Inspection on 04/05/05 for Woodlarks Workshop

This inspection was carried out on 4th May 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

Woodlarks Workshop 06/12/07

Woodlarks Workshop 13/03/07

Woodlarks Workshop 19/05/06

Woodlarks Workshop 30/08/05

Woodlarks Workshop 09/12/04

Woodlarks Workshop 15/06/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME ADULTS 18-65 Woodlarks Workshop Lodge Hill Road Farnham Surrey GU10 3RB Lead Inspector Vera Bulbeck Unannounced 04 May 2005 10:30am 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 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 Stationary 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. Woodlarks Workshop Version 1.10 Page 3 SERVICE INFORMATION Name of service Woodlarks Workshop Address Woodlarks Workshop Lodge Hill Road Farnham Surrey GU10 3RB 01252 714041 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Woodlarks Workshop Trust, Lodge Hill Road, Farnham, Surrey, GU10 3RB Mrs Moira Joan Woodage Care Home (CRH) 22 Category(ies) of Physical disability over 65 years of age (PD(E)), registration, with number 4 of places Physical disability (PD), 18 Woodlarks Workshop Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18 RESIDENTS WITHIN THE AGE RANGE OF 18 - 64 YEARS & 4 RESIDENTS 65 YEARS & OVER Date of last inspection 9 December 2004 Brief Description of the Service: Woodlarks Workshop is a care home offering personal care for people with physical disabilities who are mostly below the age of 65 years. The purpose of Woodlarks Workshop is to provide opportunities for service users to develop personal and independent skills in a setting where their social and emotional needs are met in a safe and supportive environment. The sheltered workshop facility is pivotal to the daily activities for service users, and the service additionally offers respite care. Communal lounges are light and spacious and there is a dining area where meals are served in two sittings. Bedroom accommodation is in single rooms. All have a designated living area, facilities for making drinks, a private telephone and a lockable storage facility. The building is on three levels served by two passenger lifts. The design of the environment is suitable to meet the specific needs of the service user group, many of whom have lived at Woodlarks for many years. There is a small gymnasium used for physiotherapy sessions and personal exercise. Woodlarks Workshop is situated in a semi rural location on the outskirts of Farnham, surrounded by well-maintained spacious grounds. Local shops and community amenities are within a short distance by car, and the home is accessible by rail, the station being located in the town. Woodlarks Workshop Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection to be undertaken by the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was over an eight hours and thirty minute period. The inspection was undertaken by Vera Bulbeck, lead inspector, with Damian Griffiths as the second Regulation Inspector. Mrs Morira Woodage the registered manager was the representative for the home. There are currently twenty residents living in the home and the majority have lived in the home for some considerable time. A meeting was held with all the residents, who engaged in conversation and some were very complimentary regarding the home and some of the staff members. Residents completed a service users comment card, which proved to be positive and some problems were identified, these are identified in the latter part of this report. Six members of staff were spoken to including a new deputy manager. A full tour of the premises was undertaken. Three care plans and three staff files were inspected. The inspectors were informed that the home is in the process of updating the statement of purpose, and the service users guide. It was disappointing to note that sixteen requirements remain outstanding from the previous reports 9th December 2004 and 15th June 2004. An inspection was undertaken by the (CSCI) Pharmacy Inspector on 17th June 2004 and a number of requirements were made. It was also disappointing to note that staff training on the administration of medication, was found to be still outstanding for some staff. Medication prescribed for one resident was used for another resident. The inspectors would like to thank the management, staff and residents for their time, assistance and hospitality during the inspection. What the service does well: The manager and staff have made real progress in the improvement of the physical environment for the residents. A number of areas in the home have had work undertaken, for example the security of the building has been addressed. The result is the front doors are now locked at the weekend to stop people wandering around the home unannounced. Routines in the home are flexible and residents make choices about how they wish to spend their time. Woodlarks Workshop Version 1.10 Page 6 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodlarks Workshop Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Woodlarks Workshop Version 1.10 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 standard(s) 1, 2 and 3. The home has a statement of purpose and service users’ guide. These documents, together with the home’s procedure of carrying out detailed assessments need to be updated. Information currently available for prospective residents is inadequate. The individual written contracts need to be revised to ensure that all relevant information is available. EVIDENCE: The homes statement of purpose needs to be updated and should include