Inspection on 24/07/06 for Woodville Care Home

This inspection was carried out on 24th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodville Care Home 18/11/08

Woodville Care Home 01/11/05

Woodville Care Home 16/06/05

Woodville Care Home 20/10/04

Woodville Care Home 08/04/04

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 Woodville Care Home 145 Burton Road Woodville Swadlincote Derbyshire DE11 7JW Lead Inspector Jo Wright Unannounced Inspection 24th July 2006 08:45 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 Woodville Care Home DS0000020214.V304723.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. Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodville Care Home Address 145 Burton Road Woodville Swadlincote Derbyshire DE11 7JW (01283) 551501 01283 551413 Woodville145@aol.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) Greenacres Nursing Home Limited Wendy Davies Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (1) of places Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one PD either sex. (This person is named in the notice of proposal and this agreed place will cease on the termination of this persons care at the home). 1st November 2005 Date of last inspection Brief Description of the Service: Woodville Care Home provides personal care for up 34 people, 33 people aged 65 years and over, and 1 place for a named person under the aged the 65 years. The property is a purpose built, two storey building. Residents bedrooms are located on the ground and first floor. Residents access the first floor by using the staircase or passenger shaft lift. All bedrooms are single occupancy, and 31 rooms have ensuite facilities. Woodville Care Home is close to the town of Swadlincote, which is about 10 minutes away by car. Information about the service is provided through the Statement of Purpose and Service User Guide, both of which were made available to residents. Information included on the pre-inspection questionnaire received on 01/06/06 stated that the fees for the home were £310 to £400 per week, and that this information was also included on the contracts and terms and conditions. Items not covered in the fees include hairdressing, chiropody, toiletries and meals when out. Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, carried out by one inspector, and lasted 7 ½ hours. A review of the evidence available prior to site visit was undertaken, for example, the pre inspection questionnaire, resident surveys (7 surveys received) and other information received by the Commission, and used to identify areas to be examined during the site visit. The information available was used to identify those residents whose care was to be cased tracked. Records such as care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual residents) were examined in depth during this inspection. Time was spent taking with residents and staff on duty and observing the daily routine. A small selection of bedrooms was viewed during this visit. Other records such as medication records, staff files and service certificates were also examined. The registered manager was on duty during this visit and the findings of this site visit were discussed with her. What the service does well: What has improved since the last inspection? Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 Page 6 Staff practice was being supervised on a regular basis, and this has resulted in a number of the improvements. Staff have received support and guidance, which has resulted in improvements been made to residents files. Residents needs, abilities and preferences were recorded in more detail, which assisted staff to plan residents care in a more structured manner. Care plans were detailed and provided clear guidance for staff on the delivery of care. Supervision of staff practice in relation to the administration of medication has resulted in significant improvements in this area. This has resulted in residents generally receiving their medication as prescribed. Staff knowledge in relation to safeguarding vulnerable adults has improved, and staff were able to describe what action they would take if they suspected that an individual was being harmed in any way, which protects residents from potential harm. 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. Woodville Care Home DS0000020214.V304723.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 Woodville Care Home DS0000020214.V304723.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 and 4 (Standard 6 does not apply in this home) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedures ensured that residents were assessed prior to admission, and the assessments provided staff with sufficient information to fully identify individuals’ needs and plan care. EVIDENCE: The files of two residents were looked at in depth during this site visit. Resident information was stored on computer. Case tracking confirmed that a structured admission process was completed for all prospective residents, and provided reassurances that their needs could be met at Woodville Care Home. The management team assessed prospective residents, and an initial assessment of their care needs carried out. One of the residents whose care was case tracked confirmed that the manager had visited them at home. The written documentation was adequate and included information from other health care professionals involved in the residents care. All of the residents who completed the surveys indicated that they had received enough information to decide if the home was the right place for them to live. Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 Page 9 Residents were provided with a copy of the information booklet when they moved into the home. Residents and relatives spoken with felt that they were very well looked after and that the home was able to meet their needs. Two of the residents who completed the survey indicated that they had not received a contract. This was discussed with the manager, who confirmed that all residents received a contract on admission to the home. Woodville Care Home DS0000020214.V304723.