Inspection on 19/06/07 for Woodlands Nursing Home The

This inspection was carried out on 19th June 2007.

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

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

Other inspections for this house

Woodlands Nursing Home The 26/11/08

Woodlands Nursing Home The 27/11/07

Woodlands Nursing Home The 16/01/07

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 Unannounced Inspection 19th June 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.V344175.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.V344175.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.V344175.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2007 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 is one 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 19/06/07 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.V344175.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection has used information from different sources to provide evidence for the report. 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 3 service user and 7 relatives. A visit to the home carried out by two inspectors that lasted for seven and a half hours. During the visit to the home six service users, three visitors, and seven staff were spoken with. Records relating to four service users, four staff members and the management activities of the home were inspected. Care practices were observed, where appropriate, and time was also spent watching the general activity within the home. This enabled the inspectors to gain an insight of what life is like at Woodlands Nursing Home for the people living there. The manager was available to assist the inspectors throughout the day. Feedback was given at the close of the inspection. What the service does well: What has improved since the last inspection? Since the last inspection people it has been made clear to people and staff what people can be admitted to the home. Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 6 To make sure that service users and staff are safe within the home the registered person now carries out and records the required fire checks within the home. A fire risk assessment has also been completed. If people request that the manager looks after their money, records are kept and money is now kept in individual accounts. What they could do better: It is important that the responsible individual and registered manager work to meeting statutory requirements made in inspection reports. This will ensure that the organisation is meeting people’s needs in a way that promotes their health, safety, and well-being. This applies to other regulatory authorities including Building control. The registered person could improve the assessment of people’s needs that is carried out before they are admitted and particularly for those people admitted for short periods of time. This will help staff to formulate care plans that are effective and drawn up with agreement of the person they relate to. 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. These measures will ensure that people’s needs are fully met in a safe and acceptable way. To promote dignity and respect among people using this service, the registered manager must make sure that people only wear their own clothes. The strong odour of urine on Chestnut wing needs to be addressed so that people living at the home do not have to be subjected to this on a daily basis. In order that people enjoy their daily routines at the home people could be consulted on what activities they would like to participate in. This would help towards ensuring that people are satisfied in this area. The registered person could ensure safe staff care for people by following the home’s recruitment policy 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. To make sure that service users and staff are safe within the home the registered person must implement the requirements made within the fire risk assessment and make sure that all staff receive fire safety training. To demonstrate an open door culture within the home the registered person must ensure that complaints and Adult Protection procedures and policies are Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 7 freely available within the home. They must be clear and easy for staff and service users to follow. The registered person must arrange for service users and staff to be fully consulted about all aspects of the homes activities. This could include holding regular meetings with these groups. 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.V344175.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.V344175.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. 6 is not applicable. People who use the service experience adequate quality outcomes in this area. People would benefit from a more thorough assessment of their needs and wishes before they moved in to the home. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Staff at the home carry out a pre admission assessment for people that looks at what their needs are and how these are to be met. This, however, is not in place for people who are admitted for short stays. Records of two people who have been admitted for short stays have assessments in place from previous admissions, in one case from the previous year. There was no evidence to show that their needs have been reviewed or discussed with them for this period of admission. It was obvious from speaking with staff and the people involved that care needs for these people have increased. People and staff at the home are clear now who can be admitted to the home. Woodlands Nursing Home The DS0000061590.V344175.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. People who use the service experience poor quality outcomes in this area. Service users care needs are not planned for in a way that would promote their health, safety and well-being. