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Inspection on 31/05/06 for Woodlands Nursing Home

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

This inspection was carried out on 31st May 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

Staff from the home undertake assessments prior to admission to ensure that the service users` needs can be met. Care planning and records are now of a good standard. Staff have worked hard to obtain this standard.

What has improved since the last inspection?

Since the last main inspection in October 2005, the registered manager has left the home and a new acting manager has been appointed. The acting manager and the staff have worked hard to improve the care provided, improvements have been made and further work is planned. The returned questionnaires from both relatives and health care professionals noted the improvements and positive changes. The standard of care records has improved and these now provide staff with the information they need to care for the service users. Communications within the home and with relatives and health care professionals has also improved, although some returned questionnaires said this could still be a problem at times due to the use of some overseas for whom English is not their first language. The level of training is now good and staff are more confident and competent in their day-to-day work. Staff are more aware of service users` privacy and dignity and therefore work to maintain this when service users are unable. Movement and handling training and practice has improved. New movement and handling equipment has been purchased to promote good practice.

What the care home could do better:

Some areas of the home are poorly maintained and the cleanliness and facilities in some bathrooms must be improved. Health and safety awareness needs to be improved. Staff must act promptly to eliminate or reduce the risk of any identified danger, particularly relating to repairs to the building. Although the acting manager and staff have worked to address requirements and recommendations made in the last report, some requirements and recommendations have been carried forward into this report. These include issues relating to the management of unpleasant odours, which have been discussed at a recent relatives meeting held at the home. It was decided that the floor coverings in the corridor areas would be replaced,however this work has not been carried out due to a delay in the allocation of funding from the company. The management of service users` finances remains unsatisfactory. The company deals with finances centrally. The issues relating to up to date computerised records and the holding of money belonging to service users who are no longer at the home remains. These must be addressed by the company. Staff recruitment records continue to fail to meet the required level. Again this relates to staff recruitment checks, which are carried out centrally by the company. Evidence of the completed checks are not available on file as required. Activities are offered in the home, however the level and variety of activities offered should be increased to meet all service users` needs. The acting manager and staff at the home have begun to consider the equality and diversity issues for service users. This should be developed and evidenced in all areas of the home and service provided. Adult protection training has been provided to the majority of staff, however training must continue until all staff have received training and principles are well established in the home. Although the acting manager has been in post since the beginning of the year she has not applied to the Commission to become the registered manger. A registered manager application should be forwarded to the Commission. The provider has been asked if they will forward an action plan to the Commission for Social Care Inspection in order to address the outstanding issues.

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Sands Lane Mirfield West Yorkshire WF14 8HJ Lead Inspector Sally McSharry Key Inspection 31st May 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Nursing Home Address Sands Lane Mirfield West Yorkshire WF14 8HJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01924 491570 01924 497377 Woodlands.Mirfield@Craegmoor.co.uk Speciality Care (REIT Homes) Limited Position Vacant Care Home 87 Category(ies) of Dementia - over 65 years of age (87), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (87) Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 named persons under 65 years of age Date of last inspection 19th October 2005 Brief Description of the Service: Woodlands Nursing Home provides nursing, personal care and accommodation for up to 87 older people who suffer from dementia type illnesses and mental disorders. Woodlands is a large, brick built home set within 47 acres of woodland. The home is divided into 4 units, over two floors. Access to the first floor is gained via a passenger lift. The home provides single and double room accommodation. Some rooms have en-suite facilities; some rooms have a small cubicle, which is fitted with louvre doors, the cubicle contains a toilet. The home is in a secluded position, one mile from public transport but the home has a minibus available. Woodlands 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. The provider informed the Commission for Social Care Inspection on 10/05/06 that fees range from £344.79 to £542.00 per week. Additional charges include hairdressing, private chiropody, newspapers, special toiletries, tobacco and some clothing. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide. Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit carried out by four inspectors. The inspectors arrived at the home at 8:30 am and left the home at 4:20pm. Since the last main inspection carried out on the 19th October 2005 a further five additional visits have been carried out by the Commission for Social Care Inspection as there were some serious concerns about the standard of care and management of the home. A visit was also carried out to look into a complaint about the management of pressure care. During this visit the inspectors spoke to some of the service users, some of the staff and the home’s manager. The inspectors read care records, audited a sample of medications, reviewed staff recruitment and training records and carried out a brief tour of the building. Prior to the inspection twenty five service user questionnaires were sent to Woodlands Nursing Home to obtain service users’ views about living at the home. Six completed questionnaires were returned. Many of the service users in the home have dementia related illnesses and would not be able to complete a questionnaire. There were sixty five service users resident in the home on the day of this visit. Relative surveys were sent out to 25 of the service users’ relatives or friends. Questionnaires were sent to five GPs that attend the home. Eleven questionnaires were sent out to social workers and health professionals who attend the home. When the inspector wrote this report 50 of the relatives had returned completed questionnaires. One relative also spoke to one of the inspectors on the telephone. Three responses had been received from GPs, four from social workers and three from other health professionals. Other information used in the inspection process included notifications from the provider to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider, information about one complaints investigated by the provider and a pre inspection questionnaire completed by the provider and acting manager. The inspector would like to take this opportunity to thank everyone who participated in the inspection process. What the service does well: Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 6 Staff from the home undertake assessments prior to admission to ensure that the service users’ needs can be met. Care planning and records are now of a good standard. Staff have worked hard to obtain this standard. What has improved since the last inspection? What they could do better: Some areas of the home are poorly maintained and the cleanliness and facilities in some bathrooms must be improved. Health and safety awareness needs to be improved. Staff must act promptly to eliminate or reduce the risk of any identified danger, particularly relating to repairs to the building. Although the acting manager and staff have worked to address requirements and recommendations made in the last report, some requirements and recommendations have been carried forward into this report. These include issues relating to the management of unpleasant odours, which have been discussed at a recent relatives meeting held at the home. It was decided that the floor coverings in the corridor areas would be replaced, Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 7 however this work has not been carried out due to a delay in the allocation of funding from the company. The management of service users’ finances remains unsatisfactory. The company deals with finances centrally. The issues relating to up to date computerised records and the holding of money belonging to service users who are no longer at the home remains. These must be addressed by the company. Staff recruitment records continue to fail to meet the required level. Again this relates to staff recruitment checks, which are carried out centrally by the company. Evidence of the completed checks are not available on file as required. Activities are offered in the home, however the level and variety of activities offered should be increased to meet all service users’ needs. The acting manager and staff at the home have begun to consider the equality and diversity issues for service users. This should be developed and evidenced in all areas of the home and service provided. Adult protection training has been provided to the majority of staff, however training must continue until all staff have received training and principles are well established in the home. Although the acting manager has been in post since the beginning of the year she has not applied to the Commission to become the registered manger. A registered manager application should be forwarded to the Commission. The provider has been asked if they will forward an action plan to the Commission for Social Care Inspection in order to address the outstanding issues. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 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 the following standard(s): 3 No service user moves into the home with out having had their needs assessed and been assured their needs can be met. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users and relatives confirmed when spoken to and in questionnaires that they had information about the home before they came to live there and that their needs had been assessed. The sample of case records audited showed that service users admitted to the home recently had been assessed prior to admission. No service users were able to confirm that they had actively been involved in choosing the home, however relative questionnaires confirmed that most were able to visit the home before making the decision to place their relative. The home has admitted service users with a diverse range of needs and from a variety of cultural backgrounds. Woodlands Nursing Home DS0000001100.V298334.