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Inspection on 13/08/07 for Woodleigh Manor

Also see our care home review for Woodleigh Manor for more information

This inspection was carried out on 13th August 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Case records were found to be comprehensive, include risk assessments and detailed care plans which are evaluated and have regular reviews of individual care needs documented. The home employs a full-time activities co-ordinator Monday to Friday, and there is a varied programme of activities documented in a diary. Positive responses were given both in the surveys and in conversation with residents about the activities provided which range from simple games of hoopla, to baking and weekly trips out of the home. The activities co-ordinator holds regular residents` meetings enabling residents to air their views about the services provided; a resident had chaired the last meeting and told the inspector she had thoroughly enjoyed doing so.Woodleigh Manor has an ongoing redecoration and maintenance programme and is clean, comfortable and homely which makes it a pleasant place to live. A gardener is employed for both outside and for tending the conservatory plants; a small area of the garden is tended by residents who have an interest in gardening and who have made and painted garden ornaments and plant pots to make the area attractive. The home`s approach to, and achievements in, staff training are to be commended. Staff turnover is very low with many staff working at the home for a lot of years. Comments taken from the survey forms and from conversation with the residents are all positive, e.g. "Staff make mum feel at home and go out of their way to ensure she has care 24/7, including through the night", "My friend has been encouraged to participate in various activities and they take her to places of interest/shopping etc", "Provides a good all round care service in a clean, well maintained environment; good quality meals", "Visitors are welcome at any time", "I don`t like rhubarb crumble but can ask for somethingelse and there is always fresh fruit", "Staff listen to you and resolve any problems".

What has improved since the last inspection?

The home has a good programme of ongoing redecoration and maintenance. A full time decorator is now employed between Woodleigh Manor and its sister home ensuring the home continues to be a pleasant place to live. Since the last inspection several bedrooms have been redecorated, as well as the dining room and corridor leading to the conservatory. Following government guidance regarding smoking in care homes, the provider has made the home "no smoking". People wishing to smoke are able to do so outside and the manager stated a covered facility is to be provided for the bad weather. A recommendation made at the previous inspection for resident photographs to be included in both case records and the medication administration records to aid identification has been addressed. A contract has been set up with a company to oversee health and safety in the home. One area of the home is being risk assessed every month until all areas in the home are covered. Some residents, following assessment, have proved not to be eligible for the issue of a wheelchair. However, the home has purchased additional wheelchairs to accommodate residents with limited mobility who have not been successful, and to enable them to have a better life in and outside the home. Two new washing machines and two new tumble dryers have been purchased making for an improved home laundry service. The home has had an additional toilet installed by converting an area which was previously used as a cupboard.

CARE HOMES FOR OLDER PEOPLE Woodleigh Manor Woodfield Lane Hessle East Yorkshire HU13 0EW Lead Inspector Pam Dimishky Key Unannounced Inspection 13th August 2007 09:15 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 Woodleigh Manor DS0000019776.V346920.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. Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodleigh Manor Address Woodfield Lane Hessle East Yorkshire HU13 0EW 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) 01482 359919 01482 359929 Hessle Properties Limited Miss Donna Marie Taylor Care Home 31 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (31) of places Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2006 Brief Description of the Service: Woodleigh Manor is a former large private dwelling set in pleasant grounds and situated in a residential area of Hessle approximately three quarters of a mile from the town centre, where there is a church, shops, restaurants, coffee bars and pubs. The home has been converted into a care home for older people some of whom may have a dementia type illness. Much of the building’s traditional character has been retained. The communal rooms, which include dining room, two lounges and a large very pleasant conservatory, are situated on the ground floor. Private bedrooms are situated on the ground and first floors and there is a passenger lift for less ambulant residents. Fees: £334.80- £381.30. Additional costs are charged for hairdressing (from £3.50), toiletries (various prices), newspapers and magazines (various prices), private chiropody (£10.00). Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information obtained from the pre-inspection material completed by the home, surveys completed by residents, relatives, staff, and care managers, information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home and from the site visit to the home on 13th August 2007. This unannounced site visit was undertaken by one inspector over one day; the site visit commenced at 9.15 am and finished at 2.05 pm. What the service does well: Case records were found to be comprehensive, include risk assessments and detailed care plans which are evaluated and have regular reviews of individual care needs documented. The home employs a full-time activities co-ordinator Monday to Friday, and there is a varied programme of activities documented in a diary. Positive responses were given both in the surveys and in conversation with residents about the activities provided which range from simple games of hoopla, to baking and weekly trips out of the home. The activities co-ordinator holds regular residents’ meetings enabling residents to air their views about the services provided; a resident had chaired the last meeting and told the inspector she had thoroughly enjoyed doing so.Woodleigh Manor has an ongoing redecoration and maintenance programme and is clean, comfortable and homely which makes it a pleasant place to live. A gardener is employed for both outside and for tending the conservatory plants; a small area of the garden is tended by residents who have an interest in gardening and who have made and painted garden ornaments and plant pots to make the area attractive. The home’s approach to, and achievements in, staff training are to be commended. Staff turnover is very low with many staff working at the home for a lot of years. Comments taken from the survey forms and from conversation with the residents are all positive, e.g. “Staff make mum feel at home and go out of their way to ensure she has care 24/7, including through the night”, “My friend has been encouraged to participate in various activities and they take her to places of interest/shopping etc”, “Provides a good all round care service in a clean, well maintained environment; good quality meals”, “Visitors are welcome at any time”, “I don’t like rhubarb crumble but can ask for something Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 6 else and there is always fresh fruit”, “Staff listen to you and resolve any problems”. What has improved since the last inspection? What they could do better: One resident’s special care needs were not reflected in the care plan and although the resident appeared, through conversation, to be having their individual needs met, until the care plan is amended the home cannot be sure staff have the information necessary to meet those needs. Staff should ensure the menu board in the dining room is always completed so residents know what to expect for lunch, tea etc. One resident commented it would be beneficial if toilets always had a receptacle for used paper towels after hand washing. Following refurbishment of the laundry the soap and paper towel dispenser have not been replaced; soap and towels need to be available at all times to prevent the spread of infection. Despite staff being well trained in medication procedures, errors were noted in entries made on the medication administration record sheets for two residents at the time of this site visit, and procedures should be improved to ensure the safety of the residents. Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The needs assessment process at the home is robust and thorough, enabling residents to be confident their needs can be met by the service. EVIDENCE: Three case files were seen for residents admitted since the last inspection. The manager explained she or her deputy usually make assessments of care needs with the resident and/or their relative or other involved party, either in the home or hospital, to ensure individual needs can be met before the resident moves into the home. However, apart from one social services assessment, the home’s assessment forms were not seen in any of the three case files and the manager explained one resident was admitted as an emergency and a care plan developed on arriving at the home and another came from the home’s sister home and was known to the manager. The previous inspection a year ago, reported pre-admission assessment forms were Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 10 seen in all the files examined. Resident and relative survey forms indicated they received information about the home and had the opportunity to visit before moving in. Copies of contracts were not included in the case file and were not examined as the manager stated these are kept by the home’s accountant; residents or their family have a copy signed by them and included in the welcome pack.The home does not provide for intermediate care. Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Care plans were examined for three residents who have moved into the home since the last inspection. These were seen to be generally comprehensive with evidence of monthly reviews, changes being made to the care plan as and when needed and risk assessments in place. Although one resident who has special care needs did not have these identified in the care plan and no mention was made in daily notes that any special care was being provided, in discussion with the resident it was apparent care needs are being met in all respects. The manager was advised regarding the need for staff to have the necessary information available in the care plan and for daily notes to provide the evidence the care provided meets individual needs. Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 12 All residents are registered with a general practitioner and arrangements are in place for other health service professionals to provide support and advice ie district nurse, chiropodist, annual visit by an optician (or resident’s own), weekly visits by a physiotherapist to individual residents and others who may have a need, annual dental checks for those with their own teeth and for others as needed, community psychiatric nurse and dietician. A representative from the Blind Institute visits residents who are visually impaired and gives support and advice to the home; links with a senior nurse from Dove House are also proving valuable. Medications were checked for the three residents being case tracked and generally found to be in order. However, errors had been made in entries on the medication administration record which showed drugs had been given, but due to the resident sleeping in, they had not been given; the manager stated she would look at the