Inspection on 31/08/07 for Woodside

This inspection was carried out on 31st August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 25/07/06

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 Kulwant Ghuman Key Unannounced Inspection 31st August 2007 08:30 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 DS0000033612.V349957.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.V349957.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 Not known 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.V349957.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 25th July 2006 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. Fees at the home are dependant on the financial assessments carried out by the placing social workers. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key, unannounced inspection was carried out by one inspector during one day in August 2007. A second inspector carried out a short observational assessment over a period of two hours during which the interactions of staff and people living in the home were observed. As part of the inspection process the home provided a completed Annual Quality Assurance Assessment that provided the Commission with some information about the home. During the inspection the inspector observed two mealtimes, spoke with one visitor to the home, toured the communal areas of the home and sampled some bedrooms and spoke with some of the people living in the home. The conversation with them was limited due to the level of dementia in the home. The inspector spoke with some care staff and the management team throughout the day. No complaints had been received about the service directly by the Commission. Three complaints had been made directly to the home and these had been investigated by the home. The Commission had not been made aware of any adult protection issues at the home prior to the inspection but an issue was referred to the Department of Health and Social Care following the inspection. What the service does well: The home provides a very good level of comfort and homeliness for the people living in the home. The staff at the home have a good level of knowledge about dementia and subsequently are able to continue to provide standard of care for the people living there. There were good interactions observed throughout the day between the staff and the people living in the home. There were good relationships with the family and friends of the people living in the home and there was regular contact with them through visits to the home, meetings in the home and telephone contact where information needed to be forwarded to them. The admission process to the home ensures that the needs of the people living in the home are met. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 6 The quality of food provided in the home was good and the meals were taken in comfortable surroundings with support being provided as needed in a discreet manner. The home was able to meet the dietary needs of the people living in the home. The home was proactive in looking for new ways of providing stimulation for the people living in the home. What has improved since the last inspection? What they could do better: The home must ensure that the outcomes of any complaints made to the home are recorded and available for the Commission to assess that the appropriate steps have been to taken. The manager must ensure that any issues of potential or actual abuse are forwarded to the appropriate people in a timely manner. Care plans needed to have more detail in them showing how the needs and preferences of the people living in the home have been taken into consideration. Risks assessments must be regularly reviewed and updated as needed. The manager must ensure that meal portions reflect individual needs. The manager must ensure that the television and music being played in the lounge areas do not cause a noise overload for the people using the lounges. Bolts on doors in the home should be removed as they take away from the homely nature of the home. Woodside DS0000033612.V349957.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. The summary of this inspection report can be made available in other formats on request. Woodside DS0000033612.V349957.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.V349957.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s assessment procedure ensured that the needs of the people moving into the home could be met. EVIDENCE: There was evidence in the file of one person recently admitted to the home that confirmed that the good practices identified at the last inspection continued to be maintained. The home gathered information from the place that the individual had lived prior to moving to Woodside, an assessment carried out by the social worker was received and the home carried it own assessment during a visit to the home. The home’s assessment looked at areas of mobility, confusion, conversation and continence. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 10 It was pleasing to note that the home’s assessment identified whether the individual was suitable for admission to Woodside. Following a trial period in the home a review was carried out to decide on whether the home was felt to be a suitable placement and if any concerns had arisen during the trial period. There was a residential agreement in place on two of the files sampled. The third file had an agreement with the previous home but did not have a current one on the file. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Day to day care and meeting of the individuals’ health care needs were good. The details of how care was to be provided to the people living in the home could be improved and more detail on how choices were being promoted was needed. EVIDENCE: The files of three of the people who lived in the home were sampled. Two of the individuals had a current Individual Service Statement (ISS) in place but the one for someone who had been in the home for about 6 weeks was in the process of being produced. The ISS’s contained over twenty sections that included issues such as social interactions, hair care, bathing/shower, dressing/undressing, shopping, Religion, attitude to care, continence monitoring, mental health and managing noise levels. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 12 It was evident during the observations made throughout the day that the staff were aware of the needs of the people living in the home however, the ISS’s did not always give a lot of detail in how their needs should be met by the staff. For example, one of the ISS’s said ‘I like to have a bath or shower’ and staff were to offer a bath/shower when needed and assist as required. This person had been in the home for over a year and the staff should by now have determined how the individual had responded to either a bath or shower and if he had any preferences as stated by him or whether his behaviour had indicated any preferences. One of the ISS’s stated in the section on oral care that the individual was to be encouraged to wash and clean dentures and rinse his mouth but again it did not indicate whether they were to be soaked overnight, brushed and put back in or how much of this task he could undertake for himself. Another of the ISS’s said the staff were to observe the teeth for cause of concern and as this was emboldened it appeared that the staff were to take particular notice of this but there was indication as to the reason for this or how the individual would be encouraged to clean his teeth, eg, did he use a manual or electric toothbrush, was he able to put on the toothpaste himself or did staff have to do this for him. Two of the ISS’s stated that the people had been diagnosed with dementia. One stated that the individual was able to ‘make limited choices and wander’ and the other stated that staff would observe and report any concerns to senior staff who would contact the necessary individuals. They did not contain information as to how in the first case the individual would be enabled to make choices and in the second case what it was that staff would be looking for as it was not stated how the dementia was affecting the individuals day-to-day lives. One of the individuals was observed during the inspection by one of the inspector was noted to constantly rub or fiddle with his fingers and rub the lounge wall. There was no information in the ISS that would suggest whether this was his ‘normal’ behaviour or whether this was a sign of ‘ill being’. One of the ISS’s stated that the individual liked to wander and could do so without assistance however, during the observation he was observed to be encouraged by staff to sit down and after indicating that he did not want to eventually complied. Putting a greater level of detail in the ISS’s would ensure that each person living in the home was receiving individualised and person centred care. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 13 At the last inspection it was noted that where individuals eating and toileting habits were being recorded the reason for this needed to be identified in the ISS. The assessment and review process should identify if this was necessary. There was evidence that the ISS’s were being reviewed however they did not indicate what areas were effective, what needed to be changed, what had been achieved and gave on the month of the review but did not indicate what date. One of the ISS’s indicated that it was being reviewed and that no changes were necessary however, the only review that was available on the file was from the previous home as the current one was still in the process of being written up. An improvement that the home could consider is to include a short profile of the individuals to go alongside the ISS that would give the staff a brief overview of their social background including what sort of work they did and what they used to do socially so that some of the behaviours could be put into context. Other observations made over a two hour period by one of the inspectors were that there were very good interactions between the staff and people in the lounge. The staff discreetly assisted people with personal care, spoke with the people sitting in the lounge and outside in the corridor. One member of staff was observed to be spending some real quality time with a person in the lounge but then got called away by another member of staff and the person in the lounge continued to talk as he had not realised the member of staff had gone and the member of staff did not indicate that he was leaving. Other documents available on the three files sampled included falls and tissue viability assessments, individual risk assessments and moving and handling risk assessments that had some very good details on them. One of the individual risk assessments indicated that the individual needed two staff to accompany him if he was going out, that there could be ill effects if he did not take his medication and of not eating/drinking and that staff were to encourage him to eat and drink and raise concerns if not eating. The risk assessment needed to be further developed to show the other steps that the home were undertaking to monitor diet such as monitoring weight. The risk assessment needed to be updated as it was last reviewed in July 2006 and needed to include the issue of deteriorating eyesight. There was evidence available on the files that the people living in the home were referred appropriately to the GP, specialist doctors, chiropodists and dentists. The management of medicines in the home was good. The medication was provided in a monthly monitored dosage system and at the time of the Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 14 inspection the new supply had been booked in appropriately and the home was only on the third day of the new supply. There were copies of prescriptions available against which the received medicines could be checked. There were some boxed medicines available also. There were controlled medicines in place for two people living in the home and these were correct and appropriately recorded and signed for by two staff. The medication fridge temperatures were being regularly checked. There were no people living in the home who were able to administer their own medicines. Good practice was observed in relation to the medication system during the day of the inspection in that the staff continued to give choices to the people in respect of whether to take medicines to control pain and that daily audits were being carried out by the staff on a daily basis and any problems quickly identified. All the interactions observed during the day between the staff and residents suggested that the privacy and dignity of the people living in the home was being managed in a respectful and discreet manner. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were no rigid rules in the home and activities were organised in the home to enable to the people living there to have a meaningful life and maintain contact with friends and relatives. EVIDENCE: The ISS’s sampled during the inspection indicated that the people living in the home were asked about what they liked to do socially. There was also information available about their family involvement. Views of the families were taken into consideration. There were activities sheets on the files sampled and these evidenced that there were entertainers who came into the home and parties were organised. There were bingo sessions, music and movement and reminiscence. Daily records for the people living in the home indicated other activities such as visits from families, dancing, pottering around, singing, foot spa and going into the garden. One of the activities that had gone down particularly well with some of the people was shoe polishing. During the day of the inspection one of the people living in the home had had her hair washed and put in rollers. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 16 Trips to the park had been organised however due to the very wet weather during the summer these had to be cancelled. A trip to the theatre had been organised for September. There were televisions and music was available in the lounges. The music appeared to be the same in all the lounges. It was identified that for the majority of the day there was a television on and music on in all the lounge areas. This was seen during the observation carried out by one of the inspectors. Two of the ISS’s indicated that the individuals could be affected by noise and at one point one of the individuals being observed got up and banged the television. Staff needed to be mindful of the effects of different noises in the home. It would have been more appropriate to have either the television or music on in any one of the lounges or just have music on in the centre of the home if different television channels were being watched in the lounges. Issues such as whether individuals liked to be assisted by male or female staff were recorded as were their religious requirements. The home could meet the physical needs of an ageing population. There was evidence in the small kitchen that soft diets, meat cut up or minced, gluten free and diabetic diets were catered for. For one individual cultural meals had been identified on their ISS. During the inspection one relative was spoken with who stated he was very happy with the care provided. He stated that on several occasions he had a meal with the people in the home and that he had always found the quality of the food to be good. He stated that he could visit freely and was always made welcome by the staff. Examination of the daily records of one of the people living in the home showed that the relatives were regularly informed of how the care was being provided and their assistance was sought if needed. Although the menu at the home was not looked at past history at the home comments from the relative spoken to confirmed that the food at the home was good and varied. The main meal for the day and choices were identified on a board in the dining room. There were regular consultations with the people living in the home about the menu. During the inspection the inspector was able to observe breakfast and have lunch with the people living in the home. During breakfast it was observed that staff constantly spoke with the residents offering them choices of tea or coffee, jam or marmalade and drinks were poured out by the staff at the tables. People were observed to have cereal, porridge and toast. One Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 17 individual had a gluten free diet and was not able to have toast made of bread. Gluten free bread was available but the individual was not being given this on the day of the inspection as staff had observed the previous day that she had had difficulty swallowing it. At lunchtime it was observed that apart from the inspector everyone was suffered lunch on breakfast. This was discussed with senior staff who stated that some people ate very little and that using a dinner plate was overwhelming for them. This was acknowledged as appropriate for some people but that not everyone should be being served a smaller portion unless it was specifically identified in their ISS. The staff did verbally ask the people if they wanted more but no one appeared to take up the offer. It was recommended that food was offered visually by bringing it to the people to ensure that they knew what was being offered. Staff were seen to wear the appropriate tabards and assistance was given to the people in an appropriate manner with staff speaking to them and telling them what they were eating. Bedrooms were seen to be personalised and private belongings had been brought in to help the individuals feel comfortable. People living in the home were able to sit in a variety of areas in the home. Individuals could go to their bedrooms but the doors would have to be unlocked for them. Bedrooms had the names of the individuals in large print. It might be better if there were photos or other memorabilia strategically placed to help people identify their rooms. The bathrooms and toilets had large pictures identifying what rooms they were. Other choices made by the people living in the home were included what clothes they wore and food they ate. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although there was evidence that complaints were listened to and followed up the records of the investigations of complaints made to the home were not fully completed. Improvements needed to be made to the management of and referral of issues of potential abuse to the appropriate teams in a timely manner to ensure all individuals were safeguarded. EVIDENCE: The complaints procedure was not looked at during this inspection. The complaints log indicated that there had been many compliments received by the home regarding the service provided and no complaints had been received directly by the Commission regarding the service. There had been three complaints received by the home since the last inspection. One had been made in December 2006 and had been investigated and the outcome available in the folder. The second was made in January 2007 and the complaint was about rude behaviour by a member of staff from the domestic team. This had been forwarded to the domestic supervisor however no outcome had been recorded on the folder. The manager needed to follow this up and ensure that a satisfactory conclusion was available as the manager is overall responsible for everything that happens in the home. The outcome of the investigation needed to be available for inspection. The third Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 19 complaint was made in July 2007 and was about a care staff member responding to one of the people living in the home indicating that she would hit back if the person hit her. There was no formal outcome recorded on the file but the inspector was informed that the staff member had been joking with the individual. The inspector accepted that this was probably the case however, relatives overhearing comments like that could be distressing to them and it could not be determined whether the person living in the home may have become upset or disturbed by such a comment. It was also important that any allegations were investigated and the outcome recorded. One relative spoken to during the inspection said he had had no cause for complaint but would have no hesitation raising any issues with staff if they arose. Examination of one person’s daily records raised some concerns for the inspector about the protection of some people living in the home. The records suggested that one person had made sexual advances towards one or more other people in the home. Discussion with the assistant manager at the home at the time of the inspection indicated that a relationship had developed between two of the people living in the home and the matter had been discussed with the relatives and medical staff had been involved in trying to address the matter. There had been no formal referral to Health and Social Care at the time of the relationship developing and from the records seen the inspector could not be assured that the issue related only to two people. The records suggested that on occasions the one half of the couple had become distressed and at least one other female had been approached. The records did not indicate who the individuals referred to were. The home were making some efforts to manage the situation but their actions appeared to be reactive rather than proactive. For instance there were no plans that evidenced that the individuals were being monitored or that if the relationship was of a consenting nature how the relationship was being supported. The home was asked to raise the matter as an adult protection with the relevant social workers on the next working day so that a joint decision could be made about the issues. Any evidence that the individuals referred to in the records were only the two people in the relationship was asked to be forwarded to the Commission for consideration. At the time of writing this report no information had been received by the Commission. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was well maintained and met the needs of the people who lived there. EVIDENCE: As at the last inspection the home appears to be well maintained and clean. One relative spoken to during the inspection indicated that this was the case whenever he visited. The inspector looked at the communal areas of the home and sampled some bedrooms. There were a number of communal seating areas in the home that were accessible to the people living in the home. All were pleasantly decorated and furnished in a homely manner with a variety of seating including easy chairs and small sofas enabling visitors to sit with the people Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 21 living in the home in a way that maintained their relationships. There was an identified lounge for people living in the home who smoked. The pleasant garden area was accessible from the small seating area near the dining room. The garden appeared to be well maintained. The bedroom doors were painted in particular colours depending on the corridor. Bedrooms were identified with the names of the occupant outside in large print. Some bedroom doors were seen to be locked but others were left open. On speaking to a member of staff she stated that all bedrooms were locked but this was clearly not the case. A discussion was had with some of the staff that a policy on locking all bedroom doors during the day could be seen as limiting the accessibility of bedrooms to the occupants. It was explained that this was due to the fact that some of the people living at Woodside tended to walk into other peoples bedrooms. The home needed to ensure that bedroom doors were opened to the occupants when they wanted to go to their rooms. If individuals were not allowed back into their bedrooms this needed to be recorded clearly that if was for their safety and the reasoning behind the decision. The four bedrooms seen had an en-suite facility. Some of the larger bedrooms had large en-suite showers. There were electric rising beds in some bedrooms. The bedrooms appeared to be well decorated and homely. A wardrobe in one of the bedrooms had a padlock on it and this took away some of the homeliness of the bedroom. An appropriate lock should fitted to the wardrobe if a lock is needed. There were adequate numbers of showers and baths and toilets throughout the home with appropriate adaptations including ceiling track hoists, support rails, bath seats and emergency call system. It was noted that there were bolts on the outside of bathroom and shower doors and on sluice rooms. Some of the bolts were big and chunky and not suitable for inside a home. The inspector was informed that this was to prevent the people living in the home from going in injuring themselves. There were other locks on the doors that could be used to lock the doors where needed and these would be much more discreet than the bolts and less likely to be opened by the people for whose benefit they were on the doors for in the first place. In one of the shower rooms the emergency call was activated and staff attended but switched off the alarm before attending the call. During discussions about the alarm it was identified that if a member of staff was assisting someone in the shower and got into difficulties although assistance could be called by using the pull cord the alarm could not be escalated to the ‘emergency’ setting because the button needed for this was near the door and too far away form the shower for the member of staff to activate without Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 22 leaving the person being assisted. The home needed to assess the need for the alarm switch to be re-sited nearer the shower. The switch was also placed too high for some of the staff to comfortably reach it. The home was found to be clean and free from any odours. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff were knowledgeable about the needs of the people living in the home and how to care for people with dementia. The manager needed to ensure that new staff were appropriately inducted and assessed during their probationary period. EVIDENCE: Examination of the staffing rota showed that the home was operating on minimum staffing levels and could at some points in the day fall below four care staff. The inspector was told that the rotas were being addressed to ensure that there was consistency regarding the number of staff on duty in the home. The file of one recently employed member of staff was sampled and it included all the required pre-employment checks. The file did not evidence that an induction or probationary period and assessment had been completed. Following the inspection the home was asked for a training matrix to be forwarded to the Commission however this had not been received at the point of writing this report. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 24 It was evident during the observations made through the short observational assessment and at meal times that the staff were kind, thoughtful, knew the needs of the individuals in the home and able to offer choices throughout the day and respected their dignity. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is generally good however, some issues of identifying and managing possible adult protection were identified. EVIDENCE: The manager had been managing the home for several years and had completed the Registered Managers Award. At the time of this inspection the manager was on holiday, however, the assistant managers were knowledgeable about the systems in the home and able to access all the documents required. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 26 A member of staff said she was very knowledgeable, helpful and facilitating but would not be pleased if they did not do what was required of them. There was evidence of some resident and relative meetings and staff meetings being held. Some relatives were involved in raising funds for the home and assisting people going out on visits. One of the recent meetings discussed the need for relative involvement when people living in the home needed to attend hospital appointments due to the impact this was having on staff who needed to accompany them and sometimes the length of time they had to wait to be seen. Another home was auditing Woodside against the national minimum standards and the home did carry out some audits to ensure that people using the service were happy with it. The home does manage small amounts of money kept for the people living in the home and any small items of value can be locked away in the safe. The records of the monies spent on behalf of some of the people in the home and the comforts fund were looked at found to be acceptable with two receipts and running balances. The manager carried spot checks on these records as well as daily handovers by staff. The management of health and safety in the home including premises, equipment and utilities is generally well maintained. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 27 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 3 3 2 X 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 X X 3 Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 28 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. 2. Standard OP8 OP15 Regulation 13(4)(c) 16(2)(j)1 2(1) 22 Requirement Risk assessments must be reviewed on a regular basis and updated as needed. The manager must ensure meal portions are suited to the individual needs of the people living in the home. The registered manager must ensure that a record of complaints made by residents or their representatives is fully documented to show the outcome of any investigations undertaken. 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. Not assessed at this inspection therefore carried forward. The registered manager must ensure that issues of possible abuse are referred to the appropriate teams in a timely manner. DS0000033612.V349957.R01.S.doc Timescale for action 01/11/07 01/11/07 3. OP16 01/11/07 4. OP18 13(6)18(1 )(c)(i) 01/01/08 5. OP18 13(6) 01/11/07 Woodside Version 5.2 Page 29 6. OP30 18(1)(c)(i ) 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. Previous timescale given 30/11/06 Evidence that this has been addressed must be forwarded to the Commission. 01/11/07 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 OP2 OP7 Good Practice Recommendations A current residential agreement must be provided to each person moving into the home. Monthly reviews of ISSs must include information indicating if the ISS has been effective and the date on which it was reviewed. 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. The ISS’s must include a greater level of detail of how the needs of the individuals are to be met. The staff needed to ensure that the television and music available in the lounges did not create confusion and DS0000033612.V349957.R01.S.doc Version 5.2 Page 30 3. OP12 Woodside 4. 5. 6. OP19 OP22 OP33 distress to the people living in the home. The home should remove the bolts on doors and padlocks on wardrobes and replace with more suitable mechanisms for locking the doors if required. The manager needed to review the need for resiting the emergency call system in shower/bathrooms. A report of the assessment of the service and any ongoing improvements to be made should be available for the relatives of the people living in the home and the Commission. Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodside DS0000033612.V349957.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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