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Service users’ health, personal and social care needs are set out in an individual plan of care. Suitable risk assessments are carried out and are being monitored monthly. Service users are able to make decisions about their lives with the support of staff and relatives. Members of staff then respect those choices. Medications are being managed safely. Service users are treated with respect and their privacy and dignity is maintained by the staff in the home. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The standard of care planning has improved. Those care plans audited during this visit identified service users’ needs and how they are to be met by the staff in the home. Risk assessments are in place for the individual service users’. Care plans and risk assessments are reviewed at least monthly. Care plans include service users’ individual preferences, cultural and spiritual needs. Staff are beginning to consider service users’ differing cultures and diversity and are now added detail into care plans. Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 11 Where risk assessments have identified a health risk staff at the home seek specialist advice. Questionnaires returned by visiting health care professionals acknowledge an improvement in the over all care standards and the level of communication with staff. The daily record relates to the care plan and the actual care given each day and is of a good standard. The acting manager continues to audit the standard of care plans to ensure consistency. The medications management of seven service users’ were audited and found to be correct. There were no signature omissions and the standard of medications management has improved. Staff were observed caring for service users throughout the day of the visit. Staff were interacting with service users well. Service users appeared relaxed and comfortable with the staff. Service users were well dressed, clean and well presented. Staff were observed respecting service users’ privacy and dignity and offering service users choice and encouraging service users to maintain independence where able. Relative questionnaires acknowledged that there has been an improvement in the care provided in the home and that communication has improved. The staff are more competent and confident, however the manager should continue to monitor this as one responded said in the questionnaire that at the weekend when the manager is not in the home standards are sometimes not as good. Woodlands Nursing Home DS0000001100.V298334.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 and 15. Service users’ social, cultural, religious and recreational needs are not being fully met. Service users are helped to maintain contact with their families and the local community. Service users are able to exercise choice and control over their lives. Meals provided are varied, but more effort could be made to meet some service users’ cultural and diverse needs. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Some formal activities are offered in the home and there was clear written evidence to confirm this on Thornhill unit. However the activities should be available to all service users, be more varied and reflect the service users’ individual interests. Care staff responded to service users well and when one service user said they were bored a member of staff immediately offered to take the service user out for a walk. Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 13 The acting manager is making efforts to extend and vary the spiritual support provided in the home, to meet the diverse needs of the service users’. Staff are recruited from a varied cultural background and the home has made some efforts to provide facilities for staff to worship in, away form the work place. The acting manager is to look into providing similar facilities for service users. Service users are able to maintain contact with their family and the community, however the home is not ideally placed for anyone who does not have their own transport. Woodlands has a minibus and will collect visitors from Mirfield if prior arrangements have been made. There was evidence in care plans and during the visit to show that staff are offering service users choices within their daily life in the home. Staff were observed asking service users when they would like to get up in the morning, choices were offered at meal times and many service users opted for a cooked breakfast, during the morning. Meals are varied and service users said the lunch being served was nice. Questionnaires returned also said the food was all right. Meals were individually served and were hot. Any service user who did not like the main meal was offered an alternative. Staff assisted service users who have difficulty with eating, in a sensitive manner. Some service users were offered nourishing drinks and meal supplements. Dietary intake is recorded where there are concerns and the community dietician visits the home. Although alternatives are offered at meal times the homes menus should reflect the cultural diversity of service users’. Woodlands Nursing Home DS0000001100.V298334.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 and 18. Service users and their relatives and friends are confident to make complaints. Service users are protected from abuse. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The service users, returned questionnaires and a relative who spoke to one of the inspectors by phone confirmed that they are now confident to raise concerns and make complaints. The relative who spoke with the inspector confirmed that they had made a complaint and that the new acting manager had dealt with this appropriately. Since the last main inspection in October 2005, the provider has investigated a complaint. All but one element of this complaint was up held. The Commission also investigated a complaint about the management of a pressure ulcer. This complaint was also upheld. The home does not maintain a central record of complaints and a record of the action taken as a result of the complaint. This was discussed with the acting manager and it was recommended that a central record be maintained of complaints received, any investigation, the outcome and the actions taken. Since the inspection in October 2005 adult protection referrals have been made but these relate to service users on service user abuse. Fifty eight members of staff have received training about the protection of vulnerable adults. Ten members of staff have not attended training. Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 15 Members of staff interviewed by the inspectors at the time of the visit had a clear view of adult protection and the actions they would take if they had any concerns or suspicions that any service user was being abused. Training records showed that not all members of staff have received adult protection training. Adult protection training and monitoring of care practice must continue until all members of staff have received training and good practice is well established in the home. Woodlands Nursing Home DS0000001100.V298334.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 and 26. The home is not always safe, not all parts of the home are clean or free from unpleasant odours. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Woodlands is a large building. Some maintenance work has been done; some doors and windows have been replaced and some redecoration has taken place. Repairs have been carried out to the bathrooms. However in most bathrooms and toilets on Calder and Thornhill unit there are no curtains at the windows, some baths were not clean and some lounge and corridor areas were noted to have an unpleasant odour. Requirements and recommendations made in the last report regarding eliminating the unpleasant odour and cleaning bathrooms remains in this report. At 09:00 am some service users were sat in the lounge area on Thornhill unit. Staff had opened the windows to let fresh air in but it was cold. Staff had to be Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 17 prompted to turn radiators on. This was raised with the acting manager at the time of the site visit. Once again rubbish, dirty pads and gloves had been thrown out of the windows. The acting manager advised that staff clear the rubbish on a weekly basis. Rubbish around the exterior of the building should be collected daily. There was some good evidence that service users had personalised their rooms and a few service users have had their rooms decorated to their personal choice. The acting manager advised that there are plans to replace corridor carpeting in an effort to reduce odour problems. Quotes have been obtained to replace window frames and refurbish bathrooms, however the Company has not released the necessary funds to allow this. Therefore they will remain in this report as requirements and recommendations. Woodlands Nursing Home DS0000001100.V298334.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 and 30. Suitable numbers of staff are employed. The staff receive induction and foundation training. Staff recruitment policies and records do not protect service users. Staff competency levels are improving. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Current staffing levels are sufficient to meet the needs of current number service users. Service users, relative and staff confirmed that training and competency levels have increased. This has had a positive effect on the care provided to service users and to life in the home. Staff are feeling happier and more positive about working in the home, they feel more supported by the management and feel that there is a better staff team. They said they felt able to report issues or concerns to the acting manager and they were confident that she would address these. Staffing rotas and training records support these improvements. Feedback provided in four questionnaire from health professionals who visit the home acknowledge improvements in communication with the home and the competency of staff. A sample of recruitment records was audited. One did not have a CRB disclose on file. This is a problem that has been identified before and not addressed by Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 19 the company; as the CRB checks carried out for the staff from over seas are carried out centrally by Creagmoor and not at the home. This remains a requirement of this report. Staff are recruited from diverse and varied cultural backgrounds. There was evidence of induction and ongoing training. Staff members confirmed that training is available. NVQ training is progressing and there is currently 46 of care staff that have NVQ level 2 in care. Improvements in staffing levels and skills have been noted. This progress should continue and be monitored to ensure that, at all times, sufficiently skilled and competent staff are on duty. Woodlands Nursing Home DS0000001100.V298334.