Inspection on 23/05/05 for Woodside

This inspection was carried out on 23rd May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 08/01/09

Woodside 19/02/08

Woodside 31/08/07

Woodside 25/07/06

Woodside 06/10/05

Woodside 12/10/04

Woodside 06/07/04

Woodside 10/02/04

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

CARE HOMES FOR OLDER PEOPLE Woodside 40 Woodside Road Selly Park Birmingham B29 7QS Lead Inspector Sean Devine Unannounced 23rd May 2005 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 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 E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodside Address 40 Woodside Road Selly Park Birmingham B29 7QS 0121 471 3700 0121 471 3446a Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Birmingham City Council - Social Care & Health Directorate, Chamberlain House, 2 Yew Tree Road, Moseley, Birmingham, B13 Diane Blount Care Home 22 Category(ies) of Dementia over 65 years of age (22) registration, with number of places Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home be registered to provide care for up to 21 service users with dementia who are over the age of 65 years and one named service user with dementia under the age of 65 years. 2. That minimum staffing levels are maintained at 4 care assistants plus a senior member of staff throughout a 14.5 hour waking day. 3. Additionally to the above minimum staffing levels, there are also 2 waking night care staff and a senior on sleeping-in duty. 4. Care/shift manager hours and ancillary staff should be provided in addtion to care staff. Date of last inspection 12th October 2004 Brief Description of the Service: Woodside is a care home providing personal care and accommodation for 22 older people with dementia. Woodside is owned by the City of Birmingham, Social Care and Health. Woodside is a compact single-storey building, set well back on the corner of Woodside Road and Warwoods Lane, and ten minutes walk from Pershore Road, with its shops and frequent buses to and from the city centre. All service user accommodation and facilities are found on the ground floor, which is split up into two units known as Laurel and Willow units. The accommodation and facilities are of good quality with bathrooms that are well adapted, corridors that are wide and bedrooms that are of a good size. There is off road parking to the front of the building, and an enclosed garden to the rear. Some bedrooms have en-suite facilities. The home offers both long and short term care. . Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected on an unannounced basis by two regulation inspectors over a period of one day. Some of the improvements required at the last inspection had been addressed by the home, however the home had not improved staff training, medication practice and information provided to prospective residents and their representatives. At this inspection the inspectors were able to meet with ten (10) residents to discuss the service they receive at the home. Records in respect of care provided and the health and safety practice of the home were seen and staff observed in the course of their duties. A tour of the premises including resident accommodation and communal areas was undertaken. What the service does well: What has improved since the last inspection? Since the last inspection the home has maintained appropriate staffing levels to ensure at all times the needs of residents can be met. This is kept under review. The homes practice in respect of control of infection and good food safety has improved, measures are now in place to help reduce risks in these areas. Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 6 The home has addressed the décor in areas of the home that needed improvement such as replacing wallpaper and painting in residents’ rooms. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 The information provided and assessments completed combined allow the prospective residents or their representative to make an informed choice as to whether the home is suitable. EVIDENCE: The statement of purpose included valuable information about the service, its mission statement and its philosophy of care. It also has details of facilities and services. The details in respect of staffing, numbers and qualifications had not been included. A copy of the statement of purpose and service user guide is available in each resident’s room. Written contracts known as a Residential Care Agreement were available on residents’ files, room to be occupied had been recorded, however the current cost of accommodation had not been recorded. Prospective residents are fully assessed prior to admission, this is mainly completed by Social Care and Health and includes an assessment of abilities encompassing physical, mental and emotional needs. The home has a variety of adaptations to assist with the mobility of residents including electric beds, assisted baths, overhead hoist in bathrooms and shower rooms that have been adapted to meet varying needs of mobility. The home has a specifically identified kitchen for storage and preparation of halal foods only. Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7,8,9 The health and personal care needs of residents are not adequately met by the home, written care plans and medication systems are not fully informative and unsafe, respectfully and need to be improved to provide appropriate and safe support. EVIDENCE: Written care plans known as Individual Service Statements are normally completed; of six sampled one was not available. Staff normally sign the statement to indicate they have read and understand it, however some staff had not signed the sampled statements. The statements did include health and personal support, how to provide this support varied from one statement to another. One statement indicated that a resident required a weekly bath, the records seen by the inspector reflected upon a bath often 10 to eleven days apart. Reviews of these individual service statements are not always completed on a monthly basis and they do not indicate whether the statement is effective or not. Some residents were able to confirm that they see their GP, however there was no recorded follow-up to the healthcare needs of one resident. The manager has been requested to follow this up as a matter of urgency. Other records indicate that residents see the chiropodist, dentist and optician. Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 10 Medication is recorded on a medication administration record known as a MAR, the MAR did not always fully record medicines received into the home and some medicines when administered had not been signed for on the MAR, medicines when received are clearly not checked against the copy of the GP prescription. Some tablets that had been signed for as administered to residents were in the blister pack, the blister pack was found to contain the wrong amount of tablets in this case one (1) tablet instead of two (2). Controlled medicines are safely stored and managed, although two signatures are needed to fully validate that controlled drugs are managed and administered safely. Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12,13,15 The daily life and social activity needs of residents are adequately met by the home, some improvement is necessary to encourage individual residents to take part in activities they enjoy and take pleasure in. EVIDENCE: The social activity of residents, including their likes, hobbies, pastimes and interests prior to their illness had not altogether been recorded and had not in some cases been developed into the care plan. Some information was included within single assessment documents and upon Social Care and Health care plans. Social activity records recorded events such as church services, a Christmas party, crosswords, quizzes, progressive mobility and sing-a-longs. Residents were seen to be happy, some were seen to enjoy each others company, residents were seen to read papers, chat with hairdresser, sit in communal areas, such as the reception area and chat with passers-by. Family were seen to be able to visit the residents, the hours of visiting were confirmed by one visitor as being very flexible. A cyclical menu of meals is provided, these were seen be well-balanced and nutritional meals, an optional choice is available and also a soft diet option. Mealtimes were seen to be social occasions; many of the residents went to the dining area for their meals. The manager confirmed that the menu is now due for review. Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16,18 The home has systems and procedures that enable residents and their representatives to raise concerns. However staff need to be trained in adult protection, which will help protect residents from possible abuse. EVIDENCE: The home has a complaints record that is completed on a monthly basis by the management team at the home. Records indicate that the log is upto date. There has been no complaints made to the home directly and none have been lodged with the CSCI. The manager confirmed that some staff had completed adult protection training, this was needed for staff to undertake NVQ 3 in Care, it was evident that all staff do not complete this training. The home has a procedure that adequately protects residents from abuse. Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19,20,21,22,23,24, 25 and 26., The environment is safe and well maintained, it enables residents to move freely about the building and has equipment that will support the residents changing needs. This environment also allows residents to integrate at a social level. EVIDENCE: The home is pleasantly decorated, well maintained and suitable for purpose throughout the residents’ accommodation and communal areas. All areas are clearly sign posted. The home has three lounge areas and a small lounge that offers a public telephone. These are spacious and have seating that is varied to meet the individual needs of residents. The dining area is large and spacious, and has tables and chairs for all residents. The garden has recently been extended, it now includes and new patio area, lawn and is bordered with trellis fencing. The home has several rooms with en-suite facilities, including a toilet, washbasin and shower. The skirting boards that has been heavily scratched in a residents room on Laurel Unit need to be repainted. Toilets and an assisted bathroom are available on both units within the home, there is also Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 14 a fully equipped shower area for residents with differing needs. The home has specific equipment to meet the ongoing and changing needs of residents such as hand rails, grab rails, electrically operated beds, hoists and an emergency call system. Corridors are wide to allow for wheelchair users, the home is fully accessible as it is all on one floor, with no stairs. Lighting and heating are appropriate in residents’ accommodation and communal areas, also affording a great deal of natural light. The home has a well-organised and clean laundry area, commercial washing machines have a sluice cycle and a hand washing facility. The home has two macerators for incontinence pads and has clinical waste containers and a contract for collection of waste. All toilets have good hand washing facilities that promote infection control. Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,30. Staffing levels are currently adequate to meet the needs of the residents, however staff are not fully skilled in meeting these needs, these skills should be underpinned with appropriate training. EVIDENCE: Staffing rosters reflect that the home has a minimum of four staff on duty for each shift, covering in a 14-hour day (7am until 9pm). In addition an assistant manager or senior care assistant are also on duty. The manager works flexible hours and is supported by an administrator and maintenance operative. Night times are covered by two care assistants (9pm to 7am) and a sleeping-in member of staff, being either an assistant manager or a senior care assistant. This is an adequate number of staff for the 18 residents living at the home, however, the day cover would need to be increased when the home has in excess of 20 residents to a minimum of five care staff. Staff training has not been further developed as required at the last inspection, at this inspection shortfalls in first aid training and food hygiene were discussed with the manager, either training had elapsed or had not been undertaken. Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35,38 The management and administration of the home is not fully safe for residents, improvements are needed to ensure that staff can respond effectively to emergencies and manage residents’ money safely. EVIDENCE: Each individual resident has a money account at the home, all money is kept in the safe. Account record sheets were checked and found to be correct, however transactions did not always have two signatures, second signature to validate the transaction. The home does count all money in residents accounts on a daily basis, again a second signature is needed to validate the check. Receipts were seen where these could be gained for money spent on behalf of the resident, for example paying the hairdresser. One record sheet detailed the amount carried forward as £54.58, however the new sheet recorded £56.08. Audits are undertaken on individual accounts, however documents pertaining to this were not seen. Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 17 Health and safety checks in relation to fire safety are undertaken, this included fire alarm and emergency light tests and a service of the fire system. Staff do attend fire drills, however this was not frequent enough to ensure all staff attend twice-yearly drills. Staff training in relation to fire safety is completed, however the last recorded training was in excess of the twelve months ago. Accidents are fully recorded and details filed on relevant residents files, the home does notify the commission of accidents and incidents resulting in adverse effects for the resident. The inspector observed one resident leaning heavily out of an armchair, it was clear that the resident was not supported safely in the style of chair. Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 4 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 4 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x 2 x x 2 Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 19 YES Are there any outstanding requirements from the last inspection? 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 4(1)(C ) schedule 1. Requirement The registered person must ensure that the statement of purpose includes all the information required by Schedule 1 of the regulations. Previous timescale 23/5/05 not met, this requirement is carried forward. Residents contracts known as Residential Care Agreements must include fees to be paid. All residents must have a written care plan (ISS). As per the homes protocol all staff must sign the ISS. . All ISSs must clearly indicate the support and actions staff take to meet the needs of residents. Timescale for action 31/7/05 2. 3. 4. 5. OP2 OP7 OP7 OP7 5(1)(b) 15(1) 15(1) 15(1) 31/7/05 31/7/05 31/8/05 31/8/05 6. 7. OP7 OP8 The home must ensure that actions to meet needs as recorded within the ISS are undertaken. 15(2)(b)(c Monthly reviews of ISSs must ) include information indicating if the ISS has been effective. 13(1) The home must ensure that the residents GP is informed of any health changes. This must be E54 S33612 Woodside V229309 230505 Stage 4.doc 31/8/05 27/5/05 Woodside Version 1.30 Page 20 fully recorded. 8. OP9 13(2) All medicines must be recorded accurately when received and checked against the prescribers wishes. Accurate records to confirm administration of medicnes must be maintained. The registered person must ensure that the records for controlled medicines are completed accurately and according to the medication policy. Previous timescale 13/10/04 not met, this requirement is carried forward. The social, recreational, hobbies and pastimes of residents must be fully assessed and developed into an individual written care plan (ISS). All staff must receive training in adult protection awareness. The skirting boards in residents rooms, where heavily scratched must be repaired. All staff must receive training in safe working practices, including food hygiene and first aid. Previous timescale of 1/12/04 not met, this requirement is carried forward. Fire safety and prevention training for all staff must be completed. Previous timescale of 1/12/04 not met, this requirement is carried forward. Records completed to account for the management of residents 21/6/05 30/6/05 30/6/05 9. OP12 16(2)(n) 31/8/05 10. 11. 12. OP18 OP19 OP30 OP38 13(6) 23(2)(b) 18(1)(c )(i) 30/9/05 30/9/05 30/9/05 23(4)(d) 13. OP35 13(4)(b) Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 21 13(6) money must have two signatures. All accounts must be accurately maintained.. All staff must attend a minimum of two fire drills annually, records to evidence this must be available. The manual handling needs including postural support of residents must be adequate to safely meet the needs of residents. 14. OP38 23(4)(e) 30/6/05 15. OP38 13(4)(c ) 13(5) 30/6/05 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. Refer to Standard Good Practice Recommendations Woodside E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ 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 E54 S33612 Woodside V229309 230505 Stage 4.doc Version 1.30 Page 23 - 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!