Inspection on 29/08/06 for Woodlands Nursing Home The

This inspection was carried out on 29th August 2006.

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 16/01/07

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 29th August 2006 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.V310319.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.V310319.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 Hexon Limited 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.V310319.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 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 scale of charges at 29/8/06 ranged between £350.00 and £475.00 per week. Additional charges are made for hairdressing (£7), chiropody (£14), toiletries and outings (various charges). Woodlands Nursing Home The DS0000061590.V310319.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 including a random inspection carried out in May 2006 Information provided by the registered person on a pre inspection questionnaire; Comment cards returned from 27 service users, 24 relatives, 13 staff, 2 GP’s and 2 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. Six service users, four relatives and six 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 Manager and Area support manager were available to assist throughout the day. What the service does well: What has improved since the last inspection? There were no requirements made at the last full inspection. Following a random inspection in May 2006, notifications are now made to the Commission for Social Care Inspection about any accidents or incidents concerning service users. Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. 6 is not applicable. Quality in this outcome area is poor. Although staff at the home carry out basic pre admission assessments for prospective service users, staff do not always have full and accurate information about their care needs. The service users do not receive sufficient and accurate information to enable them to make an informed choice to live at Woodlands. This judgement has been made using all available evidence including a site visit. EVIDENCE: Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 9 Service user records showed that a pre admission assessment is carried out for service users before they are admitted. The assessment takes into account information received from relatives, hospitals and social service assessments. The assessment addresses activities of daily living. The assessment does not take into account specific problems such as mental health needs. Application has been made to the Commission for Social Care Inspection to admit service users suffering from a dementia. This application has yet to be determined. Examination of the records of recent admissions and discussions with staff showed that recent admissions had been made to the home of service users falling within this category. One service user commented that recently there has been an increase in people admitted to the home that wander. A service user has also been admitted who is under the age of 65 years. Work has been carried out to reduce the number of shared rooms. In some cases this has led to bedrooms falling below the required size. The layout of some of these rooms makes it difficult to use equipment in them. Staff reported that this was the case. Woodlands Nursing Home The DS0000061590.V310319.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): 7,8,9,10 Quality in this outcome area is poor. Service users do not have all of their health care needs met. This judgement has been made using all available evidence including a site visit. EVIDENCE: All service users have a care plan in place. These plans address the basic care needs of service users. However when additional needs are identified, for example vulnerability to pressure damage or mental health needs, the care is not always planned for. This could lead to important areas of care being neglected and unnecessary medical events occurring. An example of this is an entry in a daily record that stated ‘sacral area is very red’. No care plan had been put in place to address the treatment and care that this required. Entries in the daily diary indicating mental health needs had not been addressed by referral to relevant professionals and development of a plan of care. Risk assessments are carried out initially. There is a failure to keep these under review and carry out the actions identified as needed to reduce any Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 11 risks. One example of this was a nutritional risk assessment that stated weekly weights were required and referral to a dietician needed. There was no evidence of a referral being made and only two weights had been recorded in a six-month period. Another example was of a service user assessed as being at ‘very high risk’ from developing pressure sores and monthly reviews were needed. There was no evidence these had been completed. Equipment identified as needed is available in the home. However service users that have been identified as needing the use of bed rails did not have risk assessments in place. When the identified beds were looked at it was found that the rails were fitted incorrectly and in most cases were loose. One bed rail had not been assembled correctly and was split in two in the centre. The service user occupying this bed had recently fallen out of bed and hurt their selves on the bedrails. This had been reported in the accident book. Most bed rails in use were not designed for use on the type of bed they were fitted to. The accident records also showed that there have been accidents recorded that related directly to the use of bed rails. A service user was being helped to the dining room in a wheelchair. Only one footplate was in use. An accident had been recorded where a service user had fallen out of a wheelchair as safety straps had not been in place. On the day of the inspection the call bells were constantly ringing. A service user stated, ‘I rang my bell this morning and it took them half an hour to come.’ Staff had reported in the surveys that the call bells could not be heard in all areas of the building. The inspectors confirmed that this was the case. The building has been separated into two units in anticipation that the proposed registration change will be approved and a separate unit will be allowed for dementia care. After 10 am on a morning only one member of staff works on Oak wing. The console for the call bells that tell staff which service user is calling is situated on the wing that will be used for nursing care. This means that staff from the other wing have to leave that wing to check the console if a call bell is activated. This means that service users may be unattended at times. A service user had been given her lunch in her bedroom at approximately 12MD. She had then been sat on a commode and left without her call bell. At 2pm she was still sat on the commode with her lunch on a chair near her although out of reach. She was shouting for help and extremely anxious. Medication records showed that some service users were not receiving painkillers that had been prescribed. There was no record of them being offered or refusing the medication. Service users that had been prescribed Digoxin had not had their pulse taken regularly prior to administration of the drug. A controlled drug had not been destroyed although had not been required since May 2006. A service user that self medicates had not been Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 12 provided with appropriate lockable facilities for his medication. The staff did not have details on his medication administration record about the drugs that the service user self medicates with. The drug fridge temperature had not been checked and recorded for nearly three weeks. Woodlands Nursing Home The DS0000061590.V310319.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is poor. Service users are not always satisfied with their lifestyle at Woodlands. This judgement has been made using all available evidence including a site visit. EVIDENCE: A relative visiting the home said that they were always made to feel welcome. They reported that the domestic staff always made sure that they had a cup of tea. Comments received from service users relatives included, ‘There is a general lack of activities at the home.’ This was confirmed in comments from service users. One said, ‘The biggest problem I have is boredom, there is not enough staff around to do activities, they are so busy’. Another commented, ‘The day staff are so rushed they have no time to sit and talk’. Staff commented that they do not have the time to spend with service users, as they are usually short staffed. Service users enjoyed the food on offer and the meal that was served looked appetising and nutritious. Staff assisted those service users that required help Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 14 although were unable to give individual attention. One service user had been left unable to reach her meal. The dining room on Oak wing has no call bell in place for service users. The cook covers breakfast and lunch but carers have to prepare and serve tea. This can be problematic if the staff complement is low. Woodlands Nursing Home The DS0000061590.V310319.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. Service users feel they are listened to but are not fully protected. This judgement has been made using all available evidence including a site visit. EVIDENCE: The home has a clear complaints procedure that is displayed at the home and contained in the home’s information pack. Relatives indicated on comment cards returned that they were aware of the procedure. Those spoken with on the day of the site visit were able to confirm that they knew what to do if they were unhappy about anything. They confirmed that they would be able to speak with the manager and felt happy to do so. One commented, ‘Judy is pretty good at sorting things out’. They indicated that they were aware they could speak to an inspector if they were unhappy about any aspect of their relatives care. Staff surveyed reported that issues brought to the manager’s attention were not always dealt with in a timely fashion. The manager of the home dealt with a complaint in March about the care of a service user. The complainant had been concerned about the healthcare needs of their relative not being met. The management had dealt with another complaint from a member of staff about another member of staff. This had been discussed at a recent strategy meeting. Both of these incidents should have been referred to the Adult Protection Team for consideration. There has been a recent adult protection case. Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 16 The organisation’s adult protection policy is not clear about how to refer cases and who will investigate. This needs amending to make sure that all staff are fully informed. Most staff have now received training in Adult Protection and the area manager has arranged for further training sessions to ensure all staff have this training. Woodlands Nursing Home The DS0000061590.V310319.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22,23,26 Quality in this outcome area is poor. Elements within the environment pose a risk to the health and safety of service users. This judgement has been made using all available evidence including a site visit. EVIDENCE: The organisation is currently working with the Fire Safety Officer and Building Control Officer in order that they will be able to meet their requirements following recent work completed at the home. This is necessary because the authorities were not consulted before work was undertaken and there are shortfalls in meeting their requirements. An action plan that was provided by the management detailing how they intended to meet the requirements of the Fire Safety Officer was checked. There remain some outstanding issues that need attention. Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 18 A fire exit door was locked and the key for this door was kept in the kitchen away from the door. The Georgian wired glass in the fire door was cracked and an inner door leading to this door had a pane of glass completely missing. A fire exit door that is easily opened on the top floor of Chestnut wing leads straight onto a steep flight of downward steps. The door is opposite a service users bedroom. A toilet on the ground floor had a stained urinal left in it. The sluice on the first floor was unlocked and there were chemicals in the room. The cleaner’s trolley was left unattended for a period of time. In both these cases chemicals were left accessible to service users. Windows in the bedrooms above ground floor did not have window restrictors fitted. This meant that they were able to fully open which could pose a risk to service users especially those with mental health care needs. A recent visit from the Environmental Health department had concluded that food preparation and safety was adequate. The home provides service users with sufficient bathing facilities. However there are only assisted bathing facilities on the ground and middle floor. This means service users on the top floor need to go downstairs for a bath. The recent work to reduce the number of double rooms has left some rooms small and narrow. Staff report that it is not always possible to use essential equipment such as hoists in these rooms. In some bedrooms the bed can only be positioned against the wall. This means that staff do not have access to both sides of the bed to make it easy to carry out care tasks. The laundry facilities have been improved with the provision of new washing machines and dryers. The laundry room is spacious and well equipped. There is dedicated laundry staff. The care staff spoken with were aware of infection control procedures and confirmed that they are supplied with personal protective equipment. The problems with the call system detailed in this report mean that service users do not always have access to a call bell system Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. Service users do not have access to sufficient and well-trained staff. This judgement has been made using all available evidence including a site visit. EVIDENCE: Service users reported that there has been a big turnover of staff in recent months that has led to an unsettled period for them. 5 out of 22 surveyed said they only sometimes receive the care and support they need. 7 reported they never had any activities and 3 said they sometimes had activities. On a positive note 18 said that the staff listen to them and act on what they say. Staff recruitment records showed that although staff now have the necessary checks in place, some had started employment before these had been obtained. This places service users at risk. A service user said, ‘The carers have changed a lot, I used to have a keyworker but I’m not sure now if I do’. Another commented, ‘It’s hopeless, the staff are all up and down. They are forever apologising as they don’t have enough time to talk to us’. Staff surveyed report that the staffing levels are a problem. One commented, ‘There are not enough staff and we don’t have time to sit and talk to residents so we don’t get to know them’. Another said, ‘The Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 20 lack of staff mean that key-worker duties get neglected.’ The manager acknowledged that there have been recruitment problems in recent months. On the day of the inspection call bells were constantly ringing and staff appeared rushed. One lady was left on her commode without a call bell for an excessive period of time. Staff were seen helping service users that required help at mealtimes, they were unable to give individual attention. After 10a.m on a morning there is only one member of staff available on Oak wing. Staff receive in house training and some brought in from external professionals such as a recent course on Tissue Viability. Gaps in staff training need addressing, these are particularly in Protection of Vulnerable Adults, First Aid and Health and Safety. Staff have commented that they would prefer ‘more professional’ training. One suggested ‘team building’ exercises to improve staff morale. 52 of staff at the home have achieved an NVQ qualification in care at level 2 or above. Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is poor. The home is not well managed. This judgement has been made using all available evidence including a site visit. EVIDENCE: The manager of the home is a trained nurse with many years experience. She has almost completed the Registered Manager’s Award. She has made application to the CSCI to become registered manager of Woodlands. Service users and staff feel that she is caring and approachable. Comments received include, ‘She is a good manager and will sort things out if it is within her power to do so’ and ‘ She is very approachable and open to comments and ideas’ and ‘ She really cares about the residents’. However, some staff feel that things Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 22 get over looked at times. She works in a supernumerary capacity at all times with support from the Area Manager. Some staff have yet to receive formal supervision and were unaware of what this involves. Staff supervision 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. This will ensure that appropriate, well-trained staff that are aware of the philosophy of the home are caring for the service users. There are currently no staff trained in first aid. Safety certificates were inspected. The fixed wiring certificate was out of date, there was no gas appliance certificate available. The manager was asked to forward this to the Commission for Social Care Inspection as soon as possible. The call bell system was not in full working order. The manager indicated that this was a recent problem, however staff surveys returned prior to 11th July 2006 indicated that this was a problem at that time. Some areas did not have call bell points and some bedrooms were without call bells. The bells could not be heard on the top floor and on occasions on the second floor. The lift service inspection records for the lift on Chestnut wing showed that there are a number of areas that have been highlighted as needing attention since February 2005. Service users reported that because of problems operating this lift they are prevented from using it alone. 