Inspection on 10/12/07 for Woodend

This inspection was carried out on 10th December 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

Woodend 30/11/06

Woodend 01/02/06

Woodend 18/07/05

Woodend 12/01/05

Woodend 05/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

SignHealth

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Woodend Atherton Street Springhead Oldham OL4 5TQ Lead Inspector Sandra Buckley Unannounced Inspection 10th December 2007 09:30 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 Woodend DS0000005546.V354041.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. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodend Address Atherton Street Springhead Oldham OL4 5TQ 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) 01616244739 0161 6520764 Mr Gregory Leigh Miss Susan Leigh Care Home 19 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (19), of places Physical disability over 65 years of age (1), Sensory Impairment over 65 years of age (1) Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 19 OP up to 10 DE)(E) up to 1 S) (E) and up to 1 PD(E). Maximum number of persons accommodated - 19. Date of last inspection 30th November 2006 Brief Description of the Service: Woodend is a small, detached residential home situated in the Springhead area of Oldham. It is registered to provide care for service users over the age of 65, in the following categories: dementia, old age, physical disability and sensory impairment. Accommodation is provided in nine single rooms, eight of which have en-suite facilities. The en-suites are shared with the adjoining rooms in four cases. There are five shared rooms, four of which have en-suites. A conservatory and two lounges provide communal rooms. Woodend is a privately owned, family run business. At the time of this report the fees ranged from £333.00 for a shared room and £343.00 for a single room. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection which included a site visit to the home. The manager was not told beforehand that we were coming to inspect, this is called an unannounced inspection. This inspection looked at all the key standards and included a review of all available information received by the Commission for Social Care (CSCI) about the service provided at the home since the last inspection. During the site visit information was taken from various sources, including observing care practices and talking to people in the home. The manager, relatives and some members of the staff team were also interviewed. A tour of the home was undertaken and a sample of care, employment and health and safety records were seen. Comments from questionnaires returned from residents and their relatives are also included in this report. Concerns raised by health professionals on care practices and the level of heating in the home were also investigated on this inspection. The requirement made at the last inspection had been addressed. However, there still remain a number of service developments to be addressed. The CSCI requires the home to complete an annual quality assurance assessment (AQAA) in order to demonstrate the level of care provided. The manager had completed this in full and comparisons were made with this document at the time of inspection. On this inspection the outcomes for people in the home did not reflect that indicated by the manager in the AQAA, especially in relation to daily life, personal care and protection. However, the manager had recognised what improvements could be made and stated they were developing an action plan. What the service does well: The manager obtains a professional assessment of need prior to people entering the home. It was observed throughout the day that families were made welcome and invited to stay for lunch, which one person choose to do. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 6 Numerous comments were received from families and professionals that presented different perspectives of the home. The positive comments received consisted of “Staff are always available” and “I have no complaints because whatever I ask them to do, they do.” Another relative said, “They have really brought her on. You would not recognise her to how she was. She has put on weight and looks really well compared to how she was.” People in the home and their relatives felt they would be listened to if they had any concerns. One person said, “Certain aspects have caused concern but when I mention them, an effort is made attend to this.” What has improved since the last inspection? What they could do better: Observations made throughout the day found that people who were more able and their relatives made positive comments. Those people who required more assistance were less satisfied. This is an area of practice that the manager needs to review. Some comments received were “Often staff seem too busy for smaller things to help users. More staff around probably would help, but this involves more outgoings financially for the home.” Also “Although my mother always says that meals are good and she enjoys them, to me they are repetitive and rather lacking in fresh fruit and vegetables and a varied menu.” On the day of inspection these aspects were validated. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 7 Staffing levels and deployment of staff in the home need to be reviewed. The manager must address the lack of updated care planning, reviews, risk assessments and medication issues identified throughout the report. One person said, “The regular staff are wonderful, it is the younger staff who have not yet developed their skills that give concern.” Menu planning needs to be undertaken which provides choices for people with management and staff taking a proactive approach in offering choices. Staff routines when serving meals needs to be reviewed and a more congenial environment provided at meal times. Temperatures in the home must be maintained throughout the day, with people having choices on individual temperatures in their rooms, which is reflected in the home’s assessment and care planning. Building maintenance must take place, especially replacement of broken windows. On completing the AQAA the manager had recognised many areas that needed improvement, which now must be addressed. 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. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People’s needs are appropriately assessed by professionals ensuring their needs can be met in the home. EVIDENCE: Three files were examined in depth and found to contain a detailed assessment of need from professionals and specialist consultants. One person had been resident in the home a number of years with professional reviews taking place on a regular basis. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 10 The home’s AQAA stated that people are encouraged to visit the home prior to their admission and are provided with information on the facilities offered. They had also recognised the need for improvement to continue to update the information given to people in the home. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 11 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 7, 8, 9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. In some instances, care planning had not been updated which may lead to people’s health care needs not being met. EVIDENCE: Examination of three care plans found that not all details of the care required had been transferred into care planning. For example, District Nurses were treating one person with an ear problem. No care plan was in place and staff at interview were unaware of the precautions to take. One assessment said there was a history of falls and a fractured hip. The care plan did not reflect this and no risk assessments were in place. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 12 People’s weights were recorded, however one person had a steady weight loss and had lost 9lb over a three-month period. This had not been recognised and no nutritional screening was in place. Staff said the person had sensory impairment and may now require help with meals. Records show that this person had not been weighed for three weeks. In this instance, weight should have been monitored regularly, in order to assess if professional help was required. Health professionals’ visits were recorded, consultants and hospital appointments. with evidence of visits to One person was cared for in bed, with daily visits from the district nurses for pressure sore care. The care plan for this person had not been reviewed to reflect the care required. For example, takes regular showers and turn body positions hourly. In one instance, privacy and dignity were compromised through a catheter bag not being discreetly placed. There was also documented evidence that the bag had been leaking, with the possibility of cross-infection. The AQAA completed by the manager stated that care plans are individually tailored and there is a high level of staff supervision with risk assessments being completed for each individual. This was not the case when the files were examined. Examination and medication procedures found that people who self-medicate had not been risk assessed and they were without a lockable piece of furniture to keep medication stored safely. Medication files would benefit from photographs of people in the home to aid identity. Daily records of care delivery had improved since the last inspection and these provided a clearer picture of the care provided by the staff of daily life in the home. Comments from people who lived in the home varied from, ‘Staff do not act as quickly as I would like sometimes’ to ‘Staff are always available.’ Relative questionnaires stated ‘I am informed of major falls, others I have to ask if anything has happened if I notice any bruising for example.’ One relative who lived out of the country said, ‘I talk to the staff two or three times a month on the phone at which time any needs and information on my mother are discussed.’ Also, ‘They have really brought her on in the home, you would not recognise her to how she was. She has put on weight and looks really well to how she was.’ Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 13 One person in the home said ‘Staff are very attentive.’ And ‘Staff come if I pull the cord.’ Other relatives said they felt their relative was not getting the assistance and aids required to maintain good health. Observations made throughout the day found that people who were more able and their relatives made positive comments. Those people who required more assistance were less satisfied. This is an area of practice that the manager needs to review. Woodend DS0000005546.V354041.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): Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Management and staff need to be proactive when offering choices and improve practices, ensuring the flexibility in people’s lifestyle is maintained. EVIDENCE: There was evidence in daily notes and record keeping of consultations with people in the home and flexibility in routines. For example, a residents’ committee meeting was held on 12th November 2007 to discuss Christmas activities. People said a party had been booked and an entertainer. A ‘bling’ party was also taking place on 12th December 2007. Daily notes demonstrated people’s choices; one stated ‘Took herself off to bed today feeling tired. Did not want to get up this morning, still in bed at dinner time.’ There was no planned programme of activities; these were reliant on staff availability. One person said Usually activities are arranged.’ And ‘It makes a change to join in activities.’ Staff record activities they have undertaken on a daily basis. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 15 One person said ‘I like my own room with my own television’ and ‘I asked to move to this room because I liked it better.’ The AQAA completed by the manager said, two people have Sky television in their rooms. A questionnaire returned from a relative said ‘The staff are always accommodating about when I take her out and bring her back, i.e., they will keep her meal warm, etc., and always welcome her back with a cup of tea.’ Another said ‘the home creates a calm atmosphere for the residents and they are made to feel valued and cared for.’ Contrasting comments were again reflected in this part of the inspection, for example, ‘I feel that their basic needs are being met. Stimulation and exercise may help if residents want to do it.’ Also, ‘I have always requested more activities in the past but my mother is now at the stage where she would not want to join in anyway.’ In the AQAA the manager noted that improvements could be made through more outside activities and connection with local groups. We observed the home being supportive of relatives in asking them to stay for their lunch which one person chose to do. We also dined with a group of people and found that improvements could be made in this area. For example, meals were taken in the conservatory, which was cold. The home had in place supplementary heating but temperatures remained low. The bright sunlight shone through the windows and several people struggled to see their meals because of this. Napkins were not available and people searched for tissues or whatever was available. Table linen had cigarette burns and staff practices at the table need to be improved, for example, not scraping leftover food from plates when people were eating. The meal served was meat and potato pie, mushy peas and mashed potatoes, with chocolate sponge and custard for sweet. People said they enjoyed it. The manager said meals are planned on a weekly basis. No choices were offered. The manager said, ‘With it being a small home, staff are aware of people’s preferences.’ We noted that one person with sensory problems would benefit from additional aids and staff assistance to ensure adequate dietary intake. We were offered coffee with lunch, however people in the home were not. When asked if they did not like coffee, they said yes but were not offered it. The manager said, ‘They only need to ask.’ Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 16 Over the teatime period people were offered soup or sandwiches. One person interviewed had not eaten their soup because ‘It was like dishwater.’ No sandwich was offered. One person said, ‘there are too many paste sandwiches.’ Another said ‘Sometimes I would like an extra sandwich at teatime.’ One relative questionnaire said ‘Although my mother always says the meals are good and she enjoys them, to me they seem very repetitive and rather lacking in fresh fruit, vegetables and a varied menu.’ It is acknowledged that the AQAA recognised that improvements could be made and that choices would be reinstated on the menu. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. People and their relatives were comfortable in raising any concerns they may have. The lack of staff training in the protection of vulnerable adults may pose a risk to people in the home. EVIDENCE: A complaints procedure is displayed in the home, together with a book of complaints, compliments and concerns. For example, one person was concerned about someone else entering their room. The manager had reminded staff to be more vigilant. Another record stated that people were sometimes in other people’s clothes. The manager had recorded speaking to staff about putting clothes away appropriately. One person had complained about the loss of a ring that the manager was still investigating. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 18 The CSCI had received concerns from district nurses and other professionals visiting the home about the care and treatment, and also that the home was often too cold. These issues were looked at on this inspection and were found to be valid. The manager was advised to take action on updating care planning and maintaining minimum temperatures in the home. One person said, ‘I have no complaints because whatever I ask, they listen to me and do it.’ One relative questionnaire stated ‘Certain aspects have caused concerns but once I have mentioned them, an effort is made to attend to this’ Also ‘Mother would not complain, she is worried about being in trouble. Things are ok when I mention anything.’ Staff at interview demonstrated knowledge of how adult abuse may present, however a number of staff had not received training in the protection of vulnerable adults, which was also a recommendation on the previous inspection. The manager stated in the AQAA they recognised the need for staff training in the protection of vulnerable adults. Also, their plans for improvement were to target quality assurance system to specific areas of the home, e.g., food and the environment. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 19 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, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Limited heating and maintenance to the building may pose a risk to people’s health and wellbeing. EVIDENCE: A tour of the premises was undertaken and a number of issues required addressing. Roof repairs had still not been completed. Wallpaper was peeling off the corridors in the home. It is acknowledged that redecoration had started on one of the corridors near the main entrance and both lounge areas had been re-carpeted. Some carpets in bedrooms and floor covering in the shower room were stained and needed replacing. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 20 One shared room had a large bay sash window with a crack in one pane and a hole in the other. The manager said they have been taped up and been like that for some time; however, the whole window was draughty and unsafe. There were also a number of failed double glazed units. This was also noted on the previous inspection. At the beginning of the visit the inspector noted that the home was cold, windows were open and heating limited. The manager said ‘this was for airing purposes.’ As mentioned previously in this report, visiting professionals had mentioned concerns to us regarding the home being cold. We spoke to the manager and about this and they told us that blankets were available for those people who felt the cold. However, no one had a blanket at the time of inspection. Speaking to people in the home, there was a mixed reaction to the question about heating. Some said they were all right, others said they preferred their room cold and others said they were cold. One daily report said that one person had complained of being cold and was given tea and toast. One person said “It is warm enough for me”. As mentioned previously, in standards 12 to 15, the conservatory was cold for dining. Dining tables were placed near windows that were also draughty. The manager was told to maintain temperatures to a minimum 21°C, unless specifically requested by people and reflected in care planning. Some furniture had been replaced but there was still a need for an ongoing refurbishment plan. Questionnaires from relatives said ‘Some of the furniture in bedrooms is poor, i.e., missing handles on drawers and no waste bins.’ Another said, “I would like to see the home modernised and brought up to date.” Outside, the building was unkempt and required attention to moss and leaves. The manager had recognised on the AQQA what they could do better and had stated the need for a more organised approach to redecoration and refurbishment and general tidying of the home. A plan for improvements was recorded as trimming bushes, redecoration and roof repairs. Odours were noted, although these were limited to certain areas, which the manager was addressing. People were encouraged to bring in their own furniture and a number of rooms had been personalised. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 21 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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Insufficient staff numbers may result in the needs of some people not being met. EVIDENCE: Sixteen people were accommodated in the home on the week commencing 10th December 2007. The duty rota for this week showed two staff on duty between 8am-3pm and 3pm-10pm and two night staff. The manager is supernumerary throughout the day and covers for sickness and holidays. Staff are responsible for cooking and laundry, with only 15 hours’ domestic time between 4pm and 7pm which resulted in day staff having to undertake some domestic duties. Staffing levels and deployment of staff must be reviewed in the light of the issues raised in this report that the manager must now address. Staff induction included aspects of skills for care that the manager had decided was appropriate for the home. They were advised to contact Oldham Social Services training department to discuss induction procedures and ensure all aspects required had been covered in staff induction. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 22 There had been in-house moving and handling training in the last year and staff were waiting for a refresher course. The manager should access professional outside training in order to ensure moving and handling techniques used in the home are up to date and maintain health and safety. Training had taken place in infection control, first aid and food hygiene; one member of staff had completed the falls prevention course and another two, dementia awareness. Recruitment procedures were well documented and a third reference had been sought if the second one was not returned. At interview, staff were not fully aware of people’s needs or what was on their assessment and care plan. However, they did state that they were encouraged to read care plans and assessments in order to understand people’s needs. One person in the home had MRSA, staff were aware of infection control procedures. Questionnaires from relatives said “The regular staff are wonderful, it is the younger staff who have not developed the right skills who give concern.” Also, ‘Often staff seem to be too busy for smaller things to help service users, more staff around would probably help but this involves more financial outgoings for the home.’ Another said ‘I have learned over the years mother has been in care you have to be realistic about what is possible. The biggest overhead is the staff salaries and I think the staff do very well for the number of staff on duty at any time.’ One questionnaire said ‘Staff are friendly and competent and make my mother at home and happy.’ Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 23 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The manager is qualified to carry out tasks required. Appropriate systems are in place to safeguard personal finances of people in the home. The lack of revised care planning and record keeping may result in unsafe working practices. Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager has many years’ experience in management and care. They have just completed the NVQ level 4, registered manager’s award, food hygiene and first aid certificate. There was evidence that people and their relatives were consulted about developments in the home through the quality assurance system, residents meetings and staff meetings. The staff meeting agenda consisted of how to make improvements in the laundry system and confidentiality. The last resident and relative meeting was in June 2007 with a brief meeting in December 2007 to discuss Christmas issues. Examination of people’s finances held by the home found appropriate recordings, with receipts being retained for any expenditure. Fire tests were recorded and fire risk assessments being completed on the building. Gas and electrical equipment had been tested. Environmental Health visited the home on 19th October 2007 at which time they required a designated smoking area for people in the home. The manager had acted on this and changed the spacious hallway into a smoking area and the side door into the main entrance. The health and safety of people is compromised by the lack of appropriate heating and structural issues. Issues identified on this inspection relate to maintaining appropriate care planning; staffing levels and deployment of staff, medication risk assessments and the promotion of choices in the home, which the manager must now address. The manager had stated on the AQAA that they felt the home could improve by expanding the quality assurance system and publishing the results or surveys. They also stated they would benefit from attending Oldham Social Services training in partnership and encourage staff to undertake more training through this route. Throughout this document, the manager had recognised many areas that needed improvement, which now must be addressed. Woodend DS0000005546.V354041.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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X 2 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Woodend DS0000005546.V354041.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 OP7 Regulation 15 Timescale for action Care planning must reflect all the 31/01/08 assessed needs of people in the home. Risks must be identified and recorded within care planning. Care plans must be reviewed and updated on a regular basis to ensure the appropriate care is provided to people in the home and staff have up to date information. Nutritional screening must be in 31/01/08 place for people who have identified weight loss. Risk assessments must be in 31/01/08 place for those people who wish to self medicate, outlining their ability to do so. People who self-medicate must be provided with a lockable secure facility in which to store medication for their own safety and other people in the home. Requirement 2 3 OP8 OP9 12 13 Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 27 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. 4 Standard OP19 Regulation 23/12 Requirement Temperatures in the home must be maintained at 21°C to ensure the comfort of people in the home. Repairs must be carried out to failed double glazing and broken windowpanes to eliminate draughts and promote health and safety. Timescale for action 31/01/08 Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 28 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 6 7 Refer to Standard OP12 OP18 OP19 OP14 OP15 OP27 OP28 Good Practice Recommendations Develop a planned programme of activities looking at individual needs and abilities in order to engage most of the people in the home. Ensure that staff receive external training in connection with the protection of vulnerable adults. Ensure that consideration is given to redecorating the corridors, and a planned programme of refurbishment is completed together with timescales for completion. The dining experience and staff routines should be reviewed in order to provide a more congenial atmosphere for people when dining. Ensure that people are offered choices in their daily lives and developed menus which reflect choices and the nutritional value of meals Review staffing levels, and the deployment of staff to ensure the needs of people in the home are met. Ensure all staff have access to outside professional training courses in moving and handling techniques to ensure the homes practice of in house training to not become insular and out of date. Initiate discussions with Oldham Social Services training Partnership to ensure staff have access to up to date training and induction in line with people’s needs in the home. People should be able to control the temperature in their personal rooms with any wishes for extremes of heating being reflected in their care plans together with the consultation process. Weights of people should be recorded on a regular basis to identify when professional help is needed and ensure the health care needs of people in the home are met. 8 OP30 9 OP19 10 OP8 Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodend DS0000005546.V354041.R01.S.doc Version 5.2 Page 30 - 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!