Inspection on 21/12/06 for Woodlands Nursing Home

This inspection was carried out on 21st December 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.

Other inspections for this house

Woodlands Nursing Home 16/11/07

Woodlands Nursing Home 14/02/06

Woodlands Nursing Home 21/09/05

Woodlands Nursing Home 01/03/05

Woodlands Nursing Home 10/09/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Gordon Road Ilford Essex IG1 1SN Lead Inspector Ms Gwen Lording Key Unannounced Inspection 21st December 2006 09:45 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 DS0000025966.V325078.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. DS0000025966.V325078.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Nursing Home Address Gordon Road Ilford Essex IG1 1SN 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) 0208 553 2841 0208 553 2946 Woodlands Total Care Nursing Home Limited Usha Patel Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places DS0000025966.V325078.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 Brief Description of the Service: Woodlands Nursing Home is registered to provide nursing care for up to 30 people over the age of sixty-five years. The large converted property is situated in a residential area of Ilford in the London Borough of Redbridge. There are good transport links and the home is close to shops and other amenities and community facilities. The majority of the rooms are single and some have en suite facilities. The bedrooms are located on three levels with access by lift to all floors. The home is able to accommodate people from different cultural and religious groups. The manager and some of the staff team have the ability to speak a variety of languages, and key words are taught to staff to facilitate care for residents whose first language is not English. The home is able to meet the cultural dietary needs of all residents. The home employs an activity co-ordinator, catering, laundry, domestic and maintenance staff. On the day of the inspection the range of fees for the home was between £545.00 and £560.00 per week. Copies of the home’s Statement of Purpose, service user guide and most recent inspection report are available in the main entrance hall, together with other information about the home. In addition there is a copy of the service user guide in each bedroom. DS0000025966.V325078.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 inspection undertaken by the lead inspector, Gwen Lording. It started at 9.30am and took place over four and a half hours. The registered manager was available throughout the visit to aid the inspection process. This was a key inspection visit in the inspection programme for 2006/2007. Discussion took place with the manager; senior nurse on duty and care staff; the cook, laundry and domestic staff. Nursing and care staff were asked about the care that residents receive, and were also observed carrying out their duties. The inspector spoke to a number of residents and visiting relatives/ friends. Where possible residents were asked to give their views on the service and their experience of living in the home. A tour of the premises, including the kitchen and laundry was undertaken. A random sample of residents files were case tracked, together with examination of other staff and home records, including medication, accident/ incident records and staff recruitment procedures and files. Information was also taken from a pre-inspection questionnaire, which was completed by the manager. At the end of the visit the inspector was able to feedback to the manager. The inspector would like to thank the staff, residents and visitors for their input and assistance during the inspection. What the service does well: There is a very relaxed atmosphere in the home and residents receive good care from a committed staff team who have the skills and training to meet their needs. It is evident that the home is operated for the benefit of the residents and the attitude and practice of the staff promote opportunities for residents to remain independent, exercise choice and express their wishes and needs. During the inspection staff were seen to be providing good personal care and all residents appeared clean and well groomed. DS0000025966.V325078.R01.S.doc Version 5.2 Page 6 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. DS0000025966.V325078.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 DS0000025966.V325078.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): Standards 1, 3 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive assessments are being undertaken for all residents prior to them moving into the home. Care plans are drawn up for the information in this assessment, ensuring that the needs of the residents are identified, understood and met. The home does not offer intermediate care. EVIDENCE: Individual records are kept for each resident and a random sample of four files were examined. All records inspected have assessment information recorded and the information had been used to continue assessment following admission to the home, and develop written care plans. The records showed that residents, were capable and their relatives/ representatives are involved in the assessment process. Where appropriate information provided by the placing authority was also on file. DS0000025966.V325078.R01.S.doc Version 5.2 Page 9 Through discussion with the manager it was evident that prospective residents and their relatives are given a copy of the Statement of Purpose, service user guide and other useful information is made available to them. There is always the opportunity to visit the home prior to making any decision to move in. The Care Homes Regulations 2001 have been amended with effect from 1st September 2006, for new residents, and for existing residents with effect from the 1st October 2006, so that more comprehensive information is to be included in the service user guide. Details of information to be included are contained within the amended regulations. Therefore, the service user guide must be reviewed and amended by the stated timescales. DS0000025966.V325078.