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, 35, 36 and 38. The home has a new acting manager. The home is run in the best interest of service users’. Service users’ financial interests are not being safe guarded. Staff are not formally supervised. The health, safety and welfare of service users and staff are not being fully protected. Quality in the outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Ms Palmer is the new acting manager at the home. She is a registered nurse and is working toward achieving the registered managers award. She has past Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 21 experience managing a care home. Ms Palmer is yet to submit an application to the Commission for Social Care Inspection to become the registered manager. Two returned questionnaires specifically mention Ms Palmer and her skills and abilities as a manager. The home is now operating a variety of quality assurance systems. The registered provider sends copies of the monthly management review reports to the Commission for Social Care Inspection, identifying issues that need to be addressed and the action to be taken. Regular service user and relatives meetings are held and service users and relatives said they found these useful. A system of quality auditing has been implemented in the home with positive effects seen, in care planning and staff performance. It was not possible to audit service users’ finances, as the records held on computer were out of date. The last entry was 31/12/05. Despite requirements made in the previous reports Craegmoor has failed to confirm that money held on behalf of service users now accrues interest or that the money found in the service user account belonging to service users who have passed away or are no longer resident at the home, has been returned. These issues remain requirements of this report. This is a matter dealt with centrally by the company and must be addressed by the company. There was clear evidence the acting manager is monitoring staff and their performance. At the time of the site visit the acting manager met with some staff to raise issues that she had identified, however individual supervision for staff is not taking place. During the visit significant health and safety risks were identified. On Thornhill unit some electrical wires had been left exposed. Staff had to be prompted by the inspectors to make sure the wires were covered and made safe. Staff must be alert and aware of dangers to themselves and service users and take appropriate action to reduce or eliminate the danger immediately. Regular fire safety checks are carried out and recorded. The acting manager advised that new fire doors have been fitted throughout the home and that work identified in West Yorkshire fire safety officers report has been completed. Water temperatures are monitored weekly. Movement and handling training has been provided to the majority of staff members this year. Staff confirmed this when interviewed. Poor movement and handling practice has been an issue on recent additional visits to the home and was mentioned in one questionnaire from a health professional visiting the home. Generally, on this occasion staff were seen to move and handle service Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 22 users appropriately. The manager has purchased new handling belts to help promote good practice. There are further training dates planned. Woodlands Nursing Home DS0000001100.V298334.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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 1 2 X 1 Woodlands Nursing Home DS0000001100.V298334.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 OP18 Regulation 13 Requirement Adult protection training and monitoring of care practice must continue until all members of staff have received training and good practice is well established in the home. The window frames that are in poor repair must be replaced. Timescale of 30/04/06 not met. The exterior of the home must be checked daily to ensure service users have not discarded incontinence aids and other items out of the window. Timescale of the 23/01/06 not met. Toilet and bathing facilities and practice in the home must be reviewed to ensure areas are clean, well maintained and adequately equipped. To ensure service users can be adequately bathed in pleasant and hygienic facilities with the risk of cross infection eliminated as far as possible. (Not assessed during the visit carried out on the 23.01.06) DS0000001100.V298334.R01.S.doc Timescale for action 31/07/06 2. 3. OP19 OP19 23 (2) 23 (2) 31/10/06 30/06/06 4. OP21 23 31/07/06 Woodlands Nursing Home Version 5.2 Page 25 5. OP29 19 6. OP35 17 Sch 4 (9) 7. OP38 12 & 13 Action must be taken to review 31/07/06 the current company recruitment practices and procedures, to ensure service users are adequately protected. Not all staff have a CRB result on file Timescale of 23/01/06 not met. As detailed in Regulation 17 and 31/07/06 schedule 4 (9) full details of the financial records for all service users for whom Craegmoor act as appointee must be up to date and available to enable the Commission for Social Care Inspection to audit the system. Timescale of 31/01/06 not met. The registered manager must 30/06/06 ensure so far as is reasonably practicable the health, safety and welfare of service users and staff. Timescale of 23/1/06 not met. Maintenance staff and care staff must be aware of health and safety dangers and act immediately to remove or reduce any identified hazard. Woodlands Nursing Home DS0000001100.V298334.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. 2. 3. 3. 4. 5. 6. 7 Refer to Standard OP12 OP15 OP16 OP19 OP21 OP26 OP31 OP36 Good Practice Recommendations Activities should be available to all service users, be more varied and reflect the service users individual interests. Although alternatives are offered at meal times the homes menus should reflect the cultural diversity of service users. A central record should be maintained of complaints received, any investigation and the actions taken. The redecoration programme should be continued and address all bedrooms and bathrooms. The toilet and bath facilities on Thornhill and Calder Unit should be maintained and thoroughly cleaned. All parts of the home should be free from unpleasant odours. The acting manager should submit an application to the Commission to become the registered manager for the service. Staff should receive formal supervision. Woodlands Nursing Home DS0000001100.V298334.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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