Inspection on 12/06/07 for Woodville Rest Home

This inspection was carried out on 12th June 2007.

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

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

Other inspections for this house

Woodville Rest Home 09/06/08

Woodville Rest Home 19/06/06

Woodville Rest Home 27/02/06

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

CARE HOMES FOR OLDER PEOPLE Woodville Rest Home 8-10 Woodville Road Bexhill-on-sea East Sussex TN39 3EU Lead Inspector Lisbeth Scoones Key Unannounced Inspection 12th June 2007 10:00 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 Woodville Rest Home DS0000062808.V339254.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 Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodville Rest Home Address 8-10 Woodville Road Bexhill-on-sea East Sussex TN39 3EU 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) 01424 730497 01424 736479 Pages Homes Ltd Nina Cooper Care Home 17 Category(ies) of Dementia - over 65 years of age (17) registration, with number of places Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is seventeen (17) Service users must be older people aged sixty-five (65) years or over on admission Service users with a dementia type illness only to be accommodated Date of last inspection 19th June 2006 Brief Description of the Service: Woodville provides residential and social care for seventeen older people with a dementia-type illness. Currently, the home cares for one resident who does not have a dementia–type illness. The home is a detached property, set in a quiet residential area of Bexhill-on-Sea, close to Egerton Park, the seafront and the town centre. Residents’ accommodation is provided on two floors and there is a stair lift to access the first floor. There are 11 single bedrooms and three bedrooms registered for double occupancy. Seven of the service user’s rooms have en suite facilities. The home provides a lounge with a dining area. with a sun lounge at the rear of the property. There is a small rear garden The current scale of weekly charges ranges from £410 to £575 and there are extra charges for hairdressing, chiropody and toiletries. The inspection report is on display in the front entrance. Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on Tuesday 12th June between 10.00 and 16.00. It comprised discussions with the registered manager, all staff on the duty, a meeting and conversation with the majority of the residents and a visiting relative. A tour of the premises was made, care and other documentation examined and a lunchtime session observed. The proprietor, Mr Sri, visits at least weekly but was not at the home at the time of the visit. Following the visit, a conversation was held with Mr Sri to highlight the inspection findings. The visit was further informed by 10 residents’ surveys completed with assistance from staff and 3 relatives’ surveys. Comments thus received, the majority positive, are incorporated in the report. Prior to the visit, the manager had completed an Annual Quality and Audit Assessment (AQAA). Information thus obtained is included in the report. What the service does well: Woodville provides a relaxed and friendly atmosphere for the residents and relatives. A relative wrote: “ They not only look after my relative, they take time to get to know us as a family as well. I have always been made welcome.” A resident said, “ This is a good place to be. I am happy with everything.” Staff are committed to provide the best care. Some staff have been working in the home for a long time and many staff have a NVQ qualification. Staff are patient, kind and attentive to the needs of older people with dementia. A relative wrote, “ Staff are always very friendly and helpful and demonstrate genuine care for residents.” A senior carer has overall responsibility for the safe and efficient management of medication to ensure that residents’ medication needs are met. A senior carer has been given designated responsibility to arrange social activities inside and outside the home. Opportunities are provided for leisure and pleasure. Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Very few of the requirements and recommendations of the previous inspection have been met. The poor standard of maintenance and the environment is of concern. Residents are not living in a well-maintained environment. The Service User Guide needs updating to provide residents with the required information in a suitable format to the client group. All residents must be provided with a contract or terms and conditions. Care plans would benefit from a Personal Profile. It would provide staff with additional information about residents’ previous lifestyle and interests. Staff must ensure that residents use their own toiletries rather than communal ones. Following comments made by residents, the home might like to review its menus to ensure variety and choice of meals. The home must ensure that all staff have received Adult Protection training. In relation to the environment, none of the standards are met: • The home must ensure that residents live in a safe and well-maintained environment. • The home must ensure that residents have access to a safe and comfortable indoor and communal facilities. This would include suitable and good quality furniture. • The home must ensure that residents have access to suitable lavatories and washing facilities. This would include hand wash facilities and showers in good working order. • The home must ensure that residents can move freely and independently. The previous inspection report mentioned that a ramp leading from the dining room into the sunroom was being installed. However, the ramp is too steep and no handrails have been added for residents’ safety and comfort. • The home must ensure that storage areas are reviewed to free the home from clutter and redundant furniture. • Residents’ choice to share a room must be recorded and reviewed. Appropriate screening must be provided in shared rooms. Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 7 • • • • • Resident must be provided with a suitable clean bed and with suitable and sufficient bed linen at all times. The home must ensure that in all communal areas and residents’ rooms safe hot water is provided. The home must further ensure that water is stored at the correct temperature to prevent Legionellla. The home must ensure that the premises are kept odour free. The previous inspection report stated that a vacuum cleaner with washing facilities had been purchased. However, the machine is out of order. As a result, carpets cannot be cleaned effectively as was evident during this visit. The home must ensure that staff have suitable hand wash facilities. The home must ensure that the laundry facility and equipment therein are suitable and meet all the standards. The home must ensure that staffing numbers reflect the needs of residents at all times. This would include maintenance and laundry staff. The home must ensure that employment procedures are sound. This must include Enhanced CRB and POVA check scrutiny prior to employment. The application form needs updating to include reference to the Rehabilitation of Offenders Act (1973). All staff must be provided with a contract. Staff training must be reviewed to ensure that the Induction meets the Skills for Care standards. A training matrix should be devised. Every member of staff should have an individual training and development assessment and profile. The manager must be provided with sufficient time to manage the home. The home must develop effective quality assurance systems. This would include a maintenance and development plan. The home must action agreed timescales to implement requirements made. The proprietor is required, until further notice, to submit monthly Regulation 26 reports to the CSCI. The home must ensure that all staff receive adequate formal supervision at least six times a year. Confidential records must be safely stored. The manager’s office does not provide a safe and suitable working environment. The home must ensure that residents’ and staff’ health and safety are protected. Comprehensive risk assessments must be undertaken of the environment. This must include a review of window restrictors and an updated Fire Safety Risk Assessment. All staff must be provided with moving and handling, First Aid, food Hygiene, Infection control and Fire safety training. Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 8 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. Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 9 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 Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are provided with information they need to choose whether to live in the home. The information needs to be updated and made suitable for the client group. The great majority of residents have no written contract or statement of terms and conditions. Residents’ needs are assessed before moving in. Residents are assured that their needs can be met. Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 11 EVIDENCE: Of the 10 comment cards completed by residents, 6 people commented that they had not received sufficient information of the services the home provides. The home may wish to review the Service user Guide’s format to make it more accessible to the residents. The Service User Guide needs updating to include terms and conditions, standard contract and residents’ views of the home. The manager said that the production of a colour brochure of the home is being planned. There were no residents’ contracts available for inspection. It was ascertained that residents are not routinely provided with one. All residents must be provided with a contract. From discussions with the manager it is evident that pre-admission assessments are carried out to ensure that the home can meet residents’ needs. Woodville Rest Home DS0000062808.V339254.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, 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ care plans contain adequate information for the staff to provide appropriate care. Residents’ health care needs are met. Residents are protected by the home’s medication procedures. Staff treat the residents and their relatives with kindness and respect. However, the continued poor environment indicates that residents’ dignity is not respected. Care plans provide details as to residents’ wishes in respect of death and dying. Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 13 EVIDENCE: A sample of care plans was examined and contained adequate information for staff. Care plans are regularly reviewed and include risk assessments in respect of moving and handling and nutrition. Key workers write an additional monthly review. Daily records are maintained. Care plans would benefit from a personal Profile to enhance staff’s knowledge of residents’ lives before they entered the home. Feedback from relatives’ surveys indicates that they are satisfied with the overall care provided. “The care my relative is receiving is brilliant.” “My Mum’s care has been exceptional. All the staff are very good and spend time caring for individual need.” A resident said, “I am happy and comfortable here.” General Practitioners, District Nurses, Community Psychiatric Nurses and Social Workers are consulted when necessary. Such contacts and any agreed