Inspection on 26/07/06 for Woodlands Rest Home

This inspection was carried out on 26th July 2006.

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

The inspector 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 Rest Home 23/04/07

Woodlands Rest Home 10/11/05

Woodlands Rest Home 16/02/05

Woodlands Rest Home 07/09/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Woodlands Rest Home 19-23 Lovedean Lane Lovedean Portsmouth Hampshire PO8 8HJ Lead Inspector Val Sevier Unannounced Inspection 26th July 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 Rest Home DS0000049977.V300120.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 Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Rest Home Address 19-23 Lovedean Lane Lovedean Portsmouth Hampshire PO8 8HJ 023 92 594427 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) adminrookvalegroup.co.uk Heatherland Healthcare Limited Ms Heather Saunders Care Home 31 Category(ies) of Dementia - over 65 years of age (31), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (31) Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2005 Brief Description of the Service: Woodlands is a care home providing accommodation and care for 31 service users in the category of Older Persons (OP). The home may also accommodate 5 service users who are over 65 years in age and who have mental health problems. The home is owned by Heatherland Healthcare Limited. The registered manager is Ms. Heather Saunders. Communal space comprises two lounges and dining room. Bedrooms are situated on two floors, accessed by a shaft lift. The main door is kept secure by the use of a keypad exit system. There are 28 single and 2 shared rooms, although one of these is traditionally used as a large single. Eleven single rooms have en suite facilities. There is a well-kept garden and patio area to the rear of the property and car parking space at the front. The home is situated in a quiet residential area, close to local amenities, shops and public transport. The fees for the home range between £385 & £425 dependent on need and whether the room has ensuite facilities. Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and took place over 5 hours. The visit was part of the inspection with other information having been obtained through surveys and a pre visit questionnaire from the home. The inspectors looked at the key standards for the home, which the commission feel, are key to the running a service. The inspector sampled 5 care plans and other related documents, spoke with several residents, staff and some relatives. The registered manager was available as was the care services manager. What the service does well: What has improved since the last inspection? The care services manager feels that the records and care plans have improved since the last inspection although issues were raised at this visit. The communication with residents and action following meetings with relatives has resulted in outings being arranged. The manager of the home continues to work with staff on the routines that have been established at the home so that residents have more choice in their daily lives at the home. The complaints procedure has been reviewed and the home feels that this is an improvement for them to monitor any concerns people may have. Woodlands Rest Home DS0000049977.V300120.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 Rest Home DS0000049977.V300120.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 Rest Home DS0000049977.V300120.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 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home has a satisfactory understanding of the residents needs using the assessment process. EVIDENCE: The inspector looked at 5 care plans and each individual had had an assessment prior to moving to the home. The assessments contain information about the needs of the individuals. It was observed that the information gained through the assessment had been used to complete the care plans. Relatives spoken with on the day, explained what had happened in the decision-making process regarding the home and how they had been involved. Some residents spoken with although able to speak for themselves had been unable to visit the home due to physical frailty. The relatives spoken with felt that the admission process had worked, that they had been given adequate information to assist with the decision, making process. The relatives felt that the needs could be met at the home. Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 9 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. This judgment has been made using available evidence including a visit to this service. There is not a consistent record of health care issues with little or no evidence that regular monitoring takes place so it can not be said that health care needs are fully met. Medication records and stock for controlled medication are not up to date with gaps in recording and information the current practice and lack of adequate recording puts residents at risk. In general residents are treated with respect. EVIDENCE: The records of 5 residents were examined and these documents included the plans of care that had been developed for the individuals following the pre admission assessment and admission to the home. In all the plans seen there were general risk assessments in place as well as specific assessments related to the care needs of the individual for example mobility and the use of supportive aids such as