Inspection on 29/04/05 for Woodlands Nursing Home

This inspection was carried out on 29th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodlands Nursing Home 31/03/08

Woodlands Nursing Home 18/09/07

Woodlands Nursing Home 01/05/07

Woodlands Nursing Home 02/11/06

Woodlands Nursing Home 31/05/06

Woodlands Nursing Home 19/10/05

Woodlands Nursing Home 10/02/05

Woodlands Nursing Home 17/09/04

Woodlands Nursing Home 08/04/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Sands Lane Mirfield West Yorkshire WF14 8HJ Lead Inspector Sally McSharry Unannounced 29 April 2005 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 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 J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodlands Nursing Home Address Sands Lane Mirfield West Yorkshire WF14 8HJ 01924 491570 01924 491377 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Speciality Care (REIT Homes) Ltd Proposed manager Angela Gillard Care home with nursing 87 Category(ies) of 87 Dementia over 65 years, 87 Mental disorder registration, with number over 65 years of places Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 10 February 2005 Brief Description of the Service: Woodlands Nursing Home provides nursing and personal care and accommodation for up to 87 older people who suffer from dementia type illnesses and mental disorders. Woodlands is a large, brick built home set within 47 acres of ancient woodland. The home is devided into 4 units, over two floors. Access to the first floor is gained via a passenger lift. The home provides single and double room accomodation. Some rooms have en-suite facilities, some rooms have a small cubicle within the room which is fitted with louvre doors which 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 J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced visit carried out on the 29th of April 2005. Four inspectors visited the home and focussed on a small number of National Minimum Standards relating to life in the home for the service users. The inspectors spoke to some service users and staff. The inspectors also audited a selection of care records, medication records and accident forms. Staff training records were also provided by Mrs Gillard the proposed manager. Woodlands has experienced fluctuating standards of care. Although the management of the company respond to requirements and recommendations made in inspection reports and standards improve short-term, the improvements made have not sustained long-term in the past. The last inspection took place on the 10/02/05 and identified short falls in care. The responsible individual and proposed manager are aware of shortfalls in the standard of care delivered and some action has been taken to address this, such as training and the recruitment of senior staff. Unfortunately the effects of these actions were not fully evident in the home at this visit. At the time of this visit inspectors issued three immediate requirement letters relating to care planning, the management of medications and the management of an identified risk. The CSCI continue to monitor the home and will consider enforcement action. What the service does well: What has improved since the last inspection? Since the last inspection there have been some improvements noted in the way staff, particularly on Hopton unit, interact with service users. Staff also skilfully managed an incident in which a service user became quite agitated and in accordance with the individual’s care plan. There was also some Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 6 evidence of some relatives working well with the home’s staff to meet one service user’s needs and maintain links with his family. The standard and choice of meals have improved. Attention has been given to mealtimes and staff were seen sitting and assisting service users sympathetically. What they could do better: The information provided about the home is confusing and inaccurate and it would be difficult for prospective service users or their representatives to decipher the information provided and make sense of it. Service users’ care plans are poor and fail to advise staff how to meet all the service users’ health and welfare needs whilst in the home. Staff continue to fail to act upon some risk assessments and care plan directions, therefore the health and safety of service users is being put at risk. The standard and consistency of care delivered from day to day is unpredictable and depends on the verbal information passed from one member of staff to another. Medications are not always managed appropriately and there are indications that service users are not always receiving the medications as prescribed by the GP. Staff are failing to fully respect and maintain some service users’ privacy and dignity and there was evidence during this visit of institutionalised and undignified practice; staff are failing to recognise this. Some activities are being offered in the home, but these are inadequate for the number and needs of service users. Some staff are unaware of how service users with dementia can be offered choices in their daily living in the home and this indicates a lack of training in dementia care and has a direct impact on the quality of care service users are receiving on a daily basis. The manager needs to demonstrate clearly that any complaints made in the home are fully investigated and appropriate action taken. Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 7 The responsible individual and staff at the home are currently failing to ensure service users are protected from harm or potential abuse. The inspectors feel there is a lack of skilled, trained staff at the home to ensure service users’ needs are met and safety maintained. Some areas of the home could be cleaner. Health and safety issues were identified at this inspection and these need to addressed to help maintain service users’ and staff safety. At the moment the organisation has voluntarily stopped admissions to the home until both the responsible individual and the CSCI feel adequate improvement has been made. Some improvements were noted, however, the CSCI may consider further enforcement action to ensure improvements are made throughout the home and sustained. 