Inspection on 25/07/06 for Woodside

This inspection was carried out on 25th 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 08/01/09

Woodside 19/02/08

Woodside 31/08/07

Woodside 06/10/05

Woodside 23/05/05

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 Key Unannounced Inspection 25th July 2006 09:10 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 DS0000033612.V298783.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 DS0000033612.V298783.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodside Address 40 Woodside Road Selly Park Birmingham B29 7QS 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) 0121 471 3700 0121 471 3411 Birmingham City Council (S) Diane Blount Care Home 22 Category(ies) of Dementia - over 65 years of age (22) registration, with number of places Woodside DS0000033612.V298783.R01.S.doc Version 5.2 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. That minimum staffing levels are maintained at 4 care assistants plus a senior member of staff throughout a 14.5 hour waking day. Additionally to the above minimum staffing levels, there are also 2 waking night care staff and a senior on sleeping-in duty. Care/shift manager hours and ancillary staff should be provided in addition to care staff 6th October 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Woodside is a care home providing personal care and accommodation for 22 older people with dementia. The City of Birmingham, Social Care and Health department own Woodside. 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 resident 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 including a respite service for carers. Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted unannounced by one regulation inspector over a one day period. The inspector was able to meet with many residents and relatives. Many of the residents do have needs that impact on their ability to communicate, so many of the views and opinions of this home are made by relatives and other information has been made using the inspectors ability to assess signs of well being. The inspector case tracked the care of two residents, which included talking with residents and their visitors and also assessing the standard of their care through care planning, known in this home as Individual Service Statements. Staff were observed providing support for residents and one member of staff was more formally interviewed. The three assistant managers were available during the day and were able to describe some of the many care needs of residents. A tour of the communal areas was undertaken, the focus at this inspection was upon communal areas and also toilet, washing and bathing facilities. The registered manager was on annual leave at the time of the inspection, however she had completed a pre inspection questionnaire, which was available to the commission prior to the inspection visit. What the service does well: The residents and relatives are invited to spend time at the home prior to making a decision on whether to live there, staff commented that this can sometimes be an overnight stay or for one day. Relatives were pleased that they have had the opportunity to meet the staff and view the home before making a decision and they also commented that it provides them with an opportunity to tell the staff the reality of caring for the resident. Relative’s opinion and views is that the home is very good, they feel the care of the residents who present with some complex needs is given by some very skilled and dedicated staff. Staff were observed providing care for residents in a professional manner, with the awareness to always talk to residents about what they were doing, this eased the anxieties of some residents. This was further supported by residents and relatives, as one resident immediately responded with fondness when a Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 6 member of staff came to help her, the relatives were pleased with the way the member of staff was greeted and how they had a trusting rapport. The Individual Service Statements (ISS) are written in such away that promotes a person centred approach to care and involves the residents and relatives in making choices. Relatives are frequently able to take part in reviews and feel that they are listened to and what they say is taken on board. The ISS are well written they give clear and concise information to staff. What has improved since the last inspection? What they could do better: The manager must ensure that the ISS are reviewed monthly including a statement on whether the support has been effective to help residents; where changes have been made to the ISS it must be clear in the review, why. The manager must ensure that the risk assessment process is extended to cover personal risks of residents such as challenging behaviours, and develop a management plan detailing how staff manage and reduce risk in such situations. The risk assessment for skin care and nutrition of residents must be fully completed, including how present risks are to be managed. The manager must discuss any concerns she has with regard to protecting vulnerable residents with social workers and take any appropriate action needed to protect them from harm. The manager must ensure that all staff receive required mandatory training and also training that will help them support residents with a dementia. The registered manager must ensure that a system of quality assurance is fully implemented that will consult with residents and their representatives and produce a report about the quality of service and care at the home. Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 7 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 DS0000033612.V298783.