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: All service users have a written care plan. The plans that are in place address the basic activities of daily living. Where there are more specific care needs identified plans are not in place to show how these will be met. These include plans for tissue damage prevention, falls prevention and health care needs specific to individuals. One person who was at the home for a short period of time had no plans in place to address their care needs. Where intervention from other professionals has been indicated there was no evidence that this had been sought or implemented. Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 11 Risk assessments have been completed in some cases but no plans are in place to show how the risk would be managed. It remains the case that where a risk assessment for tissue viability had indicated high risk no plans have been implemented. In two cases risk assessments have shown that service users have been identified as ‘very high risk’ of suffering tissue damage or nutritionally at risk. They have no plan in place to direct staff to how this would be managed Moving and handling assessments were complete in all records that were reviewed. These were kept under review. Staff were seen moving and handling people safely and in accordance with their assessment. There is still no call bell in the dining room on Chestnut wing. In the lounges there is only one pull cord to alert staff. One person said, ‘When I go in the lounge I have to hope that there is somebody about who can walk to ring the bell for me’. Before lunchtime a person wanted the toilet and was looking to attract staff attention. This was not possible and the inspector had to alert staff that they were needed. The manager said that should staff require emergency help then a system was devised where they would ring the bell three times. This would not work if somebody else had already activated their bell. This means that staff would not be able to summon assistance in an emergency. Robust systems are in place for checking the safe use of bedrails where fitted. There are no risk assessments in place to address the actual use of bedrails and to look at alternatives. There is a document available in the home to help staff look at this but staff report that they do not have time to complete these assessments. There are two systems used in the home for medications. One is 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. Controlled drugs are handled correctly with all records up to date. One service user looks after their own medication. This has been the subject of an assessment and this is kept under review. Care staff felt that they are not always kept informed about specific care needs of individual service users although they do receive a handover at the start of their shift. The records that care staff contribute to are kept separate from the care plans. The care plans are locked away with the nursing staff having access. Carers need to ask to look at these and do not have free access to peoples care plans to help them get to know people’s needs and wishes. People are appreciative of the help that staff give them and feel that they work very hard. Comments received from people include, ‘The care staff are smashing, terrific and willing to help at all times’. Woodlands Nursing Home The DS0000061590.V344175.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. People who use the service experience poor quality outcomes in this area. Service users are not provided with sufficient social activities to meet their interests and needs. Service users enjoy the food provided. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: There were no activities arranged on the inspection day. People were sat around with the TV on. Staff reported, ‘We don’t have time to do anything with people’. Another said, ‘We would love to be able to have time to do more with people’. Somebody staying at the home for a short period said, ‘I don’t like it here, you just get up and go to bed’. A relative has commented that they thought people would benefit from more activities going on in the home. If people wish to continue to worship then clergy of differing denominations visit the home. A member of staff who has specific key worker responsibilities described how they arranged activities on an individual basis for one person. These were well thought out and centred on the individuals needs, capabilities and wishes. Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 13 Generally favourable comments were received about the food. During the site visit the food was presented well and looked appetising. Staff gave people help when they needed. People are able to take their meals in their rooms and staff attend them promptly. In the evening there is still no dedicated person to prepare and serve meals and this means that care staff are taken away from their duties to carry out this task. Less staff, therefore, are available to assist those service users requiring help to feed. Care staff who are asked to do this say that they have had no food hygiene training. Woodlands Nursing Home The DS0000061590.V344175.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People who use the service experience adequate quality outcomes in this area. Review of policies and procedures would lead to better protection for people. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: There is a complaints procedure in place. The procedure is made available to people in the service user guide. It is not displayed in the home and does not give the name of anybody in the organisation that people may contact. Some people say they know how to make a complaint but others do not. Staff are aware of the complaints procedure and say that they would pass complaints on to the manager or senior nurse. Where complaints have been received from people they are not always fully recorded. Some records are incomplete with no outcome recorded. There have been no complaints received by the service or by the Commission for Social Care Inspection since the last inspection. The adult protection policy gives good information to staff about recognising abuse but does not give clear advice about reporting procedures and who will carry out any investigation. Staff spoken with, however, knew what procedures to follow. Some staff have had training around Safeguarding Adults. Staff spoken with felt they would benefit from some further training and updates. Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 15 There have been two referrals to the ‘Safeguarding Adults’ Team since the last inspection. One of these has resulted in a referral being made to the provisional Protection of Vulnerable Adults list. The ‘Managing Aggression’ policy had not been reviewed since February 2002 despite a recent incident that was referred to the ‘Safeguarding Adults’ team. Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. People who use the service experience poor quality outcomes in this area. People do not live in a safe environment. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The Building Control Officer has confirmed that they are still waiting for retrospective planning permission for unauthorised works carried out previously at the home. This has been the case since August of 2006. An application had been received but was not completed correctly. The organisation has still not provided an access statement and a fire strategy as they had been requested to do. The testing of fire equipment has improved since the last inspection and fire alarms are now tested weekly. A fire risk assessment has been completed. Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 17 Some issues identified within the assessment as posing a fire hazard have not been rectified. These issues included loose plugs and light switches, storage of combustible material in the flat area on the top floor of Chestnut wing and attention to the steps leading from the roof top exit. The fire door on the top floor of Oak wing that leads to the roof top exit was opened to check on some work that had been required following the last inspection. It was not possible to close the door following this. Staff reported that they do not use the ramp access on the ground floor because it was difficult to open and close the fire door that leads onto it. Service users are encouraged to personalise their private accommodation. The lounge areas are pleasantly decorated and large screen TV’s have been provided so that service users can easily see the screens. The passenger lift on Oak wing has now been condemned and is out of use. There is no signage to tell people this but the manager states that it is impossible to access the lift. It remains the case that the first and second floors on Chestnut wing smelt very strongly of urine. Some bedroom carpets were badly stained. Call bells remain a problem. Work was carried out following the last inspection to make the bells sound louder so that staff can hear them in all areas of the home. Staff are still reporting that they cannot hear the bells in some areas. This means that people may not receive prompt attention when they need this. Equipment is stored on the landing areas and in the corners of lounges, having the potential to cause accidents and block exits. It remains outstanding that decorating work is to be done on Chestnut wing. 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 august 2006 had not yet been painted. 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 chemicals. Dissolvable bags are used for soiled laundry. Spillage kits are available to deal with body fluid spillages and accidents. There are dedicated laundry staff. Individual baskets are available for service users laundry however stockings and socks continue to be stored communally. Woodlands Nursing Home The DS0000061590.V344175.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use the service experience adequate quality outcomes in this area. People would benefit if staff were better supported by management. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People at the home and their visitors appreciate the hard work that the carers do. Comments received include, ‘The staff are good and work exceptionally hard’ and ‘they look after …..well’. Staff are enthusiastic and keen to improve their skills. Staff recruitment records showed that although staff have the CRB (Criminal Record Bureau) checks in place, it was not possible to see if staff had started employment before these had been obtained, as start dates are not recorded. References could not be found for two of the people’s files that were reviewed. Previous employment history had not been fully explored. Staff feel they do not always have sufficient time to carry out their roles. One staff member said, ‘We do not have time to sit and talk to people or do any activities.’ Another said, ‘I’d love to be able to do more with residents’. An Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 19 agency worker was asked if they had been told about the fire procedure. They replied that they had worked in homes before so knew what to do. External professionals had provided some training in tissue viability following a safeguarding adults issue. Trained staff and carers have had the opportunity to attend this. Since the last inspection staff had been provided with moving and handling training. The manager was unable to find the staff training matrix on the day and there was little evidence on staff files to say they had received other mandatory training. This includes first aid training. Staff commented that they would like more training. Information provided by the manager indicates that nursing staff have had access to training in phlebotomy, syringe driver management, and medication handling. 50 of care staff at the home have achieved an NVQ qualification in care at level 2 or above. Woodlands Nursing Home The DS0000061590.V344175.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. People who use the service experience poor quality outcomes in this area. The home is not managed well. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Judy Lucas is the registered manager of the home. She is a trained nurse and has also completed the Registered Manager’s Award. People feel that she is caring and approachable. She works in a supernumerary capacity at all times with administration support and support from the Area Manager. A deputy manager is also employed at the home. Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 21 Staff have not received formal supervision since August 2006. Staff feel that they would benefit from this and that they would feel valued. It would enable the manager to have one to one discussions with staff to address their work performance in relation to the aims and objectives of the home and identify individuals training needs. Staff meetings are not held on a regular basis. Staff spoken with had good ideas for improving the services available for people. Supervision sessions and staff meetings would give staff a forum in which to put their ideas forward. The fixed wiring certificate and gas safety certificate are still not available for inspection. The manager states that the gas appliances have been tested but certificates have not been received. She also said that the electrical wiring testing had begun but work remains outstanding in this area. Fire safety checks are now completed regularly. The manager was not able to evidence that all staff had received fire safety training. There was no evidence available that the water temperature checks are completed or recorded anywhere. Random checks on the day proved to be satisfactory. The organisation has a quality assurance system that ensures that stakeholders’ views would be sought and acted upon. However it remains the case that this is still to be fully implemented at Woodlands. Surveys had been sent out and some returned but no further work had been completed. There is no annual development plan. Residents and/or relatives meetings are not held. Policies and procedures are available for all staff to use although some require updating including the Protection of Vulnerable Adults policy. The manager looks after service user’s personal allowances where applicable. Receipts are available for all expenditure but not for monies received. Although the receipts were available it took a while to find the relevant ones. Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 22 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 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 1 Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 12, 13, 14, 15, 16, 17. Requirement 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. Previous timescales of 02/10/06 and 7/2/07 not met. 2. OP8 13(4(c)). The registered person must ensure that risk assessments are DS0000061590.V344175.R01.S.doc Timescale for action 18/07/07 18/07/07 Woodlands Nursing Home The Version 5.2 Page 24 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. Previous timescale of 22/1/07 not met. 3. 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 and stockings. Previous timescale of 7/2/07 not met. 4. OP12 16(2(n)) The registered person must consult and take into account 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. Previous timescale of 16/2/07 not met. 5. OP16 22. The registered person must ensure that: • The complaints procedure is clearly displayed in the home. 18/07/07 18/07/07 18/07/07 Previous timescale of 16/2/07 not met. It has the contact details of a company representative for people to contact if they wish. Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 25 6. OP18 13(6). The policy for the Protection of Vulnerable Adults must be reviewed so that it is clear about reporting and investigating roles. 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. Previous timescale of 16/3/07 not met. 18/07/07 7. OP19 23(2). 18/07/07 8. OP19 23. A call bell must be provided in the dining room on Chestnut wing. Previous timescale of 16/2/07 not met. The call bell system must be kept under review to ensure that staff are able to hear the bells in all areas of the building and are able to identify when the call is for emergency assistance. 18/07/07 9. OP27 18(1(a)). The registered person must 18/07/07 make arrangements to employ a cook to cover the evening meal period in order that care staff are free to attend to service users care needs. Previous timescale of 16/3/07 not met. 10. OP29 19. The registered person must operate a thorough recruitment process before any member of staff is deployed in the home. This includes: • A fully completed 29/06/07 Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 26 • • application form with gaps in employment explored. A satisfactory CRB check. Two written references including one from the previous employer. This will contribute to service users safety. Previous timescales of 2/10/06 & 7/2/06 not met. 11. OP30 18(1(c)) The registered person must arrange for all staff to receive the mandatory training in the following areas: Fire Safety First Aid Food Hygiene. Previous timescale of 16/2/07 not met. 12. OP31 OP33 24. An effective quality assurance system must be implemented to ensure that the views of all stakeholders are sought and acted upon. Previous timescale of 16/3/07 not met. Areas for specific attention must include: • • • 13. OP38 23(4). Staff supervision Residents meetings Staff meetings. 19/06/07 18/08/07 18/07/07 The registered manager must ensure that: • • All staff have received fire safety training relating to this home. Fire doors are able to open and close efficiently. Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 27 The wall light in room 20 is safe. 14. OP38 23(4(d)). The registered manager must ensure that the staff highlighted at the inspection that had not received fire safety instruction must receive this. 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 Previous timescales of 2/10/06 and 16/2/07 not met. 26/06/07 15. OP38 13. 18/07/07 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 OP35 Good Practice Recommendations Record keeping should be improved in relation to people’s personal monies. This will make an audit trail easier to follow. Woodlands Nursing Home The DS0000061590.V344175.R01.S.doc Version 5.2 Page 28 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.V344175.R01.S.doc Version 5.2 Page 29 - 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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