CARE HOMES FOR OLDER PEOPLE
Woodside The Old Vicarage Slip End Nr Luton Bedfordshire LU1 4BJ Lead Inspector
Leonorah Milton Unannounced Inspection 16th September 2005 07:30 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 Woodside DS0000014988.V249385.R01.S.doc Version 5.0 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.V249385.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Woodside Address The Old Vicarage Slip End Nr Luton Bedfordshire LU1 4BJ 01582 423646 01582 423646 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 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.V249385.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12/07/05 Brief Description of the Service: Woodside was a privately owned care home. It was registered to provide for twenty-eight older people who may also have physical disabilities and/or dementia. Having received further guidance it is acknowledged that the registration for physical disabilities was not applicable to this service. The removal of this category will be discussed with the proprietor. The registered providers were Shires Healthcare (Woodside)Ltd. Mrs V Khan was the sole director and the responsible person. Mrs A Rujab had managed the home since May 2005. Her application to register as the manager was being processed by the CSCI as this inspection progressed. The home was located in a rural area at the edge of a village. Public transport was limited but access to the M1 and Luton were nearby. The premises had been suitably adapted to meet the service users’ assessed needs at this inspection with the exception of access to ensuite toilet facilities, which was limited in most instances and suitable only for those without mobility problems. Hoists were available to assist transfers. Single room accommodation was provided. Twenty-one of these had en-suite toilet facilities. A lift enabled service users to access the second floor. The third floor was used as a laundry and storage area and was not accessible to service users. It had also been used for staff accomodation. There was a large garden to the front of the house. Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over two separate visits to the home. The manager and the proprietor’s representative were present for most of the first day. The manager was also present for the majority of the second visit. The methods of inspection included discussions with ten service users, one of whom had left the home shortly before the second visit and a review of the case files for three service users and other documents. The private accommodation for six persons was seen, as were the communal living arrangements. Conversations took place with four members of staff, the manager and the proprietor. Feedback was received from two healthcare professionals. Other information was provided after the first inspection by others who had visited the home: two social workers, a paramedic and two visitors to service users. This inspection also took account of information sought with regard to the financial management of the service. This report will comment on progress to meet requirements from previous inspections, aspects of the core standards not assessed at the previous inspection and those that were reassessed at this inspection. It is recommended that this report be read in conjunction with the report of the inspection carried out on 4th April 2005 for a complete overview of the standard of the operation at Woodside between these dates. What the service does well:
The communal accommodation was spacious and comfortably furnished. Areas of the building seen were clean and orderly with the exception of two bedroom carpets that required cleaning to remove unpleasant odours. All but two of the service users who contributed to this inspection stated that they were satisfied with the care they had received. They found members of staff to be kind and helpful, even when there had been overlong waits for personnel to respond to requests for assistance. Members of staff were described as “wonderful”, “alright”, “lovely” and “kind”. Positive comments were also passed about the provision for meals, “ a good selection at breakfast” and “ some days are better than others but it is very good”. Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 6 Service users were well attired, had evidently received support with their personal care needs. Records indicated that appropriate healthcare treatment had been sought for service users. What has improved since the last inspection? What they could do better:
One service user had requested and eventually left the home because she felt frightened by a small percentage of the team and stated that she had not been assisted to move about with sufficient care. Hoists to assist with moving and handling had been provided but the service user’ representative stated that the hoist in her relatives room had not been used. There was evidence to show that at least two members of staff had not received training in safe moving and handling practice and that at least two others required updates to this training to ensure that that they were aware of current safe practice guidelines. A visitor corroborated two service users’ opinions that there was too long to wait before staff came to assist them, which in some cases had been requests to access the toilet. Service user comments about the overall management of the home were less complimentary than their praise of the care and ancillary personnel. One service user described the manager as “ not too bad” but expressed dissatisfaction with the director because “ she always says she will do something and she doesn’t”. In addition one service user stated that he rarely went out of the home and described himself as a “prisoner” and the home as being “locked in”, another stated that he had not been out of the home since the previous Christmas despite there being notices of planned trips for earlier in the year that had not taken place. To prevent this disappointment the
Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 7 management team needs to be more proactive in providing outings when planned. Four service users confirmed that they felt able to raise concerns/voice their opinions in the home with the manager and the director. However, there was evidence to show that customer satisfaction questionnaires were not representative of service users’ opinions, these having been completed by staff. Evidence of the use of support, not connected with the home, for the completion of these would achieve a more independent outcome. The management of the home had not been carried out in accordance with good practice for openness and transparency. A complaint of a serious nature that involved issues about the protection of a vulnerable adult had not been reported to the CSCI despite this being a legal requirement. In addition there has been a lack of written information about a prolonged failure of the lift or a timely notification about this situation to the Commission. There was a lack of expected levels of co-operation and openness at inspection and in the ongoing relationship with the Commission. This is demonstrated by withholding service user’s documents at the inspection; supplying conflicting dates within information regarding starting dates of the manager and conflicting information about the role of a person who attended the home with the director. Information received in relation to the financial operation of the company raised concerns about the proprietor’s practice in this aspect of the service and showed that creditors had not been promptly dealt with. The director informed the Commission that the company has and would continue to, where necessary, challenge creditors in the court where bills were disputed, this being viewed by them as good financial management practice. All of these factors, expressed by service users, relatives/representatives, exstaff, and professionals and in the relationship conducted with the Commission contribute to an overall loss of confidence and trust in the management of the home. The director and the manager are advised that they must demonstrate their fitness to manage and administer a care home by ensuring that records are properly maintained and available for inspection in relation to the complete operation of the home. The home’s quality assurance systems must be seen to be effective tools with which to measure service user satisfaction and correspondingly aim to improve the service. To ensure that information is shared appropriately, all members of staff working in the home need to be made aware, by the proprietors, that it is an offence to obstruct inspection processes, and in the best interest of the service they need to be co-operative during the inspection process. Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4. The home had carried out thorough pre-admission processes for those recently admitted to the home to ensure that the home had the ability to properly care for service users. EVIDENCE: The case file for a service user recently admitted to the home showed that an assessment of need that met the required minimum standard had been carried out prior to admission and revaluated again following a hospital admission. The conduct of the staff team had demonstrably improved so that members of staff presented as more responsive to service users’ needs. A recent complaint showed that there was a need to provide guidance for staff, particularly those at night, with regard to their manner of speaking loudly to service users’ with hearing loss/dementia, so that it could not be misconstrued as intimidating. Woodside DS0000014988.V249385.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9,10 The written care planning documents were not fully understood by staff and as such there was a risk that service users’ needs could be wrongly assessed and not met. EVIDENCE: It was evident that members of staff were endeavouring to meet service users’ needs and to a large extent they were succeeding. However the written evidence of care assessment and planning were inadequate: The ongoing assessment of need was based on a series of assessment tools that resulted in scoring ratios to identify needs and levels of dependency. These had not always been translated onto the plan of care to show how these assessed needs would be met. In some instances the scoring ratios had been incorrectly completed. On one record there was a score that equated to double incontinence, whereas another for the same person showed the service user to be continent. Risk assessments for one person gave a score that indicated her skin was at risk.
Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 12 There was no corresponding plan for the management of skin care, even though assessments of nutritional needs had been introduced. Care plans recorded in most aspects, standard phrases relating to the overall need in each section. The plans required more information about the personal preferences that each service user has for their intimate care needs, the detail of how assistance will be given and how much they were able to do for themselves. The records of health care needs for one service user showed that she had not received chiropody treatment for some considerable time. These were not consistent with the records of expenditure from the service user’s personal monies, which indicated that she had been charged for regular treatment. The administration of medicines was dangerous at the inspection of 4th April 2005. This had improved by the follow up inspection carried out on 12th July 2005. However, at this inspection it was noted that there were two entries when staff had not included their surnames to entries made in the Controlled Drugs Records. Another entry showed that one person only, rather than the required two signatures, had entered new supplies of Controlled Drugs. It was also apparent that some staff surnames had been added to these records in retrospect because the second entry had been squashed into the space available. A service user complained that she had been unable to access the telephone. Whilst there were mitigating circumstances to explain this during the lift failure, this could have been avoided if the home had a cordless telephone. Woodside DS0000014988.V249385.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14 Whilst there had been some improvements to the quality of the day-to-day lifestyles for service users, there were some who had unmet expectations. EVIDENCE: The pattern of daily life observed during these two visits to the home proceeded at a leisurely pace for service users that was conducive to their frailties, needs and preferences. However two service users expressed dissatisfaction at the lack of opportunities to leave the building even for short trips to local shops. Although it appeared that service users’ visitors were welcome in the home, there were several reported instances of difficulty in gaining access to the home because of long waits at the entry door. Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Arrangements to enable service users to make complaints were unsatisfactory and there was a risk that concerns would not be properly investigated or reported. EVIDENCE: The record of a recent complaint had been poorly documented and did not cover all of the aspects of the concerns that were subsequently reported to the CSCI by a service user’s representative, following her meeting with the manager and the proprietor. There was evidence to show that customer satisfaction questionnaires were not representative of service users’ opinions, these having been completed by staff. The use of independent support for the completion of these should be considered. Moreover the response by the director at the inspection with regard to service users’ feedback about questionnaires evidenced that there was a resistance to recognise the importance of service users’ negative comments made during the inspection process and the role in providing feedback on any dissatisfaction about the service they received. Service users’ views need to be acknowledged and addressed if improvements are to be made and good outcomes achieved. At the previous inspection an immediate requirement had been issued in relation to the training that staff had received in relation to Adult Protection Procedures. Action had been taken to provide this training for key personnel. The manager is advised to ensure that all personnel are briefed about the
Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 15 home’s protection procedures and to maintain evidence of the same. This must include guidance in the way service users are spoken to as detailed elsewhere in this report. A complaint of a serious nature that involved issues about the protection of vulnerable adults had not been reported to the CSCI despite this being a legal requirement. This service user had left the home at her request with the assistance of social services. Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,25, The layout, décor and furnishings were in the main suitable for the needs of frail older people but there had been breaches to safety that had posed a significant risk of harm to service users. EVIDENCE: Woodside had a homely atmosphere and provided comfortable surroundings. The home was clean except in two rooms where service users had continence problems. In these there was an unpleasant odour. It was evident that the domestic team had been diligent in their work. One spoken to briefly took an evident pride in her work. However there were problems with systems and safety as follows: The home had a history of problems with its heating and hot water supplies. This inspection was no exception. On the first day of the inspection there had been no hot water supplies since the preceding night and supplies were not restored until 17.00 hours on the day of the inspection.
Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 17 On the second day of the inspection it was belatedly established that the lift had been out of order for nine days. Service users on the upper floor had remained in their bedrooms. Safety precautions at the previous inspection had been insufficient in that service users could access the heating boiler through an unlocked door. Beyond the door was an accessible naked flame because the front cover of the boiler had been removed. The room contained combustible materials. At this inspection the door was secured but on the first day it was noted that the room still contained combustible materials in contravention of the immediate requirement that had been issued previously. By the second day of the inspection these materials had been removed. Action had been taken on immediate requirement notifications issued at the previous inspection in relation to fire safety. The fire officer had visited shortly after the last inspection and stated on his report that coded pads must be removed from the exit doors. This had not happened by this inspection. It was stated that another fire officer had visited and advised that the devices could remain in situ. There was no report of his visit. The fire risk assessment for the home had not been reviewed since July 