Inspection on 01/11/05 for Woodlands Villa

This inspection was carried out on 1st November 2005.

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 Villa 19/12/07

Woodlands Villa 20/03/07

Woodlands Villa 17/02/05

Woodlands Villa 16/01/05

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Woodlands Villa 496 Loose Road Maidstone Kent ME159UF Lead Inspector Mrs Ann Block Announced Inspection 1st November 2005 10:05a Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 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 Villa DS0000024084.V262784.R01.S.doc Version 5.0 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 Adults 18-65. 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 Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodlands Villa Address 496 Loose Road Maidstone Kent ME159UF 01622 746295 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) Mrs Ellen Rose Russell Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 older person with a mental disorder whose date of birth 27/08/1934 Date of last inspection 12th July 2005 Brief Description of the Service: Woodlands Villa is a large detached property with accommodation on two floors for 10 service users covering an age range of 21 to 71, who have mental health difficulties. There are 6 single and 2 shared rooms. The owners live on the premises using an extension to the side of the house. The kitchen and laundry are shared between family and residents. Five additional staff are employed who, with family, provide 24 hour cover. There is a garden to the rear of the house, which service users can use. The home is located approximately 1½ miles from Maidstone town centre. There are shops, pub and a church within walking distance. There is a bus stop outside the house and car parking is available to the front of the property. Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The commission was represented by regulatory inspector Ann Block, who carried out an announced inspection of Woodlands Villa on Tuesday 1st November between 10.05 am and 3.40 pm. At the time of inspection, 9 residents, staff and the owners were on site, many of whom chatted with the inspector both privately and as a group. The inspector was able to join in a group activity which presented a good opportunity to observe excellent staff/resident relationships and joint working. The home is very much a family environment with residents seen to be relaxed and happy. The owners and a family member deal with management and necessary paperwork. Professionals hold the service in good regard, one person recently admitted said mental health professionals had recommended Woodlands Villa to him. A letter of support for the service, written by a care manager, was also seen in respect of a proposed placement. Comments received as part of the inspection included: ‘Woodlands Villa is a small care home with a friendly atmosphere. The food is good with encouragement to lead a happy fulfilled life in the community. We try an achieve attendance at an activity such as day centres each day.’ The atmosphere is like a family and it makes me feel I belong here. I like it very much and I am very happy here. The inspector is familiar with the service. Many standards were assessed at previous inspections. Evidence based on these assessments has been incorporated in this report where it remains applicable. What the service does well: The service is particularly good at getting the balance right between residents having their independence yet being supported by encouragement and prompting. The admission process is staged to make sure that the resident knows whether the home will be right for them with pre admission visits and overnight stays. Both mental and physical health is monitored and action taken where there are problems. Residents consistently said that they liked the home. They feel well supported by the owner and staff and like the family environment. The service has very good relationships with the local mental health team which also offers advice and back-up. There are many Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 6 opportunities to follow recreational, social and educational activities and to work part time within receipt of benefit guidelines. Residents can keep contact with family and friends. Residents like having group support both in house and locally. When they move out, they can keep links with Woodlands Villa if they wish. The owner and staff are fully committed to providing residents with a good quality of life in a homely environment. What has improved since the last inspection? 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 Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard 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 Residents have good systems to support the move into a residential setting. EVIDENCE: Residents and placing agencies have written information about the service to support the process of moving in. Moving in is very carefully planned starting with meetings between the owner, the prospective resident, family if applicable and relevant professionals. A file for a proposed admission included comprehensive detail of previous history and current needs recorded by the care manager, incorporating information from a range of professionals. The owners ensure they meet the prospective resident both at Woodlands Villa and at the current placement, often a mental health hospital ward. Following initial meetings, there will be a process of visits to Woodlands Villa from having a meal to staying overnight. The system for moving in helps the prospective resident to get to know the owners, other residents and staff. The process aims to reduce any anxieties the resident might have and to assess whether the persons needs can be met at Woodlands Villa. Staff are part of the assessment process, being asked for their general opinion regarding prospective residents. Residents said any new resident would only be admitted if they fitted in with the existing group and would benefit from a home like Woodlands Villa. As part of the moving in process, residents are encouraged to bring personal possessions with them. Staff consider they are given good information about new residents by the owner and have the report book to refer to if necessary. Staff are confident they have the skills and knowledge to Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 9 care appropriately for residents who have been admitted. Given the environment, possible risks to people already living there and previous experiences, emergency admissions are not accepted. The majority of residents have a contract between the owner and themselves. The owners worry about the validity of contracts where the resident doesn’t fully understand contract terms. Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 & 10 Residents direct their own lives with the support of a team who know and respect individual choices. EVIDENCE: Each resident has a care plan provided by the placing agency. A brief record of the day is made for each client. Staff have access to care plans but are more likely to use information shared through the report book and handovers. The staff team is very small with the owners and family as consistent figures, hence information is easily shared on a day-to-day basis. Staff have a good understanding of the current needs of each resident. General and individual discussion with residents confirmed that staff and residents understood agreed goals and how these might be achieved. The emphasis in the home is that residents must direct and as far as possible manage their own lives, but with the support of staff. Many residents say this is one reason why Woodlands Villa appeals to them. Staff are expected to work with a resident towards independence but only as far as the resident chooses and can cope with. The owners understand how frightening it can be for a resident to be pushed towards independence quicker than they are able and how this can have a detrimental effect, not only to the resident concerned but to the whole group. Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 11 One resident chose to move into a more independent living setting and maintains regular contact with Woodlands Villa. The owners say that they will always be available for former residents. They are currently looking at ways in which they can offer a planned transition stage between full residential care and independent living. Residents say they like being in a group where there is both staff and peer support. As part of the semi-independent lifestyle, informed risk taking is encouraged. Where there is a significant risk, action will be taken liaising between the resident and professionals as necessary. Where any risk might restrict life for other residents, this is explained to the group. From previous experience of the service, residents are only too willing to help each other in such respects. Practices both verbal and written, maintain core resident confidentiality. Being such a small homely setting, residents and staff share information more openly than may be found in larger more impersonal settings. Residents are able to decide who to disclose information to, to the point where families may not be included if that is the choice of the resident. All staff are required to sign up to a confidentiality statement. Staff support residents to manage their financial affairs but have no other direct involvement other than acting as agent at one resident’s request. Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 & 17 Residents have a good quality of life with opportunities for social, educational, emotional and recreational experiences. EVIDENCE: Personal development is encouraged to build up self esteem and where appropriate as part of moving towards more independent living, whether that be in the home or elsewhere. Residents take on responsibilities such as cleaning their room, doing their washing and ironing, being encouraged and supported to take their medication correctly, managing their own finances, attending appointments and general life situations. Staff are aware that their role is to support and encourage residents in agreed tasks rather than doing it for them. Staff recognise that to act as support and motivator is often quite challenging and stressful, but realise through this support residents’ develop skills and gain confidence. Certain practices such as washing up by hand, putting washing out on the line to dry, peeling fresh vegetables etc, are designed to familiarise residents to a lifestyle they might follow if they move on. These tasks also provide exercise, social skills and motivation to complete Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 13 the task as part of personal development. The owner and staff explained how certain medication might affect motivation and how this would be managed. Residents and staff referred to close liaison with mental health professionals to ensure the right approaches were being taken. Residents again spoke of opportunities in the area to meet people with mental health needs and otherwise such as Choice Industries, the Blackthorne Trust, volunteering in a charity shops, doing a paper round, attending college and helping with catering at a day service. Residents said they had had outings to the pub, to concerts and shopping. Discussion was held in the group whether the voucher giving 10 off a meal at the pub over the road might interest them. Christmas shopping trips are being planned, negotiation is taking place whether the main outing will be to Maidstone or Bluewater. Residents generally use local transport, as they would be likely to if they moved out. All but two residents chose to have a holiday at Butlins earlier in the year which they really enjoyed. Discussion was underway whether they might go again in December. One resident is going on a day trip to France with colleagues. Where the resident wishes, contact with family and friends is encouraged. The owners do all they can to make sure residents can meet up with family, including meeting someone half way, inviting them for a meal and offering general hospitality. Residents talked of keeping in touch with friends, one resident recently had three friends round to visit. It had already been recorded that a prospective resident wishes to be called James ‘never Jim’. Privacy is fully acknowledged, both in accessing rooms and in daily lives. Staff and residents work and chat together. The owners say that as they live on the premises, this promotes the family feel. The main meal has been moved to the evening, as so many residents are out during the day. Staff or the owners cook the meal. Residents said the food was based on ‘good basic English home cooking’. Individual preferences are known including that one resident is ‘semi vegetarian’. Choices, such as a salad, are available. Drink making facilities are provided in the dining room. Residents helped themselves to drinks, both hot and cold, throughout the afternoon. They have use of a fridge in the dining room where they can store their own food and drink. A tuck shop is planned for the winter months as it is considered an unacceptable risk for some to go out to the shops in dark evening just to get fizzy drinks and chocolate. The residents will manage tuck shop sales themselves with the owners restocking from the cash and carry. Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Residents’ medical needs are well managed and promote good mental and physical health. EVIDENCE: Minimal personal care is needed; staff roles are more in prompting and reminding. Residents choices regarding times of getting up and going to bed are respected, but prompting will be given to meet agreed day activities. Residents said they had a certain day when they had to clean their room but they could bath or shower at any time. Meals tend to be at fixed times but will be held back if necessary. Staff are aware of individual preferences in daily routines and respect these. Residents wear their own choice of clothes but will be encouraged to present themselves appropriately for the occasion. One resident was pleased with the clothes a member of staff had purchased on his behalf, as he found it impossible to get reasonably priced clothes in his size locally. A situation at a previous inspection evidenced that health needs are very well attended to, often with the cooperation of the group. Health appointments are promoted with residents previously having talked about appointments with a variety of health services. The owner said they had explained to a proposed resident that he would be expected to attend appointments to maintain his physical and mental health. Medication records Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 15 are held in two formats, one a printed medication record provide by the pharmacy, another a record where dosage varied according to blood tests. A minor omission was recognised as not good practice but had resulted from the sleep in person and residents being distracted by a joint late night feast. Medication is stored in a lockable cupboard. All staff administering medication have had training. At the last inspection staff talked of the need to check medication received was correct and the action to take if it was not. The effects of medication on residents, especially in relation to mental heath, was understood and built into daily routines. Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Residents are protected from the risks of abuse and can complain and be listened to. EVIDENCE: Residents have access to a complaint procedure which gives contact details. The most usual format for making comment about the service is on an ad hoc basis to the owners. Residents consider they will be listened to. The owners also assist residents to complain externally where residents feel they are not being given the service they should. Staff have access to the revised Kent and Medway Joint Working adult protection policy, supplemented by an in house policy. Staff have a good understanding of the forms abuse can take. Residents feel they are protected from abuse both in the home and elsewhere through the support and understanding of the owners and staff. The effects of historical abuse and self harm are taken into consideration when planning care and support for a resident. The reasons for increased aggression leading to possible self harm are understood and diversionary tactics used. Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 & 30 Residents have a homely, domestic and relaxed environment in which to live. Safety will be improved when a full fire risk assessment is carried out. EVIDENCE: Woodlands Villa was formerly a private house and remains based on that style of property, having a homely and relaxed feel. It blends in with the local area and has good access to both local and town centre facilities. Staff carry out cleaning of the communal areas and support residents to clean their own rooms. A rota is displayed to record what cleaning has been done, including monthly ‘deep cleaning’ of the kitchen, laundry and bathrooms. Redecoration is carried out on a planned basis. Residents have use of a lounge with comfortable seating and TV and video, a dining room, quiet room, conservatory and garden. There is a small office and a separate staff/visitors toilet. The owners’ private accommodation can be accessed from ground and first floor level. Consideration is being given to changing the owners accommodation to become a three bedded semi independent unit with its own bathroom, kitchen and small living room. A stair lift remains from previous use as a home for older people; it is considered that it this might be useful in the future. There are 6 single and two shared rooms. Residents in the shared rooms again expressed a definite opinion that they preferred sharing, as they Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 18 liked the company. Each room has suitable storage for clothing, space to display personal effects and a washbasin. Rooms are personalised to the resident’s choice and can be locked. There is a bathroom with toilet on the first floor and shower room on the ground floor. One room has an en suite shower which isn’t used. There are separate male and female toilets on the ground floor. There is a laundry area with washer and drier, during the summer clothes can be hung outside to dry. The laundry room is a through route from the front door and fire exit, hence staff and residents make sure the area is kept free for emergency access. In order to promote safety, smoking is not permitted in residents’ bedrooms, the lounge or dining room with residents reminded of the rules. A simple fire risk assessment has been carried out, a full fire risk assessment as required by law, must be carried out. The latest Environmental Health Officer visit recorded that standards were ‘satisfactory’. Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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 Residents are supported in their daily lives by committed and motivated staff. EVIDENCE: The small staff team all hold the same status working under the direction of the owners. Residents said they like the staff, there was evidence of very good working relationships. Staff understand their roles and responsibilities. At the last inspection in July, a member of staff on duty said that she had worked at the home for about 10 years, including time when it catered for older people. She felt she had been provided with the training needed to work with people with mental health problems and was comfortable in her role. The owner said that all staff have had training in mental health awareness and core training. Following the collapse of an NVQ training provider, personal circumstances have affected staff pursuing another provider. Staff feel they have gained experience by working at the home and from the owner, who they considered had a good understanding of the client group. At previous inspections staff have referred to regular supervision with the owners daughter where they could discuss training needs. The owners are regularly available working with staff, hence work practice supervision is routinely carried out. In the past staff have been employed through connections with the home and the owners, as the owners feel better able to assess attitude to the client group. A personnel file of a family member employed as support worker included two Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 20 written references and contract of employment. An application form is available for use if necessary. Staff have criminal records bureau certificates. Staff work a set roster, some working 12 hour shifts. At least two staff are on duty at all times. Funding has recently been agreed for one to one support for a resident when in the community during any stage of increased vulnerability. The owner and other staff cover holidays. The owner’s son covers night duty from 8 to 8. The owners, or another qualified family member, would be on call at all times. Staff felt they had sufficient time to carry out their domestic tasks and to take residents out. Staff are aware of disciplinary and grievance procedures and that these will be activated as necessary. Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 & 43 Residents’ quality of life benefits from a well managed, safe service held in high regard by professionals. Safety will be better evidenced when staff are recorded as attending regular fire practices. EVIDENCE: The service is essentially family run with the owners and two sons living in an annex to the property. One of the owners holds key responsibility as owner/manager. She has many years experience in the care sector, and although working with adults with mental health problems is still relatively new, has a good understanding of their needs and is well liked by residents. She has decided that due to her age and collapse of an NVQ provider, she will not pursue the registered managers award. Residents consider that the owners are approachable and understand mental health needs well. Residents like the balance between having freedom yet feeling supported. The residents and staff group are supportive of each other and showed both consideration and respect for each other and the process of inspection. Residents are asked formally for their views of the service through questionnaires. Some residents Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 22 meetings have been held, the owner feels that mealtimes offer a better chance to have a chat about the service. It would be useful for the owner to obtain views of the service from professionals, especially as professionals hold the service in high regard. A file of policies relevant to the service are held, staff are expected to read and be familiar with policies relating to their work. Essential records are held safely in the office. Whilst photographs of residents and staff are available in the house, it would be more useful for these to be consistently put in the relevant files. Records of servicing and supplies showed that routine maintenance of equipment and services, including portable appliance tests, are in date. Staff and residents said that repairs would be carried out as necessary. Since the last inspection the light fitting in the kitchen has been replaced. Testing of fire safety equipment is carried out by an external contractor and in house on a weekly basis. Staff on duty at the time fire practices are held are not recorded to evidence they remain familiar with evacuation procedures. Suitable employers liability and general insurance is held. Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodlands Villa Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 2 1 3 DS0000024084.V262784.R01.S.doc Version 5.0 Page 24 No Are there any outstanding requirements from the last inspection? 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 Regulation Requirement A fire risk assessment as required by the Fire Workplace Regulations 1999 (as amended) must be carried out. It is recommended that the completed risk assessment be sent to the local Fire Safety Officer for his approval. A record must be held to evidence that all staff have attended regular fire practices. The record must be maintained from 7/11/05 and thereafter Timescale for action 31/12/05 24.11 23 (4) (a) & (c) 2 42.2 23 (4) (e) 07/11/05 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 2 Refer to Standard 20.6 32.5 Good Practice Recommendations Care should be taken that all medication is signed for on administration When circumstances allow, staff should undertake NVQ DS0000024084.V262784.R01.S.doc Version 5.0 Page 25 Woodlands Villa training. 3 4 41.1 39.2 Views of professionals should be included in the quality assurance process Records of staff and residents should have a recent photo, as required by regulations 17 and 19, held where it is easily accessible for the processes of inspection. Woodlands Villa DS0000024084.V262784.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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