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 DS0000033612.V298783.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): Standards 2, 3, 5 and 6. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home clearly demonstrates it has the ability to ensure they can meet the needs of prospective residents and that prospective residents are able to make an informed choice on whether to live at the home. EVIDENCE: As identified in the summary two residents were case tracked, this included seeing documents on their files. One file did have a Residential Care Agreement detailing terms and conditions of residency, whilst the other did not. Both files contained information gathered by the home prior to agreeing admission, these included care plans and assessments of need from social workers describing needs and abilities of each resident. The home had also invited prospective residents for a visit, records indicate that during these Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 10 visits the care staff had made an assessment of need, this included many of the activities of daily living such as mobility, communication and diet. Relatives stated that from day one of admission staff had been very supportive and were pleasant and that they had been able to visit the home with the prospective resident. A care assistant during interview described the admission process, including the pre admission assessment and stated “it is often better when family are available as they share important information”. The home does provide a respite service for carers but this does not include intermediate care providing rehabilitation prior to going home. Woodside DS0000033612.V298783.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): Standards 7, 8, 9 and 10. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home generally has the capacity to ensure that the personal and healthcare needs of residents are met, yet the lack of risk assessments and their management plans and some areas of poor management of medicines does not support this judgement, thus some of the healthcare needs of residents may not be met or residents maybe put at risk. EVIDENCE: The residents who were case tracked both had care plans available, these are known as Individual Service Statements (ISS); this statement identifies what the resident wants to achieve, how staff will support the resident to achieve this, how the resident will know its been achieved and when it will be achieved. Both residents had comprehensive statements reflecting how staff support residents with their needs, they were written clearly and concisely. Both files had in excess of twenty statements, it is recommended that some statements be revised and amalgamated with others, for example personal care and oral Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 12 health care. This would help new staff to quickly and effectively identify the residents’ needs. The ISS are reviewed on monthly basis, where any changes are needed they are made, however there is no recorded review of the ISS to state whether it has been effective or not or why it needs to be changed. Some ISS did not indicate why residents needed to have a diary of their continence habits and what the information in the diary was for; this was also seen to be the case for fluid and dietary intake charts. Residents’ files contained an assessment of falls, for one of these residents falls is a high risk a detailed risk assessment and management plan had not been completed. Both residents had a very detailed moving and handling risk assessment, this defined where moving and handling is needed (task), equipment required (type of hoist and size of sling) and how many staff are needed to safely move the resident. Staff were observed supporting residents, including using hoists and wheelchairs, it was evident that staff are good communicators and for one resident who was distressed by using a hoist the procedure was completed safely, quickly and with reassurance. There was evidence within the ISS that the nutritional needs of residents are assessed, for some residents a more detailed nutritional screening is needed. An assessment of risk for skin integrity / tissue viability had not been completed, a blank form for this assessment was seen on one file. It was evident from records that one resident often displays some aggressive behaviour, no risk assessment of how this is managed was available. Whilst talking to relatives and staff it was apparent that they act quickly when such incidents occur and that they will take appropriate action. This resident had recently been treated in hospital as a fracture had been sustained. The cause of the fracture was unknown however the resident had called out and had been found sitting on the floor. The assistant manager acted appropriately and informed the residents’ social workers. Further discussions and plans are needed to promote the safety of this resident and the safety of others; this must involve the social workers of respective residents. Residents’ files recorded when they had accessed community healthcare services and also the outcomes of the visits. These include appointments with the GP and at hospital; other records indicate that residents do see a chiropodist, optician and dentist when needed. The staff manage all medicines on behalf of residents. The staff approved to manage medicines have completed an accredited course in the safe handling of medicines. At present most residents have the same GP who visits weekly and when needed, prescribed medicines are mainly dispensed by a local chemist and are blister packed using a monitored dosage system. Residents who are admitted for respite stay do however bring in their own medication which