Inspection on 18/07/06 for Woodside

This inspection was carried out on 18th July 2006.

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

Woodside 10/04/07

Woodside 02/11/06

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 Ms Louise Trainor Unannounced Inspection 18th July 2006 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 Woodside DS0000014988.V302851.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.V302851.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.V302851.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd April 2006 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. The registered providers were Shires Healthcare (Woodside) Ltd. Mrs V Khan was the sole director and the responsible person. Mrs Theresa Vincent had managed the home for several months. 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. 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, storage area and for staff accommodation. The manager was unable to provide any written list of fees but stated that these were between £425.86 and £470 per week. Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report sets out the significant evidence that has been collated by the Commission for Social Care (CSCI) since the last visit to and public report on, the home’s service provision in September 2005. Taken into account were information submitted to the CSCI by the provider, reports from other statutory agencies and information gathered at visits to the home carried out on 3rd April 2006 and 18th July 2006. Mrs L Milton and Mrs L Trainor carried out the most recent visit to the home over eight hours. The manager was present throughout and assisted with enquiries. The second visit to the home included a review of the case files and conversations with three service users, conversations with three other service users, four members of staff and the manager. Time was spent in both lounges and the dining area to assess the lifestyle experienced by service users during the day. What the service does well: What has improved since the last inspection? The visits to the home in April and July 2006 had noted a significant improvement in the management of the home since the appointment of the current manager. Staff and service users spoken to at these visits were complimentary about her management abilities. It was apparent that the manager had high expectations of herself and her team and that she had introduced strategies to inform and support personnel. This, coupled with the departure of some members of staff who had not fulfilled their roles properly, had resulted in a rise in the overall performance of the team and in its morale. Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 6 Whilst there were some shortfalls to training requirements, there had been progress to provide personnel with the minimum training they needed to carry out their roles effectively. Similarly, documentation to underpin the service and evidence how service users had been cared for had undergone some improvement. There was also evidence to show improvement in the provision of stimulating activities for service users but there remained shortfalls to these arrangements for service users with short-term memory loss. However, it was reported that the recruitment of an activity organiser was planned. Although the inspection identified that there was still much to be done to bring this service up to a minimum standard, it also showed that there had been significant progress towards this. Those carrying out the inspection were confident that this progress would continue under the current manager’s leadership. What they could do better: One service user commented that it had been a long wait for staff to respond to a request for assistance but was unable to assess the time. Sufficient care staff must be rostered at all times to ensure that service users are cared for properly. Service users and members of staff must not be put at risk of injury by poor moving and handling practice. If service users do not wish to be moved via a hoist, then an assessment by a qualified health care professional must be sought. Procedures for the administration of medicines and records of the same must comply with safe guidelines. New personnel must not commence duties in the home until recruitment procedures have included the obtaining of two relevant references and a satisfactory disclosure from the Criminal Records Bureau. Members of staff must be provided with sufficient training to enable them to understand and meet service users’ needs. This must include health and safety issues, dementia awareness and the protection of vulnerable people from abuse. Any injury sustained by a service user must be recorded. Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 7 Service users must be provided with meals that are nutritious and in accordance with their preferences. Meals must be properly prepared. handlers must comply with hygiene requirements. The home’s fire risk assessment must be reviewed. Food Call bells must be provided for service users’ convenient access throughout the building, to include communal living areas. All areas of the garden that are accessible to service users must be cleared of nettles and similar to remove the risk of harm. Light fittings must be clean and in working order. The shaft lift must be maintained in working order. If service records indicate that the lift is in need of a major overhaul or requires replacement, this must be arranged. The documents that set out how service users are to be cared for must contain more detail about service users’ preferred lifestyle within the home. Detailed information about additional fees must be available to service users and their representatives. The policies and procedures that identify now the home will be operated must reflect the service provision at Woodside. 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.V302851.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.V302851.