2004 and did not take account of this locked door policy where members of staff had to be available to let people out of the building. In the event of a fire reliance on members of staff who might be at the other end of the building is not acceptable. These arrangements had not taken account of service users basic rights to move freely out of the building. The home’s fire safety policy stated that it had a “no evacuation” policy. There was no evidence to show that the no evacuation policy had taken account of the safety of all persons who live, work and visit the home or that the fire officer had been consulted about this policy. Whilst the use of the staff flat is not disputed there were no procedures for the use of the flat above service users’ accommodation to ensure the protection of vulnerable adults and meet safety requirements. On the inspection the flat was occupied by the manager, staff were not aware of her presence and fire safety was compromised in the stairwell by a table propping open the fire door. Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30. The team on the whole had the skills to care for service users but there were still concerns that a service user had not been properly cared for. EVIDENCE: The gradual turnover in the compliment of the team over the inspections carried out in the last year appeared to have removed those staff who had undermined the performance of the team. The morale of the individual members seemed had improved since the appointment of the new manager and the team was seen to be operating more consistently. As mentioned previously in the report service users were far more complimentary about the skills of the team than at previous inspections. There were, however, still concerns about communication skills, two service users having commented about feeling isolated by the habit of staff talking together in their own language. A service user had reported she had experienced pain when staff had moved her. There was a lack of evidence to show that members of staff had received guidance in the correct use of hoists. Records assessed during the inspection showed that two members of the team had not undertaken training in safe manual handling techniques. One staff member had last received training in safe techniques in September 2003 and another in October 2003. The employment contract for one employee stated that she was employed as a carer/senior carer but the rota showed her working as a carer. Other
Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 19 documents such as work permit and job application referred to senior carer positions. The rota did not sufficiently clarify who was on call mid-week. This apparently was the manager. Given that her home at some considerable distance there must be written contingency plans to identify a senior person on call who could come to the home at short notice. The manager was not working the shift pattern identified on the rota. She was advised that she must record her presence in the building as a safety requirement. On the morning of the inspection staff had stated that the manager was en route to the home and yet she was found to be in her night attire behind a locked door in the staff flat. Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,37,38. The manager presented as committed to improving the home but her lack of openness with the regulating authority raised concerns that she would not act in the best interests of service users at all times. EVIDENCE: The manager’s application to be registered was being processed by the CSCI as the inspection took place. Documents submitted to support her application showed her to be experienced and qualified in the care of older people with the exception of training in dementia care, which had been a one-day course only. The manager’s start in the home and the beginnings of her relationship with the regulating authority had been inauspicious. It had been difficult to assess the level of induction and supervision she had received. Her personnel file was disorganised and did not contain sufficient information to show when she had started work in the home. The start date of the manager provided by the director following the inspection has been given as 16th May 2005. We were
Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 21 informed that the manager was on induction from this date. There is evidence in information provided by the director on the 19th May 2005 where she states that she (the manager) has not yet commenced work. There is evidence from another statutory agency that identifies the manager attending a meeting with the agency as the manager of the home on the 18th May 2005. The director supplied written information to the Commission on the 23rd May 2005, which states that the manager was commencing on that day. Copies of the signing in record supplied by the director after the inspection show the manager present in the home from 16th May 2005. Evidence from this inspection showed that the manager had introduced much needed strategies to improve staff performance to the benefit of service users. Staff passed favourable comments about the manager’s skills and remarked on recent improvements within the home. These efforts were negated by the lack of transparency with the regulating authority about serious situations in the home. There had been a failure to notify the CSCI under Regulation 37 about a recent complaint about staff practice that had resulted in the service user’s wish to leave the home. Documents pertaining to this issue had also been initially withheld from the inspector. There had been a failure to notify the CSCI under Regulation 37 about the break down of the lift over a prolonged period and there were no entries in the staff communication book to alert inspectors that anything might be amiss. The manager had made records of a meeting with a service user and her representative. These had not fully documented all aspects of the complaint and it is questionable if they accurately recorded those present at the meeting. The meeting took place in the service user’s bedroom. This was an evening meeting with a service user and her representatives in relation to complaints she had raised about her care needs. The service user’s representative described a man being present introduced as the owner. The inspection was unable to identify the identity of this man. The manager stated that a man, she believed to be a director of the company did visit the home that evening but he waited outside of the service user’s room. The director has subsequently confirmed that a man, described by her as a friend who provided a lift to the care home, did accompany her to the home that evening at 10pm but denies that he had any involvement with relatives or service users and he did not attended the meeting. The entries in the signing in book for that evening only record the arrival of the director at 7.20pm. The accuracy of the record in the home is therefore questionable. The director has confirmed that she is the sole director of the company. Details confirming the identity of the male visitor on the night in question have not been provided to us. All parties agree that they attended the meeting. All parties agree that a man was present at the home that evening. The director
Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 22 and manager give conflicting accounts as to his role and amount of involvement. The record of the meeting is incomplete. It is therefore unclear as to the reason why the service user’s representative would describe him as being present as an owner if he had no involvement with service users and relatives as stated by the director. We are concerned that any involvement in the home by this unidentified male visitor compromised the privacy and dignity and safety of the service users and if he did not attend the meeting, it is unclear as to how he was supervised in the building. The requirement to keep a record of all visitors has been made. Records for one service user’s personal monies showed that she had been without resources to pay for hairdressing services and the last recorded hairdressing service had been in January 2005. The manager stated that the service user had had her hair done free of charge. The service user’s hair looked clean at this first day of the inspection but was straggly. At the second day the service user’s hair looked styled. Further enquiries to the organisation’s HQ at this inspection showed that some of her monies had been held centrally. The director explained that this had been an oversight. Recent enquiries about the financial operation of the company showed that six creditors had sought payment through court proceedings during 2004 and 2005. The director provided information to show that four of these debts had been settled before the CSCI contacted the director. One of these was the contractor who serviced the fire safety systems. The inspection by the fire officer in July 2005 identified that these systems were overdue for testing. . The director has informed the Commission that she considers it to be sound financial business to challenge any creditor up to and including use of the court system where there are disputes and the Company will continue with this practice where necessary. Whilst the home may wish continue with this practice consideration does need to be given as to the safety and welfare of service users when disputes may impact on provision for them. The home’s policies and procedures had not been updated in relation to the National Minimum Standards for the operation of a care home. In some cases they did not reflect the actual day-to day practice in the home. There were none in the manual given to the inspector in relation to care planning, assessment and review, staff recruitment and supervision, the provision of meals and service users’ nutritional needs, care of the dying, confidentiality. Previous inspections had raised concerns about the organisation’s fitness to operate a care home. Despite the evident progress in some aspects of the service the significant shortfalls were still cause for serious concern, as was evidenced by the failure of the director and the manager to meet their obligations to conduct the home so that its dealings with service users, their representatives and others are open to scrutiny. Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 23 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 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 1 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 x COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 3 1 x x x x 1 1 x STAFFING Standard No Score 27 2 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 1 1 x 1 1 Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation Requirement Timescale for action 30/06/05 2 OP7 4(1)(2) Service users must be provided 5(1)(2)(3) with accurate information as specified by these standards and the legislation to enable them to make an informed choice about their decision to move into the home. Not assessed at this inspection. 15(1)(2) More specific detail about capabilities and personal preferences must be included in plans of care and record service users’ agreements to their plans of care. This must include wishes for at death including last rites. (Previous timescales of 31/08/04, 30/11/04 and 31/07/05 had not been met in full). 12(1)(a) 15(1)(2) Care plans must take account of risk assessments about service users’ inability to summon help and in relation to those who may become isolated in their bedrooms. Service user files must contain
DS0000014988.V249385.R01.S.doc 31/12/05 3 OP7 31/12/05 4
Woodside OP7 17(1)(a) 26/09/05
Page 25 Version 5.0 Sch 3.3(j) 5 OP9 13(2) 6 OP10 12(1)(a) 12(4)(a) 12(1)(a) 16(2)(m) 7 OP12 8 OP14 12(1)(a) 16(2)(m) 17(1)(a) Sch 4.11 12(1)(a) 22(3)(4) 9 OP16 10 OP16 11 12 OP19 OP19 23(4)(c) (iii)(v) 12(1)(a) 16(4)(b) accurate records of events that affect their well beingcomplaints, meetings and similar. (Issued as an immediate requirement at the inspection). Staff signing the Controlled Drugs Register must include their last name/surname. (Previous timescale of 18/07/05 had not been met) The registered person must not allow unauthorised persons to be involved in any arrangements for the operation of the care service. Service users must be provided with regular opportunities to have trips out of the building that suit their preferences and which have been arranged by the home. Service users’ visitors must be allowed entry into the home at reasonable times to suit service users’ preferences. Complaints must be fully documented and reference made to each complaint in the central log of complaints. Issues of concern must be investigated under the homes complaints procedures. Those expressing concerns must be informed about the home’s complaints procedures. (Previous timescale of 30/04/05 had not met in full). Fire evacuation procedures and the fire safety risk assessment must be agreed with fire officer. The registered person must provide adequate means of escape. Coded-pads on exit doors must be removed or have their codes clearly displayed by them.
