Inspection on 10/04/07 for Woodside

This inspection was carried out on 10th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodside 02/11/06

Woodside 18/07/06

Woodside 16/09/05

Woodside 04/04/05

Woodside 14/09/04

Woodside 01/06/04

Woodside 15/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Woodside The Old Vicarage Slip End Nr Luton Bedfordshire LU1 4BJ Lead Inspector Mrs Louise Trainor Unannounced Inspection 10th April 2007 07:15 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 Woodside DS0000014988.V334009.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. Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodside Address The Old Vicarage Slip End Nr Luton Bedfordshire LU1 4BJ 01582 423646 01582 423646 vibhakiran@aol.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Shires Healthcare (Woodside) Limited Teresa Vincent Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (28) Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 2006 Brief Description of the Service: Woodside is a privately owned care home. It is registered to provide for twenty-eight older people who may also have physical disabilities and/or dementia. The registered providers are Shires Healthcare (Woodside) Ltd. Mrs V Khan is the sole director and the responsible person. The home now has a Registered Manager in place. The home is located in a rural area at the edge of a village. Public transport is limited but access to the M1 and Luton were nearby. The premises have been suitably adapted to meet the service users assessed needs at this inspection with the exception of access to ensuite toilet facilities, which is limited in most instances and suitable only for those without mobility problems. Single room accommodation is provided. Twenty-one of these had en-suite toilet facilities. A lift enables service users to access the second floor. The third floor is used as a laundry, storage area and for staff accommodation. The fees for this service vary between £450.00 and £495.00 per week. Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection for 2007 for this home. It was carried out by Regulatory Inspector Louise Trainor on 10th of April 2007 between the hours of 07:15 and 16:00 hours. The home manager arrived at 09:00 hours and was present for the remainder of the inspection, and the newly nominated Responsible Individual for this home also attended twice during the day to receive feedback and discuss issues raised throughout the day. Three service users were case tracked, and six members of staff were interviewed during this inspection. Documentation including four staff files, three service users care plans/ files, service user s financial records, accident records, service user information documents and medication charts were examined Care practices were observed throughout the visit, and the inspector had the opportunity to spend some time with the cook and meet with the district nurse that visits this home on a regular basis. The inspector would like to thank everyone involved for their assistance and support during this inspection. What the service does well: There is a Statement of Purpose and Service User Guide in place for this home, so that service users can make an informed choice about where they live. The document has been reviewed since the previous inspection. All service user files that were inspected contained pre admission assessments. These were all clearly dated prior to the admission date and signed by the manager or the deputy manager. They gave a detailed profile of the of the service users needs and the level of assistance required. The homes recruitment policy is sufficient and is adhered to so that service users are supported and protected at all time. Four staff files were examined and were all found to be in order. There is a complaints policy in place and this is easily accessible to all service users and visitors to the home at all times. As well as being summarised in the Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 6 in the Service Users Guide, it is also on display in the entrance hall of the home. All staff have attended training in the Protection Of Vulnerable Adults (POVA) and have a clear awareness and understanding of the subject. There have been no POVA referrals in the last six months. The majority of service users have daily spending money kept on the premises. The accounts for these finances were inspected. Three service users accounts records were picked at random by the inspector. The records were all clearly dated, transactions detailed and signed by the manager. What has improved since the last inspection? What they could do better: The home continues to require a member of staff dedicated and experienced in activities to ensure service users benefit from meaningful pastimes. The day areas were generally tidy however the seating did not appear clean, and some of the chairs had pressure cushions on them that were stained. On this visit there was a noticeable odour indicative of poor continence management. Despite recent decoration, much of the ground floor of this home remains rather dull and dark. This is exaggerated by the dark wood and dark carpets. It Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 7 would benefit from some attention to brighten it up and make it more welcoming and homely. Accident / incident forms were inspected. Five falls that had been recorded in the accident book were tracked back to the service user’s files. With the exception of one, all had been appropriately recorded. However none of these falls had been reported to the Commission for Social Care Inspection (CSCI) via the Regulation 37 process. The manager was reminded to be mindful of this practice. The process for handing over one shift to another requires review, to ensure that all appropriate information relating to service users is accurately communicated between staff. Menus require a review to ensure that all service users have a choice at every meal. More fresh and home baked produce and should be introduced on to the menu. 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. Woodside DS0000014988.V334009.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 Woodside DS0000014988.V334009.