Inspection on 12/12/05 for Woodstock Residential Home

This inspection was carried out on 12th December 2005.

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

Woodstock Residential Home 28/06/07

Woodstock Residential Home 05/07/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Woodstock Residential Home 80 Woodstock Road Sittingbourne Kent ME10 4HN Lead Inspector Helen Martin Unannounced Inspection 12th December 2005 2:00 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 Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodstock Residential Home Address 80 Woodstock Road Sittingbourne Kent ME10 4HN 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) 01992 636464 Nellsar Limited Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: Woodstock Residential Home provides personal care and accommodation for up to sixty older people and is owned by Nellsar Limited. The home is located in a residential area on the outskirts of Sittingbourne, approximately two miles from the town centre and a main line railway station. The premises are large, with good car parking facilities to the front and a well-maintained, established garden to the rear. Residents’ accommodation is on two floors, accessed by either a passenger lift or a stair lift. There is a mixture of single and shared rooms. There is a good choice of communal areas available to residents both within the home and in the garden. The home employs care staff, working a roster, which gives 24-hour cover. Ancillary staff for catering, laundry, maintenance and domestic duties are also employed. Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken on 12th December 2005 between 14.00 and 17.00. The visit included talking with residents, staff, the manager and the regional manager. Some judgements about the quality of life within the home were taken from observations and conversation. Some records were looked at. In addition, a tour of the home and garden was undertaken. The home currently has thirty-nine residents and twenty-one vacancies. The regional manager said that currently all shared rooms are used for single occupancy. The new manager appointed at that time is currently in the process of registration with the CSCI. Since the home’s registration and the appointment of the manager, much work has been undertaken. The home is currently in a transitional stage, in the process of development and with plans for the future. This has been taken into consideration within the inspection process. What the service does well: Woodstock Residential Home is welcoming and has a relaxed and inclusive atmosphere. Residents enjoy living in a spacious, clean and comfortable environment. Residents benefit from an assessment and being able to look around the home before they move in. Residents are treated with respect. Arrangements are in place to maintain their privacy and dignity. Residents’ views are listened to and receive proper consideration. They are able to exercise choice and enjoy the range of leisure activities provided. Residents are encouraged to keep contact with their relatives and friends if they wish. Their health and social care needs are met by a competent manager and appropriately supervised staff. The home is sensitive about issues surrounding the aging and death of a resident. Procedures are in place, which protect residents from abuse. Since the home’s registration, procedures and records have been reviewed. All new maintenance contracts had been set up for the systems and equipment within the home. New staffing rosters, an activities diary, residents’ contracts and staff employment contracts have been developed. A new medication trolley had been purchased. The home has introduced a new system for the recording of accidents and incidents, which maintains confidentiality. Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 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 Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 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): 1, 2, 3, 4, 5, 6 Prospective residents and their representatives would benefit from additional written information about the home before they decide to move in. Some residents would benefit from re-assessment to ensure that the home can continue to meet their needs. EVIDENCE: Since the registration of Nellsar Limited on 19th October 2005, a new statement of purpose for the home has been developed. The document includes the aims and objectives of the home together with individual rights of residents. Some amendment would provide prospective residents with more detailed information. The regional manager said that the home was in the process of developing a new service users’ guide that would take the form of a welcome pack and brochure. The regional manager said that all terms and conditions of accommodation for residents had been reviewed. A sample was seen. It was mentioned that all residents had a contact with the home. Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 9 Pre admission assessments are undertaken by the home. Documentation was seen containing the detail listed in Standard 3. Residents spoken with said that they and/or their relatives could look around the home to see if it was suitable before they moved in. Both the regional manager and the manager demonstrated a clear understanding regarding the category and needs of residents that the home could meet. It was mentioned that some residents would be re-assessed to ensure that the home can continue to meet their needs. Currently the home does not and has no plans to offer intermediate care. Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 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, 11, Residents are treated with respect. Their health and social care needs are met, although this could be better reflected in care plans. Residents’ protection would be enhanced by improvements in the procedures for the administration and handling of medication. EVIDENCE: A written plan of care is provided from a pre-admission assessment for each resident. This gives staff guidance about action to be taken to meet the health and welfare needs of residents. The manager said that they, together with existing staff, are in the process of reviewing the content and format of care plans for all residents. The format for ‘old’ care plans seen was difficult to follow. The regional manager said that assessment would also be undertaken four weeks after admission and at regular intervals following this. Documentation seen included information regarding risks, healthcare appointments, medication and daily activities. It was mentioned that residents would be involved in regular