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 J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 9 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 standard(s) 1 and 3. It would be difficult for a service user or his relatives to make an informed choice about the home from the information provided in the statement of purpose. The inspectors were not confident that once admitted to the home all the service user’s care needs would be met. Intermediate care is not provided at the home. EVIDENCE: The statement of purpose was available during this inspection. Information held was very detailed and could be confusing for prospective service users and their representatives. Some information was inaccurate and incorrect; the complaints policy referred to an employee who no longer works for the organisation and to the NCSC, which no longer exists. Pre-admission assessments are carried out or obtained prior to service users being admitted to the home. The assessment is obtained to help the home make a decision as to whether they are able to meet the needs of the prospective service user; despite this the inspectors continued to have Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 10 concerns that some service users in the home are not having their health and welfare needs fully met at Woodlands. Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 11 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 standard(s) 7,8,9 and 10. Service users’ plans fail to fully meet all the health and welfare needs of service users. Staff at the home are failing to provide all the care required to meet all the health and welfare needs of the service users in the home; they are failing to respond appropriately to identified risks and care needs. There are unsafe practices being carried out in the home relating to the recording, administration and storage of medications. Staff are failing to maintain the privacy and dignity of some service users in the home. There is evidence of institutionalised practice and that staff have a lack of awareness about good practice and avoiding institutional practice. EVIDENCE: Staff have worked on care plans and received some care planning training since the last inspection. Service user plans were looked at on each unit. The inspectors found that two plans for service users with diabetes failed to clearly identify how their diabetes was to be managed in the home. One of the service users had recently returned from hospital, this service user’s care plan and assessments had not been up dated to reflect the changes in the service user’s condition. Some new care plans had been developed but old care plans had not been Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 12 removed therefore there were two care plans in place providing conflicting information. The staff on duty at the time of this inspection did not have a clear or consistent idea how the service user’s diabetes was being managed. Another service user’s care plan stated that the service user was to have regular optical and foot care. There was no evidence to show that since admission to the home over three months earlier that any arrangements had been made for this service user to receive such care. The care plan of a service user from an ethnic minority failed to reflect communication difficulties or take into account any ethnic and cultural differences at all. Several service users had been assessed in relation to their nutritional needs. The assessment used indicated that there were some risks of poor nutrition and the assessment score indicated a care plan should be developed to manage the risk of poor nutrition. No care plan had been developed. Other more specific risks relating to individual service users had not been assessed or a plan produced for the management of these risks. One service user’s care plan was very specific in that it said that if the service user’s blood sugar level rose above a certain level, a GP should be contacted. Records showed that this service user’s blood sugar level had reached that level or had been above the level stated on several occasions; the GP had not been contacted. Daily records are often vague and do not actually reflect the care that has been given or evidence that the care detailed in the care plan has been delivered; for example where a care plan indicates that a service user should have a bath at least twice a week, daily records stated “ hygiene needs fully attended” therefore it was not possible to assess whether care had been delivered as planned. Medications are not being managed to an acceptable level in the home. The stock balance from one month had not been carried over to the next; therefore some medications could not be audited. Some medications were audited and it was found that there were too many tablets left. This indicates that staff are either signing to say they have given medications when they have not or that where the GP has prescribed two tablets staff are only giving one. One service user was prescribed medication at night, however the medication sheet stated none had been dispensed this month, staff were recording the drug as being out of stock. This is not acceptable. Medication administration sheets had been amended by hand. The amendment to the doses of medications had not been dated or signed. This is unsafe practice. Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 13 There was little evidence to show that service users’ privacy and dignity is actively being maintained in the home. The inspectors commented on the use of plastic nursing aprons as they are being used to protect service users’ clothes at meal times. It is accepted that some service users may need to wear an apron to protect their clothes while they have their meals, however it is not acceptable for all service users to wear plastic aprons as seen on this inspection. Some relatively independent service users put aprons on themselves; this is learnt institutionalised practice and staff must have awareness of this and help prevent this erosion of dignity occurring. In relation to staff promoting the respect and dignity of service uses, on the Calder unit pop music was playing. Two service users complained that this was too loud and it was evident that they had had no choice in what they were listening to. Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 14 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 standard(s) 12,13,14 and 15. Some service users are receiving some social activities and maintaining good contact with their families and friends with limited contact with in the community. Some service users are able and allowed to exercise choice and control over their lives; however this is not taking place throughout the home and on all units. The standard and choice offered at meal times has improved and staff are assisting service users with their meals appropriately. EVIDENCE: Inspectors observed some positive care on Hopton unit during this visit. There was good interaction between staff and service users. Staff chatted to service users and were attentive to service users’ needs. One service user asked for assistance with personal care needs and staff responded appropriately. During the inspection visit one service user became quite agitated. Staff on Hopton Unit were able to divert the service user and offered to take the service user out for a drive. This action corresponded with the written advice in the service user’s care plan. One service user’s family had liaised with staff and the service user themselves to provide information as to when the family would be next visiting the home. Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 15 A large notice board had been placed in the service user’s bedroom to inform the service user of visits, in order to reduce worry and agitation. There was also good evidence that this service user’s likes, preferences and hobbies were respected and accommodated in the home, in that his room had been personalised. The service user enjoyed spending time in his room surrounded by photographs and other personal items, however this approach is not consistent throughout the home. Less positive activities and interaction was seen else where in the home. On Calder Unit one service user’s care plan states that staff should make sure that the service user is occupied and aware of social activities. There was only one day in the last four months that staff have recorded that the service user has participated in specific activities. The social needs and preferences of this service user are not being met. The care records of service users on Thornhill unit showed little evidence of social activities taking place. However there was an aromatherapist visiting the unit at the time of the inspection. It was reported by staff that the home has one activities organiser and that a second is to be employed. Staff on Mirfield unit were attentive to the service users and were talking to service users in a relaxed manner. Staff on this unit were unsure how they offered choice to the service users and felt that this was not possible due to the degree of dementia the service users on this unit have. This highlights a training need for the staff as choice and preferences can be offered to the most profoundly disabled or ill service users. Menus at the home indicated that choice is available at most mealtimes and this was also evident at the time of the inspection. The chef visits the units and helps serve some of the meals; this enables him to receive feed back from service users. The chef confirmed that diabetic meals are provided and that specialist diets are prepared. The inspectors observed lunch being served on Thornhill unit. Staff were sat with service users and were assisting service users in a sympathetic manner. The staff on Mirfield unit ensured service users were offered and assisted with cups of tea or juice in the afternoon. Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 16 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 standard(s) 16,and 18. The inspectors could not be confident that complaints raised by service users and their relatives are being acted upon appropriately as there is no evidence that this is occurring in the home. The inspectors are not confident that service users are being protected from abuse or harm in the home. EVIDENCE: The complaints procedure displayed in the home and included in the home’s statement of purpose refers to complainants contacting a member of Craegmoor staff. This member of staff no longer works for the organisation. The procedure also refers to the National Care Standards Commission and not the Commission for Social Care Inspection. Since October 2004 CSCI has received six complaints about the service, one remains outstanding. Mrs Gillard reported that there have been no complaints made to the home since the last inspection on the 10/02/05. The record of complaints made to the home prior to the 10/02/05 is unclear. It records the complaint made but does not clearly record the investigation carried out, what the findings of the investigation were, what action was taken and whether the matter was resolved for the complainant. These detailed records must be maintained. The National Minimum standards state that the registered person should ensure that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 17 inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. At this visit the inspectors felt strongly that the staff at the home are not protecting service users against harm or abuse sufficiently. On one unit, of the twenty-eight accident reports recorded between the 20/02/05 and 27/04/05, nineteen of those accidents were to report bruising, with the cause unknown. Injuries may be accidental and result from poor movement and handling techniques, nevertheless service users are sustaining bruising and staff are recording they cannot account for this. This is totally unacceptable. Service users’ care records reported that all toiletries and hazardous products should be locked away. The inspectors found toiletries and razors stored in unlocked cupboards in communal bathrooms. Cabinets must be locked or the items removed. Care records also stated that all service users’ bedrooms were to be kept locked when service users were not in their rooms, so as to promote the privacy and dignity of the service user and safeguard their personal belongings, also to guard against the risk of other service users wandering in and having access to items that might be unsafe for them. One bedroom door on Calder Unit was open and the room contained potentially hazardous products. One service user’s care plan stated that a member of staff must always be in the lounge to observe the service user’s behaviour. This was not the case during this visit. These short falls put service users at risk of injury or accident and are not acceptable. Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 18 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 standard(s) 26. Some but not all areas of the home are clean. EVIDENCE: This inspection did not focus upon the environment of the home particularly. However the inspectors noted that there were some dried faeces on some of the walls on Calder unit and that the corridor area on Thornhill unit smelled stale. Bathrooms and some light fittings on Calder unit were dirty. General corridor areas, Hopton and Mirfield units were clean and tidy. Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27. Not all staff are skilled to care for service users with dementia. There is a lack of awareness of how to meet some of the needs of dementia clients and staff are not safeguarding service users from harm or abuse in the home. Staff are not aware of what constitues institutionalised or degrading practice. EVIDENCE: The poor standard of care planning, lack of insight into the care of service users with dementia and the poor level of protection against abuse, be it accidental or by act of omission by staff, shows that the registered person is failing to employ sufficient skilled and competent staff. Efforts have been made to employ skilled senior staff. One clinical manager has been appointed and a second promoted from within the home. Mrs Gillard advised that a third clinical manager has been appointed and is to commence work at the home shortly. Some staff training has taken place however issues still remain around the staff’s ability to write and maintain good care plans, to manage medications appropriately, to provide suitable care to service users with dementia, to move and handle service users safely, to protect service users from potential or actual abuse or harm and to recognise institutionalised and degrading practice. Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The health and welfare of service users and staff is not being adequately promoted or protected. EVIDENCE: Hazardous substances are not being securely stored. Toiletries and disposable razors were accessible in unlocked cabinets in communal bathrooms. Door closers require maintenance as the inspectors noted that some were closing quickly and there is a danger that service users will be knocked down by the door or have their fingers trapped. Action must be taken to ensure door closers work appropriately. The high level of bruising of unknown cause on one unit may indicate the staff are not moving and handling service users appropriately. Action must be taken to ensure that all service users are moved and handled safely. Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 3 COMPLAINTS AND PROTECTION x x x x x x x 2 STAFFING Standard No Score 27 1 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 1 x x x x x x x 1 Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4&5 Requirement 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 not met. The registered person shall.prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. Timescale of 30.04.05 not met. Unnecessary risks to the health or safety of service users are identified and so far as possible eliminated.Timescale of 30.04.05 not met. Accurate records of all medications must be maintained.Time scale of 30.04.05 not met The registered person shall make suitable arrangements to ensure that the care home is conductedin a manner which respects the privacy and dignity of service J51J01_s1100_Woodlands_v220526_290405.doc Timescale for action 01.07.05 2. 7 15 16.05.05 3. 8 13 09.05.05 4. 9 13 16.05.05 5. 10 12 01.07.05 Woodlands Nursing Home Version 1.30 Page 23 users. 6. 14 12 The registered person shall so far as practicable enable service users to make decisions with respect to the care they receive and their health and welfare. Complaints must be fully investigated and a full record of the investigation made, including any action taken and the outcome. The registered person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users-ensure that at all times suitably qualified competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users; Toiletries must be stored safely. Time scale of 10.02.05 not met. Door closers must be maintained to ensure they are closing appropriately. The registered person shall make suitable arrangements to provide a safe system for the moving and handling of service users. 01.07.05 7. 16 22 01.07.05 8. 18 13 09.05.05 9. 27 18 16.05.05 10. 13 38 09.05.05 11. 13 38 01.06.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 24 1. 3 2. 3. 4. 7 12 26 Service users should not be admitted to the home unless the registered manager is sure the staff at the home have the skills and training needed to meet all the service users health and welfare needs. Daily records should accurately reflect the care provided each day and any outcomes to that care. The provision of activities in the home should be increased to meet the needs and number of service users. All parts of the home should be clean and free from odours. Woodlands Nursing Home J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 Page 25 Commission for Social Care Inspection 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 J51J01_s1100_Woodlands_v220526_290405.doc Version 1.30 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. 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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