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): Standards 7, 8, 9, 10, 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are set out in individual care plans and provide staff with the information they need to satisfactorily identify and meet residents’ needs. Residents are treated with respect and the arrangements for their personal care ensure that their right to privacy is upheld. All residents could be assured that at the time of their death, staff would treat them with care, sensitivity and respect. EVIDENCE: A significant improvement was noted in the standard of care planning since the last inspection. A total of four residents were case tracked and their care plans and related documentation inspected. All residents had comprehensive care DS0000025966.V325078.R01.S.doc Version 5.2 Page 11 plans, which covered health and personal care needs, including control of infection and care of indwelling catheters. There was evidence that care plans were being reviewed on a monthly basis and updated to reflect changing needs. All residents have an individual ‘night care plan, and are detailed to the degree of identifying specific preferences, such as times for getting up/ going to bed; night light to be left on; curtains not to be drawn at night. Particularly of note was the detail of care plans relating to residents who have specific religious or cultural needs and for staff to be able to understand and assist with the communication of the individual’s needs. As far as possible, residents’ and/ or their relatives are involved in the drawing up of their care plan. The documentation/ health records relating to wound management; the management of a resident with diabetes; and a recently admitted resident, were examined. These records were found to be detailed and being adequately maintained. Risk assessments are routinely undertaken for all residents around nutrition, manual handling, continence, falls and pressure sore prevention; and reviewed on a regular basis. Records examined showed that residents are seen by other health professionals such as GP; tissue viability nurse; optical, dental and chiropody services. Weights are monitored monthly, or more frequently were indicated and a record is maintained, including weight gain or loss. It was noted that some staff are recording in metric weight and others in imperial weight. It is strongly recommended that there is a consistent use of one weight measurement. Fluid/ food intake charts are maintained where necessary however, staff must record the amount of food intake as well as the type of food. On one chart staff entries included “porridge, soup, sandwich”. The amount of food taken by the resident must be clearly recorded for example, two tablespoons; large bowl; size and number of sandwiches. This detail of recording will ensure that an accurate record is being maintained of nutrition. There was no evidence of ‘End of Life’ care plans and the importance of developing these was discussed with the manager. However, from discussions with staff, and the inspectors knowledge of the home it was evident that staff dealt with a person’s dying and death in a sensitive and understanding manner, both for the individual and their relatives. Staff in the home routinely support relatives following the death of a resident. The registered manager has expressed an interest in implementing the Liverpool Care Pathway (LCP) for the Dying Patient and has recently met with the co-ordinator for the North East London Cancer Network. This transfers the hospice model of care into other care settings and has been effectively used in care homes. Staff talked about and were observed to treat residents in a respectful and sensitive manner. They were seen to be very gentle when undertaking moving and handling tasks and offered explanation and reassurance throughout the activity. During a tour of the premises it was noted that many of the bedrooms overlooked public areas such as a school, neighbours gardens and the main road, but had no net curtains or blinds at the windows, only the heavy curtains. In view of this it is essential that the privacy and dignity of residents DS0000025966.V325078.R01.S.doc Version 5.2 Page 12 be assured and that staff ascertain individual’s preferences regarding the provision of either net curtains or blinds to the bedroom windows, or to remain as they are. However, throughout the visit staff were observed to be closing the curtains in bedrooms prior to the provision of personal care to residents. There are clear medication policies and procedures for staff to follow. Discussions with staff and the review of medication records show that staff are following policies and procedures, so as to ensure that residents are safeguarded with regard to medication. Where oxygen is in use in bedrooms a warning sign must be displayed on the door to indicate as such. Several residents and visiting relatives/ friends were asked about the care in the home. Comments included: “Kind and friendly staff. I am very happy here”………..” We looked at other homes but warmed to the atmosphere here straight away. They provide top quality care”…..”Plenty of staff and they are always in attendance” DS0000025966.V325078.