reviews. The promotion of residents’ health care is maintained. They have access to local NHS community services, including GPs, district nurses and health care Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 11 professionals. Residents are offered appropriate exercise on a regular basis. The regional manager said that no residents currently have pressure sores, although suitable equipment could be made accessed if necessary. A record of food consumed by individual residents is kept. Residents spoken with said that the quality of care provided within the home was good. Procedures are in place for the storage and administration of medication within the home. Medication records are completed appropriately and kept with photographs of residents. A signature list for staff administering medication is in the process of development. Drug storage is secure, with the exception of a lock on the medication fridge. The regional manager said that the regular monitoring of the medication room and fridge temperatures would be undertaken and recorded in future. Facilities are available for the storage and administration of controlled drugs. The manager said that a new medication trolley had been purchased. It was mentioned that all staff who administered medication were appropriately trained to do so. Arrangements are in place to maintain residents’ privacy and dignity. Staff were observed to speak with residents in a respectful and appropriate manner at the time of inspection. A hairdresser comes to the home on a regular basis. It was mentioned that the system for the return of laundry within the home works well. The manager demonstrated an understanding regarding the aging and death of a resident. It was mentioned that the home aimed to provide care for individuals as long as possible and that specialist nurses could be accessed if required. Relatives can visit and stay as often and for as long as they wish. Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 12 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, 15 Residents are able to exercise choice and enjoy the range of leisure activities that the home provides. EVIDENCE: The routines of daily living and activities made available aim to be flexible. Residents spoken with said that they could choose when to get up, when to retire and when to have a bath. The home has an activities co-ordinator for thirty hours per week and a diary has been developed. The co-ordinator offers both group and individual activities. A designated room is provided which contains many games and art and craft materials. Residents’ paintings, drawings and jigsaws are in evidence. Activities provided for residents also include exercises, films, bingo and games, such as giant snakes and ladders. Residents were enjoying watching a film at the time of inspection. Preparations are underway for Christmas. A Christmas party has been planned for residents and their friends and relatives. A local school choir will sing carols in the home. Residents have been making Christmas cards and serviettes. Residents spoken with explained that visitors from local churches come into the home. They said that they enjoyed the activities provided and that they were hoping to go out more in future than Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 13 they had done in the past, when the weather was warmer. Residents were also looking forward to the planned entertainment for New Year’s Eve. Residents are encouraged to keep contact with their relatives and friends if they wish. One resident spoken with described how their relatives and friends are able to visit them on a regular basis at the home. Another has requested not to see members of their family. The manager said that the cook now asks residents for their choice of food during the day. Options are written on a board in the dining room. Residents spoken with confirmed that they always had a choice of meals. It was mentioned that a new four weekly written menu is the process of development. The cook said that hot alternatives are available for all meals. Residents spoken with mentioned that cooked breakfasts and grapefruit are available in the mornings. Special diets such as diabetic can be provided. Records of food consumed by residents and individuals’ likes and dislikes are kept. The main meal on the day of inspection offered a choice between chicken burgers and ham, beans and potatoes. Some residents spoken with said that they enjoyed the food, whilst others stated that they thought the quality had decreased recently. Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 14 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, 17, 18 Residents’ views are listened to and receive proper consideration. Procedures are in place, which protect residents from abuse. EVIDENCE: Residents are at ease talking with staff who listen to their views and concerns. Residents spoken with said that the new manager was very approachable. The regional manager stated that they had not received any complaints since the registration of the home in October 2005. It was mentioned that, should any complaints be received that these would be investigated and recorded appropriately. The regional manager said that all permanent residents, with their representatives, had been offered the opportunity to be registered for a vote. The regional manager and manager demonstrated an understanding of the procedures in place within the home for the protection of residents from potential abuse. Discussion took place regarding a recent incident where appropriate action was taken to safeguard residents. All policies and procedures are in the process of review. Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 15 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, 20, 21, 22, 23, 24, 25, 26 Residents enjoy living in a spacious, clean and comfortable environment. They would be better protected by improvements in the systems for infection control, safeguarding hot surface and water temperatures and the provision of specialist equipment. EVIDENCE: Maintenance of the home is ongoing, with a member of staff employed, directly responsible for decorating, maintenance and the upkeep of the garden. It was mentioned that the home was in the process of being re-decorated and refurbished where necessary. The decorations for Christmas within the home are attractive. The garden and patio at the rear of the property is well-maintained, with the garden arrangement creating separate areas with seating provided. The home occupies large premises; within the home several separate lounge areas are available, offering residents a good choice of communal areas. There is also