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal and health care needs were met with support and assistance from staff and other health care professionals. EVIDENCE: Residents and relatives spoken with commented very positively about living at Woodville Care Home, and said that ‘it couldn’t be better’, and ‘I like it here or I wouldn’t stay’. Residents commented that the staff team were very good, and they were able to discuss any concerns or issues with the staff, manager and the owners. One visitor commented that their relative was always dressed smartly, clean clothes worn every day, and clothing changed if anything was split down them during the day. No issues around privacy and dignity were raised, and staff were observed knocking on doors prior to entering, and speaking with residents in a respectful and polite manner. Staff have put considerable effort into improving the amount of detail recorded in residents files. Residents care plans showed signs of improvement and staff had recorded individuals’ needs, preferences and abilities. The care plans Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 Page 11 were sufficiently detailed to guide staff on the delivery of care. Assessments and care plans were reviewed and updated as required or on a monthly basis. However, it was not clear from the computer records whether residents had been involved in planning and reviewing their care. Additional information was gathered through risk assessments. Moving and handling and pressure area care assessments had been completed. However, not all of the pressure area care assessments had been reviewed on a regular basis. Information about individual daily lives was recorded in the logs. The files supported that attention was paid to residents’ health care needs, and access to other health care professionals was facilitated as required. Residents and relatives spoken with confirmed this to be the case. Considerable improvements have been made to administration of medication. This has been achieved by the introduction of a monthly audit of the medication records that highlights any shortfalls, which can be discussed with the staff concerned, and appropriate action taken, and the regular assessment of staff practice, to ensure that safe practices were adhered to. Staff were now recording the date when medication was discontinued and who had authorised this. It was noted on the odd occasion, staff had administered medication but not signed the medication record, and had not used the correct code when medication was not administered. Hand written entries were not checked for accuracy and signed and dated by two members of staff. Storage of medication was generally satisfactory. However, the temperature of the medication refrigerator was not recorded daily, and on occasions, the temperature had been above the maximum temperature. Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of suitable activities was being provided, which met the leisure and recreational interests of residents. The meals were good offering both choice and variety and catering for any special dietary needs. EVIDENCE: The routines at Woodville Care Home were generally planned around the residents needs and wishes. Residents spoken with said that they were able to get up in a morning at the time they wished, and go to bed/bedrooms in an evening when they were ready. Discussion with staff supported this. One resident was in their nightclothes before tea, and when asked, confirmed that it had been their choice to get changed. Residents were encouraged to remain as independent as possible, and to make choices about their lives. A number of residents chose to remain in their rooms throughout the day, whilst others made good use of the communal areas. Residents commented positively about the activities provided at the home, and talked about joining in with bingo, gentle exercises, and a recent shopping trip into Burton on Trent. Staff talked about organising activities such as board games, playing cards and hand and foot massages. Information gathered from the surveys supported Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 Page 13 that activities were usually provided, and that residents had the choice to join in if they wished. Information about activities was displayed around the home. Regular resident meetings do not take place, and dedicated staff time was not available for activities. This was discussed with the owner of the home, and consideration should be given to providing dedicated activities hours within the weekly rota. Visitors spoken to during this site visit said they were able to visit at any time and were always made welcome when they came to visit their relative, and offered refreshments. Their comments indicated that they had confidence in the manager and staff team to care for their relative appropriately, and to keep them fully informed of any changes, and commented ‘that it couldn’t be better’. Visitors also spoke highly of the owners, and commented on the recent refurbishment and that the owners took time to seek their views on the home when they visited. Residents were encouraged to remain as independent as possible, and a number of residents continued to manage all or part of their own finances. Residents were placed on the electoral register, so that they were able to take part in political processes. Information about advocacy services was readily available in the home. Menus were varied and offered a choice of meals. There was sufficient dining space for residents, and dining tables were well presented with tablecloths, placemats, napkins, cutlery, condiments, and drinks. The lunchtime meal was served in a relaxed manner. Residents’ independence was aided by the use of plate guards and appropriate cutlery. Residents commented highly about the meals provided at the home, and this was generally supported by the residents’ surveys. One concern raised on the surveys was that occasionally the portion sizes were small. This was passed on the manager to discuss with the catering staff. Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints procedure was in place with some evidence that people felt that their views were listened to and acted up. Staff had a good knowledge and understanding of adult protection issues, which protects residents from harm. EVIDENCE: Residents spoken with commented that they felt safe, listened to and able to speak to the owners, manager and staff if they were not happy about anything to do with their care. The complaints procedure was available to all residents and relatives and was clearly displayed in the home. Staff spoken with aware of the complaints procedure and were able to describe how they would deal with any complaint that they received. The manager has dealt with three complaints since the last inspection and these have been resolved to the satisfaction of the complainant. The concern raised with the Commission was discussed with the manager during this site visit. The concern had not been raised with any of the staff or the manager, and the manager could not recall when these concerns may have occurred. Without the details of which resident the concerns related to, it was not possible to look into this matter any further. Residents were protected from potential harm through staff knowledge and training. The required polices and procedures were in place, and the staff Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 Page 15 spoken with had a good understanding of these procedures and confirmed that the majority of staff had attended safe guarding vulnerable adults training. Both the manager and staff commented on the standard of the training provided by the local authority, and that they had learnt a great deal by attending this training. Training records supported that the majority of staff had attended this training. The manager reported places were booked onto the next available training day for those staff who had not yet attended. There have been no referrals made through these procedures during the previous 12 months. Woodville Care Home DS0000020214.V304723.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, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment was good providing residents with an attractive and homely place to live. EVIDENCE: Residents commented that Woodville Care Home was generally clean and fresh and this was supported by observation at the time of this site visit. All areas of the home were well maintained and decorated, with evidence to support that systems were in place for ongoing maintenance. Individuals liked their bedrooms, and were happy with the facilities in the home. One resident commented that they would like a larger room, and the manager indicated that as soon as a larger room became available, this resident would be offered the opportunity to move. The rooms of the residents whose care was case tracked showed individuals had been able to personalise their rooms, and they were satisfactorily clean and well presented. Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 Page 17 Aids and adaptations were provided and satisfactory to meet the needs of the resident group. All equipment had been maintained within the specified timescales. The home has a limited range of bathing facilities, as several bathrooms have a type of bath that residents do not choose to use. The manager reported that there were plans to refurbish the bathrooms and quotes had been obtained. The owner and the maintenance person/gardener undertook routine maintenance of the home and the garden. A number of trees had been removed from the rear of the home, and this had greater improved the natural light to the bedrooms in this area. The owners have recognised that lighting in some areas of the home was poor and as a result have fitted additional spots lights in the corridors, and additional skylights in bedrooms with poor natural light. Residents welcomed the investment by the owners, and commented positively about the areas that had been refurbished. Residents were very pleased with the new carpet in the main lounge and the new chairs and settees, and commented on how nice this area now looked. New carpet had also been fitted in corridors. The laundry area was well organised, and the equipment in good working order. The laundry staff took pride in their work and residents personal clothing was well laundered and ironed. Relatives commented on the high standard of the laundry service provided at the home. Woodville Care Home DS0000020214.V304723.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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team as a whole was not competent and trained to fully support the residents, due to new staff not completing the required induction programme. Inconsistent recruitment practices did not provide safe guards to offer protection to people living in the home. EVIDENCE: Comments on surveys suggested that residents felt that they received care and support when they needed it, as sufficient staff were usually available. Residents and relative spoken with expressed no concerns about the number of staff on duty. Staff felt that they had time to meet peoples care needs, as well as being able to spend time with residents, socialising or organising activities. The staff team as a whole was not competent and trained to fully support the residents living at Woodville Care Home. Although the home has achieved over the 50 target of care staff trained to NVQ Level 2 or equivalent, not all newly appointed staff work through an induction programme that meets the required specifications. Arrangements were in place for staff for study towards NVQs and the majority of staff without this qualification were currently undertaking this training. Senior care staff were due to start Level 3 in Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 Page 19 September 2006. Staff confirmed that they were offered a range of training opportunities, and kept up to date with the mandatory training. There was a stable staff team at Woodville Care Home, although a number of staff (5 in total) have left their employment since the last inspection in November 2005. The manager reported that she was in the process of recruiting additional staff. The manager has recognised the need to introduce a checklist for the recruitment and selection of staff, so that all of the required information was obtained prior to employment. Three staff files were looked at during this inspection, and none of these files contained all of the required information. This has been a requirement in the previous two inspection reports. However, the file where the checklist had been used did contain the majority of the information. The manager was observed speaking with a new member of staff who had not yet commenced employment and informing them that they could not start until the Criminal Record Bureau check had been received. The manager was advised to audit the staff files and to obtain all of the required information. Woodville Care Home DS0000020214.V304723.