Care Home: Woodheath Nursing Home

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What the care home does well Throughout the visit staff demonstrated a genuinely supportive and kind attitude to the people that they support. Staff when spoken with were clearly able to explain how they maintained the dignity of people living in the home. This was supported by the people living in the home who told us that staff are "caring", "kind", "helpful" and "very nice". The manager is keen to maintain good quality in the home and has put into place regular audits on items such as medications in order that the home will be managed safely and that people living in the home get a good quality of service. There is a variety of different places in the home for people to spend their time. The staff team supports individual choices as to where they would like to spend their day. Staff have an understanding of people`s individual preferences and communicate these to each other well. What has improved since the last inspection? Woodheath is considered a new service by us and as such there is no previous visits that can be taken into account. The current owners have remained the same and have owned Woodheath for over 20 years. During the visit we did noticed that there had been improvements in staff recruitment and training that helps the home recruit staff who can meet the needs of people living in the home. What the care home could do better: The care plans in place for people living in the home need to provide enough information for staff to have clear, up to date and relevant guidance. This will help promote a consistent service and make sure that all staff have the same knowledge of people`s needs. Also in need of clear instructions are medications which need to have good information about creams and "when needed" medications. Instruction should include, when, where, how and in what circumstances these items are to be used. Consideration should be made to make sure that menus and activities are planned from the choices expressed by the people who live in the home. Information such as activities and menus needs to be made easily accessible to the people in the home and be available in different formats to meet their individual needs. CARE HOMES FOR OLDER PEOPLE Woodheath Nursing Home 40 Ford Road Upton Wirral CH49 0TF Lead Inspector Julie Garrity Key Unannounced Inspection 12th February 2009 10:15 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 Woodheath Nursing Home DS0000072421.V374161.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. Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodheath Nursing Home Address 40 Ford Road Upton Wirral CH49 0TF 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) 0151 677 2496 Woodheath Care Limited Mrs Jayne Eileen Shillcock Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To people of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of people who can be accommodated is: 42 New service. Date of last inspection Brief Description of the Service: Woodheath is registered to provide care for forty two older persons. The building is an older converted building with a modern extension. The service provides information about any visits from us in the main foyer and in each persons own bedrooms. Accommodation is provided on three floors with stairs and passenger lift access to all floors. Many of the bedrooms have an en-suite toilet and hand-basin. There are three lounge areas, one of which is located in the extension and provides dining space as well, another separate dining room and a conservatory are located next to the separate dining room. Woodheath is a no smoking home, space is available in the garden area for people who wish to smoke. The home is located in a residential area on a main road in the Upton Wirral. There are shops at the top of the road, a local library opposite, a main train station and bus stops are within 10 minutes walk from Woodheath. There is a car park area to the front of the home and maintained gardens to the rear. Fees range from £395 up to £629 and depends on peoples individual needs. Extra charges are made for newspapers, hairdressing and toiletries as examples. The cost of these vary depending on what the individual chooses to buy. Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that people who use the service experience good quality outcomes. The site visit was carried out over a period of one day. We arrived at the home at 10:15 at and left at 18:30, the site visit was a total of 8 hours and 15 minutes. We looked at all areas of the home including all of the bedrooms of the people who live in the home. People who lived in the home and their relatives were offered the opportunity at the site visit to discuss their opinion of the care and support provided. On this occasion we spoke with ten people who live in the home, six members of staff, two relatives, the deputy manager and the manager. Additionally ten questionnaires sent to people who live in the home and staff. Four questionnaires from staff were returned to us. The service was sent an Annual Quality Assurance Assessment known as an AQAA. This asks them to let us know how they have improved the quality of the service that they provide in the last 12 months. A number of areas of support were reviewed and this involved us looking at records such as how the staff found out peoples needs and care plans that showed how they plan to meet their care needs. We also reviewed the health and safety arrangements to maintain safety such as managing medications and identifying and reducing any risks. Observation of how the staff provide care and support was also undertaken. We reviewed the training, support and monitoring of staff skills. Feedback was given to the manager throughout the visit and at the end of the day. The arrangements for equality and diversity were discussed during the visit and are detailed throughout this report. Particular emphasis was placed on the methods that the staff in Woodheath used to determine individual needs, promote independence and support to make informed decisions in line with individual choices. What the service does well: Throughout the visit staff demonstrated a genuinely supportive and kind attitude to the people that they support. Staff when spoken with were clearly able to explain how they maintained the dignity of people living in the home. This was supported by the people living in the home who told us that staff are caring, kind, helpful and very nice. The manager is keen to maintain good quality in the home and has put into place regular audits on items such as medications in order that the home will be managed safely and that people living in the home get a good quality of service. Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 6 There is a variety of different places in the home for people to spend their time. The staff team supports individual choices as to where they would like to spend their day. Staff have an understanding of peoples individual preferences and communicate these to each other well. 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. The summary of this inspection report can be made available in other formats on request. Woodheath Nursing Home DS0000072421.V374161.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 Woodheath Nursing Home DS0000072421.V374161.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards reviewed were 1, 3 and 4. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All people wishing to move in the home have their needs ascertained and are given information about the home. This makes sure that Woodheath is the right place for the person to live and that their needs can be met there. EVIDENCE: The AQAA from the home told us that, they have information available for people who are thinking of moving into Woodheath. They also told us that an assessment (where the service looks at the needs of people) is carried out by manager or the deputy. People who are thinking of moving into the home are encouraged to visit before they decide to move in. We spoke with people living they were confident and spoke warmly of the way that staff understood their needs. One person told us, “my family came and looked around. They thought it was somewhere that I would be happy. So far I am the staff are very kind, pleasant to be with. Im sorry I had to leave my home but this is the Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 9 next best thing”. People wishing to move into Woodheath get the opportunity to decide if they would like living there. We looked at the care records of four people living in the home. These showed that all people wishing to move into Woodheath had assessments carried out before they move into Woodheath. The assessments were clearly written, signed most of the time, dated when done and were used to determine if the staff can meet the individual needs of the person wishing to move in. Staff spoken with had a clear understanding of the range of different needs of the people that they supported and were able to speak with knowledge on what peoples needs were. They told us that are informed about new people moving in and told what their basic needs are so that they can meet their individual needs. We looked at the information that the home gave to people to help them decide if the home could meet their needs. We spoke to people living in the home one of whom told us, did get some stuff when I moved in. I might have read it then. The AQAA from the home told us that the service was looking at making sure that they had, information in different forms to meet peoples needs. The information known as a statement of purpose (which shows the service to be provided) and service users guide (which shows how the service will meet peoples needs) was available in the main entrances to the home. Woodheath Nursing Home DS0000072421.V374161.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards reviewed were 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. People living in the home have their individual healthcare needs met. Peoples medications are managed in a safe manner that makes sure that they receive their medications appropriately. EVIDENCE: We looked at how people were supported in getting their medications. This showed that all people living in the home received their medications in a safe manner that maintained their health. There were some minor documentation areas that do not maintain good practice. This included clear instructions for some medications such as when needed and external medications such as creams. Good instructions need to be available at all times to make sure that staff can give medications as they are needed. The AQAA for the care home told us that each person has their own plan of care. We looked at care plans and noticed that each person had their own plan Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 11 of care. We sampled four care plans and noticed that in all but one case where a persons needs had been identified they had a care plan that contained instructions to staff on how to meet the persons needs. The instructions available in the care plans were not specific as to how to meet the persons individual needs. Examples of this included, give regular mouth care, this did not tell staff precisely what was meant by mouth care or how often. Staff told us that they did not always read the care plans but did get a verbal report each day. The manager told us they were planning to introduce further training and support to staff to make sure that this was improved. We looked at how the staff members monitor the effect of the support that they give. Each person living in the home has a record kept of care or support they received that day (a daily record). The quality of these records was not sufficient to detail the care that had been given that day. The daily records were not specific, individual or explained what had happened to the person that day. A daily record that accurately shows what support has been give that day supports the staff to monitor individual care. When we looked at how the service accessed external professionals such as doctors or dieticians we found that in all cases the staff had recognised changes in peoples needs and contacted the relevant expert. An example of this included two people who had lost weight in both cases the service had contacted a dietician who had visited the home to give advice and guidance. The staff had recorded this visits, when we looked at those records we found that they were very clear with good information. This information had not always been used to update the persons care plan and as such the instructions were not easily available to staff. Woodheath Nursing Home DS0000072421.V374161.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were reviewed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mealtimes and activities are a relaxed social opportunity that the people who live in the home enjoy. The individuals personal preferences, choices and needs are not always used to influence their daily routines. EVIDENCE: The AQAA from the home told us that there was a memory board available with large print activities available. The people we spoke with were not aware of the memory board or what activities were available. We spoke to people who live in the home who told us I get bored just sitting here, would like things to do other than in the afternoon, would like more trips out even just down to the local shops and I never know what things are happening and not seen any information about activities. The manager told us that they hold regular meetings, the minutes of the meetings showed that several of the people living in the home wanted more activities and trips out. Information to people living in the home about activities is not in enough detail to inform them of their choices or meet their needs. Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 13 The activities available in the home do not always meet peoples individual needs. We looked at assessments to see if peoples personal choices were recorded before they moved in. We found that there was little or no information in assessments. We looked at care plans to see if people living in the care home had a social plan. Of the four plans we looked at none had a social plan. The records of the activities co-ordinator were looked at. There was some information in these records but this did not appear to be reflected in the activities available. An example of this include several people had said that they enjoyed gardening, but this was not an activity available. There are menus available to tell people who live in the home about the food available. A daily menu board is filled out as to what meals are available that day. People living in the home told us that dont know what we are having for lunch, they do come around with a list but I never remember what it is. The menu available in the kitchen did not reflect the meal that was served that day. The menu did not identify special diets such as vegetarian or diabetic. Special diets need to be identified in order to support people who need a special diet to choose food that meets their needs. The menus did detail a choice of meals. We spoke to the kitchen staff who told us that they are happy to cook additional choices such as omelettes if the person does not like what is on offer. People spoken with had varying opinions of the food including its okay, the food is lovely, I really like the food, it’s a bit boring, would like more variety and if you dont like whats available you can have a butty (sandwich) or some biscuits. All the people spoken with told us that their daily routines were pretty much of their own choosing they were aware of when meal times are and what they could do to influence their own days. They told us that they generally get up and go to bed as they want one person told us, stay up as late as you want to. Visitors are welcome at the home. We spoke to a visitor who told us that I can come and visit whenever I want. Staff are very good to me always offer me a drink. Woodheath Nursing Home DS0000072421.V374161.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were reviewed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are confidant that they are able to raise any concerns and that these will be dealt with to their satisfaction. EVIDENCE: People spoken with where confident that they where able to express any concerns and that these would be addressed. We spoke to two people living in the home who told us, “I have no need to complain, but if I have a problem it gets fixed and The staff are nice and happy to help”. The AQAA from the home told us that a complaints procedure is available in each persons bedroom and in the main entrance to Woodheath. When we looked around the home we noticed that there was a copy of the service users guide in each bedroom. This did contain a copy of the complaints procedure and informed people o how to raise concerns and what the service would do to fix any concerns. The manager records any concerns raised, in the care records of people who live in the home and in a complaints file. We viewed the investigation records from two concerns that were dealt with by social services. The manager undertook their own investigation regarding this concerns following social services investigation and has altered the way they record pressure ulcers (bed sores) and wounds. We had not received any other concerns about the service. Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 15 All staff have received training in protection of adults from abuse. This is part of their induction and also a separate training course. Staff spoken with had a clear understanding of this process and the ways in which an allegation of this nature would be dealt with. A policy and procedure is also available to guide staff should serious concerns occur. When serious concerns have been reported to the service, these have been properly investigated and action taken to prevent them occurring again. Woodheath Nursing Home DS0000072421.V374161.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25 and 26 were reviewed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Woodheath is well maintained and presents a nice, pleasant and hygienic place for people to live in. EVIDENCE: A tour of the home was undertaken and a sample of peoples bedrooms seen. The people living in the home spoken with said, “it’s a nice place to live, have all my own bits and bobs and “it’s always very clean, the girls here work very hard to keep it nice. The home is decorated in a style similar to a persons own home and attempts have been made to keep it homely with pictures etc. The AQAA from the home told us that all bedrooms have been redecorated in the last 12 months. Peoples bedrooms were viewed. They all had items that the individual had brought in from their own homes such as pictures and odd items Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 17 of furniture. One person spoken with said, “its nice to have my things around me.” The Kitchen is located on the ground floor near on of the dinning rooms. A full cleaning schedule was available for the staff and the kitchen was clean and well maintained at the visit. The freezers and fridge were checked, the chef detailed that there was sufficient equipment available in the kitchen and any breakdowns are dealt with very quickly. The laundry is situated on the ground floor of the home. Woodheath is a converted building with an additional extension containing a number of bedrooms, a lounge and a dining area, quiet lounge, extra shower and some storage. In total there are four seating areas and two dining areas. Most of these were well used by the people living in the home on the day of the visit. In the afternoon there was a quiz taking place in one of the main lounges. This is a large enough room to accommodate most of the people who live in the home. The carpets in the main lounges at the front of a house, main corridors and dining areas have been replaced. People living in the home thought that the home was pleasant, clean and tidy. The bedrooms and corridors are decorated in a very similar style and whilst in keeping with the decoration that would be in individuals own home, does not make it easy for people with short term memory issues to identify their bedrooms or bathrooms. There are gardens at the rear of the building that the people living in the home enjoy spending time in, in the summer. Several of the staff have received training in preventing the spread of infection. When we observed staff during the day we noticed that they used protective equipment such as gloves and plastic aprons. In our tour of Woodheath we found that hand washing facilities were available to people living in the home, staff and visitors that would help prevent the spread of any infection. Woodheath Nursing Home DS0000072421.V374161.