action are recorded. Staff have an understanding of the needs of people with dementia and they are patient, kind and respect the individuality of each person. A relative said: “Staff keep the people in their care motivated and care for them as individuals. Everyone is well dressed and clean.” A resident said,” I am happy here and prefer it to my old place.” See also standard 33. A senior member of staff has overall responsibility for ensuring the safe and efficient management of medication within the home. Medication records are well maintained. It was recommended that the medication trolley, kept in the dining room, be chained to the wall. Residents who are able to self medicate are encouraged to do so. While staff treat the residents and visitors with kindness and respect for their dignity and privacy, the poor environment is an indicator of lack of respect. Examples are: broken bedroom furniture, stained beds and carpets, curtains missing or off the wall, cluttered conservatory and inadequate privacy curtains in shared rooms. Staff must ensure that residents use their own toiletries rather than communal ones seen in bathrooms. Residents’ wishes in respect of death and dying were recorded. This is good practice. Woodville Rest Home DS0000062808.V339254.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. Residents are provided with opportunities for leisure and activities. Contact with residents’ families and friends is encouraged. Staff ensure that residents have as much choice and control over their daily life as their condition would allow. Residents are provided with nutritious meals thus ensuring that their dietary needs are met. EVIDENCE: A relative write,” The home provides a good range of pastimes and activities.” A senior carer has been given the responsibility of organising activities for the residents. A range of social and leisure activities are provided including board games, arts and crafts, puzzles and walks to the park, the sea front and into town. A resident commented,” I like it here because it is near the beach.” Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 15 Some information is recorded in care plans about resident’s occupational and recreational activities in the past. Staff and residents said that they had enjoyed an activity the previous day with singing and dancing. Residents’ participation had been excellent. Each resident’s religious denomination is recorded in their care plan. Residents are supported to participate in their beliefs. Residents are enabled to attend the church of their choice. Relatives can visit the home at anytime and in private should they wish to do so. Two relatives commented on the home’s friendly and homely atmosphere. “It is like one big family.” The menus indicate that residents are provided with a varied and nutritious diet. Residents enjoyed their meal on the day of the visit. The majority of surveys returned from residents indicate that residents enjoy the food provided. However, two residents commented, “A greater variety of meals would be nice” and “Meals are good but sometimes they lack variety.” The cook said she knows the residents’ likes and dislikes very well. A choice of meals is not routinely provided but an alternative would be offered. Woodville Rest Home DS0000062808.V339254.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives know that any complaint would be taken seriously and acted upon. Not all staff have received Adult Protection training. EVIDENCE: There is a complaints procedure and feedback from surveys indicates that relatives and residents know how to make a complaint. No complaint have recently been received The home have an adult protection and prevention of abuse policy and procedures for staff to follow in the event of suspected abuse. However, only some staff have received training in adult protection. This training should be extended to all staff. See also standard 30. Recruitment records indicate that for one member of staff no POVA first or CRB had been returned. The manager said this would receive her immediate attention and that the member of staff did not work unsupervised. See also standard 29. Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 17 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, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not well maintained with many areas that need repair, tidying up, upgrading and decorating. The home does not provide a safe environment in respect of access to the sun lounge, safe hot water and missing window restrictors. Some areas in the home are malodorous. Residents are not protected by adequate infection control measures. New furniture in the dining area enhances the residents’ communal environment. Some beds were stained with ill-fitting sheets, non-matching bed linen and torn plastic covers. Some bedroom furniture is in need of repair or replacement. Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 18 EVIDENCE: Many parts of the home look unkempt and are in need of repair, redecoration, replacement and refurbishment. A list of maintenance work to be done is available but the work not carried out. The home does not employ a maintenance person and the provider is the designated maintenance man. The manager said that a decorating programme is to commence in July 2007 starting with hallways and stairwells. It is acknowledged that the provider is trying to get planning permission to build an extension. The conservatory would be demolished in the process. So far the permission has been refused. Both front and back gardens are overgrown. The furniture and carpet in the conservatory are stained. A large area of the same room is used for the storage of redundant furniture. A no longer-in-use bed was stored on a flat roof area. The home is generally clean but several bedrooms are malodorous. The vacuum cleaner with washing facilities is out of action thus preventing effective carpet cleaning. A contract cleaner is employed for three hours a day. It is noted that new dining room furniture has been provided since the last inspection. A ramped area from the lounge to the conservatory is unsafe for residents’ use. The ramp is too steep and no handrails are provided. As required at the previous inspection, the home must consult with the Fire Officer. Arrangements for fire doors leading out into the garden and sunroom are unsatisfactory. There was no evidence that such consultation has taken place. See also standard 38. A senior member of staff has overall responsibility for fire safety procedures and in–house training. She organises fire drills for staff and regularly tests the fire alarm system but has had no formal training. Staff have no facilities for hand washing when giving personal care to the residents. Several communal toilets have no washbasin. The home must carry out an Infection Control audit in respect of hand wash facilities both for residents and staff. This should include the availability of liquid soap, paper towels and disposal bin. The home has a poor laundry facility based at the back of the conservatory, which is a communal area for the residents. On the day of the visit, staff were prevented from washing their hands as dirty linen blocked the sink. The Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 19 laundry is poorly lit. The washing machines are of the domestic type. There is no evidence that the services comply with the Water Supply (Water Fittings) Regulations 1999. The laundry floor is not impermeable. There are no designated laundry staff. See also standard 27. The home has no sluicing facility. An improvement plan to address all environmental issues is a requirement of this report. Woodville Rest Home DS0000062808.V339254.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are well met by staff who are caring, committed and competent. However, staffing levels need to be reviewed to ensure a good service at all times. Many staff have an NVQ qualification but the induction training does not meet the required standard. This and other additional training (some mandatory) would ensure that residents’ health and welfare needs are met at all times. Residents are not fully protected by the home’s recruitment policy and procedures. EVIDENCE: Of the ten comment cards completed by residents, two people said that staff were always available when they needed them, 7 people said “usually” and one “there was a shortage of staff”. Two residents said they would like their call bell answered more quickly. One person said, “ Sometimes they are busy with other people but fortunately I am able to do most things unaided”. Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 21 The rota indicates that there are three members of staff on duty in the morning and afternoon. On the day of the visit this included the manager. There are two night staff who, in addition to caring for residents, carry out cleaning and laundry duties. See also standard 26. No additional staff are made available for sickness, holidays or emergencies. As already referred to, there are no designated maintenance or laundry staff. The home must review its staffing levels to ensure that residents’ needs can be met all times. See also standard 31. 60 of the staff have an NVQ qualification at levels 2 and 3. Staff receive a variety of training, such as moving and handling, infection control, first aid and challenging behaviour. Some staff are undertaking a long distance dementia care course. However, scrutiny of training records identified that not all staff have had all the mandatory or Adult Protection training. New staff are provided with induction training but this does not meet the Skills for Care standard. It was strongly recommended that a training matrix be devised as well as individual staff training profiles. The need for other training was discussed at the visit such as diabetic care and continence management. The manager is introducing equality and diversity training to the staff. This is a good initiative. A sample of employment records for newly recruited staff was perused. It indicated that employment procedures are not sound. The application form needs updating to include reference to the Rehabilitation of Offenders Act (1973) and the need for an Enhanced CRB check. For one staff member no POVA first or CRB check had been received prior to starting work. It was of concern to be advised that apart from two senior members of staff, staff have not been provided with a contract. A copy of the Staff Handbook is available in the home but staff are not provided with their own copy. The home’s staff room is out of order and staff have no designated break area or secure facilities to keep their belongings. Woodville Rest Home DS0000062808.V339254.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, 32, 33, 35, 36, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed but the manager needs more time to carry out her role effectively. Quality assurance systems need to be further developed to ensure that the home is run in residents’ best interests. Residents’ financial interests are safeguarded. Staff supervision has been delayed. Confidential documentation is not securely stored. Residents’ and staff’ health and safety are not fully protected. Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager has returned form maternity leave. She demonstrated a strong commitment to the residents and her staff to provide the best possible standard of care. She has the Registered Managers Award qualification. She tries hard to keep herself and her staff updated. She is studying for the assessors award in order to help staff with their NVQ. Her management style is open and inclusive. She is much respected by the residents and staff who feel well supported. Staff meetings are held. The manager acknowledged that “time is her biggest challenge”. Due to staff shortages she regularly works on the floor. This visit evidenced that there is much for the manager to do and some important tasks are outstanding. The hours available for management need to be reviewed and agreed with the provider. As part of the quality assurance procedures the home carries out residents’ and relatives’ surveys on an ongoing basis. Visiting professionals are also encouraged to compete the surveys. A district nurse wrote, “ Thank you for your continuing help and cooperation with the community nursing team.” The provider carries out monthly monitoring visits. Records of these were not seen at the visit. Due to the lack of progress and the amount of work outstanding, the provider is required to submit Regulation 26 reports to the CSCI until further notice. A development plan needs to be produced based on planning, action and review. Due to residents having a dementia type illness, they do not have control of their own money. Records are kept of any items purchased on their behalf and relatives/representatives are invoiced for these. Monies retained at the home on residents’ behalf are safely stored and any transactions recorded. The manager’s office does not provide a suitable and private working environment. Whilst some records are stored in locked cabinets, other records are not securely stored with due regard for confidentiality. Pre-inspection information indicates that all health and safety checks are made and recorded. A current electrical certificate is in place. At the previous inspection, the provider was urged to consult with a fire officer about the arrangements for the dining room fire doors. There was no evidence that such consultation has taken place. The home must ensure that there is a current Fire Risk Assessment and that staff are provided with external fire safety training. A health and safety audit and risk assessments should be carried with particular emphasis on hot water temperatures and window restrictors Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 24 Some staff spoken with felt that “the environment lets them down” and that “it would affect the good reputation of the home”. See standards 19 to 26 in respect of the environment. As already referred to in standard 30, some mandatory training is overdue for some members of staff. The manager said she would address this without delay. Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 25 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 1 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 1 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 x 18 2 1 2 2 2 2 2 2 1 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 2 3 2 x 3 2 2 2 Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 5 Requirement That the Service User Guide be updated and made available in an appropriate format suitable to the client group. That every resident has a written contract That arrangements are made to ensure the privacy and dignity of the residents. That all staff are provided with Adult Protection training That the premises are kept in a good state of repair; That all parts of the home are kept clean and reasonably decorated; That suitable provision is made for storage; That external grounds are suitable and safe and appropriately maintained. That the fire officer be consulted (Carried over from previous inspection. Target date of 15/07/06 not met) re Fire Safety Risk assessment and staff training That an annual redecoration and refurbishment plan is sent to the CSCI. Carried over from previous DS0000062808.V339254.R01.S.doc Timescale for action 15/07/07 2 3 4 5 OP1 OP10 OP18 OP19 5 (1) (b) 12 (4) (a) 13 (6) 23 (2) (b) (d) (l) (o) 15/07/07 15/07/07 30/07/07 30/07/07 6 OP19 23 (4) 30/07/07 7 OP20 OP33 23(2)(d) 30/07/07 Woodville Rest Home Version 5.2 Page 27 8 9 10 OP24 OP26 OP27 16 (2) c 13 (3) 18(1)(a) 11 12 13 OP29 OP36 OP38 19 schedule 2 (7) 18 (2) 13 (4) c inspection. Target date of 31/07/06 not met That residents are provided with adequate beds and bed linen That suitable arrangements are made for the prevention of infection That staffing numbers reflect the needs of residents at all times Carried over from the previous inspection. Target date of 19/06/06 not met That a thorough recruitment procedure is carried out which must include a CRB check That all staff are appropriately supervised That any unnecessary risk to the health and safety of the residents be identified and acted upon 15/07/07 15/07/07 30/07/07 15/07/07 30/07/07 15/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP7 OP10 OP26 OP30 OP38 5 OP37 Good Practice Recommendations That for every resident a personal profile is obtained That for the purpose of dignity, residents do not use communal toiletries That a laundry assistant is employed to carry out domestic tasks so care staff can spend more time with residents That the induction training complies with the Skills for Care standards That a training matrix be devised That individual staff training profiles are devised That all staff have received mandatory training That records are securely stored with due regard for confidentiality Woodville Rest Home DS0000062808.V339254.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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