Inspection on 05/12/06 for Woodlands Residential Home

This inspection was carried out on 5th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodlands Residential Home 13/09/05

Woodlands Residential Home 12/04/05

Woodlands Residential Home 27/09/04

Woodlands Residential Home 29/04/04

Woodlands Residential Home 10/02/03

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Woodlands Beacon Road Crowborough East Sussex TN6 1UD Lead Inspector Elizabeth Dudley Key Unannounced Inspection 5th December 2006 10:00 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 DS0000021392.V314404.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 DS0000021392.V314404.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Address Beacon Road Crowborough East Sussex TN6 1UD 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) 01892 653178 Sussex Housing and Care Mrs Christine Joyce Coles Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users must be older people aged sixty-five (65) years or older on admission. The maximum number of service users to be accommodated is thirtyeight (38) 13th September 2005 Date of last inspection Brief Description of the Service: Woodlands is a purpose built care home situated on the outskirts of Crowborough; the town centre is approximately one mile away and bus services run past the home. Accommodation is provided on three floors with shaft lifts fitted to assist those who may have mobility problems. Bedrooms are all ensuite and are situated on five separate units, each with its own lounge. The home is registered to accommodate up to 38 older people and the registered owners are Sussex Housing and Care. The amount of fees charged range from £366 - £519.90 per week. Extra services including hairdressing and chiropody are charged separately and charges for these are available from the manager. This information was received from the manager on 16th October 2006. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on the 5th December 2006 over a period of eight hours and was facilitated by Ms C Coles, home manager. During the inspection a tour of the home was undertaken, documentation which included care plans, medication charts, personnel files, health and safety and catering menus were examined. Eighteen residents living in the home were spoken with; eight of these were in a group in the lounge area, and ten in their rooms or in the dining room. Six of these were spoken with in depth in order to find out about their experience of living in the home. Seven staff and four visitors to the home were spoken with and their views about working and visiting the home gained. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service users guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people Prior to the visit to the home questionnaires were sent out by the CSCI to residents and their relatives and to other health care professionals. Six out of ten questionnaires sent to visitors were returned and ten questionnaires were returned from residents. No responses were returned from health care professionals. Comments received from residents included ‘Activities are good, but there is no one to play bridge with now’, ‘The care and support is over and above the call of duty’, ‘The home is always very fresh and clean’, ‘Standard of catering varies - but it is always good for parties’, ‘It would be good to have roast chicken with bones in’, ‘Very varied, good menu’, ‘The staff are very good and very helpful’, ‘Nice rooms, good activities, good staff, my only criticism is it is far too warm in the dining room’ and ‘At times they are busy and can’t do everything at once, but they help as soon they can’. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Several residents said that they had not had a Residents Handbook, which gives them all the information on daily life in the home, including access to the complaints procedure. Risk assessments for individual residents within the home need to be expanded to ensure that incidents or accidents are prevented as much as possible. Care plans must include details of how care needs are to be met and be reviewed to reflect current social abilities and goals. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 7 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 DS0000021392.V314404.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 DS0000021392.V314404.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 and 6 Quality in this outcome area is good, this is based on the available evidence including a visit to this service. Residents receive information in order to assist them with their choice of home. However information relating to the daily routines and organisation within the home has not been made available to some residents. EVIDENCE: The Statement of Purpose and Service User Guide (Residents’ handbook) provided by the home contain all information as required by the regulations and the National Minimum Standards. Eleven of the residents spoken with during the day said that they did not, or could not recall having a copy of the Residents’ Handbook. This was discussed with the manager. The home produces a Statement of Terms and Conditions (Licensing Agreement); this meets the regulations and the National Minimum Standards. Some residents could not recall seeing this or having a copy, but records were in place to indicate that they or their representatives had received this. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 10 Residents who had their own licensing agreements said that any changes to this were sent to them in writing by the head office once a year. All prospective residents are assessed by the manager prior to their admission to the home; this includes a ‘mini-mental’ assessment as well as an assessment of their physical needs and forms the basis of the care plan. This assessment either takes place in the residents’ current place of residence or when they come to look around the home. The majority of residents’ spoken with could recall the manager assessing them prior to their admission. One resident said ‘The manager came to see me and brought lots of paperwork with her’. All residents are encouraged to visit the home prior to their admission and are admitted on a trial period prior to committing themselves to living at the home. Staff receive adequate training to enable them to meet the assessed needs of residents admitted to the home. Fifty per cent of staff have attained their National Vocational Qualification level 2 in care. The home does not admit residents for intermediate care. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is excellent, this is based on the available evidence including a visit to this service. Care plans are formed and reviewed in conjunction with the residents; improvement in some areas would benefit residents. The standard of medication administration safeguards the residents. Individual privacy and dignity is maintained and residents can receive end of life care in their own rooms. EVIDENCE: All residents have a plan of care, which details the care to be given based on their assessed needs. During the inspection six care plans (17 ) were examined in detail. Care plans are formed from the initial pre admission assessment and reviewed on a monthly basis to include current care needs, there was evidence that the care plans had been formed in conjunction with the resident or their representative and where this is unable to take place, a reason had been given. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 12 Care plans include risk assessments, wound care plans and continence care plans. Some risk assessments relating to the frequency of falls need to be more in depth. Care plans relating to continence needs should provide details of the catheter care required, and also need to address the care required by residents at night. Care plans addressing social care needs need expanding to show past and present interests and arrangements for meeting these. There was evidence of visits by both health and social care professionals and outside practitioners including chiropodists, opticians and audiologists. District nurses provide the nursing and wound care for any residents that require this. Residents spoken with said ‘They look after us very well here, the doctor is always called when we need it and the medications arrive on time’. Residents stated that they are treated with courtesy and dignity with their privacy respected, and this was evident on the day of the inspection. All chiropody and nursing procedures take place in private. There are policies and procedures in place relating to the administration of medications. All medications had been signed for following administration, and in most cases reason for non-administration had been recorded. There was evidence of regular audit and risk assessments for those residents who administer their own medications. It is recommended that when medications are given to a resident for self medication that the member of staff signs the form to evidence that these have been given, when drugs are controlled drugs, or used as controlled drugs, two members of staff should sign this. This will safeguard staff and residents. More information is required in the medication charts regarding when to give homily medicines and as required medications. There is provision for the storage and recording of controlled drugs within the home but there are no controlled drugs held in the home at present. The majority of staff have undertaken medication training and this includes the acceptable parameters of blood glucose monitoring and the drawing up of insulin via an insulin pen. The drug trolley required cleaning. Staff have received training in the administration of palliative care to terminally ill residents and the home can provide end of life care to residents Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 13 under the guidance of the district and Macmillan nurses. There was evidence in the care plans that wishes for terminal care has been discussed with residents to some extent on their admission to the home. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is excellent, this is based on the available evidence including a visit to this service. Residents are encouraged to participate in the planning of the activities provided by the home, thus ensuring they retain control over the way they spend their time. A varied menu and choice of meals served in the dining room, encourages residents to think of mealtimes as a social event and aid adequate nutrition. EVIDENCE: Residents are able to exercise choice in all activities of daily living including their times of rising and retiring. The home offers a variety of activities, an activities programme being formed in conjunction with residents. All residents have a copy of the programme. Activities currently being provided include outside entertainers being brought in, flower arranging, exercise classes, craft sessions and outings to various venues for coffee and lunches. Computer training for those interested residents was provided with computers being kept in one of the lounges, however the manager stated that these are not used much now due to residents having bought their own laptops. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 15 The home has a minibus that will take residents into the town twice a week with varying pick up and set down times. Residents spoken with stated that they found the amount of activities provided ‘very good’ and that ‘we choose which activities are available’. Those residents who felt they did not wish to take part in activities for various reasons said that care assistants came into their rooms and talked to them on a one to one basis. There is an open visiting policy and residents said that their visitors were made welcome and they were able to see visitors in their rooms or in the any of the lounges in the home. Residents are encouraged to manage their own finances for as long as possible and the manager will help them access solicitors and financial advisors or can access advocacy for them. All residents can bring their own furniture into their rooms. During the course of the day many residents were spoken with, the majority of residents were having their meals in the dining rooms and they all stated that they have a choice of menus and that the food is usually very good. The manager stated that the fridges on the different floors always held sufficient food to make sandwiches etc for residents at any time of night. Residents said that three times a week they can have a cooked breakfast and that at suppers were varied. The meal of the day was smoked haddock, potatoes and vegetables followed by ice cream and fruit. Alternative meals to the menu were given to residents who did not wish to have the main menu. There did not appear to be much choice in the way of desserts offered to diabetics, and it is recommended that the manager contact a dietician for ideas over alternative foods. Homemade cakes were served at afternoon teas and residents said they get homemade cakes every day. Residents said that they have been able to choose how the tables will be decorated at Christmas and have chosen an aubergine and gold theme. The kitchen was clean and all records required by the Environmental Health Authority were in place. All catering staff have their food hygiene certificate. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 16 Residents may have their meals in the dining rooms or in their rooms. The dining rooms are pleasant with tables being attractively laid out for meals. No residents in the home at this time required assistance with their meals or pureed meals. Residents stated that ‘The food is usually very good’ and ‘The food is good, obviously some things are not always to taste, but there is always an alternative’. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 17 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): 16,17 and 18 Quality in this outcome area is excellent; this is based on the available evidence including a visit to this service. Not all residents were aware of the complaints procedure but were aware that any concerns they had would be dealt with in an open and transparent manner. Residents are protected by staff training in the safeguarding of the vulnerable adult. EVIDENCE: The complaints policy meets the regulations and is displayed on the main notice board and in the Residents’ Handbook. Three concerns have been raised in the past year, one directly to the CSCI relating to a malodorous room and the provision of snacks at night. The manager has addressed this. Two concerns raised at the home related to the provision of barbeque meals, and the inclusion of certain residents in activities. The manager had already addressed the barbeque meals by arranging a separate cooked meal for the resident, and the concern relating to activities could not be addressed to the individual residents satisfaction, due to maintaining the rights of other residents. There was evidence of documentation of complaints and the actions taken to address these. The complaints procedure is included in the Residents Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 18 Handbook and those that said they were not aware of the complaints procedure corresponded with those who did not have a Residents’ Handbook. Some residents were not aware of how to make a complaint –but all said they would go to the manager. There was evidence of staff receiving training in safeguarding of the vulnerable adult and staff spoken with were aware of their role in safeguarding the residents in their care. Residents have the opportunity to vote by postal voting or can go to the polling station in the mini bus. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 19 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): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is excellent; this is based on the available evidence including a visit to this service. The home is clean and well maintained with attractive accessible gardens, thus providing a pleasant homely environment for residents. EVIDENCE: The home is purpose built and is surrounded by 11 acres of woodland and a landscaped garden area which is accessible to all residents. The provider is considering putting footpaths through the woodland areas to facilitate resident use of these. The home is built around a central courtyard and residents decided that wished for a water feature and sitting area to be incorporated into this. This has been provided. All areas within the home are well maintained and decorated. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 20 There are five communal rooms situated over the two floors and these provide quiet rooms and also dining rooms for residents. The home has a licensed bar available to residents and visitors. There are five assisted bathrooms and all rooms have an ensuite bathroom consisting of shower, washbasin and wc. All rooms in the home meet the amended National Minimum Standards. Residents’ rooms are clean, homely and attractively decorated, residents generally provide their own furniture but this can be provided. All six residents that self medicate have a locked cupboard provided by the home. Rooms have lockable doors and keys are provided under the auspices of a risk assessment. The water temperatures to resident outlets are tested and recorded on a regular basis and action taken to rectify any that go outside recommended parameters. There was evidence of the appropriate aids and equipment being in place in the home, hoists and assisted baths are available and pressure relieving aids are obtained as required. Shaft lifts give access to all parts of the home. Wheelchair storage cupboards are provided. All areas of the home are clean, offensive odours are present in one room, but the manager is aware of and addressing these. Laundry facilities are good, with red bags being used for any soiled linen. The home has mechanical sluicing facilities; these areas were clean and free from odours. There are policies and procedures relating to the control of infection and staff have received training in this. The home sends water samples for testing for Legionellas disease on an annual basis. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is excellent, this is based on the available evidence including a visit to this service. There are sufficient staff employed over a twenty-four hour period to meet the assessed needs of the residents, and staff undertake training to enable them to meet these needs. The recruitment process safeguards residents within the home. EVIDENCE: The duty rota showed that sufficient staff are employed on a 24 hour basis to meet the assessed needs of the residents in the home. Staff stated that they had sufficient staff on duty over a twenty-four hour period. There are no residents with high needs in the home at present. Extra staff will be brought in according to resident needs. There are sufficient domestic staff and catering staff employed to support the care staff. The home has 50 of staff with National Vocational Qualification level 2 in care and staff are encouraged to attain this qualification. Six personnel files were examined and all of those belonging to staff employed in the last ten years include all documentation as required by the regulations. One new member of staff recently employed is working under constant supervision until the Criminal Records Bureau check is in place. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 22 Staff have a range of training including medication training, all mandatory training, Healthy eating and Food hygiene, First aid and National Vocational Qualification level 2 in care. Some staff have had training in catheter care and diabetic management. Six members of care staff were spoken with and one member of the domestic staff, all stated that they had received training ‘its always some thing to train for’. Staff has an induction course on commencement of employment. This is the ‘Core Standards for Care which is recognised by NTO and city and guilds. Domestic staff study some of the modules from this. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 23 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): 31,32,33,34,35,36,37 and 38 Quality in this outcome area is excellent, this is based on the available evidence including a visit to this service. Management procedures in place ensure the safety of residents, staff and visitors to the home. EVIDENCE: The manager, Ms C Coles has managed the home for four years. She has attained her National Vocational Qualification level 4 in care, the registered managers award and is registered with the CSCI. Staff residents and relatives stated that the ethos within the home was good, with residents saying that they could see the manager at any time. Residents spoke well of the staff saying that they were polite and caring and come quite quickly if they ring their bells. Comments from residents included ‘The staff are good and come when you need anything, they are always polite’ and ‘We can talk to the manager when we need to, but the staff are always willing to listen and act on what we say’. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 24 The home has a quality monitoring system with residents’ and representatives’ views being sought on an annual basis. The manager also undertakes a quality review six weeks following a residents’ admission to the home. Audits around the home including catering, cleanliness and medication are undertaken annually. Results from these audits are collated and an improvement plan commenced. Staff meetings are held on a three monthly basis. Residents meeting are also held three monthly and representatives are able to attend. Minutes were seen of all meetings. The inspection report results are made known to all interested parties on request and discussed with staff and residents. All said they were aware of the inspection reports. Policies and procedures are reviewed annually. The business plan for the home was seen and in place and all relevant insurances and certificates of registration were seen. The home is not appointee for any service users but keeps personal monies if requested. Receipts and accounts of expenditure were seen as many residents have families or solicitors dealing with their expenditure. Receipts for valuables in safekeeping were also in place. Staff supervision records were in place and these showed that staff have supervision on a two monthly basis. The manager is not receiving supervision at present. Regulation 26 visits (Provider visits to the home) take place on a monthly basis and records of these are kept in the home, these were seen to be very thorough. All records are kept secure in locked offices and filing cabinets, the catering manager keeps her own staff and other records, but this is done in conjunction with the manager. All certificates relating to the servicing of utilities and equipment were in place and in date. The fire officer has recently visited the home and examined the fire risk assessment and other matters related to this and no requirements were made. All staff have mandatory training including fire drills and nine members of staff are in possession of the yearly first aid certificate. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 25 Ancillary staff have received COSHH information and were aware of its implications. Risk assessments are in place. Some risk assessments relating to individuals need to be more in depth. Most staff have undertaken health and safety training. There was adequate recording of any accidents to residents and Regulation 37 (notification of accidents and incidents) reports have been received. All rooms have automatic closures on them but one resident had her door wedged open, this is the resident’s choice and the manager was asked to put measures in place to ensure safety in the event of fire. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 26 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 3 18 3 4 3 3 3 3 4 3 4 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 4 3 2 3 4 Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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. 2 Standard OP7 Regulation Reg 15(1)(2) Reg 13(4) Reg 23(4) Requirement That care plans fully reflect the health and social needs of the service user and the care to be given. That risk assessments relating to the individual service users address aspects of the risk involved and that the fire authority is contacted regarding the safety of those service users who prefer their doors left open. Timescale for action 30/01/07 3 OP38 30/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP9 OP9 Good Practice Recommendations 1 2 That medication records identify the members of staff that give the medications to those service users who self medicate. That full information is contained in the medication charts to ensure staff administer ‘as required’ or homily remedies in the appropriate situations. DS0000021392.V314404.R01.S.doc Version 5.2 Page 28 Woodlands 3 4 OP15 OP36 That the manager contacts the dietician regarding increasing the variety of desserts offered to diabetic service users. That the manager arranges a method whereby she is receives regular formal supervision. Woodlands DS0000021392.V314404.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 DS0000021392.V314404.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!