relevant information as detailed in The Care Homes Regulations 2001, Schedule 1. This has been an on going requirement. The statement of purpose needs to be separate from the Service users guide. Residents stated they had not received a copy of the service users guide. The document seen at the time of inspection needs to have details of how to contact the local Commission for Social Care Inspection (CSCI) office. Also extra costs need to be included in the document, for example hairdressing, phone calls, washing liquid for washing machines, dry cleaning and personal items. Prospective residents would find it difficult to understand the homes service user guide, as the document is lengthy and needs to be in a format for all the residents to read. For example some residents had difficulty completing service Woodlarks Workshop Version 1.10 Page 9 user comment cards, which, were used as part of the inspection process the inspectors were required to help complete and read. The inspectors sampled three care plans and it was noted that care plans are in need of updating and require more detailed information. On one care plan it had not been recorded that a resident had a fit and a fall, it was neither recorded in the accident book. Assessments had not been completed on all residents; because at the time they were admitted to the home there was no formal assessment procedure in place. It would be advisable for all existing residents to have a through assessment carried out in order to identify their current needs. Woodlarks Workshop Version 1.10 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 standard(s) 6, 8 and 9. There is still a lack of progress made to improve arrangements to ensure that the health care needs of residents are identified and met. These shortfalls have a potential to place residents at risk. EVIDENCE: Individual plans of care were available in several places, as the home is in the process of updating the care plans. These have been ongoing since the last inspection. Little progress has been made on the requirement to ensure that all aspects of health, personal and social care needs are identified and planned for. Two out of the three care plans had not been reviewed in the last six months. Plans do not appear to reflect some of the area of needs are not up to date and have not been regularly reviewed. Significant events in the home had not been recorded, daily entries into case records had not been made and entries made gave little indication of the actual care given. This was particularly evident for one resident where it had been recorded that a resident had a fit and fall. This was not recorded in the accident book or his care notes, and there was no plan on preventative measures. Woodlarks Workshop Version 1.10 Page 11 Risk assessments had not been completed on residents who are able to undertake a number of daily living tasks for example using the laundry, selfmedicating and making hot drinks in their bedrooms. A key worker system is in place and staff have the responsibility of helping residents achieve everyday goals, such as holidays or going shopping. It was noted by the inspectors on one of the residents daily record notes had not been completed for some days. Staff in a Key worker role helps residents to arrange social events of their choice hospital and GP appointments Residents commented should they have a problem they would talk to the registered manger or a member of staff. Woodlarks Workshop Version 1.10 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 standard(s) 13,14 and 15. Activity programmes are varied and on the whole are designed to meet individual need. Links with the families, friends and the local community are good. EVIDENCE: All residents have full and varied activity programmes. Examination of the home’s records confirmed a high degree of personal empowerment and choices in resident’s daily lives. They were encouraged and supported in the use of community amenities and in maintaining relationships with friends and families. The majority of residents attend woodlarks workshop and various adult education activities. Residents had access to a range of appropriate leisure opportunities in accordance with individual preferences. They were encouraged to pursue individual interests and hobbies. Staff attempts to maintain links with resident’s families. The home has maintained some good family links. There are no restrictions in terms of visiting times. There was evidence in the care plans that service users Woodlarks Workshop Version 1.10 Page 13 are supported to be as independent as possible, and are free to make decisions where possible. Woodlarks Workshop Version 1.10 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 standard(s) 18,19 and 20. Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. Policies and practices are in place for the administration and management of medications. However all staff administering medication require training. EVIDENCE: The practice of using medication prescribed to named individuals and used for another resident was observed and staff reported that they had been instructed to do this. This practice is illegal and places residents at risk, and may adversely affect their health and well-being. It was also noted that another resident’s medication had run out on 29.04.05, the medication administration record in the controlled drugs book indicated the drug had been administered on a regular basis until it had run out. It was also noted that residents who self medicate do not always lock their medication in the lockable facility provided. Staff must ensure