Inspection on 16/01/07 for Woodlands Nursing Home The

This inspection was carried out on 16th January 2007.

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 The 26/11/08

Woodlands Nursing Home The 27/11/07

Woodlands Nursing Home The 19/06/07

Woodlands Nursing Home The 29/08/06

Woodlands Nursing Home The 10/01/06

Woodlands Nursing Home The 04/08/05

Woodlands Nursing Home The 11/11/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home The 8-14 Primrose Valley Road Filey North Yorkshire YO14 9QR Lead Inspector Mrs Rosalind Sanderson Key Unannounced Inspection 16th January 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands Nursing Home The DS0000061590.V331771.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 The DS0000061590.V331771.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Nursing Home The Address 8-14 Primrose Valley Road Filey North Yorkshire YO14 9QR 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) 01723 513545 01723 513545 Hexon Limited Judith Anne Lucas Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th August 2006 Brief Description of the Service: The Woodlands is a large detached property set in secluded gardens approximately 2 miles from the seaside town of Filey and 8 miles from Bridlington. It is registered to provide personal and nursing care for up to 34 older people. The property is on three floors including ground floor and there are two passenger lifts providing level access to all areas. The building is separated into two wings, Oak wing and Chestnut wing. The majority of bedrooms provided are single with en suite facilities. Basic information about the home and what services are offered is provided in the homes Statement of Purpose. Prospective service users and their families are given a copy of this document when they express an interest to live at Woodlands. The charges made for the services provided at 16/1/07 were £389.00 per week plus the free nursing contribution. Additional charges are made for hairdressing (£7.50), chiropody (£14), toiletries and outings (various charges). Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Woodlands is owned by Hexon Limited and was registered with the Commission for Social Care Inspection in September 2004. The key inspection has used information from different sources to provide evidence. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the registered manager on a pre inspection questionnaire. Comment cards returned from 17 service users, 14 relatives, 7 staff, 2 GP’s and 3 care managers. A visit to the home carried out by two inspectors. A site visit was carried out by two inspectors and lasted for nine hours. Seven service users, three relatives and five staff were spoken with. Records relating to service users, staff and the management activities of the home were inspected. During the visit care practices were observed, where appropriate, and time was also spent watching the general activity within the home. This enabled the inspector to gain an insight of what life is like at Woodlands for the people that live there. The Registered Manager was available to assist throughout the day. What the service does well: What has improved since the last inspection? Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 6 Since the last inspection the manager has gained her Registered managers award. She has also become registered with the Commission for Social Care Inspection as registered manager of Woodlands. The Fire Safety Officer has confirmed that his previous requirements have now been met. There are more staff employed at the home so that service users needs are able to be attended to in a more timely fashion. The manager has implemented robust checks on bedrails whilst in use. These are checked every two hours while the service user is in bed. What they could do better: The registered person could take steps to ensure that the registration category is clear to all staff, service users and placing authorities. This would ensure that everybody is clear about what category of service users the home caters for. The registered person could ensure that all service users have a full assessment of their needs carried out to include social needs and wishes. These should be transferred to a care plan where every aspect of individual care needs is planned. These should be reviewed and updated regularly to ensure that the plans are current and fully inform care staff as to the service users needs. Where equipment is used or the service user has specific needs that could pose a risk to them or staff, a risk assessment must be in place that is regularly reviewed and updated when needed. To ensure service users dignity and respect is maintained the registered person must ensure that service users have access to their own socks, stockings and underwear at all times. The registered person must investigate and address the strong odour of urine on Chestnut wing so that service users and their visitors do not have to be subjected to this on a daily basis. Service users could be consulted on what activities they would like to participate in. This would ensure that the majority of service users are satisfied in this area. The registered person could ensure safe staff care for service users by following the home’s recruitment procedures and ensuring that all pre employment checks are in place before staff are deployed at the home. Once employed all staff must receive the training they need to carry out their care role effectively. To ensure this is monitored and remains effective all staff must receive regular supervision. This would enable the manager to discuss any issues regarding individual practice, training requirements and for staff to discuss any areas of concern they may have. Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 7 To make sure that service users and staff are safe within the home the registered person must carry out and record the required fire checks within the home. They must also be more pro active about recognising fire hazards within the home and taking steps to reduce these. Similarly risk assessments must be in place for other hazards such as unguarded or free-standing radiators in use. Measures that are identified to reduce these risks must be implemented. To demonstrate an open door culture within the home the registered person must ensure that complaints and Adult Protection procedures and policies are freely available within the home. Staff and service users must be aware of these. Service users monies must be kept individually and not within the business bank account. The registered person must arrange for service users to be fully consulted about all aspects of the homes activities. 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. Woodlands Nursing Home The DS0000061590.V331771.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 The DS0000061590.V331771.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. Service user’s would benefit from a more thorough pre admission assessment of their social needs and wishes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although staff at the home carry out a pre admission assessment, it does not always address the social needs of service users. Service users that have specific mental health needs secondary to their general nursing care needs have not been assessed for these. This means that care plans are not developed and staff are not always aware of how they can be met. A number of comments were received that refer to Chestnut wing accommodating people with mental health needs. Staff on the day also referred to this. The application that was presented to admit people with a dementia has now been withdrawn. Woodlands Nursing Home The DS0000061590.V331771.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): 7,8,9,10 Quality in this outcome area is poor. Service users do not receive care in a way that fully meets their needs safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users have a written care plan. The plans that have been implemented address the basic activities of daily living. Where there are more specific care needs plans are not always in place. These include plans for tissue damage prevention, falls prevention or addressing mental health needs. The care plans that are in place had not always been reviewed regularly and so it is unclear whether the care needs are current or not. Where intervention from other professionals had been indicated there was no evidence that this had been sought or implemented. Similarly risk assessments, when they are in place, had not been reviewed. Where a risk assessment for tissue viability had indicated high risk no plans Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 11 had been implemented. In two cases service users had been identified as ‘very high risk’ of suffering tissue damage. They had no plan in place as to how this would be managed and had not been provided with a suitable mattress to sleep on that would help to prevent damage occurring. The home has a copy of the NICE guidelines for the prevention of pressure damage that clearly states the action that should be taken for ‘at risk’ service users. Where wound assessment charts are in place for wounds these had not been reviewed or evaluated so it is difficult to tell at what stage they are. In one case where tissue damage had been mentioned on the pre admission assessment the information had not been transferred to the care plans. Moving and handling assessments were not complete in all records that were reviewed. Where they were in place they had not been reviewed. One care plan stated that the service user required the use of a hoist at all times. They were observed been transferred using a combination of the handling belt and an underarm lift. Another service user unable to take any weight was transferred in the same way. An accident had been recorded where a service users assessment had indicated the need for two staff to assist them. One staff member had attempted to lift them by theirselves and had dropped them. Although this had been recorded in the accident record there was no mention in the service users care plan. Although the manager had robust systems in place for checking the safe use of bedrails where fitted there were no risk assessments in place for the actual use of bedrails. In one case accidents directly relating to the use of bedrails had been an issue for one service user on four separate occasions between October and December. No action had been taken following these incidents. Nutritional risk assessments are utilised and weights are recorded. However where there has been a significant weight loss as identified in three cases, no action had been taken. This included action that was detailed within the risk assessment. The medication trolley was left unattended and unlocked on two occasions during the site visit. There are two systems used in the home for medications. One was the monitored dosage system (MDS) and the other is for medications supplied from the surgery in individual containers. An audit trail was correct for the MDS medications. However with the individual medications in some cases there were more tablets left than there should have been. This could indicate that medicines had been signed for but not given. One person’s medication had been changed with a verbal order from the GP. The staff had written the dosage incorrectly. The staff had continued to give the dosage they knew to be correct but had failed to correct the error or get the GP to correct the Medicine chart. The same medication prescribed for a number of service users had been dispensed from the same bottle. Controlled drugs were handled correctly with all records up to date. Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 12 One service user looks after their own medication. A requirement had been made at the last inspection that this should be kept under review. This had not been done since May 2006. The nurses had no written record of the dosage of some of his medications. The majority of staff that returned surveys felt that they were not always fully informed about specific care needs of individual service users although they do receive a regular handover at the beginning of each shift. Comments from relatives included, ‘I have noticed that when some residents ask to go to the toilet they have to wait a long time’ and ‘ there are times when it takes several minutes to find anyone’. Others commented favourably about the care their relatives had received. These include, ‘All the staff we meet are very friendly and helpful’ and ‘……was treated well with every consideration given for their dignity’. Woodlands Nursing Home The DS0000061590.V331771.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): 12,13,14,15 Quality in this outcome area is adequate. Service users are not provided with sufficient social activities to meet their interests and needs. Service users enjoy the food provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a list of activities displayed in Oak wing and on the day of this site visit an outside entertainer was visiting the home. Service users gave mixed responses to the question about sufficient activities on the questionnaires. One commented, ‘ the TV is always on but I think additional activities would help to relieve the boredom’. A relative said, ‘The thing that could be improved is more exercise’. Five staff responses felt that the leisure and social needs of residents were not met. One service user said that they felt that the activities were mainly provided for the people that were confused on Oak wing. The manager has arranged for visiting clergy of differing denominations to visit service users if they wish. Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 14 The cook was aware of individual dietary needs and was able to explain about special diets and how to provide enriched diets if needed. Generally favourable comments were received about the food. During the site visit the food was presented well and looked appetising. Staff assisted service users when they needed. Service users were able to take their meals in their rooms and staff attended them promptly. In the evening there is no cook and this means that care staff are taken away from their duties to prepare and serve the teatime meal. This means that there are less staff available to assist those service users requiring help to feed. Woodlands Nursing Home The DS0000061590.V331771.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): 16,18 Quality in this outcome area is poor. Service users are not fully protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure but it is not clearly displayed to inform residents and visitors to the home. There is no reference to the Commission for Social Care Inspection so people are not aware that they are able to contact them at any stage. There was one complaint that had been recorded since the last inspection. The investigation had not been completed yet and so no outcomes were recorded. Four relatives indicated on comment cards that they had had to make a complaint to the home. One person who was spoken with confirmed that a recent complaint had been made. There was no record of this. There was no Adult Protection Policy available. The whistle blowing policy did not refer to the Local Authorities role in adult protection. However the manager had recently attended Adult Protection training and intended to formulate a new policy. The tissue viability nurse has recently made a referral to the Adult Protection Team regarding a particular care practice at the home. This is currently under investigation. An incident that involved a member of staff attempting to lift a service user and then dropping them had not been reported either to the Commission for Social Care Inspection or to the Adult Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 16 Protection Team. The reporting of incidents was an issue at the last inspection. Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 17 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): 19&26 Quality in this outcome area is poor. Service users would benefit from more attention to the environment in terms of décor, cleanliness and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Written confirmation has been received from the Fire Safety Officer that requirements that he had made have now been attended to. The Building Control Officer has confirmed that they are still waiting for retrospective planning permission for works carried out previously at the home. Service users are encouraged to personalise their private accommodation. The lounge areas are pleasantly decorated and large screen TV’s have been Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 18 provided so that service users can easily see the screens. Dining areas are pleasant, however there did not appear to be sufficient seating for all service users to be able to sit at the dining tables. The passenger lift on Oak wing that was identified at the last inspection as requiring a programme of work to ensure its’ safety remains out of use. This has been the case since the last site visit. The first and second floors on Chestnut wing smelt very strongly of urine. Relatives had also reported this with comments made such as, ‘I feel the home is dirty and smells, others beside me must have to hold their breath’ and ‘the smell of urine is terrible, no-one should have to put up with that’. Some bedroom carpets were badly stained. The housekeeper reported that the carpet cleaner had been broken and then another home had borrowed it. A bed base was seen that had the covering torn exposing wood underneath. A cushion on a chair was uncovered and the foam was badly stained. A commode cover had been left off showing a badly stained commode bucket. The call bell system has been modified and improved so that call bells can now be heard clearly throughout the building. The dining area on Chestnut remains without any means to call for assistance. In some bedrooms radiators were unguarded and had high surface temperatures. Oil filled radiators were in use in some bedrooms on the top floor. They too had high surface temperatures. Their use had not been