a ‘smoking lounge’, activities room, hairdressing salon and conservatory. The home is comfortably furnished and provides a ‘homely’ Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 16 environment. The regional manager said that the home was in the process of developing new office facilities. There are currently thirty-one single and twenty-eight shared bedrooms, four of which are en-suite. Twenty-one bathroom and toilet facilities are provided. Residents’ rooms seen were pleasant and personalised. The regional manager said that currently all shared rooms are used for single occupancy, offering the residents within these rooms additional personal space. It was mentioned that fixed screening would be considered if rooms were shared in future. Residents spoken with at the time of inspection said that they liked the general environment and their rooms. It was said that all residents are provided with a lockable facility and bedroom door lock. Accommodation for residents is over two floors accessed by either a passenger lift or stair lift. Not all rooms have level access and some steps and raised door thresholds are present throughout the home. One resident’s room is at the top of a flight of stairs. There are ramps to the garden. A staff call system is provided. The regional manager assured the inspector that alarms were not necessary for external doors. It was mentioned that the garden area is secure. The regional manager explained that an assessment regarding equipment and the environment had been undertaken by an Occupational Therapist on the day of inspection. It was mentioned that any recommendations within the report would be acted upon. The regional manager said that radiator guards would be installed throughout the home. The surface temperature of one radiator within a bathroom was very hot to the touch. One hot water outlet tested on the day of inspection was very hot to the touch. It was unclear at the time as to whether temperatures were checked and recorded regularly. The general ventilation and temperature of the home was appropriate on this occasion. Lighting is bright and domestic in nature. The premises are clean, hygienic and free from offensive odours throughout. The laundry room contained suitable facilities, with the exception of a designated hand washing facility. The regional manager stated that the environmental health visit of September 2005 made no recommendations. Soiled and clean items are separated. The method for dealing with soiled items could be improved; currently no ‘red bag’ system is in place. Both the laundry room and the sluice room were clean. Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 17 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, 30 Residents would be better protected by a review of the staffing hours, recruitment procedure and training programme. EVIDENCE: The home currently has thirty-nine residents and twenty-one vacancies. At the time of inspection sufficient staff were available to meet the needs of residents. The home employs approximately thirty-eight staff, working a roster, which gives 24-hour cover and an activities co-ordinator. The regional manager said that there are five staff on duty in the mornings and four or five in the afternoons with three waking staff at night. The regional manager said that they were currently in the process of reviewing staffing hours. Ancillary staff for catering, laundry, maintenance and domestic duties are also employed. The regional manager explained that catering staff prepare all the meals within the home, although evening teas are served by care staff. New staffing rosters have been developed. Residents spoken with said that staff are very good and that they always come quickly when they use the staff call system. The recruitment procedure in place within the home aims to ensure that suitable staff are appointed to meet the needs of residents. The regional manager described the system for pre-employment checks. It was mentioned that Criminal Records Bureau (CRB) checks were undertaken for all staff; four individuals are currently awaiting the return of a CRB application, although a Protection of Vulnerable Adults (POVA) check has been undertaken. Staff files Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 18 seen contained an application form, proof of identity, references and evidence of CRB checks. It was noted that one individual had not undertaken an enhanced CRB check. It was mentioned that the home is in the process of auditing all staff files. The regional manager said that they were currently in the process of recruiting four staff, including an assistant manager. A new employment contract has been developed. The regional manager said that they were in the process of reviewing staff training. It was said that they are developing a matrix and a new programme of appropriate training for staff. Some staff were undertaking fire and health and safety training on the day of inspection. The regional manager said that one current and two of the new members of staff are NVQ qualified. It was mentioned that three staff were currently undertaking an NVQ with more planned for January 2006. Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 Residents benefit from a competent manager and appropriately supervised staff within a relaxed and inclusive atmosphere. Their welfare could be better protected by improvements to the procedures for fire, records and quality assurance. EVIDENCE: The new manager appointed at that time is currently in the process of registration with the CSCI. The manager said that they were able to spend time at the home before they took up the post. They have had previous experience of managing a residential care home. The home is welcoming and has a relaxed and inclusive atmosphere. Residents are able to approach the staff with ease. All residents spoken with said that the Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 20 new manager was very nice and approachable. The manager said that one residents’ meeting had been held since the home’s registration and that they intended to hold meetings every six to eight weeks. It was mentioned that these were recorded. The regional manager explained that a system for quality assurance would be introduced to the home early in 2006. It was mentioned that this would include monthly audits for any complaints and accidents and incidents. The regional manager explained that a range of policies and procedures are currently available for staff. It was mentioned that these were in the process of review; new documentation would be introduced together with training for staff. Most residents or their representatives