DS0000014988.V249385.R01.S.doc 10/10/05 10/10/05 30/11/05 10/10/05 10/10/05 10/10/05 31/10/05 31/10/05 Woodside Version 5.0 Page 26 13 OP19 23(1)(a) 13(6) 14 OP24 12(1)(a) 23(2)(c) 12(1)(a) 23(2)(p) 15 OP25 16 16 OP29 OP29 12(1)(a) 19(1)(a) 13(6) 19(1)(a) 17 OP30 18(1)(a) (c)(i) 18 OP30 13(6) 18(1)(a), 19 OP30 18(1)(a) (c)(i) 20
Woodside OP30 13(6)18(1 )(a)(c)(i) The registered person must introduce a policy and procedure for the use of the staff flat to take account of the need to protect vulnerable service users and safety requirements. Service users must be provided with bedrooms that are large enough to meet their assessed needs. The integral heating system throughout the home must be sufficient so that there is no need to use freestanding heaters, which increase the risk of accidental burn. (Not assessed at this inspection). Staff must only be employed in roles that comply with their legal permit to work in England. Evidence must be maintained to show that staff working under a POVA First check do not have unsupervised access to service users until a CRB check has been obtained. Every member of staff who engages in manual handling tasks must be provided with training in safe manual handling techniques, updates as required, and the safe use of hoists. Staff must be instructed about the correct way to communicate with service users so that there is no risk to service users of isolation or fear of intimidation. Staff must receive instruction so that they respond promptly to service users’ requests for assistance in relation to their continence and other personal needs. (Previous timescale of 18/07/05 had not been met). The manager must undertake comprehensive training in the
DS0000014988.V249385.R01.S.doc 31/10/05 14/10/05 01/09/05 14/10/05 10/10/05 30/11/05 31/10/05 14/10/05 31/12/05
Page 27 Version 5.0 21 OP32 37(1)(g) (2) 37(1)(e )(2) 18(1)(a) (c)(i) 22 23 OP32 OP32 24 OP33 24(1)(2) (3) 25 OP34 25(1)(2) 26 27 28 OP35 OP37 OP37 17(2) Sch 4.9 17(2)Sch 4.17 17(2) Sch 4.12 care of those with dementia. Complaints of a serious nature must be reported to the CSCI. (Issued at the inspection as an immediate requirement) Incidents that affect the well being of service users must be reported to the CSCI. Training must be provided for the manager and staff about the requirement for anyone involved in the operation of the care home to co-operate with the inspection process and advised about the consequences for failing to do so. Quality assurance systems must be introduced to enable service users to express their opinions in ways that are independent of any influence from within the home. The registered person must provide the CSCI with a copy of the home’s business and financial plan. Records must be maintained in the home of all monies held on behalf of service users. A record must be maintained of all visitors to the care home. Records must be maintained in the home of any event that affects the well-being of service users. 26/09/05 10/10/05 14/09/05 31/12/05 31/10/05 10/10/05 10/10/05 10/10/05 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
Woodside Refer to Standard 10.2 Good Practice Recommendations It is recommended that the home consider providing a
DS0000014988.V249385.R01.S.doc Version 5.0 Page 28 2 33.9 cordless telephone to enable service users to make phone calls in the privacy of their bedrooms. Policies and procedures to show how the home will operate in accordance with legal requirements and the National Minimum Standards should be introduced. Woodside DS0000014988.V249385.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodside DS0000014988.V249385.R01.S.doc Version 5.0 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!