the subject of a risk assessment and one service user had accidentally fallen over one. Equipment is stored on the landing areas and in the corners of lounges, having the potential to cause accidents and block exits. The steps from the internal fire exit door that leads to the external fire escape were rotten and loose. The fire door leading from the boiler room to the laundry was unable to be closed, as there was no door ‘keep’ in place. The manager was left a notice requiring her to attend to these issues within twenty-four hours. Generally on Chestnut wing there was a need for decorating. Skirting bards in the corridors were badly scuffed and down to bare wood in some places. New woodwork that had been put in place in the summer had not yet been painted, this was the entrance to the lounge area. The cook had a cleaning rota for the kitchen but there was evidence that a deep clean of this area is required. The walls behind the cooker were covered in a grease film as was the grill and deep fat fryer. The laundry area is well equipped with appropriate equipment. COSHH sheets are available to tell staff what to do in the event of accidental contact with Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 19 chemicals. Dissolvable bags are used for soiled laundry. There are dedicated laundry staff. Individual baskets are available for service users laundry with the exception of stockings, socks and pants that are stored communally despite some having labels on. Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 20 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): 27,28,29,30 Quality in this outcome area is poor. Service users are not fully protected by recruitment procedures adopted at the home and by the shortfalls in staff training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff recruitment records showed that although staff now have the necessary checks in place, some had started employment before these had been obtained. Four out of the six staff files reviewed showed that this was the case. Three members of staff had not got two written references in place and one trained nurse had no references from previous employers. This remains outstanding from the last inspection. Staffing levels have increases since the last inspection. This is reflected in the staff survey comments. A relative commented, ‘Staffing levels have improved but the EMI unit could do with somebody there more often’. Staff surveys reported that generally staff feel that they do not have time to get to know service users and their interests. One commented, ‘eventually over time we get to know service users’. Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 21 Staff receive in house training and some brought in from external professionals. Gaps in staff training need addressing in particular in First Aid Fire Safety, Moving and Handling and Food Hygiene. The staff training matrix showed that new staff had not received mandatory training. Staff commented that they would like more training with four out of seven staff reporting that they have not been offered or provided with sufficient training. 48 of staff at the home have achieved an NVQ qualification in care at level 2 or above. Staff supervision has been sporadic and in cases where supervision and/or disciplinary action had been indicated this had not been instigated. This refers to the incident where the carer had lifted a person by herself and subsequently dropped her. Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 22 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): 31,33,35,38 Quality in this outcome area is poor. The service is not well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home is a trained nurse with many years experience. She has completed the Registered Manager’s Award and recently become registered manager of Woodlands. Service users and staff feel that she is caring and approachable. She works in a supernumerary capacity at all times with support from the Area Manager. Not all staff have received formal supervision. Staff supervision would enable the manager to have one to one discussions with staff to address their work Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 23 performance in relation to the aims and objectives of the home and identify individuals training needs. This will ensure that appropriate, well-trained staff that are aware of the philosophy of the home are caring for the service users. It remains the situation that no staff are trained in first aid. The fixed wiring certificate and gas safety certificate are still not available for inspection as there is work outstanding. Fire safety records had not been completed since August 2006. This included the weekly testing of the fire alarm. The manager stated that this was her responsibility. All of these issues along with other Health and Safety issues detailed within this report need attention to ensure that service users and staff are safe at Woodlands. The organisation has a quality assurance system that ensures that stakeholder’s views would be sought and acted upon. However it remains the case that this is still to be fully implemented at Woodlands. Policies and procedures are available for all staff to use although some require updating including those mentioned within this report. Service user’s personal allowances are paid direct to the company’s office where they are held within the business bank account. This account accrues a small amount of interest but this is not apportioned to any service user. When a service user requires some cash, the manager from Woodlands requests this from the administrator at head office. When this is received at the home all service users monies are handled and kept securely. Receipts are available for all transactions. Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 24 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 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 1 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X X X X X X 3 STAFFING Standard No Score 27 1 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 1 X X 1 Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14 Requirement Timescale for action 07/02/07 2. OP3 OP15 OP7 12,13,14, 15,1617. The registered person must ensure that people wishing to use this service are clear about what category of people the service aims to cater for. 07/02/07 At the point of admission the registered person must: • Ensure that they have full and sufficient information about care needs of service users. • Confirm to the service user that their care needs can be met by the home. Following admission the registered person must: • Ensure that comprehensive care plans and risk assessments are completed and kept under regular review to ensure all service users’ current health needs are met. Specific areas for attention are nutrition, tissue viability, mental health and social care needs. This is outstanding from the Random inspection carried out on 26/5/06 and the key Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 26 inspection of 29/8/06 Previous timescale of 02/10/06 not met The registered person must ensure that risk assessments are in place to ensure that bed rails are used safely. Where the assessment indicates that there is a risk to service users then this must be reduced or alternative arrangements put in place to ensure the safety of service users. The registered person must arrange for all service users to have in place a current moving and handling assessment. All staff must have undergone training to ensure that service users are moved and handled safely. The registered person must ensure that all staff responsible for the handling and administration of medicines are fully aware of their responsibilities and adhere to their professional Code of Practice. Training must be provided for staff in the safe handling and administration of medicines. 6. OP10 12,13,16 The registered person must ensure that service users wear their own clothes at all times. This is specifically in relation to socks, stockings and pants. 07/02/07 3. OP8 12,13,14, 15,1617. 22/01/07 4. OP8 13(5) 07/02/07 5. OP9 12,13,14, 15,1617. 16/02/07 7. OP12 16(2(n)) The registered person must consult and take into account DS0000061590.V331771.R01.S.doc 16/02/07 Page 27 Woodlands Nursing Home The Version 5.2 8. OP16 22 9. OP18 13(6) 37 10. OP19 23(2) 11. OP19 23 service users views on what social activities they would like to partake in. These should then be implemented and a system put in place to ensure that this is monitored regularly. The registered person must ensure that: • The complaints procedure is clearly displayed in the home. • It is clear within the procedure that the complainant can contact the Commission for Social Care Inspection at anytime during the complaint process. • All complaints and their outcomes are recorded. The registered person must formulate a current Protection of Vulnerable Adults policy and ensure that all staff are familiar with it. All incidents of suspected and actual abuse must be reported to the vulnerable Adults team and to Commission for Social Care Inspection under regulation 37. The registered person must put in place a programme of redecoration and refurbishment of the home to ensure that it is well maintained and a pleasant place to live for service users. This should include upgrading of divan beds in use. A call bell must be provided in the dining room on Chestnut wing. This is outstanding from the previous inspection. The registered person must make arrangements to employ a cook to cover the evening meal DS0000061590.V331771.R01.S.doc 16/02/07 07/02/07 16/03/07 16/02/07 12. OP27 18(1(a)) 16/03/07 Woodlands Nursing Home The Version 5.2 Page 28 13. OP29 19 14. OP30 18(1(c)) 15. OP33 24 16. 17. OP35 OP38 20 13 18. OP38 23 period in order that care staff are free to attend to service users care needs. The registered person must operate a thorough recruitment process before any member of staff is deployed in the home. This includes: • A fully completed application form. • A satisfactory CRB check. • Two written references including one from the previous employer. This will contribute to service users safety. This requirement is outstanding from the previous inspection. The registered person must arrange for all staff to receive the mandatory training in the following areas: • Fire Safety • First Aid • Food Hygiene. An effective quality assurance system must be implemented to ensure that the views of all stakeholders are sought and acted upon. Service users personal monies must be kept in an account in their name. The registered person must ensure that risk assessments are in place to address the potential risk to service users from: • The use of freestanding unguarded oil filled radiators. • Unguarded central heating radiators in service users rooms. Action must be taken to make good the steps on the fire escape so that they are safe and stable. DS0000061590.V331771.R01.S.doc 07/02/07 16/02/07 16/03/07 07/02/07 22/01/07 17/01/07 Woodlands Nursing Home The Version 5.2 Page 29 19. 20. OP38 OP38 23 13 A ‘keep’ must be fitted to the boiler room fire door so that it can be kept closed. The weekly testing of the fire alarms must be undertaken and maintained Certificates must be obtained to show that the electric wiring and Gas appliances in the home are safe. These must then be forwarded to the Commission for Social Care Inspection This remains outstanding from the previous inspection 22/01/07 16/02/07 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 OP1 Good Practice Recommendations The home should review the statement of purpose to ensure it includes all the required detail. This will make sure that future and prospective service users will have full and comprehensive information about Woodlands. The manager should continue to encourage and promote NVQ training for staff to ensure that 50 of staff hold this qualification. 2. OP28 Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Woodlands Nursing Home The DS0000061590.V331771.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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