deal with their own finances. The home currently holds no cash on behalf of residents. Residents are protected by the arrangements in place for the supervision of staff. Samples of records were seen. The home has a system for the maintenance and storage of information pertaining to residents. Records are stored in a manner that preserves confidentiality. Since registration the home has introduced a new system for the recording of accidents and incidents, which maintains confidentiality. The regional manager stated that due to a situation beyond their control some of the home’s records were in the process of being transferred back to the premises, and were therefore not currently available within the home. The regional manager said that all new maintenance contracts have been set up since the home’s registration. It was mentioned that the maintenance and testing of systems and equipment had been undertaken as part of the sale of the home in October 2005. The regional manager explained that recommendations made by the fire officer in November 2005 had been implemented. A fire risk assessment has been undertaken and recorded. The fire alarm system is due to be serviced shortly. The fire logbook is completed appropriately with the exception of emergency lights checks, which are not currently undertaken on a regular basis. Cleaning chemicals are stored securely. The regional manager stated that window restrictors are provided throughout the home with the exception of a few that are in the process of installation. Arrangements are in place for the maintenance of food hygiene. The kitchen is clean. All dry food is stored appropriately. Records are kept for the regular testing of fridge, freezer and hot food temperatures. Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 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 2 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 2 3 3 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 2 2 Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? N/A 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 OP1 Regulation 4(1)(c) Sch 1 Requirement The registered person shall compile a statement of purpose in relation to the home, which shall consist of a statement as to the matters listed in Schedule 1. In that, the new statement of purpose needs additional information to comply fully with regulations, including details of the manager, staff qualifications and experience, whether the home provides nursing or not and how residents are consulted about the operation of the home. 2 OP1 5(1) The registered person shall produce a service users’ guide to the home. In that, the home is currently in the process of producing a new service users’ guide. 3 OP9 13(2) The registered person shall make 31/01/06 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the home. DS0000065797.V271774.R01.S.doc Version 5.0 Page 23 Timescale for action 28/02/06 28/02/06 Woodstock Residential Home In that, a lock must be provided for the medication fridge; the regular monitoring of the medication room and fridge temperatures must be undertaken and recorded. 4 OP25 13(4)(a) (b)(c) The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; any activities in which service users participate are so far as reasonably practicable free from avoidable risks and unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. In that, hot water must be provided for residents at an appropriate temperature; hot water temperatures from all outlets must be monitored and recorded on a regular basis. Radiators must be low surface temperature or guarded. (An action plan must be provided to the CSCI) 5 OP29 19(1)(b) Sch2 7(a) The registered person shall not employ a person to work at the home unless they have obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. An enhanced criminal record certificate. In that, all staff must undertake an enhanced criminal records bureau check. 31/01/06 31/01/06 Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 24 6 OP37OP38 17(2) Sch 4.14 The registered person shall maintain in the care home the records specified in Schedule 4. A record of every test of fire equipment (including fire alarm equipment). In that, regular tests of the emergency lights system must be recorded in the fire logbook. 31/01/06 7 OP38 23(4)(c) (iv)(v) The registered person shall, after 31/01/06 consultation with the fire authority, make adequate arrangements for the maintenance of all fire equipment and the testing of fire equipment at suitable intervals. In that, the emergency lights system must be tested on a regular basis. 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 OP4 Good Practice Recommendations It is strongly recommended that the regional manager complete their stated intention to re-assess some residents where necessary to ensure that the home can continue to meet their needs. It is recommended that the manager complete their stated intention to review the content and format of care plans for all residents. It is strongly recommended that the signature list for staff administering medication should be completed. 2 OP7 3 OP9 Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 25 4 OP22 It is strongly recommended that the regional manager complete their stated intention to implement any recommendations made by the Occupational Therapist following the assessment of equipment and the environment. With regard to the maintenance of infection control within the laundry room, it is strongly recommended that: • • Consideration should be given to a designated hand washing facility. A ‘red bag’ system should be introduced for dealing with soiled items. 5 OP26 6 OP27 It is recommended that the regional manager complete their stated intention to review the staffing hours available to ensure that resident needs can be met at all times. It is strongly recommended that the regional manager complete their stated intention to audit all staff recruitment files. It is strongly recommended that the regional manager complete their stated intention to review all staff training, including NVQ qualifications, develop a matrix and an appropriate staff training programme. It is strongly recommended that the regional manager complete their stated intention to introduce a quality assurance system early in 2006. It is strongly recommended that records pertaining to the home be transferred back to the premises. It is recommended that restrictors should be fitted to all windows as necessary. 7 OP29 8 OP30 9 OP33 10 11 OP37 OP38 Woodstock Residential Home DS0000065797.V271774.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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