walking frames. The plans Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 10 identified support and assistance that staff needed to carry out and where residents remained independent how staff could encourage this. Discussion with residents and relatives confirmed that they felt assistance was received when required in a timely way. Residents are happy with the way most staff deliver their care and respect their dignity. However there were gaps in the daily records with some days only an acknowledgement of personal care carried out such as a bath. Where a concern had been recorded by staff in the records of those sampled, there was no evidence of follow up action for example: Friday 21st July 2006, ‘Right eye sticky needs to be bathed, if no better will call GP on Monday. Drops being put in’. There was no follow up action or confirmation that eye had improved or that GP was called. Another example was that individual ‘unwell 23/7/06 GP will be rung tomorrow, test being carried out’. Next and last entry available entry was 25/7/06 person ‘didn’t want tea, very tired, no urine passed, although felt they wanted to’. One person it was noted had been admitted to hospital with dehydration following a period of time during July 2006 when they had sustained several falls. There was no indication in the daily notes that a review had taken place following any of the incidents and or that staff intervention should be changed. The inspector was able to discuss this with both the manager and the care services manager at the time as concern was felt that with no evidence of action or care given, it might lead to inappropriate care or action by staff. The care services manager feels that the care plans and recording have improved at the home, and following an inspection of another home in the group recently, she is advising managers to record something weekly in the daily records on the life of that person for that week. The accident book was seen and followed through in the relevant daily records. It was noted that there had been incidents affecting the well being of residents within the last two months (June and July 2006), which the commission should have been notified of. The manager agreed to complete one Regulation 37 notice to cover all the incidents. During a tour of the home meeting residents, the inspector was able to speak with several residents who indicated that they liked the home, with the exception of one person who wanted to ‘get out of here’. There were no staff in the vicinity to allay the anxieties. The same individual managed to leave the home whilst the inspector was there and was found quickly by the staff. Also whilst walking around the home an individual who was waiting to go to hospital was found to be laying across the bed with an armchair against the side of the Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 11 bed. Whist it was appreciated that the person was unwell and awaiting transport, the use of an armchair as a method of protecting someone from falling out of bed was inappropriate. In the lounge a resident was independent enough to walk across the room to obtain fruit however manoeuvring themselves with a frame and with one hand full caused some difficulties resulting in them falling into the chair. The inspector ensured that they were not hurt, whilst doing so a member of staff came into the room. There was also a malodour from the resident indicating that they had had an accident. The inspector discreetly told the member of staff. On discussing this with the manager the inspector was told that this was an issue for the individual and that they could be ‘changed every five minutes and it would still be a problem’. The medication records were seen and as there were 10 gaps since the middle of July 2006 where there was no indication of whether medication had been administered or not, the records were therefore not completed as per the homes policy. Medication was seen to be stored appropriately in a locked cupboard and blister packs were used. The home has bought a small trolley to use to transport the medication, with nothing being taken from its original packaging. There was no list of signatures of staff that dispensed medication so that the inspector was unable to identify who had administered medication. The home had medication that it had recorded in the Controlled Drug book Morphine Sulphate 10mg/5ml and Fentanyl patches 25mcg. There were gaps in the Controlled Drug book and in the MAR sheets. The homes policy states that two signatures must be in place for administering these medicines. Which is in line with Royal Pharmaceutical Guidelines for Controlled medications. The stock record however was wrong. There was evidence that Morphine Sulphate had come into the home on 17th July 2006, when the balance then became 430mls. At the bottom of that page on the 21st July 2006 the stock balance read as 360 mls. However the next page, still the 21st July 2006, shows that the stock was 95mls decreasing to a balance of ‘0’ on the day of the inspection with a comment ‘finished’ written in the stock column. However there were two 100mls of Morphine Sulphate in the Controlled Drug cupboard. The care services manager showed the inspector that staff had been spoken to on the 11th July 2006 about the medications records particularly the Controlled Drug records administration. An immediate requirement was made for this. The home is disposing of the Fentanyl patches in the sharps container on advice of the district nurse. The home does not have a policy or guidance for staff to support this. Staff were heard speaking with residents at lunchtime and around the home. Whilst sounding pleasant they were heard discussing personal issues such as pain relief in a communal area. A member of staff was also heard to speak over a poorly resident to an ambulance crew about her uniform. Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 12 The same resident was observed to have an armchair against the side of the bed to restrict their movement. Whilst acknowledging that there may have been a need to have something there was no evidence of a risk assessment in place and a chair is not an appropriate item to use. There had been concerns raised at the last inspection visit of the routine of the staff affecting the residents being able to make choices for example having to stay in their rooms for breakfast. Residents and the manager spoken with at the time felt that this had improved and that they were able to make these choices. Woodlands Rest Home DS0000049977.V300120.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 good. This judgment has been made using available evidence including a visit to this service. The home offers a variety of activities that are suitable for the needs of the residents. The home assists residents to maintain social contacts with the community and family. The meals in the home were balanced and offered a choice. EVIDENCE: On arrival at the home it was noted that the tables in the dining room were already set for lunch at 10:30 a.m. It had been felt at the previous two inspections in 2005 that this practice would discourage residents from coming down to breakfast if they wanted to and could also confuse residents who through their dementia, had problems with time and place. There was no evidence that the residents came into the dinning room during the morning until it was lunchtime, spending their time in the lounges or their rooms. The pre admission assessments for those new to the home indicated that ‘they were happy to have their breakfast in their bedrooms’. It was unclear if a choice had been given. The care services manager said that one person had chosen to come to the dinning room but because they were alone in this now have their breakfast in Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 14 their rooms. The residents spoken with at the inspections that were able to give an opinion said that this was not an issue for them. Many residents were in their rooms after lunch, ‘pottering around’, tidying up, watching television or listening to their radios, whilst four remained in the lounge helping themselves to drinks and fruit that were readily available. The registered manager has asked residents what activities they would like provided and following residents meetings an outing and a garden party are arranged. In house activities include regular visits by someone to take a keep fit class, do arts and crafts and activities that promote the wellbeing of older persons (NELE). The Patey group who work with those who have dementia attend fortnightly to carry out activities and a music man for singing attends regularly. All those spoken with said they enjoyed the activities that had been arranged. There is a new cook at the home and a monthly menu available. The menu offers choices daily and records are kept of choices, allergies, likes and dislikes. The residents said that they liked the food. Woodlands Rest Home DS0000049977.V300120.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 good. This judgment has been made using available evidence including a visit to this service. The manager has established a sense of openness at the home so that relatives, residents and staff can voice their concerns. The complaints and protection policies reflect the homes need to monitor and respond to issues. The lack of risk assessment with regard to the use of restraint places residents at risk. EVIDENCE: The care services manager stated that no complaints or allegations under the protection of adults had been received at the home. The inspector was able to confirm that the CSCI had also not received any concerns or allegations related to the home. Relatives spoken with felt staff treated the residents with dignity and respect. They were aware of the complaints procedure and felt comfortable about taking any concerns to the manager or staff. The complaints procedure was seen to be on display on the foyer of the home informing the reader how to make a complaint. The registered manager said the current in house policy and procedure for the protection of vulnerable adults has been reviewed as they needed to be revised. The home had a copy of Hampshire’s Protection of Vulnerable Adults Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 16 procedure so that the registered manager and staff could refer to it when necessary. The registered manager said all staff have read the revised policy and procedure and that it has been discussed at a staff meeting. Staff spoken with were aware of their responsibility to report any incident of abuse and could name the home’s policy that required them to do so. However it was observed that a resident had had a chair placed against the side of their bed. This is not an appropriate form of support and must be reviewed. (See previous section 7 - 10 of this report). Woodlands Rest Home DS0000049977.V300120.