is normally boxed or bottle. Copies of GP prescriptions for permanent residents are made and these are used to ensure they receive the correct medicine from the chemist. All residents have a medication administration record (MAR), this Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 13 record is completed for receiving medicines into the home and for confirming the administration of medicine to residents. The residents who were case tracked do not always have it managed safely, for example medicine had been signed for as administered on the morning yet the tablets were still in the blister pack. The management of boxed medicines was assessed, there were some concern that stocks of medicines for two residents were incorrect, in that after deducting the amount of medicine administered from the amount received to many tablets were available, no explanation as to why was given. The staff also manage controlled drugs for four residents, the team manager has recently asked that the controlled drug register be signed by two staff, including who administered and who witnessed the administration. The inspector found the register to be accurate with stocks and two signatures had been made. The staff team were observed to at all times talk positively with residents, they did not use patronising terms of endearment and were always professional. Staff were seen to knock on doors and await a response before entering. No personal care was seen to be given in communal areas. Relatives described staff as being excellent at their job and also they confirmed that visits can be in private. During the inspection visit a chiropodist and a district nurse visited residents, the residents were seen in private and conversations with staff were seen to be managed in a confidential manner. Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All standards. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home clearly demonstrates it has the capacity to meet the varied daily life and social activity needs of residents; residents do have a choice in what they do and how they are supported and they are encouraged to take part in meaningful activities. EVIDENCE: Residents’ files indicated that their needs in respect of social contact and activity is well planned, this was seen on the ISS. This included supporting residents to access local community facilities for services such as shops and for another resident maintaining her religious needs inside the home and external to the home was very important. The likes and dislikes of residents are recorded and included within the ISS, this was seen in a practical context and included providing meals without onions, providing female care staff and ensuring disability access throughout the home. The social activities of residents are nearly always discussed in the regular residents and relatives meetings; minutes included reviewing what was planned and providing new activities. At present weekly bingo and fortnightly music and movement are available and regular entertainers are booked to provide fun and reminiscence Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 15 at the home. Relatives and residents are actively involved in activities including maintaining the garden. During the inspection relatives advised that some staff have the ability to communicate very well with residents, where they sometimes have difficulty, this was seen when a resident responded with delight when singing a song with a member of staff and the family. Relatives advised that they can visit at anytime, although some indicated they do try to avoid very busy times of day, like early morning, however this is their choice. One relative did have knowledge of the homes statement of purpose and was aware of how he could be involved in planning care, and that they can be involved practically with supporting residents. Another relative described that she has been involved in initial and ongoing reviews with the home, social workers and resident. The ability of residents to manage their own financial affairs is referred to in some parts of the ISS, yet it is clear that the families and representatives of residents mainly collect their personal allowances. These are very often paid in part to the home and where needed relatives do bring in clothes and toiletries. A member of staff was pleased that with the support of a relative she had been able to interest a resident in a different style and colour of clothing and that she with the wishes of the relative had been able to do the shopping. Relatives are pleased that they can bring in small items of personal possessions such as photographs and decorations. The inspector was provided with a copy of the four week cyclical menu; the menu does reflect the cultural needs of residents and is available in special diets such as gluten free, diabetic and soft (blended) option. The inspector did have lunch with the residents, it was found to be tasty and of a generous portion. The menu for that day was advertised on the notice board in the large dining area. Residents were seen to enjoy the meal and it was evident that some thought had been put into making it a sociable occasion. Tables had condiments and cold drinks, pressed table clothes and cutlery had been laid. Relatives did comment on the good standard of food and that they too can have a meal with the resident if they wish. Some residents were supported to eat their lunch by members of staff, this was done with respect and sensitivity and one resident who did not wish to eat at 1pm had a meal put aside for later. The cyclical menu includes optional meals, however these options are not advertised on the notice board. Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 18. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home does not fully demonstrate its capacity to meet the needs of residents in ensuring complaints and protection matters are adequately managed. This may mean that residents are at risk of not having their complaints listened to and where needed the service improved and some staff may not be fully aware of what they must do to protect vulnerable residents. EVIDENCE: The assistant managers on duty were unable to locate the complaints log. Staff described how residents are supported to raise their concerns and they advised that if it is not something they can manage they will report it to the person in charge. Many relatives stated that they have not had cause to raise a complaint and that if they are alerted to a concern it is dealt with immediately by the staff and managers. The outcome area for health and personal care details that the home has contacted social workers with a concern, however further discussions and plans are needed with social workers to effectively manage the safety of a resident. A member of the care staff confirmed that she had attended training in respect of adult protection and when asked what she would do if a vulnerable person was at risk of abuse she replied appropriately, taking action to ensure initially the safety of the resident and she advised of how it should be managed and reported to relevant agencies including possible the police. Two staff files were Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 17 sampled for training information, one for a member of staff in post for several years did include details confirming that adult protection training had been undertaken, the second file was for a member of staff recently recruited and did not detail such training. No details of induction training where Skills for Care modules (HSC335) would have alerted this member of staff to what constitutes abuse and what she must do were available. Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 18 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): Standards 19, 21 and 26. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home demonstrates its ability to ensure that the environment is maintained to a good standard and that it meets the group needs of residents. There is a good range of facilities available that encourages and promotes the independence of residents and also for staff to safely support residents when needed. EVIDENCE: The inspector viewed most communal areas of the home, it was evident that furniture, fittings and the building are well maintained and clean. Relatives stated that it’s always nice and clean, that it never smells and that it’s like being in your own house. The requirements of the most recent fire officers’ inspection had been completed and there were no records of a recent visit by the environmental health. The garden was tidy and access for residents appears to be safe, there are paved patio areas and lawn grass that also appear to be safe and in good condition. Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 19 There are a range of toilet facilities on both units of the home, including large disabled toilets, smaller cubicle toilets, two fully assisted bathrooms with chair hoist into the bath and two floor draining assisted shower rooms with shower chairs and well sited grab rails, which support residents mobility and movement. All facilities are close by residents’ rooms, mostly off the same corridors. Sluice rooms are sited on both units; they have sluice sinks with hot water, commode pot washers and incontinence pad disposal units. There is also a domestic storeroom on Laurel Unit, which stores all chemicals used in the home including, the laundry and cleaning products, the wash hand basin in this room was not accessible due to boxes being in the way. Data sheets and risk assessments were available for chemicals used in the home. All high-risk areas in communal areas have good hand washing facilities and the home was observed to be free from odours. Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 20 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): All standards. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has not demonstrated it has the ability to provide staff that have been safely recruited and who have been trained to meet the varied needs of residents, this may lead to some residents being put at risk and of not receiving appropriate care. EVIDENCE: Staff rotas were sent to the inspector as part of the pre inspection questionnaire. These rotas reflect minimum staff levels. At the inspection these rotas were seen to be different in that some staff were on annual leave and others were not on duty due to sickness absence. However the minimum staffing levels of 4 care assistants plus a senior member of staff throughout a 14.5-hour waking day had been maintained through the use of casual care staff. At night a staffing level of two waking care assistants and one senior care assistant / manager who is on sleep-in duty is maintained. The pre inspection questionnaire asks for the number / percent of staff who have achieved NVQ level 2 in Care or above, this section of the questionnaire had not been completed, however as of the last inspection in October 2005 the registered manager provided evidence that there are above 50 of the staff trained to this level and since this inspection two staff have left the home. Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 21 The two staff files that were sampled included details of a criminal records bureau disclosure. One file for a member of staff recruited in 2001 did not have evidence of health screening, two written references and an application form. The second file for a member of staff recruited very recently contained all required information. The staff files did contain some evidence of training in safe working practices and also for service specific training. The training file for the member of staff recruited in 2001 detailed recent fire safety training, a dementia workshop, adult protection training and also challenging behaviour training. The file for the member of staff recruited recently did not have any details that an induction programme had commenced; it did have details of recent fire safety training. The pre inspection questionnaire recorded the following as training for staff in the past twelve months: Fire training, adult protection, first aid, food hygiene, NVQ 2 and 3, NVQ level 4 in Care and The Registered Managers Award. A care assistant advised the inspector that she had completed a course in adult protection; food hygiene and following recruitment had undertaken a seven day induction at college and at Chamberlain House. Relatives were keen to describe the skills of staff and stated “they understand the dementia”, “they talk to the residents a lot” and “we trust that they (residents) are in good hands”. Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35, 36 and 38. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home does not fully demonstrate its capacity to ensure it is run with effective management and administrative procedures, the home does however have the ability to improve this area and provide residents with a home that is safe, inclusive and effectively managed. EVIDENCE: The manager has completed training and received certification for the Registered Managers Award. Staff described her as being very knowledgeable of the needs of residents and always available to provide support both with encouragement and with assisting care staff to support residents whenever it’s needed. Relatives stated “she is very approachable and always interested and pleasant” and that “she is a good manager”. The manager is aware of her role Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 23 and effectively manages the team’ she has when needed taken guidance and made representation to agencies (including the commission) to ensure that residents receive a good service. At the time of inspection the manager was on annual leave and the assistant managers were unable to find current details of the quality assurance system. The team manager visits the home at regular intervals and provides a report for the manager under Regulation 26 of the Care Home Regulations 2001, those reports seen indicate the team manager speaks with residents, relatives and staff, that she often inspects the building and examines care and some staff records, such as staff rotas. The residents and relatives meet on a quarterly basis to discuss important issues in the home such as activities for residents and raising funds for the home. The meeting also briefs residents and relatives about health and safety, more recently the fire officers’ report was discussed with a focus on the fire alarm. Formal staff meetings do take place, however these are infrequent, the last being for day staff in March 2006 and night staff in October 2005. Very important issues have been discussed at some of these meetings including; training, rotas, and new residents, recommencing providing a respite service and activities for residents in the home. There was no evidence provided by the staff that residents and their representatives are consulted about standards and the quality of service at the home and no annual report on quality was available for inspection. The home will receive and keep in safekeeping small amounts of money and the valuable items of residents. The two residents who were case tracked do keep some money in the safe, which is mainly brought in by family members as they are usually in receipt of the residents’ personal allowance. Records seen were fully reconciled with balances; the staff check these accounts regularly as part of the handover process. Some transactions for staff spending money on behalf of residents did not have receipts available such as for the hairdresser who has a salon at the home and who visits weekly and another resident had a receipt for £5 which could not be seen as expenditure on the record sheet. On examining a residents file a chain, ring and cross were found in an envelope, and these items must form part of safekeeping or be returned to the resident. The sampled staff files included details about supervision; including the process, a contract and the agendas for the meetings. It was evident that staff meet regularly with their supervisors and that the staff can add items to the agenda. Minutes seen included discussions about training, roles and responsibilities and also an appraisal of performance. The care staff who was interviewed considered the process to be supportive and two way and she was pleased she has the opportunity to meet on a regular basis. The management of health and safety in the home including premises, equipment and utilities is generally well maintained. Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 24 The fire system is regularly serviced and a fire risk assessment is available and routinely reviewed. There is a fire procedure on display at various points about the home but always close fire exits, this was seen to require updating following the work undertaken following the fire officers last inspection. Fire drills are regularly undertaken with outcomes recorded, however more details are needed including, which staff have attended as the manager must ensure that all staff attend a minimum of two drills annually. Utilities including water, gas and electric are tested and certified where required as being safe including disinfecting the cold water system, checking gas safety and electrical safety through portable appliance tests and periodic electrical installation checks. Equipment such as hoists, specialist beds and washing machines and tumble dryers all have recent records of safety tests and maintenance where needed. A very detailed risk assessment is available for the building this was however seen to require updating following review. The staff are provided with good practice and safety guidance and where needed risk assessments are in place such as for the safe use of display screen equipment and for new and expectant mothers. Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X 3 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 3 X 2 Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5(1)(b)(c) Requirement Timescale for action 30/09/06 2 OP7 The registered manager must ensure that all residents have a contract / residential care agreement detailing terms and condition of residency, that this includes accommodation to be occupied and current fees payable. 15(2)(b)(c Monthly reviews of ISSs must ) include information indicating if the ISS has been effective. Previous timescale of 31/8/05 not met, this requirement is carried forward. The registered manager must ensure that the ISS’s indicate why fluid and diet intake of residents are being monitored and recorded and also why this is being done for toileting habits. Fall risk assessments must be developed for residents who are identified as at risk. Nutritional Screening and tissue viability assessments must be completed for all residents, where a risk is identified a risk 30/09/06 3 OP7 15(1) 30/09/06 4 OP8 12(1)13(4 ) 31/08/06 Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 27 5 OP8 OP18 13(6) 12(1) management plan must be implemented. The registered manager must 04/08/06 ensure that all residents are appropriately protected and raise concern with social workers, where needed consideration must be given to adult protection. A risk assessment and management plan to effectively manage the aggressive behaviour for one resident is needed. This must include identifying signs of anger, fear, agitation and frustration and detail how staff will alleviate these feeling before an act of aggressive behaviour. The registered manager must ensure the safe handling and administration of residents’ medicine at all times. Accurate stocks of medicine must be maintained in the home at all times, records must indicate when medicine has not been administered and only signed for when administered. All frozen foods items must be appropriately labelled. 6 OP9 13(2) 12(1) 04/08/06 7 OP15 13(3)13(4 (c ) 31/07/06 8 OP15 16(2)(j) 12(1) 9 OP16 22 Not assessed at this inspection and is carried forward. The registered manager must 04/08/06 ensure that the notice board advertises optional meals as planned on the four week cyclical menu. The registered manager must 31/08/06 ensure that a record of complaints made by residents or their representatives is available that records action taken in respect of any such complaint. DS0000033612.V298783.R01.S.doc Version 5.2 Page 28 Woodside 10 OP18 13(6) 18(1)(c)(i ) 11 OP26 13(3) 12 OP29 17(2) Sch 4 (6) 13 OP30 18(1)(c)(i ) The registered manager must ensure that all staff have an awareness through training of how to recognise abuse of vulnerable adults and what they must do to help protect such people. The registered manager must ensure that the wash hand basin in the domestic store room is fully and safely accessible for staff to use. The registered manager must ensure that all records in respect of recruitment of staff are available in the home for inspection, including evidence of health screening, two written references and an application form. All staff must receive safe working practice training, which is to include manual handling and infection control, staff must receive regular manual handling training updates. All staff must be updated at required intervals in all safe working practices and receive initial training based upon the Skills for Care induction modules. The registered manager must ensure that residents and their representatives are consulted about the quality of the service, to review and improve upon quality standards. 31/10/06 31/08/06 30/09/06 30/11/06 14 OP33 24 31/12/06 15 OP35 13(6) 16(2)(l) A report of quality indicating the performance and where improvements are needed must be available to residents and the commission. The registered manager must 04/08/06 ensure that receipts are available for all expenditure made by staff DS0000033612.V298783.R01.S.doc Version 5.2 Page 29 Woodside on behalf of residents. Resident’s accounts must be maintained up to date and accurate. The registered manager must ensure that the valuables of residents are at all times kept in safe keeping. All staff must attend a minimum of two fire drills annually, records to evidence this must be available. Previous timescale of 30/6/05 not met, this requirement is carried forward. The registered manager must ensure that the building risk assessment is updated following review. 16 OP35 13(6) 04/08/06 17 OP38 13(4)(c) 23(4)(e) 31/10/06 18 OP38 13(4) 31/10/06 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 Refer to Standard OP7 Good Practice Recommendations It is recommended that some ISS’s be amalgamated with others to reduce the amount of statements which could aid staff when they come to read them. Woodside DS0000033612.V298783.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham 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 DS0000033612.V298783.R01.S.doc Version 5.2 Page 31 - 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. 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