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Adequate arrangements were in place to enable service users to make an informed choice about moving into the home and for the home to determine that it had the capability to meet assessed needs. EVIDENCE: The statement of purpose was advertised on notice board in the foyer of the home, as was the report of the previous inspection. The statement had been updated at the change of manager. She stated that it was due for a further revision to incorporate the recent changes to personnel. A service user guide was available in each bedroom seen at this inspection. Records in relation to the investigation of a recent complaint identified that one of the issues had been in relation to taxi charges for a member of staff to accompany a service user to hospital under emergency circumstances. Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 10 Contractual arrangements did not show in sufficient detail how such charges could be levied. Case filed assessed showed that satisfactory pre-admission assessments of need had been carried out. Although the home provided respite care this was not classified as an intermediate care service. Woodside DS0000014988.V302851.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. There were risks to service users’ well being because procedures for the safe administration of medicines and recording of the same had not been followed. EVIDENCE: Three care plans were assessed at the inspection carried out in July 2006. The entries in relation to service users’ preferred lifestyle were brief and would benefit from more detail about abilities, preferred activities, and food preferences. A dependency assessment (Barthel Modified Index) for a service user scored as “low dependency”. Other records for this person showed that the service user had in fact needs that scored as “high dependency”. There was no risk assessment in place for a service user who was treated for epilepsy. Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 12 There were no records of height and weight on the nutritional needs assessment for at least one person. Records indicated that service users had been referred to their doctors as need be and to other healthcare professionals for specialist services and routine appointments such as chiropody, dental and optical care. Training records indicated that majority of staff with the responsibility for administering medicines had undertaken training in safe practice. Those outstanding were recent employees. Records for the administration of medicines to six service users were assessed. Four of these, when compared to the stock of medicines, showed that the medicine had been taken from its packaging but the corresponding record had not been signed as given. Where service users were prescribed variable doses of medicine the actual dose administered had not been entered on the records. Fifty pounds in cash had been stored in the medicine cupboard that must be reserved for the storage of Controlled Drugs only. However, at this inspection none of the service users had been prescribed Controlled Drugs. Service users confirmed that they had been treated with respect. Woodside DS0000014988.V302851.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. Service users had not experienced a lifestyle that met their assessed needs because the arrangements to provide service users with stimulating activities and to meet their nutritional needs were inadequate. EVIDENCE: Service users confirmed that there had been improvements in the provision of activities for stimulation and recreation. There was evidence to show that some service users had been escorted on trips to the nearby village. Service user had taken part in a summer fete. A service user described helping on a stall as “fun”. However there were evident constraints on staff time to provide activities; care staffing ratios were below the minimum requirement and the personal care needs of service users, of necessity, having taken up much their time. It was also evident from discussions with the manager that there was a lack of knowledge about the provision of activities for those with dementia. However it was explained that the management team was scheduled to undertake comprehensive training in the care of those with dementia in the near future. Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 14 It was reported that five service users took in external religious services and that an ecumenical service took place in the home each month. Service users confirmed that their visitors had been welcomed into the home. Case tracking processes showed that only one of the three service users assessed was able to manage their finances. The service user confirmed that they held their personal monies. Records showed that the home operated a four weekly rotation of menus. These showed a balanced choice. The statement of purpose stated that service users would be provided with appropriate alternatives if meals were not to their choice. At the inspection carried out on 18th July 2006, it was noted that the meal provided at lunchtime was not in accordance with the advertised menu. Whilst the inspectors observed that service users were offered an acceptable alternative to the meal, two service users, who did not like either choice, were served toast for this main meal of the day. The main meal included minced beef. It looked unappetising. Two service users confirmed that the meal did not taste nice. It was noted that the fingernails of a food handler were unclean. The personnel file for this employee contained records of previous problems and reprimand about this person’s hygiene practice in relation to food preparation. Woodside DS0000014988.V302851.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. Service users had been put at risk because the home had failed to follow robust recruitment procedures for the protection of vulnerable people. EVIDENCE: Records indicated that appropriate action had been taken in relation a recent complaint that an uneven paving slab had caused a service user to fall. It was noted that there had been recent action to walk ways in the garden. Other aspects of the complaint had raised concerns about evidencing charges for a taxi. A satisfactory response was noted, even though such charges were not fully detailed on contractual arrangements. Training records identified that members of staff who had worked in the home for sometime had received training in adult protection procedures. The turnover in staff, however, had meant that several employees had yet to receive this necessary training. Assessment of personnel records and staff rotas showed that one person had been employed on 3rd June 2006 without any references. The file only contained one reference that was dated 7th June 2006. In addition, there was no evidence in relation to a CRB or POVA First check on this file. The manager explained that the responsible individual held such checks centrally until the monthly visit. The manager was unable to obtain a facsimile copy of this Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 16 document from HQ during the inspection. She explained that she had been told that the document had been put in the post. The inspector contacted the manager on 24th July 2006. She stated that she had still not received a copy of the CRB check. Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The premises were mostly suitable for the care of frail older people but their comfort had been compromised by failures of the shaft lift. EVIDENCE: The accommodation provided a homely environment. It was evident that staff had strived to maintain the cleanliness of the environment. Areas of the building seen at the two visits to the home were clean and orderly. However, it was noted at both visits that light fittings in the communal lounges that fitted close up to the ceiling contained much debris that obscured the illumination. This must be addressed so that risks of falls because of poor lighting are removed. It was also noted at the second visit that a light fitting in the rear dining area was broken and hanging askew from the ceiling. A wall light near to the front entrance was broken. Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 18 At the inspection carried out in September 2005 the shaft lift had been out of order for several days and service users had been unable to come down stairs. A temporary lounge had been set up in an unoccupied bedroom on the first floor. Since then the Commission has been informed of two further breakdowns. The manager stated that she had obtained quotes for the installation of a stair lift that could be used as a back up. The Commission is concerned that such a lift could become a replacement for the shaft lift. Whilst use of a chair lift as well as a shaft lift would be acceptable, the Commission would view prolonged use of a chair lift as a retrograde step in the development of the service. The proprietor must ensure that the shaft lift is properly maintained and if necessary arrange for any major overhaul or replacement of the lift. The inspector noted that the ground towards the rear of the home was overgrown with weeds and nettles. Given that service users could access this area this represented an unacceptable risk of harm. Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Service users’ needs for a fulfilling lifestyle had been compromised by failures to provide sufficient care staff during the day. EVIDENCE: Despite the overall improvement in the performance of personnel, it was agreed in discussion with the manager that members of staff were predominately involved with service users’ personal care needs and had little time to provide recreational activities. The provision of such activities was also discussed. The need to provide activities that are suitable for service users with dementia was acknowledged by the manager. Training had improved but required further input. The central training record presented at the second inspection showed that there were gaps in essential training; only the manager and the trainee deputy had undertaken training in the care of those with dementia. These had been short courses usually taken by care staff; three members of the care staff were without adult protection training and none of the ancillary team had undertaken such training; two of the care team required manual handling training and a third required an update; there were no records of training in relation to the management of continence, diabetes, or in the nutritional needs of older people; four of the Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 20 twelve care staff had achieved National Vocational Awards (NVQ) in care at level 2, a senior was nearing completion of the award at level 3. As detailed previously, recruitment practice did not meet required standards. It was also noted that a recent employee had not received sufficient induction before commencing night duties. The rota indicated that the employee had worked in the home for one day only for induction purposes and had then been scheduled to commence night duties as part of the minimum staffing arrangements, as the second person on duty. Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 21 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): 31,32,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The management of the home had improved significantly as had the care of service users. EVIDENCE: The manager was qualified and experienced to manage a care home for older people. Her training record showed that she had achieved an NVQ at level 4 and the Registered Manager Award. Her knowledge in relation to the care of those with dementia will be improved by attendance at the planned training discussed previously in this report. Strategies were in place to consult with service users; records and discussions with service users showed that they had been provided with opportunities to Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 22 attend meetings on the 9th February 2006 and 16th June 2006; consultation had taken place formally on the quality of the service via questionnaires. The resulting report/plan identified an analysis of the response to the surveys and also detailed actions to be taken in response to some of the issues raised. However, actions were only in relation to the additional comments from questionnaires and had not taken account of feedback where responses showed that a percentage of service users were not satisfied with aspects of the service. For example, only 75 stated that they were satisfied with arrangements for their privacy and cultural needs; 50 only stated that they received clear explanations about their treatment, other options and risk assessment. The plan must address all of the issues arising from the quality audit and identify timescales for action. Records showed that there had been four meetings with staff this year. Although staff supervision