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 & 26 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The home’s bedroom accommodation was furnished and equipped satisfactorily for residents needs. The systems and procedures in place to ensure the accommodation was both safe and comfortable for residents use were satisfactory. Improvements can be made to remove hazards that prevent thorough cleaning. EVIDENCE: All residents spoken with were satisfied with the standard of their bedroom accommodation and the furnishings in the rooms. The furnishings of the rooms and décor were mostly in good repair. All bedrooms were fitted with carpets and they were naturally ventilated and heated by radiators. A tour of the home was undertaken and the inspector was able to see that that the rooms were furnished in a variety of ways offering a choice of Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 18 accommodation, new residents had been encouraged to bring their own furniture with them to make it more ‘homely’. The grounds outside were well kept offering several areas to sit. The laundry was seen and either care staff or the domestics carry out this function. Hand washing facilities for staff are situated in the laundry which was inaccessible due to laundry baskets and washing materials. Machines were available and they had settings to manage soiled articles. There is a sluice in the home for staff to use to clean commodes. There were several bottles of various toiletries in the upstairs shower room left on the side. Suggesting communal use and certainly a risk of sharing. The home was generally clean and hazard free with the exception of one area upstairs that had malodour. This was bought to the attention of the manager and care services manager. Woodlands Rest Home DS0000049977.V300120.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 adequate. This judgment has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers to meet the needs of residents at all times. Current recruitment practice does not fully protect residents at the home. Appropriate training is provided to ensure staff are qualified in understanding and meeting the needs of residents. EVIDENCE: A sample two-week rota was sent to the CSCI as part of the inspection visit. It stated that there are four or five staff plus the manager who work 8 – 4 pm, except weekends when there are four staff on duty. In the afternoons there are three staff 3.30 – 10 pm with a fourth person who works 5 – 8pm. At weekends the afternoon staff changes to four staff plus the person working 5 – 8pm. There are two staff on duty at night both awake. In addition there is a cook seven days a week and a domestic five days a week. The staffing levels appear to be adequate to meet the needs of the residents. The care services manager explained that they are trying to create a professional supportive structure at the home with a manager, senior care staff and care staff. They have implemented a new induction pack for staff based on ‘skills for care’ induction and training packs. New staff attend for a minimum of three supernumerary shifts at the home and begin to go through the induction portfolio. The first part is expected to take two weeks with the overall induction Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 20 taking twelve weeks. The induction standards are linked to the core standards of both NVQ level 2 & 3. The home received the ‘Investors in People Award in January 2006. The inspector sampled four staff files for those that had begun employment at the home since the last inspection in November 2005. Two files contained evidence of robust checks. One file had only one reference which was sought from a previous employer and faxed through to the home at the time if the inspection. The manager stated that she had obtained a verbal reference but had not followed up when a written one was not received. There was no evidence that a verbal reference had been received. The fourth file had no CRB or POVA check, this was found at the time of the inspection. This file also had no references, the individual had worked at the home previously but evidence indicated that they had left in October 2004 and returned in February 2006. The care services manager said that the company policy is that if employees return to the company within two years they do not request updated references. The inspector discussed this with the managers as it was felt that this was not safe and robust recruitment. That whilst the Care Standards Regulations only require that references are in place good practice would imply that any absence where a person has worked elsewhere would indicate that references should be updated. Staff have undergone training in several areas such as dementia, challenging behaviour, manual handling and food hygiene. Training requested and planned includes first aid and infection control. Woodlands Rest Home DS0000049977.V300120.