Inspection on 16/11/06 for Woods Court Care Home

This inspection was carried out on 16th November 2006.

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.

Other inspections for this house

Woods Court Care Home 09/01/09

Woods Court Care Home 15/11/07

Woods Court Care Home 22/02/06

Woods Court Care Home 08/09/05

Woods Court Care Home 25/03/05

Woods Court Care Home 02/02/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Woods Court Care Home Hatton Gardens Newark Nottinghamshire NG24 4BP Lead Inspector Richard Ramsden Unannounced Inspection 16th November 2006 09:30a 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 Woods Court Care Home DS0000035542.V319768.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. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woods Court Care Home Address Hatton Gardens Newark Nottinghamshire NG24 4BP 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) 01636 673548 01636 673548 Nottinghamshire County Council Miss Caroline Ann Falshaw Hobson Care Home 49 Category(ies) of Dementia (20), Dementia - over 65 years of age registration, with number (20), Old age, not falling within any other of places category (49), Physical disability (10) Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Out of the total number of beds (49), there will be 20 beds for DE 55 and over and/or DE(E Out of the total number of beds (49), 10 may be used for PD 55 and over A maximum of 5 PD 55 years and over to be accommodated outside the intermediate care unit Service users shall be within category OP Date of last inspection 22nd February 2006 Brief Description of the Service: Woods Court is a care home providing personal care and accommodation for 49 older people, 10 of which receive intermediate care. It is owned and run by Nottinghamshire County Council Social Services. The home is located within easy walking distance of Newark town centre where there are a variety of shops and facilities. The home was opened in 1988 and consists of a two-storey purpose built property, divided into five units. There is a shaft lift to assist independent access between levels. All of the bedrooms are for single occupancy, with wash hand basins. None of the rooms have ensuite facilities. The gardens are well tended and are accessible by service users. The inspector was advised that there is a secure garden area leading directly of one of the units, which has been specially designed for people who have dementia. The monthly accommodation charges for those residents who are self funding would be £1,508 per calendar month. A copy of the most recent inspection report was available in the home. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector completed this unannounced visit over one day it took approximately 8 hours. It included the inspection of care and of the records, a discussion with the registered manager, two team leaders, two members of care staff, the administrator and the cook. The inspector spoke with five residents and one visitor to the home. A partial tour of the building was also completed. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history and a Pre-inspection questionnaire completed by the registered manager. Eighteen completed residents satisfaction questionnaires were also received prior to this inspection. This inspection also included a thematic inquiry as part of a national pilot scheme. This consisted of asking a number of standardised questions to a sample of residents. The registered person was informed and the agreement of the residents was sought before asking a set of questions about the care they received. What the service does well: The residents spoken with during this inspection were very complimentary about the services provided by the home. One person said that they were grateful to live in the home, as it is an excellent place. They said that staff ensures that they always have a good time and that in their opinion they couldnt live anywhere better. Another person stated that “ the staff are goodness itself from top to bottom they cannot be faulted” All of the residents spoken with, stated that the staff are always friendly and respectful and confirmed that they ensure that residents privacy and dignity is maintained at all times. The purpose-built accommodation is maintained to a good standard. It is comfortably furnished and reasonably decorated. All of the residents spoken with said that they liked their bedrooms and confirmed that they had been encouraged to personalise them with small items of furniture photographs ornaments etc. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 6 People confirmed that they could have visitors at any time and that their visitors are always made welcome. One person said that her son regularly has Sunday lunch with her in the home and that this year he will be having his Christmas dinner with her in the home. The meals provided by the home appear wholesome and nutritious. Residents stated that the cook regularly asks them if there is anything special they would like to have included on the menu. People said that there is always a choice of food and that alternatives will be provided if they do not want the food suggested on the menu. One visitor said how impressed they were at the time and effort that the cook had taken to ensure that their relative got the specialist diet she required. The manager is very well qualified and experienced and ensures that the home is run in the best interests of the residents. The home is committed to providing appropriate training for staff. The records show that 65 of the staff have completed their NVQ training. There were many aspects of good practice highlighted in the main body of this report. What has improved since the last inspection? What they could do better: Residents care plans must contain sufficient information and be reviewed regularly enough to ensure that staff are always aware of what support and assistance each resident requires. It would be good practice to encourage residents to sign their individual care plans to confirm that they have been involved in the care planning and review process. Risk assessments must be completed with all residents who wish to administer their own medication. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 7 The registered person should look at ways of ensuring that all prospective residents receive sufficient information about the home for them to make an informed choice about whether they wish to live in the home. It would be good practice to display a programme detailing all activities, entertainment and outings to be provided for the residents on a monthly basis. This would enable residents to decide which activities they wish to participate in. A central record of all complaints should be kept to provide an overview of the nature and frequency of complaints received. The registered person should produce a development plan for the home and must inform the commission for social care inspection of any serious incidents that occurred within the home. 