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were reviewed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have a variety of skills that assist them to support the individual needs of people living in the home. EVIDENCE: On the day of the visit there were several members of staff available in the home. People living in the home told us there are plenty of staff, staff never rush us and great staff that work really hard. Staff were observed during the visit to be calm and unrushed. A staff member was observed as we arrived in the home to show patients and caring towards an individual. The staff member gave her plenty of time and encouragement to walk down the corridor in a manner that encouraged her independence. The AQAA for the home told us that there is an extensive training programme for all staff. Staff spoken with told us that they had, had lots of training in the last few months. We received four staff surveys they told us that not all staff felt that they had received enough training. Records were well organised and showed clearly what training staff had received. Training certificates for staff were available on individual files what training staff had. In most cases staff had up to date training, in some cases staff training needed to be updated. The manager monitors the practices in the home to make sure that Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 19 staff are competent in their job roles. Training such as moving and handling and fire safety for some staff members needs to be updated as this can place both people living in the home and staff at risk. Staffing files were reviewed and detailed that all staff had the relevant checks of employment, such as police checks, references and a check that they are suitable to work with older people before they started working. Nursing staff are required to have an up to date registration with the Nursing and Midwifery council (PIN) that demonstrates that they are able to work as a nurse. All nursing staff had up to date PINs that showed that they were still registered to work as a nurse. Staff were given a recruitment that showed that they were suitable to work with the people living in the home. Woodheath Nursing Home DS0000072421.V374161.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 were reviewed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home makes sure that the service can safeguard the people who live there and support the staff to undertake their job roles. EVIDENCE: The registered manager has many years experience within the care sector. She is a Registered General Nurse (RGN) and has an NVQ level 4 in management (a qualification specific for managers of care homes). There are arrangements for obtaining the views of people who live in the home and their relatives such as meetings and questionnaires that are regularly sent out. Minutes of meetings were available that showed activities had recently Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 21 been discussed with people living in the home. The information from these does influence the running of the home such as activities and menus as examples. The manager had also sent out questionnaires to staff working in the home. These were anonymous and in sealed envelopes, the manager allowed us to open these. There were seventeen questionnaires all but two contained positive comments about the way that the home was run. Staff reported that in general they felt listened to and supported to do their jobs. Staff also received supervision to support them to do their jobs and regular staff meeting. Minutes of recent meetings were shown to us and these reminded staff of the standards that were expected from them. There are policies and procedures in the home that also include aspects of equality and diversity such as harassment and equality of opportunity. The policies and procedures were all up to date and covered areas of best practice that staff needed to be aware of. These are available and discussed at induction, staff spoken with said that they don’t often have time to read them, but they area aware of them and aware that its their responsibility to read them. Some personal allowances are held on behalf of the people living in the home. The service does not have a legal responsibility for any of the funds of the individuals they support. Receipts are kept for any spending or money given the service by relatives. A float is available at evenings and weekends in case any of the people living in the home want some of their money. The training records showed that many of the staff are provided with training around safe working practices. Records demonstrated forthcoming training courses that staff are to attend to update their health and safety training. Maintenance certificates for gas, electricity and equipment in the home were all up to date. The fire systems were regularly checked and any issues were identified and fixed. The home has fire risk assessments and general environmental risk assessments. These have been recently reviewed in order to maintain the safety of Woodheath. Woodheath Nursing Home DS0000072421.V374161.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 3 x 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 3 Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 5 Refer to Standard OP7 OP7 OP9 OP12 OP27 Good Practice Recommendations Care plans need to be specific and individual to the people that the service supports. Daily records that detail what support was received by the people living in the home should be specific and detail what has occurred to the person that day. Creams and PRN medications need to have clear instructions for their used. This makes sure that staff are aware of their correct use. Review how information on activities and menus is given to people in the home. Make sure that both match the views expressed by the people living in the home. Review all staff files and make sure all training is up to date in particular new staff who need their training place as part of their induction. Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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 Woodheath Nursing Home DS0000072421.V374161.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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