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): Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The registered manager demonstrates her commitment to providing a good service for residents by her continued development and training. The registered manager is actively seeking the views of residents and is making decisions based on this information. The homes system for managing residents’ money is not robust to safeguard their financial interests. The registered manager ensures all safety checks are completed on a regular basis to promote the safety of residents and staff. EVIDENCE: Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 22 The registered manager has many years experience of working in care. She has completed an NVQ 4 in care and the Registered Manager’s Award. She was supported to manage the home by the care services manager, management team and senior care staff. In addition to her management training, she has also continued her personal development by completing relevant training and updating in such areas as first aid. However as demonstrated in the report areas of ensuring the correct delivery of care and documentation of this including medication, restraint practices, records for personal accounts are areas for management improvement. Questionnaires had been given to all residents or relatives and feedback from them are discussed at senior meetings of the care home group. Relative’s spoken with stated that they felt that action was taken as a result of this consultation. Staff meetings were also held and minutes from these evidenced that issues raised by the Commission for Social Care Inspection were discussed and acted upon. The provider carries out a monthly audit of the service. This includes asking residents for feedback about the quality of service they received. The manager showed the inspector the records kept in respect of any monies held on behalf of residents. An individual record of any income and expenditure was kept, together with any receipts. A previous recommendation at the inspection in November 2005 was that any money given by a third party should have the record signed by the third party to evidence the home had received the money. It was also recommended that the person carrying out the Regulation 26 visit should check a random number of accounts to see that the amount tallied with the written record. The inspector discussed these recommendations as it was seen in the records that this had not always taken place for a third party and not all by the person who carries out the Regulation 26 visits. Whilst sampling the records and monies the inspector found that one record indicated an amount and the actual amount of money available was £2 less. All records and monies were checked there was only the one that was not correct. There was one record, which was confusing, and because of this mistakes could be made. The system of looking after personal monies were discussed and the care services manager advised the manager to check all monies weekly and record the balance and she would do this monthly. The fire log recorded that regular testing of equipment was carried out. The home employs its own fire safety company to give staff fire training twice a year. Fire fighting equipment had recently been serviced. Information in the pre inspection questionnaire indicates that regular tests and maintenance is carried out on equipment in the home for example the lift. Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 23 Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 2 X X 3 Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 25 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. 1 Standard OP7 Regulation 15 (1)(2)(b) (c) Requirement The registered provider must ensure that daily records are written and concerns are followed through and give clear guidance to enable staff to consistently and appropriately meet the care needs of residents, especially in relation to health care needs. The registered provider must ensure that the records, stock and storage of Controlled Drugs kept at the home is safe and meets Royal Pharmaceutical The registered provider must ensure that a list is available of staff who administer medication. The registered provider must ensure that the records for administration of medication are maintained. The registered provider must ensure that there is a policy and guidance for staff on the use, recording of administration and disposal of Fentanyl patches. The registered provider must ensure that staff respect residents privacy and dignity DS0000049977.V300120.R01.S.doc Timescale for action 30/09/06 2 OP9 13(2) 26/07/06 3 4 OP9 OP9 13(2) 13(2) 26/08/06 26/08/06 5 OP9 13(2) 26/08/06 6 OP10 12(4)(a) 26/08/06 Woodlands Rest Home Version 5.2 Page 26 7 OP18 13 4(c) (6)(7) 8 OP26 16(2) (k) 13(3) 9 OP29 19 Schedule 2 16(2) Schedule 4 10 OP35 when discussing personal issues. The registered provider must ensure that residents are not restrained. Clear risk assessment must be carried out and guidance must be in place for staff to lesson risk areas. The registered provider must ensure that all areas of the home are adequately cleaned and maintained to avoid the risk of infection. Also that staff have access to hand washing facilities in the laundry. The registered provider must ensure that the residents are protected through a robust recruitment of all staff. The registered provider must ensure the safety of residents monies through a system of audits. This is a partial re requirement based on a recommendation from the inspection in 11/05. 26/08/06 26/08/06 26/08/06 26/08/06 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 OP35 Good Practice Recommendations 2. That the record of residents’ money is signed by the person putting money into the account and that the sums held are randomly checked against the record by the person carrying out the Regulation 26 visit. Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 27 Woodlands Rest Home DS0000049977.V300120.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Rest Home DS0000049977.V300120.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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