home’s procedures and ensure these are followed by staff. (The day following the inspection the inspector received confirmation from the home that the general practitioner had been contacted to ensure the omission of not giving the medication to the resident at the correct time had not had a detrimental effect on the resident). The home has a locked medication room where a locked and secured drug trolley and drug cabinet are situated. A record is being kept for medications returned to the pharmacist and the inspector suggested it would be good practice to ensure the record includes the strength of the medication returned, is dated when collected from the home and for any blank rows to be scored through so nothing else can be added. All staff responsible for giving out medications have had appropriate training through Hull College and receive updates from the pharmacist; from staff interviews and staff questionnaires, it is also evident arrangements are in place for receiving training and updates. From discussions with residents and staff it is apparent the principles of respect, dignity and privacy are understood and put into practice. Woodleigh Manor DS0000019776.V346920.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are, as far as possible, able to enjoy a full and stimulating lifestyle with a variety of options to choose from. Meals are well balanced and nutritious and cater for people with varying dietary needs. EVIDENCE: The home employs an activities co-ordinator all day Monday to Friday and a diary is kept of all the many varied events taking place. Trips out feature regularly and the home has its own mini bus which is adapted for wheelchair users. The week previous to the inspection three residents had gone to the Grimsby Heritage Centre and one of the residents told the inspector how much he had enjoyed the trip. Residents go out to lunch every week and a ladies darts teams competes with other homes. A visit to a local Pizza Hut had also proved to be very successful as they had opened especially early for residents to be shown how to make their own pizza and then to be able to eat it at lunch time. Arrangements have been made for a visit to the BBC studio in Queens Gardens and a guided tour has been booked. A minister from the Church of England visits every month and provides a service but also visits on an individual basis when requested. Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 14 The home operates a bath rota as a reminder to ensure everyone is offered a bath and the manager gave assurance that residents only have a bath according to their choice. Three residents spoken with confirmed they are able to have a bath when they want and also get up and go to bed when they want. All the residents spoken to said that staff provide very good personal care and always ensure privacy and dignity is maintained. Staff interviewed were able to describe how they give personal care to residents in a way which makes sure their dignity is respected. The activities co-ordinator holds regular residents’ meetings which allows residents to participate in decisions made about their life in the home.Relative surveys indicate the home helps residents to maintain contact with relatives and friends and residents stated their family and friends can visit at any time and are made welcome. One resident said her daughter visits every day. All the residents said how much they enjoyed the food and this was evident when lunch was observed. Chicken pie, turnip, mashed potato and green beans were on the menu at the time of this inspection and looked very appetising and nutritious. One resident said she did not like rhubarb but was always offered a choice of something else. Although there is a menu board in the dining room this had not been written up, but the cook visits the day before and writes down the residents choice of meal for the next day. Four weeks’ menus were examined and seen to include a standard choice of alternative to the main course, i.e. poached egg/omelette, cooked sliced meat and fresh fruit or yoghurt for a dessert. Residents said they can have their lunch either in the dining room or in their own room and staff were noted with trays delivering lunch to residents in their room; staff give assistance to those residents needing help. Woodleigh Manor DS0000019776.V346920.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system and there is evidence that residents feel their views are listened to and acted upon; safeguarding adults policies, procedures and staff training ensure residents are protected from abuse. EVIDENCE: Six complaints have been recorded since the last inspection and these were seen to have been investigated and satisfactorily resolved within the 28 day timescale laid down in the complaints policy; one complaint was upheld. Residents spoken to indicated they would talk to the manager if they were concerned about anything and from resident and relative surveys it is evident the home responds appropriately to any concerns. Staff interviewed confirmed they have received awareness training for Safeguarding Adults and the manager and her deputy have undertaken managers training on the subject. There have been no Safeguarding Adults referrals made during the last twelve months and the home has policies and procedures in place for Safeguarding Adults as well as a copy of the local authority’s policy, procedures and guidelines. Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a well-maintained, clean and comfortable environment which encourages independence EVIDENCE: The home is attractive, well maintained and has easy access to community facilities and services; the home has its own mini bus to facilitate this and for trips out further afield. A gardener is now employed to tend outside and the conservatory plants. A small area outside is looked after by residents who have an interest in gardening and although not a lot has been possible due to the inclement weather this year, last year several garden ornaments were made and painted by the residents and pots planted with geraniums. A range of special equipment is provided, either by the home or by arrangements made through the district nurse, including special mattresses, lifting equipment and wheelchairs. Some beds have been replaced with hospital style beds. Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 17 Although maintenance records were not available at the time of this visit, the manager stated there is an ongoing programme for redecoration and a fulltime painter and decorator is employed to work across both Woodleigh Manor and its sister home. Evidence of redecoration was noted during a tour of the premises eg dining room, corridor, and several bedrooms. Some gloss paintwork is badly damaged from wheelchairs and spoils the overall appearance in some areas. The laundry has had two new washing machines and two new dryers installed since the last inspection. The paper towel and soap dispensers have been removed and not yet replaced, although the manager said she would arrange for this work to be done as soon as possible. An area previously used as a cupboard has now been changed to a toilet. The kitchen was not inspected at this visit as the environmental health officer had visited the week before and the manager confirmed no requirements were made. However, the report had not yet been received and the manager agreed to forward a copy to the Commission when this arrived. Four residents’ rooms were not inspected as the resident had their own key and kept the door locked. Of those rooms seen, all were pleasantly personalised with the resident’s own belongings and items of memorabilia; residents spoken to said they were pleased with their room. The environment was noted to be clean and pleasant with no unpleasant odours. One resident stated there is not always a waste bin for used paper towels in toilet areas and the manager stated she would look into this. Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. EVIDENCE: Thirty residents were living in the home at the time of this inspection and were supported by sufficient numbers of staff on each shift to meet their needs. Staff interviewed confirmed they considered residents’ needs are being met by adequate staff being available at all times. One resident said “staff are always around when needed or within ten minutes”. Staff records were examined for three new employees and evidenced all the required checks and induction training had taken place to ensure residents are protected. The majority of staff have worked in the home for many years ensuring continuity for the residents and the manager puts staff training high on the home’s agenda. Fifty per cent of staff are trained to NVQ level II and a further three are to commence the training shortly; two members of staff interviewed are qualified to NVQ level III. The training programme was seen to schedule both mandatory and more specialist subjects through to February 2008; all staff have recently completed a course on understanding dementia. Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The manager has worked in the home for many years and is experienced, qualified and registered with the Commission; she has attained NVQ level IV in care and has the Registered Manager’s Award. Staff interviewed said “the manager is approachable and they receive good management support”. A survey form completed by a health professional stated “good support from the manager”. Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 20 The home has been awarded the local authority quality development scheme and has the Investors in People award. The provider visits the home daily and completes the monthly report required by regulation. Copies of recent months reports were given to the inspector at the time of this site visit. Residents meetings are held alternate months as part of the home’s consultation process. The home does not hold any monies on behalf of residents but they are provided with a locked facility in their room for any money valuables they wish to keep themselves. An information pack from the Care Aware Advisory Service regarding financial matters is given to all relatives and information is also displayed around the home. The home has a current employers’ liability insurance certificate displayed in the office which is current to 15th May 2008. Records were seen of fire alarm and emergency lighting tests taking place and certificates were seen for the passenger lift, mobile hoists, fire extinguishers and the landlord’s gas safety certificate which were all up to date. A poster regarding the use of bed rails is displayed in the office and the manager has obtained the current guidance for information; bed rails are not being used at the present time. Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 21 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X x 3 Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 22 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 OP8 Regulation 13 Requirement Ensure staff follow the home’s policy and procedure for giving out medication Timescale for action 13/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP8 Good Practice Recommendations It is good practice to record drugs returned to the pharmacy, for the record to be dated by the collecting person and for any blank lines on the form to be scored through The menu board should be written up every day so residents are reminded of their meals for the day To improve the overall appearance of the redecoration taking place in the home, gloss paintwork should also be completed Paper towels and soap should always be available in the laundry to prevent the spread of infection A copy of the report of the recent environmental health officer visit should be forwarded to the Commission for Social Care Inspection 2. 3. 4. 5. OP15 OP19 OP26 OP26 Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Woodleigh Manor DS0000019776.V346920.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!