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The lifestyle within the home matches the expectations and preferences of residents. The attitude and practice of the staff working in the home, promotes opportunities for residents to remain independent, exercise choice and express their wishes and needs. EVIDENCE: There is a part time activity co-ordinator who works three days a week. There is a general programme of activities available for all residents and regular visits by professional entertainers. There is a variety of small and large group activities and the activity co-ordinator takes into account the needs, preferences and capabilities of all residents in the home by arranging activities suited to individual’s interests. On the day of the visit there was carol singing by the local church, which was well attended and clearly enjoyed by residents and their relatives/ friends. A group of four residents had recently been invited to the local high school’s Christmas concert and meal, which they were able to attend with support from staff. Relatives and friends are encouraged and welcomed to be involved in special events in the home, so that residents are able to maintain contact with them. DS0000025966.V325078.R01.S.doc Version 5.2 Page 14 The inspector observed members of staff allowing time for residents to express their wishes and supporting individuals to make choices in their daily lives, for example choosing a drink, were to sit, and choice of clothes and make up. A visit was made to the kitchen and the inspector discussed the storage, preparation of food and menus with the cook. The cook and assistant cook have worked in the home for a number of years and are very much aware of individual’s preferences. There is a separate Asian menu and a vegetarian option each day. The following was noted and discussed with the manager: • The tiled floor and walls require deep/ steam cleaning. When completed this must continue at regular intervals as the kitchen staff are only able to undertake superficial cleaning of these areas. The serving of the lunchtime was observed and was seen to provide residents with an appealing and nutritious meal. Staff were seen to offer assistance where necessary and this was done discreetly and individually. Pureed meals were presented in an attractive manner and residents who required assistance were not hurried. The cook/ assistant cook supervises the serving of the lunchtime meal and this enables them to supervise the provision of food to residents and receive any comments/ feedback. DS0000025966.V325078.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff make very effort to sort out problems and concerns and ensure that residents and their relatives feel confident that their complaints are listened to and will be acted upon. EVIDENCE: The home has a complaint policy/ procedure and the records indicate the number of complaints received and includes details of the investigation, any action taken and the outcome for the complainant. The complaint procedure is also produced in three Asian languages i.e. Gujarati, Punjabi and Hindi. At the last inspection a requirement was made around the home’s policy requiring all verbal complaints to be followed up in writing; and the capacity of some individuals to use such a formal process. The policy has now been amended accordingly and residents/ relatives can be confident that their complaints and concerns will be listened to and acted upon, regardless of how they are communicated. There is an in house training programme for all staff working in the home in adult protection/ abuse awareness. Those staff spoken to during the inspection were aware of the action to be taken if they had concerns about the safety and welfare of residents. DS0000025966.V325078.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 24 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The overall atmosphere in the home is very welcoming, but there are still a number of areas requiring refurbishment and general maintenance, so as to provide residents living in the home with a comfortable and well-maintained environment. The concerns around the refurbishment and general maintenance of the premises impacts upon the assessed judgement on this group of standards. A new passenger lift has recently been installed and has improved this facility for the benefit of residents, staff and visitors to the home. EVIDENCE: The building was toured, accompanied by the manager, at the start of the visit, and all areas of the home were visited unaccompanied, later during the day. Some bedrooms were seen either by invitation of the resident, whilst others DS0000025966.V325078.R01.S.doc Version 5.2 Page 17 were seen because the doors were open or being cleaned. There were no offensive odours and generally the home was clean and tidy. Most of the bedrooms seen were very personalised and were representative of the occupant’s interests, religion and culture. At previous inspections a number of areas in the home have been highlighted for action with regard to maintenance, refurbishment and re-decoration. Whilst some of