residents are risk assessed and are aware of the regularities regarding medication. Medication procedures must be followed and staff training must be undertaken on all staff that administers medication. An immediate requirement on medication has been issued. Woodlarks Workshop Version 1.10 Page 15 Woodlarks Workshop Version 1.10 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 standard(s) 22 and 23 Residents are aware of the complaints procedure. Procedures were in place at the home. Some staff confirmed they had received the protection of vulnerable adults training. Further training is required in the handling and protection of vulnerable residents. EVIDENCE: There have been three complaints since the last inspection; the Commission investigated two for Social Care Inspection and one by the management of the home. All three complaints were partially substantiated. The home and (CSCI) received a complaint. The complaint was investigated by the home. However, the outcome of the complaint was not forwarded to the complainant. The record of the investigation was available and was found to be well documented. At the time of the meeting with the residents it was confirmed they would discuss any complaints with a member of staff or the manager. There were no recorded complaints in the home. The inspectors gave residents a comment sheet to complete and fourteen residents completed the sheet. A number of comments were regarding staff being rough and one member of staff shouting. Details of the comments were feed back to the registered manager on the day of the inspection. The majority of staff has completed the protection of vulnerable adult training. However, a senior member of staff who has been in post for three years had not completed the training. The manager informed the inspectors that training Woodlarks Workshop Version 1.10 Page 17 had been arranged for the senior member of staff and a new member of staff to complete. Three staff spoken with were aware of the vulnerable adult procedures and of the whistle blowing policy. Woodlarks Workshop Version 1.10 Page 18 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 standard(s) 24, 25, 27 and 30. Very little improvements have been made to the décor in the home. The outstanding requirements indicate that areas in the home need to be attended to. EVIDENCE: Since the previous inspection very little has been done to improve the environment of the home. At the last inspection it was identified that the locks on a bathroom and toilet door were broken. This is not acceptable for residents to use the toilet and bathroom without a privacy lock. The following shortfall were identified: • In one of the bathrooms the showerhead holder was out of the wall and in need of repair. • A blind was broken in another bathroom. • A number of radiators were without guards and one was exceptionally hot. • The majority of bins in resident’s bedrooms were unclean and some need replacing. • Carpets were in need of deep cleaning and some need replacing. Woodlarks Workshop Version 1.10 Page 19 • • • • The door was off the dining room and standing in the hallway. The inspector was informed the maintenance person was waiting for the hinges to be delivered. The door has been off its hinges for some time. The shelf under the sink in the kitchen is rusty and needs to be attended to this could be a potential health and safety hazard. The ceiling in the hallway and room 3 needs attention. A tile was loose on the roof at the back of the building, which could be a potential hazard if it fell and hit someone on the head. This was located near the ramp, which the residents use. Residents bedrooms were comfortable and homely, the majority of residents maintain their own cleaning and generally independent. However, on the day of inspection a number of bedrooms had washing littering the floor and the inspector advised the staff to be more vigilant and support residents and to provide a bigger washing basket instead of a small bucket to house dirty clothes. Some of the residents make their own drinks for example have an electric kettle. Residents need to be risk assessed to ensure they are safe and the area is safe to undertake this task. One bedroom has a small fridge. Residents commented they want to be independent and prefer the staff to let them manage if possible; some residents need more support from staff. It was noted in some resident’s bedrooms that rubber gloves were left in the room and in one bedroom the nurse’s surgical dressings were tucked under a dressing table. In full view. These articles should be stored appropriately out of sight. Woodlarks Workshop Version 1.10 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36. The procedures for the recruitment of staff are not robust enough and do not provide the safeguards to offer protection to residents living in the home. EVIDENCE: The staff need to have clearly defined job descriptions. The key worker system needs to be reviewed to enable staff to support some residents who require more help in maintaining their independence and ensuring residents are aware of health and safety issues. The management of the home has developed a training manual for all staff. A training programme was advised which would help to identify staff training needs at a glance. There are a number of staff that require further training, and some who have not received relevant training. There was no evidence that staff working in the home had received equal opportunities training, including disability equality training provided by disabled trainers and race equality and anti-racism