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. Woods Court Care Home DS0000035542.V319768.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 Woods Court Care Home DS0000035542.V319768.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): 1,2,3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Not all prospective residents are receiving sufficient information about the home to enable them to make an informed choice about whether the home will meet their needs. All residents are provided with written contracts/ terms and conditions of residence. Residents’ needs are appropriately assessed prior to moving into the home. The intermediate care service is helping to maximise residents independence and where possible and enable them to return home. EVIDENCE: The literature available to prospective residents contains sufficient information to enable them to make an informed choice as to whether the home will meet Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 10 there assessed needs. However in the service user questionnaires received prior to this inspection six people stated that they did not receive sufficient infornation about the home before their admission. The manager agreed that some residents are being admitted to the home without first receiving the homes literature. She stated that wherever possible people are encouraged to visit the home prior to their admission or staff visit them in their own homes. However as the home has a wide catchment area this is not possible for all residents. The manager was advised that she must look at ways of ensuring that residents always receive the homes Service User Guide prior to their admission. The intermediate care unit has separate facilities and is geared to help maximise resident independence and where appropriate enable them to return to their own homes. The unit offers a multidisciplinary approach and is joint financed by social services and the health authority. The manager was reminded that if any risks are identified for the individual residents in the intermediate care unit, appropriate, individual risk assessments must be produced. The risk assessments must, where possible, identify ways of reducing the risk and inform staff of what assistance and support they must provide. One resident in the intermediate care unit said that he was very satisfied with the services he had received, he stated that he had completed a home assessment and hoped to return home in the near future. In response to thematic inquiry question-: Two of the residents spoken with could not remember if they had been given an up-to-date copy of the Service User Guide. One person confirmed that they had been given this information prior to their admission to the home and that staff had discussed the issues with them as part of the admission process. A copy of the Service User Guide was included in each resident’s bedroom, viewed during this inspection. People stated that they did not know if there had been any changes to the cost of their care as their families dealt with their financial affairs. Everyone confirmed that this was a decision that they made as part of the admission process. Two people did not know if they had been given a contract or a statement of terms and conditions of residence, one person confirmed that she had received this documentation. None of the people spoken with knew whether the information in the terms and conditions of residence documentation had change since they came to live in the home. Copies and signed contracts were available in each residents file viewed during this visit. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 11 Two people said that their needs had been assessed prior to their admission to the home one person who has lived in the home for many years could not remember if anyone chatted to her about her care needs prior to their admission to the home. Pre admission assessments had been obtained for all residents whose records were viewed during this inspection. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all care plans contain sufficient information and are reviewed frequently enough to ensure that staff have sufficient up-to-date information about the care and support each resident requires. Residents’ health care needs are being met. The homes medication systems are generally well maintained, however appropriate risk assessments have not been completed with all residents who wish to administer their own medication. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: Four residents care plans were viewed as part of this inspection. One of the care plans did not contain any details of the residents needs during the night; two of the care plans were not being regularly reviewed. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 13 When checked it was noted that the first resident had previously had a ‘night’ care plan but this had not been transferred when the main care plan had been reviewed and updated. It is essential that care plans contain sufficient up-to-date information to ensure that staff are always aware of what support and assistance each resident requires. Not all residents, or where appropriate their representatives had signs the individual care plans to confirm their involvement in the planning and review process. The residents spoken with during the inspection said that they believe their health care needs are being appropriately met. This was also confirmed in the records viewed as part of this visit. The homes medication systems are generally very well managed. Medication administration records had been appropriately maintained. The records of receipt and disposal of medication were also up-to-date. The records of one resident in the intermediate care unit indicated that he was administering his own medication however no risk assessment had been completed. One of the other resident’s records indicated that she was administering her own medication. This person had are generic risk assessment however staff were not following the procedures set out in the risk assessment. While it is considered good practice to encourage residents to continue to manage their own medication it is essential that individual risk assessments be completed. The risk assessments should as far as possible ensure that residents are safe to administer and keep their medication securely. It must include details of how staff can review and monitor the risks. Since the last inspection an air-conditioning unit has been provided in the room where medication is stored to ensure that the temperature does not exceed 25°C as medication can deteriorate if stored at higher temperatures. Staff who administer medication have all received appropriate training. All of the residents spoken with during the inspection said that the staff are always friendly and respectful and ensure that their privacy and dignity is maintained at all times. The observed interaction between residents and staff was of an excellent standard. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a variety of activities and entertainment for the residents. People are encouraged to maintain contact with family and friends. Where possible residents are encouraged to make decisions about their individual lifestyles. The residents spoken with said that they enjoy the food provided by the home. EVIDENCE: The residents spoken with during the inspection said that they were generally satisfied with the level of stimulation provided within the home. However seven people stated on Resident’ Satisfaction Questionnaires, that the home only sometimes provides activities that they can take part in. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 15 Minutes of residents meetings show that residents have been asked about the type and frequency of activities they would like to have provided within the home. Staff were able to demonstrate that they are providing a reasonable range of activities and entertainment. During the inspection and organist was entertaining some of the residents while others were enjoying a game of bingo in another area of the home. It was suggested that details of all the activities entertainment and outings to be provided, should be prominently displayed in the home. This will enable residents to choose if they wish to participate in the entertainment programme. All of the residents spoken with confirmed that they can see visitors at any time and that their visitors are always made very welcome. One person said that her son regularly has Sunday lunch with her in the home and that he is also booked to have his Christmas lunch at the home. (This is good practice). One visitor spoken with during the inspection said that she has always been made to feel very welcome in the home. Residents are asked, as part of the admission process, if they wish to manage their own finances. This issue is also discussed as part of the review process. Details of how to contact local advocates and copies of access to records policies are available to all residents. The staff spoken with during the inspection were clear about the procedures they would follow, if a resident or their representative, asked to view a residents confidential records. The home has regular residents meetings where people are encouraged to voice their opinions about the services provided. All of the residents spoken with during this visit said that they are very satisfied with the food provided by the home. One person said they had only ever had one meal they didnt like and they couldnt remember what that was. She stated that the cook asks residents if there is anything special they would like to have included on the menu. (This is good practice). The cook was able to demonstrate how the menus have been changed to incorporate the residents’ choices. An individual menu had been produced in consultation with family members, for one resident who required a specialist diet. This resident’s relative said that she was amazed at how much time and effort the cook had given to ensure their relative had an appropriate diet. She was full of praise for all the services provided by the home. (This is good practice). Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 16 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): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives are confident that their complaints will be dealt with appropriately. The registered person is taking appropriate action to protect residents from abuse. EVIDENCE: All residents have been provided with a copy of a user-friendly complaints procedure. The homes complaints records show that three complaints have been received since the last inspection. One of these complaints was an incident between two residents, which resulted in one of the residents having their arm broken. Although the complaint was appropriately investigated and appropriate action taken this incident was not reported to the Commission for Social Care Inspection under Regulation 37. The manager confirmed that she has not recorded all informal complaints/concerns in the homes complaints records as these have generally been dealt with immediately. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 17 It was recommended that all complaints be recorded in a central book or file to provide an overview of the nature and frequency of complaints received. It is important that this information is recorded in a confidential format. Staff confirmed that they have received training in adult protection issues and the home has an appropriate Whistle Blowing Procedure. The staff spoken with during this inspection were able to demonstrate a clear understanding of this procedure. The inspector was informed that there have been no incidents of abuse in the home in the last 12 months. In response to thematic enquiry questions-: Two people said that they had received written information informing them how to make a complaint and both said that if they had any complaints they would discuss them with the senior staff. One person did not know whether they had been given any written information informing them how to make a complaint but said that they would talk to the manager if they had any concerns. All of the residents spoken with said that they had never had to make complaint but believed that any concerns they did raise, would be dealt with appropriately. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 18 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): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation is maintained to a good standard. At the time of inspection the home was clean and there were no offensive odours. EVIDENCE: A partial tour of the premises was completed as part of this visit. The residents stated that the accommodation is comfortably furnished and reasonably decorated. Three residents said that they like their bedrooms and confirmed that they could use them at any time. They said that they had been encouraged to personalise the rooms were small items of furniture, photographs and ornaments. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 19 The residents confirmed the home is always kept appropriately clean. The laundry has recently been extended, it is now large and well equipped with washable wall and floor coverings. The home has comprehensive infection control policies. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 20 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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff rotas provided prior to the inspection and those viewed for the week of this inspection showed that adequate staffing levels are being maintained. The homes recruitment policies and practices are supporting and protecting residents. The registered person was able to demonstrate the homes commitment to staff training and development. EVIDENCE: The staff rota for the week of this inspection showed that sufficient staff are being, provided to meet the assessed needs of the current residents. Residents stated that the staff are always busy but that they still find time for social interaction. One person said “ the staff of goodness itself, from the top to the bottom they cant be faulted they are like friends to me.” The staff training records show that 65 of the care staff have completed NVQ level 2 or above. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 21 Three members of staff were completing NVQ level 3, one person was completing level 4 and two people were completing the registered managers award at the time of this inspection. (This is good practice). The staff spoken with confirmed that they have been encouraged and supported to attend regular training courses. The personal records of two members of staff are assessed as part of this visit. One of the records contained all the required information, including satisfactory criminal records bureau checks and two written references. The other records contained the majority of required information however there was not a copy of their Criminal Records Bureau check although there was confirmation that a satisfactory check had been received by Nottinghamshire County Councils Personnel Department. The manager stated that a copy of the completed check would be included on the file in the near future. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 22 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): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes manager is well qualified and very experienced. The home is run in the best interests of the residents. Residents’ financial interests are safeguarded. Where checked the health and safety of residents and staff are promoted and protected. EVIDENCE: The registered manager has managed older peoples homes for approximately 21 years. She is a State Registered Nurse, has Certificate of Management Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 23 Studies, the Certificate of Social Services and has completed the Registered Managers Award. She operates an open door style of management, which encourages residents and staff to voice their views about the way in which the Home function. The residents and staff described her as approachable and believed that they could talk to her about any concerns they may have. One member of staff said is that she is a very good manager but that she sometimes wishes that she gave the staff more praise when they do a job well. The home participates in Nottinghamshire County Councils Quality Assurance Scheme. Residents and stakeholders in the community are encouraged to express their views about the services provided by the home. A departmental development plan is produced from the information obtained from the quality assurance system. It was recommended that the registered person should produce an individual development plan for the home. The records of residents’ finances were checked at random and were well maintained. The homes Fire records were checked as part of this inspection and they had all been well maintained. The home has a legionella risk assessment and water temperatures are being tested on a regular basis. And Environmental Health Officer completed a kitchen assessment at the home on 03/10/06. The only issues identified following this inspection was that some kitchen cupboards and drawers may need repair in the near future. Regulation 37 It was noted from the homes complaints records that a resident has sustained a broken arm. This should have been reported to the Commission for Social Care Inspection under Regulation 37. This information enables The Commission to monitor the type & frequency of incidents occurring within the home and to assess if they are being dealt with appropriately. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 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 X X X 3 Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) (2) Requirement It is required that all care plans contain sufficient information & are reviewed frequently enough to ensure that the staff are always aware of what support & assistance each resident requires. It is required that individual risk assessments are completed with all residents who wish to administer their own medication. It is required that the registered person informs CSCI without delay of any incidents listed in Regulation 37. Timescale for action 16/11/06 2. OP9 13(2) 13 (4)(c) 37 16/11/06 3. RQN 16/11/06 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 OP1 Good Practice Recommendations It is recommended that the registered person explores ways of ensuring that all prospective residents receive a copy of the homes Service Users Guide. DS0000035542.V319768.R01.S.doc Version 5.2 Page 26 Woods Court Care Home 2. OP7 3. OP12 4. OP16 5. OP33 It is recommended that the residents or where appropriate their representatives be encouraged to sign the residents individual care plans to confirm their involvement in the planning and review process. It is recommended that the Registered Person display a programme detailing all activities, entertainment and outings to be provided for the residents on a monthly basis. It is recommended that the Registered Person Keeps a central record of all complaints received by the home. The information must be stored in a format, which can be viewed confidentially. It is recommended that the Registered Person produce a development plan for the home based on the findings of the quality assurance system. Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Woods Court Care Home DS0000035542.V319768.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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