these areas have been addressed the planned refurbishment programme for the home must be progressed, as this will greatly improve the environment for all current residents and any prospective residents. The following issues were noted for action and discussed with the manager: Ground Floor • The dining room on the ground floor was previously a bedroom. The room is bright, attractively furnished and provides a small, alternative dining room in which residents can chose to eat. However, the sink and vanity unit were not removed when the use of the room changed. This unfortunately spoils the overall appearance of the room. At a previous inspection a strong recommendation was made for the existing sink/ vanity unit to be removed and any damage to the décor made good. During this visit it was noted that the sink/ vanity unit had not been removed and staff were routinely using the sink for general hand washing and disposal of gloves/ aprons, not related to the purposes of the dining room. In light of this it is now a requirement that the sink/ vanity unit be removed and the décor made good. This will not only provide more effective infection control but provide more appropriate dining facilities overall. Both the disabled bathroom and toilet require re-decoration and the floor covering needs to be replaced. • Middle Floor • • • • • Room 213 – Waste bin requires replacing. Room 212 - Metal clinical waste bin is broken and requires replacement or repair. Room 211 - Chest of drawers noted to have broken drawer and handles. Requires replacement or repair. Room 207 - Window handle broken. Toilet adjacent to room 209 – Sign post on the door states that this is a disabled toilet, but this toilet has no disabled access. Sign to be removed. DS0000025966.V325078.R01.S.doc Version 5.2 Page 18 Top Floor • • • Room 301 (Toilet) - Plastic coating on the handrails peeling off and exposing metal beneath. Requires replacement or repair. Room 312 - Metal clinical waste bin is broken and requires replacement or repair. Room 310 - Blind covering ceiling window requires cleaning. Comments have been made earlier in this report regarding the deep/ steam cleaning of the kitchen tiles and floor. The laundry area was visited and soiled articles, clothing and foul linen were being appropriately stored, pending washing. However, the room is very small and cluttered and requires redecoration. Protective aprons and gloves were available and in use however, in line with health and safety legislation laundry personnel must also be provided with other items of Personnel Protective Equipment (PPE) such as goggles and masks. Hand washing facilities are prominently sited. In general staff were observed to be practising an adequate standard of hand hygiene, with the exception of staff inappropriately using hand-washing facilities in the dining room. This has been commented on earlier in this report with an accompanying requirement. Adaptations and equipment are in situ which are capable of meeting the needs of all residents. Call alarm systems are provided and were accessible and within reach of residents whilst in their rooms. During the tour of the building it was noted that some rooms have magnetic closures fitted and others do not. From discussion with the manager and records inspected there was evidence to show that an officer of the local London Fire and Emergency Planning Authority (LFEPA) had visited the home on the 6/11/06. The report was satisfactory and fitting of the remaining magnetic door closures is scheduled to take place early in the New Year. DS0000025966.V325078.R01.S.doc Version 5.2 Page 19 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): Standards 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are satisfactory and there is sufficient staff on duty to meet the individual assessed needs of the residents. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. Residents benefit from a committed staff team who have the skills and training to meet their needs. EVIDENCE: Staff rotas were inspected and the staffing levels and skill mix of qualified nurses and care staff was sufficient to meet the assessed nursing and personal care needs of residents. The home has a relatively stable staff team and effective team working was observed throughout the inspection. Staff interacted well, both with each other and residents. Care workers were being effectively deployed to ensure that residents choosing, or needing to remain in their bedrooms were being cared for appropriately. There has been only one member of staff recruited since the last inspection. The personnel file of this member of care staff was inspected. This was found to be in good order with necessary references, Criminal records Bureau (CRB) DS0000025966.V325078.R01.S.doc Version 5.2 Page 20 disclosure, and application forms duly completed. It was evident that recruitment procedures are robust and in accordance with regulation and in line with the organisations recruitment policies. In discussion with the manager and examination of training records it was evident that nurses and care staff have undertaken a wide variety of training. Staff had received training in essential areas such as moving and handling, fire safety and first aid. Staff have also received training specific to the care of individuals, for example care of the dying, wound care, rectal catheterisation and peg feeding. There is a programme of accredited training in dementia care for all staff. The pre-inspection