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): 1, 3, 4, 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure all prospective service users are assessed prior to being offered a place in this home. Information is issued to prospective service users, however some minor adjustments are required to ensure accuracy. EVIDENCE: There is a Statement of Purpose and Service User Guide in place for this home, so that service users can make an informed choice about where they live. These documents have been reviewed since the previous inspection as was required, however due to the appointment of a new Responsible Individual, further changes are required. It was also suggested that more specific detail be included regarding things that incur additional costs, such as toiletries and hairdressing. This will ensure that there is no confusion for service users and their representatives, as to what is and is not included in the fees. Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 10 The three service user files that were inspected, all contained pre admission assessments. These were all clearly dated prior to the admission date and signed by the manager or the deputy manager. They gave a detailed profile of the of the service users needs and the level of assistance required. These assessments all contained information relating to medication, medical history, allergies, mobility, nutrition, pressure area care, activities and personal capabilities and preferences. One service users assessment indicated their need for glasses, but also identified that they did not like to wear them and preferred to use a ‘spy glass’. Another indicated his dislike for spicy foods. This home does not offer intermediate care, but does have service users visiting for respite care. Woodside DS0000014988.V334009.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): 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. Policies and procedures relating to the administration of medication are good and are being adhered to, and work continues on a new format of service users plans, so that service users are protected. EVIDENCE: The medication trolley was tidy and well organised. There was a specimen signature sheet at the front of the records file, and each individual sheet had a photograph attached so that service users could always be identified. During this inspection all the service users Medication Administration Record (MAR) sheets were inspected. Some were rather shabby and torn in places, but prescriptions were clear. They had all been completed appropriately with signatures and omission codes. Where an omission code had been inserted, there was a corresponding explanation for the omission on the reverse of the sheet. The blister packs were examined, and the contents corresponded with the MAR sheets in all cases. Returns were sealed in individual envelopes that were Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 12 clearly marked with the date and time that the refusal took place, and had been signed by the member of staff responsible at that time. There were no variable doses prescribed. Since the last inspection the manager has subscribed to further training for all staff regarding medications, and has carried out MAR sheet audits on a regular basis. This has evidently had the desired effect as no errors were found during this inspection. The manager and her senior staff have worked hard since the last inspection to improve the standard of the care plans. There were multiple care plans in place in the three service user files that were inspected. These were however at different stages of being transferred and rewritten in the new format. Care plans covered all aspects of care, varying from mobility and pressure area care, to sensory needs, such as eyesight and hearing, and social activities. The care plans included personal choices and preferences indicating service users had been involved. One service user who required glasses preferred to use an eye- glass. Another service user with nutritional needs preferred certain supplement drinks to others and this was documented. Care plans had been generated from risk assessments and were being reviewed on a monthly basis. One service user had been admitted with pressure sores. A ‘Waterlow Assessment’ had been completed and the appropriate pressure relieving equipment was in place. The visiting district nurse confirmed that although she does visit twice weekly, she is confident that the staff are managing this service users needs well, and his skin condition is much improved. The manager and her team still have some way to go before all service user plans are transferred on to this new documentation, however progress since the previous inspection is very positive. Observations of care indicated that staff were being respectful when interacting with service users, and in general relationships appeared relaxed and friendly. There were however mixed comments from service users. One said. “The staff are lovely, I can’ t fault them”. Some visitors said. “The staff are lovely, they work hard, cope really well, and are always helpful”. But one service user said. “They ‘ll all dodge a job if they can”. It was also noted during the morning that perhaps more care should be taken ensuring service users dignity was maintained at all times. One gentleman was being assisted to transfer. On completion of this transfer he was left with his T. shirt rolled up exposing his back. The inspector had to bring this to the attention of the carer three times before she understood, and made him more comfortable. Another service user appeared rather unkempt and unshaven, and when asked said. “They didn’ t have time today”. When touring the first floor of the home, another gentleman was seen sitting on a commode in his bedroom, with the door wide open. Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. There are activities offered within this home, however the staff appear to need some guidance to ensure different programmes are used appropriately so that service users enjoy and benefit from them. EVIDENCE: This home offers a variety of activities, however despite attempts, they have still been unable to appoint a dedicated activity staff, therefore care staff co ordinate this as and when they can. On the afternoon of the inspection one carer was delivering a music session. This was a disc that played the beginning of an ‘old time war song’, it then paused, and required staff intervention, to encourage and allow participants to sing the full song. Unfortunately, the staff, although very attentive and caring to the service users in her care, did not appear to understand this concept and therefore the disc just kept playing the first line of various songs, which was rather confusing. This carer was also trying to encourage a service user to do some knitting, and trying to mobilize another, and therefore could not focus on the main activity session. Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 14 During this session a carer came in from another lounge and was advised to do some ‘chair aerobics’, she clearly did not understand what this meant. These are all ideal activities for this group of service users, however it is imperative that staff are competent and confident in how they should be delivered. Other service users, in particular the men, were not involved in any of the activities, and one gentleman talked to the inspector of how bored he was. However a visiting professional commented on how much improved the activities were. The inspector recognises how difficult it can be to provide activities that are meaningful for service user that have cognitive impairment, but with some guidance from specialist services this could be improved greatly. The inspector visited the kitchen and met with the cook who has been in post for approximately six months. He was somewhat frustrated that, on return from a weekend off, other staff had clearly not respected his cleanliness and tidiness in the kitchen. Dirty crockery had been left on the work- tops, the base of the oven, although covered with foil had food spillages that should have been cleaned up, and the fridge revealed cheese and cooked meats left uncovered so that they could not be used. He discussed certain procedures that should be being followed at all times in the kitchen, but stated that at times food temperatures are not taken, and sometimes there is not enough food to allow him to keep samples. The present menus offer a wide variety of choice, however these are somewhat limited, for example the choice for one meal maybe lamb casserole or lamb chops, this does not allow for those who do not like lamb. Another day gave a choice of quiche or pie, for those who do not like pastry this is unacceptable. The cook is very aware of these issues and is presently in consultation with the manager to amend them. The amount of frozen and powdered produce was also an issue. The cook prefers to make his own cakes etc, but the cupboards were full of sponge and crumble mix. There were limited fresh vegetables, some of which looked old, and fresh fruit is only offered in fruit salads, as it is felt that leaving a bowl of fruit out for service users to help themselves would not be appropriate. This should be researched more thoroughly and considered as a positive option. Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. There is a complaints policy in place, and a brief summary of this is in both the Statement of Purpose and the Service User Guide so that service users and their representatives are confident their views will be listened to and acted upon in a timely fashion. EVIDENCE: There is a complaints policy in place and this is easily accessible to all service users and visitors to the home at all times. As well as being summarised in the in the Service Users Guide, it is also on display in the entrance hall of the home. There have been no complaints made to the home since the last inspection six months ago, and comments from the District Nurse that visits regularly, indicated that the standards of care in this home have improved greatly. All staff have attended training in the Protection Of Vulnerable Adults (POVA) and have a clear awareness and understanding of the subject. There have been no POVA referrals in the last six months. Woodside DS0000014988.V334009.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): 19, 20, 25, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This home provides comfortable surroundings, however the level of cleanliness needs to improve. EVIDENCE: This home provides sufficient communal space for the service users. There are two lounge areas and a dining room with an extension overlooking the garden. Some of the service users remain in the dining area throughout the day. The day areas were generally tidy however the seating did not appear clean, and some of the chairs had pressure cushions on them that were stained. On this visit there was a noticeable odour indicative of poor continence management. This was not only first thing in the morning, but throughout the whole day. Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 17 A brief tour of the first floor revealed dirty clothes being left in shower rooms, this did not help with the odour. There was also staining on the lounge carpet. This may have also been contributory to the smell. Despite recent decoration, much of the ground floor of this home remains rather dull and dark. This is exaggerated by the dark wood and dark carpets that run right through the ground floor. It would benefit from some attention to brighten it up and make it more welcoming and homely. The garden has received attention, and debris from the works during the last inspection has been removed. It now provides a bright and safe area for service users to relax weather permitting. Woodside DS0000014988.V334009.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): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes recruitment policy is sufficient and is adhered to so that service users are supported and protected at all time. However further training is required in some areas to ensure that the staff fully understands the specialist needs of the service users and how to meet them effectively. EVIDENCE: Staffing levels in this home are adequate. There is presently four staff on duty between the hours of 07:00 and 19:30 hours. The manager works from 09:00 to 17:00 hours on Monday to Friday and provides an on call out of hours service for staff support. The night shift (21:30 – 07:00 hours) however, has only two care staff, caring for twenty- two service users, many who suffer with Dementia and have medium to high needs. This matter was discussed with the manager and the new Responsible Individual at the home, during the inspection, and the night staffing levels were increased to three, with immediate effect. This was a very positive move. Four staff files were examined during this inspection. All contained appropriate documentation. This included fully completed application forms, Contracts and terms and conditions of employment all clearly signed and dated. Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 19 Two or three appropriate references, Photographic ID, proof of address, fully completed health questionnaires, Enhanced CRB clearance checks all dated prior to employment commencement, with the exception of a new kitchen assistant that started his induction programme on the day of the inspection. He had been POVA first checked, but was still awaiting CRB clearance confirmation. The staff files and staff interviews all indicated that staff are being offered and encouraged to attend a wide variety of training. All staff files seen contained the certificates confirming that mandatory training sessions such as Moving and Handling, Protection of Vulnerable Adults (POVA) and Fire are being attended by all staff. Other training is being addressed in more specialist subjects. In particular, Dementia Awareness training has now been attended by the majority of staff, and ten staff have just commenced on an advanced Dementia Course with a local college. On the day of the inspection, the inspector observed the handover from night staff to day staff. This was very basic and contained minimal information about the service users. It also concerned the inspector that neither of the senior cares on duty were 100 sure of how many service users should be, or were in the building. This was discussed with the manager and the Responsible Individual, who agreed to look at a new system for the ‘handovers’ that will ensure all staff have an accurate and up to date account of each service user, and are aware of how many service users are in the home at all times. The inspector will look forward to seeing this new system implemented and monitoring its effectiveness at future visits. Woodside DS0000014988.V334009.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): 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 has appropriate policies and procedures in place, however systems for reporting incidents within the home need reviewing to ensure service users’ health, safety and welfare are promoted and protected at all times. EVIDENCE: The manager remains committed to improving the quality of care delivered in this home, and interviews with staff, service users, visiting professionals and relatives indicates that she has gained their confidence and support. The district nurse stated that since this manager had come into post, she had seen a great improvement, and could now reduce her visits, as she was confident that the home was safe and the care appropriate. Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 21 A visitor to the home said. “The manager leads by example and I’m very happy with the home. The staff are lovely, they’re really helpful and work together.” Staff interviews generally indicated that they felt well supported, and staff files evidenced that both supervision and appraisals of staff are taking place on a regular basis. The majority of service users have daily spending money kept on the premises. The accounts for these finances were inspected. Three service users accounts records were picked at random by the inspector. The records were all clearly dated, transactions detailed and signed by the manager. Each account is the checked and audited by the Responsible Individual on a monthly basis, and countersigned. All the accounts inspected had receipts corresponding to each transaction, and the sum of money remaining corresponded with the records. Accident / incident forms were inspected. Five falls that had been recorded in the accident book were tracked back to the service user’s files. With the exception of one, all had been appropriately recorded. However none of these falls had been reported to the Commission for Social Care Inspection (CSCI) via the Regulation 37 process. The manager was reminded to be mindful of this practice. Woodside DS0000014988.V334009.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 2 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 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 3 3 3 X 3 3 2 2 Woodside DS0000014988.V334009.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. 1. Standard OP1 Regulation 6(a) Requirement Timescale for action 31/05/07 2. OP10 12(4)(a) The registered person shall ensure that the Service User Guide and Statement of Purpose are reviewed regularly and kept up to date. The registered person shall make 30/04/07 suitable arrangements to ensure that all staff understands the importance of respect and dignity towards the service users. The registered person must ensure that appropriate activities are available for all service user and staff are competent in the delivery of these activities. The registered person shall ensure that suitable and wholesome, nutritious meals are provided for service users, and that meal choices are always available. The registered person must ensure that the home is kept clean and free from offensive odours. The registered person must ensure that illness and other DS0000014988.V334009.R01.S.doc 3. OP12 16(2)(n) 18 (1) ( c)(i) 16(2)(i) 31/05/07 4. OP15 30/04/07 5. OP26 16(k) 30/04/07 6. OP37 37(1) 30/04/07 Woodside Version 5.2 Page 24 events in the home are appropriately recorded and reported to CSCI. 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 OP14 OP15 OP26 OP37 Good Practice Recommendations The registered person should consider using picture menus or a similar system to ensure service users with cognitive impairment are able to make choices at mealtimes. The registered person should consider different ways of ensuring service users receive adequate fresh fruit and vegetables. The registered person should consider how the home could be made brighter and more inviting to visitors. The registered person should consider internal service user file audits to ensure information is appropriately documented. Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Woodside DS0000014988.V334009.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!