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 this has yet to be fully implemented at Woodlands. Once it is implemented the results will better inform the management where improvements are needed and assure people that their views matter and are taken into account. Policies and procedures are available for all staff to use although some require updating. Service users monies are handled and kept securely. Receipts are available for all transactions. Woodlands Nursing Home The DS0000061590.V310319.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 1 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 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X 2 1 2 X X 3 STAFFING Standard No Score 27 1 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 1 Woodlands Nursing Home The DS0000061590.V310319.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 OP3 Regulation 14 Requirement The registered person must ensure that they do not admit any service user that does not fall within their registration category. 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. Timescale for action 12/10/06 2 OP3 OP7 OP8 OP15 12,13,14, 15,1617. 02/10/06 • 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, including assistance with feeding; tissue viability, Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 25 mental health and social care needs. This is outstanding from the Random inspection carried out on 26/5/06 To ensure service users are safe from immediate risk, the registered person must: • Ensure that all bed rails in use are checked to ensure that they are the correct equipment for the beds they are fitted on, they are fitted correctly and are safe. The service user identified at the inspection must have a full re assessment of their needs especially in relation to their need for the use of bedrails. If, following the risk assessment, bedrails are required then they must be used safely. Immediate arrangements must be put in place in order that service users can have access to care staff at all times. Where service users do not have access to a call bell alternative arrangements must be put in place. The risk assessment relating to the service user that is self medicating must be reviewed and arrangements put in place to ensure that the medication is stored securely and all service users in the home are Version 5.2 Page 26 3 OP8 OP9 OP22 OP38 12,13,16 29/08/06 • • • Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc safeguarded. A risk assessment must be carried out to assess service users are safe to handle their own Steradent tablets. If the assessment concludes that they are, then they must be provided with secure storage facilities to safeguard other service users. The registered person must develop and implement a robust quality assurance system. Specific areas that need addressing include: Activities. Safe systems of work for medications. • Audits of accidents • Checking of equipment for safety. • Staff supervision To ensure that service users are cared for by sufficient and appropriate staff the registered person must: • Carry out a full review of the staffing levels and deployment to ensure that care needs of the service users currently resident can be met in a safe and timely fashion and with regard to service users dignity. Arrange for all staff to complete mandatory training, including First Aid and Protection of Vulnerable Adults • • • 4 OP9 OP12 OP38 24(1) 30/10/06 5 OP10 OP27 OP29 OP30 OP36 OP18 12,13,18, 19 02/10/06 • Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 27 The above requirement is outstanding from the Random inspection carried out on 26/5/06 • Review the Adult Abuse policy so that staff are fully informed of what they should do in case of an allegation. Arrange for staff to be regularly supervised addressing areas such as the aims, objectives and philosophy of the home in addition to identifying training needs. • 6 OP19 OP22 OP23 OP38 12,13,16, 23. Ensure all future staff are recruited according to the homes policy and procedures and DoH guidelines. To ensure service user’s continued safety the registered person must: • Review the call bell system for the whole of the building. Call bells must be accessible at all times and be heard in all parts of the home. Put in place a system whereby equipment used in the home is regularly checked and maintained and a record kept of this. Ensure staff are aware of their responsibilities under the COSHH regulations and do not leave chemicals unattended in the home. Continue to work with the • 02/10/06 • • • Woodlands Nursing Home The DS0000061590.V310319.R01.S.doc Version 5.2 Page 28 Fire and Rescue department and Local Authority Building Control Officer in order that their requirements are met. Evidence that they have been met must be provided to the Commission for Social Care Inspection when available. • Arrange to have the electrical wiring and gas appliances tested and forward a copy of these certificates to the Commission for Social Care Inspection when available. Carry out risk assessments for the upstairs windows and where a risk is identified, fit window restrictors to reduce that risk. Make arrangements to ensure that only safe systems of work are used when staff are dealing with medications. • • The above requirement is outstanding from the Random inspection carried out on 26/5/06 Provide an action plan including timescales to the Commission for Social Care Inspection to address the work required on the lift on Chestnut wing. The registered person must 08/11/06 provide an improvement plan to show how they are going to action these requirements and effect improvement for this DS0000061590.V310319.R01.S.doc Version 5.2 Page 29 • 7 *RQN 24A Woodlands Nursing Home The service. 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 work towards achieving her Registered Manager’s Award 2 OP31 Woodlands Nursing Home The DS0000061590.V310319.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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodlands Nursing Home The DS0000061590.V310319.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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