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, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager was providing clear leadership and guidance for staff, which has resulted in improvements in the quality of the service provided. The introduction of formal quality assurance system, which seek the views of residents, relatives and staff, would allow further improvements to the quality of the service to be made. EVIDENCE: Residents spoke highly of the owners, manager and staff team, and commented that the manager would deal with any issues that they raised with her. Residents and staff commented that they have regular contact with the owners who visit regularly and ask them questions about how satisfied they Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 Page 21 are with the care aand the support they are getting. This information was now recorded on a regular basis. Following the last inspection, the manager has started to provide more guidance and clear leadership for staff, which has resulted in the improvements noted during this site visit. Staff receive clear instruction on what is expected of them, and their practice is reviewed on a regular basis through supervision. In addition, the owners have taken a more active role in supervising the manager, and recording discussions in their reports on the home. The service could be further improved by the introduction of formal quality assurance systems. Residents have not been given the opportunity to contribute to the running of the home through regular residents meetings, or a resident questionnaire. Any suggestions or comments were made on informal basis, why may result in contributions and ideas getting ‘lost’. The system in place for safeguarding residents’ money has been strengthened. Two signatures were obtained for all transactions. The records and the money held on behalf of two residents were cross referenced and found to be accurate. Information provided on the pre-inspection questionnaire and the resident surveys indicated that the home has experienced a number of incidents that are reportable to the Commission under Regulation 37. These were discussed with the manager, who acknowledged that these incidents had not been reported. Discussion with staff confirmed that they were offered training opportunities. Records supported that staff were either up to date with mandatory training or this training was planned, with the exception of basic food hygiene. A sample of service/maintenance records was examined (including equipment, gas and electricity services) and there was confirmation that equipment and services are properly maintained. The manager was unable to locate the certificate for the fire alarm system and emergency lighting, but stated that both had recently been checked. The manager was unsure when the five yearly electrical wiring certificate was due. Although the temperature of the hot water was controlled within safe limits, there were no records to support that these temperatures were checked on a regular basis. This potentially places residents at risk of scalding themselves. Woodville Care Home DS0000020214.V304723.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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 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 3 Woodville Care Home DS0000020214.V304723.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 Standard OP29 Regulation 17(2) Sch 2&4 Requirement Staff files must contain all of the required information in accordance with Schedules 2 and 4 (Previous timescales of 30/09/05 and 31/03/06 not met) All staff must receive induction and foundation training that meets the specifications Systems for reviewing, and where necessary improving, the quality of the service and publish the results of findings must be developed and implemented e.g. satisfaction surveys. (Previous timescale of 31/03/06 not met) All deaths, illness and other events as outlined in Regulation 37 must be reported to the Commission. All staff must be provided with training in basic food hygiene. Provide evidence that the fire alarm and emergency lighting have been checked within the specified timescale. Timescale for action 31/10/06 2 3 OP30 OP33 18(1)(a) & (c)(i) 24 31/10/06 31/10/06 4 OP37 37 30/08/06 5 6 OP38 OP38 18(1)(a) & (c) 23(4) 31/12/06 30/08/06 Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 Page 24 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. 2 3 Refer to Standard OP7 OP9 OP9 Good Practice Recommendations The records should demonstrate that the resident and/or representative has been involved in planning and reviewing their care. Hand written entries on the medication records should be checked and countered signed by a second member of staff. . The maximum and minimum temperature of the medication refrigerator should be checked and recorded daily and kept within the range of 2 and 8 degrees centigrade. Regular residents meetings should be held. Consideration should be given to employing an activity coordinator. Establish when the five yearly electrical wiring certificate is due for renewal. The temperature of the hot water should be checked and recorded monthly. 4 5 6 7 OP12 OP12 OP38 OP38 Woodville Care Home DS0000020214.V304723.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Woodville Care Home DS0000020214.V304723.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!