Inspection on 30/08/06 for Woodley Hall

This inspection was carried out on 30th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodley Hall 12/06/07

Woodley Hall 30/01/06

Woodley Hall 12/09/05

Woodley Hall 01/02/05

Woodley Hall 02/09/04

Similar services:

Ashlea Mews Residential Home

Eastwood

West Lodge

Arran House

Avenue Community Nursing Home

Cosin Lodge

Farmborough Court

Cragston Court

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

CARE HOMES FOR OLDER PEOPLE Woodley Hall 1 Gill Court Brunswick Village Wideopen Newcastle Upon Tyne Tyne & Wear NE13 7DU Lead Inspector Aileen Beatty Key Unannounced Inspection 09:30 30th August 2006 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 Woodley Hall DS0000000492.V291140.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. Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodley Hall Address 1 Gill Court Brunswick Village Wideopen Newcastle Upon Tyne Tyne & Wear NE13 7DU 0191 217 1749 0191 236 7495 managerwoodleyhall@careuk.com 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) Care UK Mental Health Partnership Limited (Arc Healthcare Limited) Vacant Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Registered Mental Nurse staffing coverage. All detained patients will have a Responsible Medical Officer. All detained patients will have a current Section 17 (Leave of Absence). Forms 38/39 (Consent to Treatment) will be in place. Detained patients will be regularly informed of their rights of Appeal (Sec.132). 30th January 2006 Date of last inspection Brief Description of the Service: Woodley Hall is a 20-bed Care Home, which provides nursing care for people with enduring mental illness. The residents are former patients of St Nicholas Hospital, no longer felt to be in need of acute care and able to be cared for in a community setting. Located in Brunswick Village to the north of Newcastle upon Tyne, the home is ideally situated for shops, pubs, a wildfowl park and other local amenities which include churches and a major national racecourse. The home is staffed by Registered Mental Nurses at all times. The fees per week are £616.66 Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 30th August 2006 and took 6 hours. The inspection involved a tour of the premises, discussions with residents and staff, and a review of records. The inspection found that the overall standard of care is good. 10 residents completed surveys. Most expressed satisfaction with the service. What the service does well: What has improved since the last inspection? New cleaning schedules are in use and the cleanliness in the home has improved. Some furniture has been replaced, so the home looks much tidier in some areas. The main kitchen records such as temperatures and cleaning schedules are now all up to date. This helps to ensure that the kitchen remains hygienic, and the food that is served is safe. Preventative care plans are now usually in place where a high risk is identified in assessments, for example to help prevent the formation of pressure sores. Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Intermediate care is not provided. Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. No service user moves into the home without having his or her needs assessed. EVIDENCE: All service users have their needs assessed before moving into the home. Copies of these are available in resident’s files, and a copy of terms and conditions of residency are publicly available in the foyer. The home enjoys close working relationships with St Nicholas Hospital, and no residents are admitted without them being sure that the home can meet their needs. As needs change a reassessment can take place, including admission to hospital if necessary. Intermediate care is not provided by the home so this standard was not assessed. Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 9 Standard two was not assessed but it was noted that three residents said in their survey that they had not received a contract upon entering the home. Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Needs are set out in an individual plan of care. Health care needs are fully met. Medication procedures are not always followed. Service users are treated with respect and their right to privacy upheld. At the time of their death service users and their family will be treated with care, sensitivity, and respect. EVIDENCE: Care plans for three residents were examined. They contained a good cross section of plans to deal with a variety of different needs and were selected for this reason. Plans to deal with mental health issues are detailed and reviewed regularly. A Psychiatrist visits the home, usually weekly, and care staff are well supported by qualified staff and managers to meet the needs of residents. Some concerns remain that the approach of some of the qualified nurses can vary depending who is in charge. This is potentially unsettling for residents Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 11 who may be confused by mixed messages. Care staff also need clear guidance about how to respond in some circumstances. It is very important that care plans are agreed and followed by all staff. This has been a problem for some time now, and has been raised at the last two inspections. Although there is no evidence of this adversely affecting residents, it does need to be addressed. Upon questioning staff there have been no opportunities for learning about new developments in the field of rehabilitation specifically. Again it is recommended that a record is maintained of training carried out