had not been provided with the frequency detailed by the standard, it was evident that the manager was striving to ensure that personnel were fully briefed about their roles. It was evident that action had been taken where necessary to improve individual and collective staff performance. Service users commented on the improvement in the service under the current manager. Members of staff were positive about the support and guidance they had received. One commented that she felt “free” to express her opinion and to get good advice by return. The home’s policies and procedures had been replaced. Unfortunately, they were not reflective of the service provision at Woodside. The documents referred to the service provided by Southwark Nursing Home and in some instances did not provide accurate guidance. For example, the medication procedure stated that two registered nurses must administer medicines to service users. Woodside did not employ such personnel. Procedures handling service users’ monies were satisfactory. Of the three service users who were included in the case tracking processes, one managed their personal finances and another’s were managed by their family. Monies were held by the home on behalf of the third service user. Records about transactions had been properly maintained and showed that expenditures had been for small amounts for hairdressing, chiropody care and toiletry requisites. Records must be maintained of all injuries. A service user was seen to have a skin tear on their arm. It had bled onto a supporting pillow, which was subsequently changed. There was no reference to this injury in the service user’s daily log or in the accident book. Woodside DS0000014988.V302851.R01.S.doc Version 5.2 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X 2 X X 2 3 STAFFING Standard No Score 27 1 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 X 2 Woodside DS0000014988.V302851.R01.S.doc Version 5.2 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. OP2 Standard Regulation 12(1)(a) 17(2) Sch 4.8 Requirement Information about the scale of fees for accommodation must be available to service users and include detailed information about additional charges. This must include taxi charges for staff to accompany service users to health appointments.. 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, 31/07/05 and 31/12/05 had not been met in full). 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. (Previous timescale of 31/12/05 had not been met DS0000014988.V302851.R01.S.doc Timescale for action 31/10/06 2. OP7 12(1)(a) 15(1)(2) 31/10/06 3. OP7 12(1)(a) 15(1)(2) 31/10/06 Woodside Version 5.2 Page 25 in full, there being a lack of access to call bells in the communal lounges.) 4. OP7 Care plans must contain a section for every need identified in the preceding assessment of need. (Issued at the inspection carried out on 03/04/06) 12(1)(a) Medicines must be stored, 13(2) administered and recorded as detailed by the safe practice guidelines issued by the Royal Pharmaceutical Society. 12(1)(a) Service users must be provided 16(2)(m) with activities for stimulation and recreation that are in accordance with their preferences and abilities. 12(1)(a) Service users must be served 16(2)(i)(j) with meals that are nutritious, meet their preferences and that have been properly prepared. 12(1)(a)6 All staff must receive training in 13(6) procedures to identify and prevent the abuse of vulnerable people. (Issued at the inspection carried out on 03/04/06) 12(1)(a) Personnel must not commence 19 Sch 2, duties in the home until all the 1-7 necessary checks in relation to employment have been obtained. (Issued at the visit on 18/07/06 as an immediate requirement). 12(1)(a) Nettles and similar must be 23(2)(o) cleared from the rear of the premises. 12(1)(a) Light fittings must be clean and 23(2)(p) in working order. 12(1)(a) The integral heating system 23(2)(p) throughout the home must be sufficient so that there is no need to use freestanding heaters, which increase the risk DS0000014988.V302851.R01.S.doc 12(1)(a) 15(1) 03/08/06 5. OP9 31/07/06 6. OP12 31/08/06 7. OP15 31/07/06 8. OP16 06/08/06 9. OP18 19/07/06 10. 11. 12. OP19 OP25 OP25 31/07/06 31/07/06 01/09/06 Woodside Version 5.2 Page 26 13. 14. OP27 OP29 12(1)(a) 18(1)(a) 12(1)(a) 13(6) 19(1)(a) 15. OP30 12(1)(a) 18(1)(a) (c)(i) 16. OP30 12(1)(a) 18(1)(a) (c)(i) 13(6) 18(1)(a) (c)(i) of accidental burn. ( Not assessed at this inspection. The previous action date was 01/09/05. This has been requirement has been restated with a revised action date.) Sufficient staff must be deployed to meet service users’ assed needs at all times. 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. (Previous timescale of 10/10/05 had not been met in full. An immediate requirement was issued at the inspection. See above) 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. (Previous timescale of 30/11/06 had not been met in full). Staff must receive sufficient training, including induction; to enable them to meet service users’ assessed needs. The manager must undertake comprehensive training in the care of those with dementia. (Previous timescale of 31/12/05 had not been met. Whilst this had applied to the previous manager, it is still applicable to the current manager and is restated with a revised action date). The action plan resulting from the quality audit processes must address all of the issues arising DS0000014988.V302851.R01.S.doc 31/07/06 19/07/06 31/10/06 31/10/06 17. OP30 31/10/06 18. OP33 12(1)(a) 24(1) 31/08/06 Woodside Version 5.2 Page 27 19. OP33 12 20. OP38 17 from service users’ questionnaires. The registered person must ensure that policies and procedures reflect the service provision at Woodside. Injuries/accidents must be recorded. 31/10/06 31/07/06 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. Refer to Standard OP28 OP36 Good Practice Recommendations The home should show on its training plan how it intends to support its care staff to achieve NVQ awards to the standard where 50 of the team are qualified. Staff should receive supervision at least six times each year. Woodside DS0000014988.V302851.R01.S.doc Version 5.2 Page 28 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.V302851.R01.S.doc Version 5.2 Page 29 - 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!