,17, Schedule 3 13,17, Schedule 3 13,17, Schedule 3 30/09/06 5 OP9 30/09/06 6 OP9 30/09/06 7 OP18 13(6) 31/12/06 Page 25 Woodlands Nursing Home Version 5.2 ensure that all staff receives training on the protection of vulnerable adults. Previous timescale 31/05/06 This has been partially met as it was confirmed that some but not all staff have received training 8 OP30 18 Training records must be available to evidence that staff are receiving all mandatory/role specific training and are fully supported to undertake the role for which they are employed A skills based induction package must be implemented for each new staff member There must be development of the service provided to ensure the needs of service users are met and their health and safety are protected at all times The home must ensure robust recruitment procedures are adhered to which includes all the checks as required by Schedule 2 being completed prior to staff commencing employment All records containing personal data must be held securely in accordance with the Data Protection Act 1998 The use of the Bain Marie must be risk assessed and any identified action to prevent the risk of burns and scalding must be implemented Where area areas in the home are identified as requiring to be locked for health and safety reasons this must be implemented to safeguard service users Chemical cleansers must not be in areas which are potentially accessible by service users DS0000002099.V304819.R01.S.doc 30/10/06 9 10 OP30 OP33 18 12 30/10/06 30/10/06 11 OP34 19 30/10/06 12 OP37 17 30/09/06 13 OP38 13 30/09/06 14 OP38 13 30/09/06 15 OP38 13 30/09/06 Woodlands Nursing Home Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations Where entries on the medication administration record are handwritten these must be checked and verified by a second staff member The storage areas for medications should not be used for any other purpose The registered manager should ensure that care staff maintain all mandatory training within required timescales. Service users financial records must record accurately where and how monies are stored i.e. cash/bank All records in the home for individual service users should be held separately according to data protection legislation Water temperatures of all water outlets particularly ones where full body immersion is possible should be checked regularly 2 3 4 5 6 OP9 OP27 OP35 OP37 OP38 Woodlands Nursing Home DS0000002099.V304819.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 DS0000002099.V304819.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!