training. This area must be addressed as a priority. The rota was examined and it was noted that a member of staff who was currently on duty until 2pm had worked from 5pm the previous day. The same member of staff was on the rota to work from 5pm until 9am the next day, Woodlarks Workshop Version 1.10 Page 21 having only three hours break. This was discussed with the manager who was advised to change the rota. Recruitment records have greatly improved since the last inspection. However, full recruitment procedures must be followed. A member of staff who commenced worked in January 2005 was without a POVA check or Criminal Record Bureau (CRB) application was not applied for until 16.02.05. Some staff files were without a recent photograph, and staff employed under a working permit, need to have details on file also notes of the interview need to be on file. The registered manager informed the inspectors that supervision on staff had commenced. However, staff when spoken to stated that supervision had been arranged but cancelled and some were not aware what supervision was. Supervision needs to be undertaken on a regular basis at least six times a year. The registered manager stated that supervision training had been organised for herself and the deputy manager to attend in September 2005. Appraisals need to be undertaken on a yearly basis. Woodlarks Workshop Version 1.10 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41,42 and 43. The leadership, guidance and direction to staff need to improve, to ensure residents receive consistent quality care. The shortfalls in the result of some practices do not promote and safeguard the health, safety and welfare of the residents living in the home. EVIDENCE: It was disappointing to note that sixteen out of twenty one requirements from the previous inspection had not been actioned, and will be carried over to the next inspection. The home must apply for a variation to registration to include a resident with a sensory impairment. The administrator manages the budget for the home; the records are kept up to date. Residents confirmed they receive a regular allowance and some residents manage their own finances with support. Woodlarks Workshop Version 1.10 Page 23 At the time of the inspection the inspectors discussed the need for the management of the home to hold regular meetings with the staff, and minutes of the meeting to be held on file. There are currently no recorded visits by the responsible person undertaken; therefore a number of issues in the home are not identified. The management of the home needs to produce an Annual Development plan based on a systematic cycle of planning. Regular residents meetings need to be introduced and minutes of the meeting need to be taken. It would be of particular interest to involve the support of an independent advocate, to enable the residents to speak freely. On the day of inspection the residents were given a comment card and fourteen residents completed these questionnaires. There were a number of positive comments regarding the management, home, staff and general issues some relating to the food and the serving process. This was discussed with the residents who clarified that they feel rushed plates are taken away as they put down their knives and forks. Policies and procedures were observed and some were found to be in need of updating, the last reviewed date was 2002. A number of records were examined these include: • The accident book, which was found to have recorded accidents, not signed by management or dated. The last recorded accident was dated 28/02/05. However, the handover book had recorded a resident to have had a fit and fall on 27.04.05, which had not been recorded in the accident book. • • • Fire records were up to date and management to ensure the homes risk assessment is up to date and includes the whole of the premises. The handover book was well documented. The security of the building was of concern to some of the residents particularly at weekends when there are no members of the management team on duty. There were a number of cleaning materials found in bathrooms, toilets and the kitchen, these must be stored in a lockable facility at all times. This was an immediate requirement. Residents who have been risk assessed to have cleaning materials in their bedrooms must ensure their bedroom door is kept locked so that other residents who may wander into their bedroom are safe from harm. In the kitchen there were opened packets of breakfast cereals on the shelf. All dried food must be stored in a sealed plastic container with a lid once opened. It was also noted during a tour of the premises that bars of soap were found in bathrooms. This practice is open to cross infection. Any bars of soap belonging to a resident must be kept in a soap container and specifically used by that resident. Version 1.10 Page 24 • • Woodlarks Workshop The laundry is automated and regulated by a liquid; a number of residents are able to use the machines without support. The washing machines are maintained by the gardener on a regular basis. This system was found to be easy to use and very little problem. However, the liquid cleaning system connected to the washing machine is prone to leakage and has damaged the floor and could be a potential hazard. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 3 x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 Woodlarks Workshop Score 2 x 3 Standard No 24 25 26 27 28 29 30 Version 1.10 Score 3 3 x 2 x x 3 Page 25 9 10 LIFESTYLES 2 x Score STAFFING Standard No 11 12 13 14 15 16 17 x x 3 3 3 x x Standard No 31 32 33 34 35 36 Score 2 2 2 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 2 2 2 Woodlarks Workshop Version 1.10 Page 26 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 26 (2)-(5) Regulation 43 Requirement For monthly unannounced visits to be conducted in accordance with this regulation by the Responsible Individual or other persons responsible for the management of the Trust. A written report must be produced of these visits, on the conduct of the home and a copy supplied to the registered manager and the Commission. (Time scale of 30/07/04 & 21/01/05 not met) All cleaning materials must be stored in a lockable facility at all times.(Timescale of 09/12/04 not met) Risk assessments required for service users using the laundry facilities(Timescale of 21/01/05 not met) A two-way lock is required on the downstairs bathroom.(Timescale of 17/12/04 not met) The carpet badly stained in a service users bedroom must be replaced (Timescale of 21/03/05 not met) A variation to registration to be applied for one service user with a sensory impairment(Timescale Version 1.10 Timescale for action 10.06.05 2. 13 42 04.05.05 3. 13 9 20.05.05 4. 12 27 20.05.05 5. 16 26 10.06.05 6. 24 37 20.05.05 Woodlarks Workshop Page 27 of 21/01/05 not met) 7. 19 34 Full recruitment procedures must be followed as required under Schedule 2. (timescale of 21/01/05 not met) The statement of purpose needs must be updated and include details as specified in Schedule(Timescale of 21/01/05 not met) The Responsible Individual is required to supervise the Registered Manager at regular intervals (Timescale of 21/03/05 not met) The Registered Manager is required to undertake Supervision & Appraisal training to enable more effective supervision of all other staff (Timescale of 21/03/05 not met) Risk assessments & reviews of service user’s individual facilities for making hot refreshments to be carried out, as on the day of inspection many of these were observed to be hazardous, with a kettle flex trailing over the service user’s bed in one instance (Timescale of 21/01/05 not met) All dried food must be stored in appropriate, sealed & lidded containers to prevent contamination.(Timescale of 17/12/04 not met) Meetings between the service user’s & the Home Manager must take place at regular intervals & a record retained of those present & the items under discussion (minutes).(Timescale of 21/03/05 not met) An Annual Development Plan is to be produced. (Timescale of 21/02/05 not met) Meetings to be undertaken Version 1.10 13.05.05 8. 4 1 10.06.05 9. 18 36 10.06.05 10. 13 35 10.06.05 11. 13 9 20.05.05 12. 16 42 06.05.05 13. 17 39 10.06.05 14. 15. 17 17 39 39 10.06.05 10.06.05 Page 28 Woodlarks Workshop 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 18 20 35 41 27 42 28 27 42 42 42 35 13 17 17 23 23 16 16 16 23 23 27. 28. 29. 30. 42 42 37 42 23 13 24 16 between all staff and the Home Manager on a regular basis and minutes of the meeting to be taken(Timescale of 21/03/05 not met) All staff to receive Vulnerable Adults Protection training. (Timescale of 21/03/05 not met) All staff administering medication must have appropriate training. A staff training and development plan to be implemented. The accident book must be signed and dated on all entries made. The bracket for the shower head needs replacing. All radiators must have protective covers. The community nurses equipment and dressings must be stored appropriately. A blind in the bathroom must be replaced. A number of bins in residents bedrooms must be replaced. The T.V stacked on books needs to be appropriately secured on a bracket. The dining room door must be repaired without delay. The door is currently standing propped against the wall in the entrance to the lift area. The shelf under the kitchen sink is rusty and must be attended too. A fire risk assessment to be completed on the whole of the premises. The manager to complete the Registered Managers Award. Key workers to be involved with residents over flow of laundry, which is currently left on the residents bedroom floor, a bigger laundry bag is required. Version 1.10 08.07.05 27.05.05 17.06.05 04.05.05 27.05.05 29.07.05 20.05.05 27.05.05 20.05.05 11.05.05 20.05.05 27.05.05 17.06.05 06.11.05 18.05.05 Woodlarks Workshop Page 29 31. 32. 33. 42 24 42 16 23 13 34. 42 16 Rubber gloves used by staff to be stored appropriately and not in residents bedrooms. The ceiling in a residents bedroom and the hallway must be attended to. Staff to ensure residents who self medicate and have cleaning materials in bedrooms, are kept locked. The computer room is cleared of rubbish and items currently stored. 18.05.05 17.06.05 04.05.05 03.06.05 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. Refer to Standard 42 Good Practice Recommendations All electrical sockets in service users bedrooms to be reviewed as on the day of inspection numerous plugs and use of adaptors/extension leads were observed (Recommended 09/12/04 still outstanding) Dressings and personal hygiene equipment was observed in service users bedrooms, on the floor and on open display. All dressings and equipment to be stored appropriately.(Recommended 09/12/04 still outstanding) The ceiling in the corridor and a service users bedroom was observed to be water marked. To be attended to under the ongoing maintenance programme ( Recommended 09/12/04 still outstanding) 2. 42 3. 24 Woodlarks Workshop Version 1.10 Page 30 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Woodlarks Workshop Version 1.10 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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