by nurses, to demonstrate they are meeting the requirements of their registration and that their knowledge remains up to date. Some staff were vague about the exact remit of the home, and the overall philosophy of care. A new manager is in post, and training and development to look at these issues is planned. Physical care plans are detailed and up to date. Additional staff are on duty to help care for one very physically ill resident, who requires one to one attention at times. Where physical assessments highlight a risk to the health of an individual, a care plan is usually in place. One resident identified as at risk of malnutrition, has a care plan and also a contingency care plan in place, should their health deteriorate. This contains clear advice to staff and is an example of good practice. It was noted that one resident is at risk of developing pressure sores (sometimes called bedsores) yet no preventative care plan is in place. This is an outstanding requirement from the last inspection. A number of other people do have preventative plans in place. Residents appear well cared for, although the standards of dress and personal care vary depending upon the preferences of the individual. This is respected by staff, although residents are encouraged to maintain an acceptable standard of appearance. All residents wear their own clothing. Eight out of ten residents said that they always receive the care they need, one said that they usually do. Specialist advice is sought from district nurses, speech therapist, palliative care services (care of dying), and tissue viability nurses (to help care for people with pressure sores). A local continence advisor is being sourced. There are some unexplained gaps in medication records. A code should be entered to say why medication has not been given, such as refused. It was agreed that medication records will be regularly audited. Medication is provided by pharmacy at St Nicholas hospital. The box that it arrives in is not locked, and secured by a cable tie. Medication for disposal is returned in this box and it is recommended that a lockable medication box be provided. Unnamed eye drops and an antibiotic that was out of date were found in the fridge. This must be checked regularly and old stock removed. A random check of the controlled drug Temazepam was carried out and found the correct quantity. One staff nurse was observed administering medication with a student nurse. Advice and training was given to a good standard. Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 12 Residents are treated with respect. Staff are polite and helpful. Staff were noticed knocking before entering rooms, and addressing people by their preferred form of address. Most residents say that they feel well cared for. The home has a clear policy for caring for terminally ill residents. Where possible, residents will remain in the home so long as their physical needs can be met. Relatives are also supported during this difficult time. A letter to one relative about the serious illness of one resident was seen. It was informative and sensitive, offering maximum support and reassurance to the family member of a terminally ill resident. A record of what arrangements should be made in the event of a death of a resident is not currently recorded. It is recommended that the home consider this, involving family members if appropriate. Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users generally find their social, cultural, religious and recreational needs are met. Service users may maintain contact with family friends and the wider community with relative ease. Service users are usually helped to exercise control over their lives. Service users do not all agree that they receive a wholesome appealing diet in pleasing surroundings at times convenient to them. EVIDENCE: Of the ten residents surveyed, two said there are always suitable activities available, two said sometimes there are, and six said usually there are. Residents were doing various activities at the time of the inspection, including Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 14 watching TV, going to the local shop, asking for a taxi to go out, being escorted to visit a relative, and listening to music in their bedroom. A number of residents said that it is more difficult to go far as the taxi service from St Nicholas Hospital was stopped. While Woodley Hall is on a major bus route, a number of residents do not have the confidence to use a bus, or would require a staff member to accompany them. A number of people are used to using taxis which were previously available and are understandably daunted by using any other transport. It was also subsidised, and residents express concerns about the cost of private Taxis, although some are happy to pay. Photographs from outings displayed on walls are very old, and could be replaced with pictures from more recent trips. Despite this, residents use the nearby Bradbury centre, where they can go for coffee, and there is a pub relatively close by. A large convenience store is also nearby for essential items. There is a pleasant secure garden to the rear of the home. Residents are offered choices on a regular basis. Staff are also very responsive. One staff member overheard a resident saying he was thirsty, and immediately went over and offered him, and others around him a choice of drinks. The home is kept locked, and entry and exit is via a key-pad entry system. In the past, residents could have the number for the door, if they had been assessed as safe to leave the building unescorted. Currently