questionnaire completed by the manager stated that 85 of care staff are qualified to NVQ level 2 or above. Four members of care staff have successfully qualified to NVQ level 3. This demonstrates a very positive commitment to training from both the organisation and the care staff. DS0000025966.V325078.R01.S.doc Version 5.2 Page 21 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): Standards 31, 32, 33, 35, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager of the home is a very experienced and well-qualified person and residents benefit as the home is run in their best interests. EVIDENCE: The registered manager has been in post for more than seven years, is a registered nurse and has the appropriate clinical and management qualifications. She is very resident focused, has a good understanding of their needs and works in partnership with their families. All staff spoken to throughout the visit, spoke very positively about how well supported and valued they felt by Mrs Patel. DS0000025966.V325078.R01.S.doc Version 5.2 Page 22 The responsible individual undertakes monthly regulation 26 visits to the home and a copy of the report is sent to the Commission. The report of such visits is recorded on a seven page pro-forma document. It has the potential to be a valuable tool in providing the Commission with comprehensive information about the quality of care being provided to people living in the home. However, the information recorded is very limited and does not provide the Commission with the level of detail required. Such monthly visits must be conducted so as to check on the quality of care being provided, ensuring that care is delivered in accordance with the individual care plans and wishes of residents; inspect the premises of the care home; its record of events. Currently the manager does not act as an appointed agent for any resident. Resident’s financial affairs are managed by their relatives/ representatives. The manager has responsibility for the personal allowances of a small number of residents and secure facilities are provided for their safekeeping, with records being maintained. A random check was undertaken of monies held on residents’ behalf and this concured with records being maintained. A wide range of records were looked at including fire safety, accident/ incident records, nurse call system, portable appliance testing (PAT); and hoist maintenance. These records were found to be up to date and accurate. The organisation employs a maintenance person who visits the home once a week or more regularly if required. However, the manager must ensure that there is a more effective system in place for staff to report items requiring repair or maintenance. DS0000025966.V325078.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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 11 3 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 3 2 3 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 3 DS0000025966.V325078.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 OP19 Regulation 23 Requirement The registered persons must ensure that all areas of the home are adequately maintained. (Timescale of 30/04/06 not met) The registered providers must ensure that there is an ongoing programme of renewal for the fabric and decoration of the premises, which includes timescales and areas highlighted for priority action. A copy of this written programme must be provided to the Commission by the stated timescale. (Timescale of 30/04/06 not met) 3. OP8 12 The registered persons must ensure that where food intake charts are being maintained, staff must record the amount as well as the type of food. For example, two tablespoons, large bowl, size and number of sandwiches. This detail of recording will ensure that an accurate record is being DS0000025966.V325078.R01.S.doc Timescale for action 31/03/07 2. OP19 23 31/03/07 21/12/06 Version 5.2 Page 25 maintained of nutrition. 4. OP9 13 The registered persons must ensure that where oxygen is in use in bedrooms, a warning sign must be displayed on the door to indicate its use. 21/12/06 5. OP10 12 (4) (a) As many of the bedrooms 31/01/07 overlook public areas, it is essential that the privacy and dignity of residents be assured, by the provision of either net curtains or blinds to the bedroom windows. The registered persons must make suitable arrangements for the deep/ steam cleaning of the floor and walls in the main kitchen. When completed this must continue at regular intervals. The registered persons must ensure that the hand basin/ vanity unit be removed from the dining room and the décor made good. The registered persons must ensure that both the disabled bathroom and toilet on the ground floor are re-decorated and the floor covering replaced. The registered persons must ensure that the reports of Regulation 26 visits are more comprehensive and include information about the quality of care being provided to people living in the home. 28/02/07 6. OP19 23 7. OP19 OP26 23 28/02/07 8. OP21 23 31/03/07 9. OP33 26 28/02/07 DS0000025966.V325078.R01.S.doc 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 OP8 Good Practice Recommendations It is strongly recommended that there is a consistent recording of one measurement of weight. i.e. either metric or imperial. DS0000025966.V325078.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 DS0000025966.V325078.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. 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