no residents are able to leave independently, due to the risk of other more vulnerable residents following, or themselves getting access to the key code. It is acknowledged that this is a difficult issue, especially as at least one resident is otherwise almost entirely self -caring. It is something that the manager and deputy are aware of, and risk assessments will reflect why a decision has been taken for the doors to remain locked. It is recommended that this is continuously reviewed as the needs of residents may change. Eight residents said in the survey that staff always act upon what they say. Two said that they sometimes do, depending on the staff member. Regular residents meetings are held and minutes taken. One resident said that although promises are sometimes made at these meetings, they not always followed through. This concern was feedback to the manager and deputy and it was agreed that the minutes will contain the name of the individual responsible for ensuring action is taken. A choice of meals is offered to all residents. Three people said they always enjoy the meals in the home, six said they usually do and one said they sometimes do. One survey specifically stated that they would like to see an improvement in the standard of meals. Residents spoken to say that they do not feel the meals are always of a good standard. Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service user’s and their relatives are generally confident that their complaints will be listened to and acted upon. Service user’s are protected from abuse. EVIDENCE: A satisfactory complaints procedure is in place. This is on display at the main entrance, and in the information pack. It is also on some bedroom walls. Information about how to complain to The Commission for social care Inspection is also displayed. There have been no complaints since the last inspection. Despite this, some residents said that they are uncertain about how to make a complaint, so it is recommended that they are reminded of the process. Managers have previously encouraged residents to express any concerns they may have. Regular residents meetings are held, and some residents said that they felt that it was not always clear who was going to deal with concerns following meetings and ensure action was taken as agreed. Managers in the home agreed that it would be useful to identify who would be responsible for this at the meetings. Adult protection policies and procedures are in place, and were discussed more fully at the last inspection. Staff receive training in adult protection. Woodley Hall DS0000000492.V291140.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally safe and well maintained. Not all areas of the home are satisfactorily clean and hygienic. EVIDENCE: A tour of the premises was carried out, with all communal areas, kitchen. Laundry and clinic inspected. Some bedrooms were also seen, with permission from the occupants. Externally, there are a lot of weeds at the front of the home, and some in the rear garden. The rear garden is otherwise a pleasant place for residents, who were seen going into the garden via the patio doors. There are tables and Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 17 chairs, and garden shed at the bottom for storage. This was unlocked during the visit see standard 38. Internally, a satisfactory standard of cleanliness has been maintained in most areas. The kitchen areas on each floor need to be kept clean, cupboards and cutlery drawers and the fridges were grubby. All open items in the fridge had labels and dates. The main kitchen is clean and tidy. Cleaning schedules are kept up to date. Some new furniture has been purchased. Additional lounge and dining chairs in particular need to be provided as the current ones are heavily marked, or faded and mismatching. Residents said that some lounge chairs are uncomfortable. Some walls have been damaged with the back of armchairs, and look unsightly. A number of bedrooms were found to be clean, nicely personalised and homely. There is no longer malodour upon entering the building, but there is an odour problem in a small number of bedrooms. Managers are aware of this and agreed that this should be dealt with fairly urgently. The laundry was inspected and remains clean and tidy, dirty laundry is stored in skips, and commercial machines are available. All residents have their own laundry basket for clean laundry. There is a problem with storage in the home, the sluice is used on the ground floor to store items including sterile packs used for mouth care. It is recommended that these be moved to somewhere more appropriate. The extraction system upstairs appeared to be working more effectively, as the atmosphere appeared less smoky. Woodley Hall DS0000000492.V291140.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. 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 protected by the homes recruitment procedures. Staff are trained and competent to do their jobs. EVIDENCE: There are sufficient staff on duty. There are currently 70 hours of support staff hours vacant. Short staffing is met by agency staff, and the home tries where possible to use staff familiar to the home. Staff files were examined. All staff have a criminal records check and references are obtained prior to employment. Two staff files were examined and contain all of the required information. Student nurses are carrying out placements in the home. The home welcomes the attendance of students, and two were having their induction day on the day of the inspection. Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 19 The training programme introduced before the last inspection continues as a rolling programme. There remains an improvement in the regularity of training provided. There is a facility where qualified nurses can record their own individual learning and development. Not all nurses use these, but there is a new manager in post and training is an area that has been targeted for further development. Qualified staff confirmed that in addition to statutory training, advertisements for courses that may be of interest are made readily available to them. Staff files found that training has been delivered in moving and handling, Break away techniques, equality and diversity, adult abuse, first aid, fire safety, COSHH and use of syringe drivers. The manager and deputy demonstrate a commitment to the continuing development of the training programme. Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. A new manager has been appointed. The home is run in the best interests of service users. Service users financial interests are safeguarded. Staff are not always appropriately supervised. The health safety and welfare of service users are generally promoted and protected. EVIDENCE: Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 21 A new manager who is experienced in the field of mental health and rehabilitation specifically, has been appointed. They have yet to go through the fit person process with CSCI and will be doing the Registered Managers Award (RMA) The deputy who was acting manager before the appointment of the new one, has resumed their former role as deputy manager. The manager, deputy and nursing and care staff all commented that they looked forward to this period of stability in the home, and working together. The home is generally run in the best interests of residents. Staff are caring and approachable, and demonstrate through discussions with them that they genuinely want to provide a high standard of care. Staff must now strive to work together to achieve this and to further enhance areas of good practice. Some records are kept in dining areas for easy access by staff, these include daily records, and food and fluid balance records. These are not always stored securely. Service user finances continue to be administered by St Nicholas hospital and this appears to work well. Residents were seen asking for their money a number of times and there was no delay in them receiving what they wanted. Staff supervision systems have been improved. There were previously two systems operating at the same time, which was confusing. This has now been changed and is more user friendly and focussed. The standard that all staff must receive supervision at least 6 times a year has not quite yet been achieved, but there has been significant improvement. There are plans to further develop staff supervision and appraisal systems. Health and safety procedures are generally good. There are systems for the regular testing of equipment, water temperatures and electrical appliances. The lift is routinely serviced. Two new student nurses were being given the fire tour of the premises on the day of the inspection. Regular training is provided. The shed was again found to be unlocked, and contains hazardous items. This must be kept locked at all times, or hazardous items removed to secure storage elsewhere if this cannot be easily achieved. Staff receive training in challenging behaviour and “breakaway” techniques. Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 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 2 X 3 2 X 2 Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 2 Standard OP7 OP8 Regulation 15 (1) Requirement Timescale for action 30/09/06 30/09/06 Care plans must be followed consistently by all staff. 13 (4) (c) Preventative care plans must be in place where risk is identified during assessment. Medication recording, storage and disposal procedures need to be improved. Review menus in light of numerous comments from service users about the choices available. The programme of replacing furniture must continue until dining and lounge chairs are all satisfactory. OUTSTANDING All areas of the home must be kept satisfactorily clean, especially remote kitchen areas. Malodour must be addressed in identified rooms. All records must be held confidentially. Staff must receive formal supervision at least six times a year. OUTSTANDING DS0000000492.V291140.R01.S.doc 3 4 OP9 OP15 13 (2) 16 (2) (i) 30/09/06 30/11/06 5 OP19 23 (2) (b) 30/11/06 6 OP26 16 (2) (k) 30/09/06 7 8 OP37 OP36 17 (1) (a) 18(2)18(1 )(c) i 30/09/06 30/09/06 Woodley Hall Version 5.2 Page 24 9 OP38 13 (4) (a) Shed must remain locked or hazardous items removed and secured. 30/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP30 Good Practice Recommendations It is recommended that there is an up to date record of training carried out by nurses to meet the requirements of their registration. Consider providing replacement terms and conditions to those who say they do not have them. Consider including instructions from service users about what they would like in the event of their death, in care records. Individual and general risk assessments are completed which record whether residents may leave the premises unsupervised, and that they are reviewed regularly. Consider alternative storage for sterile packs. 2. 3 4 5 OP2 OP11 OP14 OP26 Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Woodley Hall DS0000000492.V291140.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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