Inspection on 06/10/05 for Woodside

This inspection was carried out on 6th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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 Announced 6 October 2005 th 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 V245385 061005 AI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wood side Address 40 Woodside Road, Selly Park, Birmingham B29 7QS 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) 0121 471 3700 0121 471 3446 Birmingham City Council Diane Blount Care Home 22 Category(ies) of Dementia - Over 65 (22_ registration, with number of places Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 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 addition to care staff Date of last inspection 23rd May 2005 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 residents 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 V245385 061005 AI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted on an announced visit by one regulation inspector. The inspector was able to meet many residents and their relatives, informally interview staff and view communal areas of the home. Records pertaining to care, staff and service provision were seen including evidence of health and safety practices. Two requirements from the last inspection were not addressed including frequent fire drills for staff and effectively reviewing the written care plans known as individual service statements for residents. All other requirements were met in a timely fashion. What the service does well: What has improved since the last inspection? Residents and relatives were keen to inform the inspector that they are made fully aware of care needs and staff support, as this is discussed in frequent reviews. Relatives also commented on the frequent support from community healthcare services and the GP, that the staff will make immediate arrangements for residents to see these professionals. Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 6 Relatives informed the inspector that seating in communal areas was comfortable and that the two-seater settees enable them to sit with the resident. 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 V245385 061005 AI Stage 4.doc Version 1.40 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 V245385 061005 AI Stage 4.doc Version 1.40 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, 5 and 6. The residents and their representatives are provided with information and opportunity to consider whether the home can meet their needs. The home gathers assessment information and decides whether the referral would be appropriate. EVIDENCE: The statement of purpose has been improved to provide potential residents and their representatives with all the information as required under standard 1 of the National Minimum Standards. Sampled residents files all contained a detailed licence agreement, which stated the terms and conditions of residency, this included fees to be paid and room to be occupied. Those seen had been signed by an advocate on behalf of the residents. Residents’ files included care plans provided by social workers prior to admission, whilst some of these care plans identified the needs of residents others did not and information of assessed need was brief. Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 9 Prospective residents are able to visit the home for a one day assessment, this time is used positively by the staff to further gather important information as to the needs of the resident and helps the staff decide on whether they can meet these needs. Intermediate care is not provided at Woodside. Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 10 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 and 10 The staff closely monitor the healthcare needs of residents. The health and personal care needs are fully met; residents have access to all required community healthcare services to ensure they receive appropriate treatment. EVIDENCE: Sampled residents’ files all included detailed individual service statements (ISS). The ISS informed care and catering staff in how to meet the assessed needs of residents and included for example nutrition (diet and fluids), physical care and personal care, social support, mental health and medication. Elements of the ISS include: how staff will help me (residents) achieve, who will carry out this service, how will I know I have achieved and by when. The ISS are detailed and instructive for staff. Monthly reviews are completed, however records need to reflect upon the ISS being effective or otherwise. Residents and their families are involved in the planning process and are invited to quarterly reviews to discuss the ISS and agree any changes where needed. Relatives were pleased with healthcare services that the home co-ordinates for residents including regular GP visits and medication reviews, district nurse, chiropody, dentist and opticians. Records are well maintained and outcomes of the healthcare support recorded. Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 11 On the day of inspection the new GP was visiting and was familiarising himself with the histories and medical care of the residents. Risk assessments for the manual handling needs of residents are completed and reflect all areas of consideration, including: task, equipment, environment, communication / language and physical ability. On the day of inspection members of the local authority manual handling team had visited to give advice. Some manual handling risk assessments had not been reviewed following incidents of concern. Other risk assessments include tissue viability and the nutritional assessments for residents are detailed within the ISS. It was evident from accident records that some residents are prone to falls. No falls risk assessments had been completed. Medication management is in line with good practice; some staff have completed accredited courses in the safe handling of medicines. A local chemist dispenses medicines using a monitored dosage system and frequently completes audits on the safety of medicine management. Medication administration records are fully completed including when medicines are received and administered; medicines received are checked against copies of GP prescriptions to ensure they are correct. Control drugs are safely managed. Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 12 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) All standards Residents needs in respect of daily life and social activity are fully met. This means residents are able to make choices and influence the day-to-day running of the home. EVIDENCE: Opportunities for residents to have social contact and activity is assessed and planned for on an individual basis and adequately recorded with the ISS. The ISS includes such support as culture, leisure and social relationships. Relatives confirmed they are able to support residents to meet some of their needs, this was seen to vary and included personal care and emotional support. Residents were able to have visits in private and relatives were complimentary of staff assistance ensuring the visits are positive and undisturbed if requested. A relatives support group has recently commenced, relatives and staff were positive about the group and described how residents are supported to make choices and that sharing information, such as who can provide support is being discussed. Menus have recently been reviewed and a further review is planned in consultation with residents. Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 13 The current menu provides a good choice of healthy diets and also provides special meals, for example diabetic and soft options. Where needed, the home records the dietary intake of residents and a nutritional assessment is completed and recorded within the ISS. Food storage, preparation and cooking facilities are hygienically maintained. Kitchen cleaning is well planned and reflects good practice. A food safety risk assessment is completed and measures to reduce risks are fully implemented. However, all food items in freezers must be appropriately labelled including use by dates. Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Residents are supported to raise their concerns and the home is committed to improving services wherever possible. Residents are protected by the skills and policies in place. EVIDENCE: A complaints file is available and a monthly complaint audit form is sent to the Local Authority complaints department. No formal complaints have been received in the past 12 months. The CSCI have not received any complaints in respect of this service in the past 12 months. Some staff have recently completed Adult Protection training and an ongoing program of training has been developed. Staff during informal discussions with the inspector were able to adequately describe how they would protect residents from abuse. Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 15 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, 26 The premises and environment are maintained to a good standard, which promotes comfort, interest and the health and safety of residents. EVIDENCE: Communal areas including foyer, lounges, quiet rooms and dining areas were maintained to a high standard of domestic decoration and furnishings. All areas appeared safe and were fully accessible to all residents. Infection control measures are reflective of good practices; these include appropriate hand washing facilities in all high-risk areas. Laundry facilities are sited away from all food areas and items of laundry have colour coded laundry bags to ensure safe management. It was unclear from staff training records that regular infection control training is undertaken. Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 16 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, 28, 29, 30 Residents are supported by a range of staff including care, management and ancillary, who are generally well trained and available in sufficient numbers to meet all their needs. EVIDENCE: Minimum staffing levels are maintained, however agency staff are needed to supplement permanent staff. Rotas indicate that four care staff are on duty between the hours of 8am to 10pm. The manager and the deputy managers are on duty during most day hours and are supernumerary. Two night care assistants are on duty whilst one sleeping-in manager or senior care assistant is on duty. Ancillary support is provided which includes domestic, laundry and catering staff. The home also has a maintenance operative. The pre-inspection questionnaire did not record the amount of staff with NVQ level 2 in Care or above, training records seen by the inspector included some reference to this award but it is not clear the home maintains a minimum ratio of 50 of staff with this award. Since the inspection the manager has provided the CSCI with records of staff hours and those staff with a minimum of NVQ Level 2 award. These reports reflect that at present there is above 50 of care staff with the award. Recruitment records are in line with legislation and good practice, they include written references, medical checks and criminal records bureau disclosures. Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 17 Some staff files did not include application forms, the manager advised the inspector that these are retained at Human Resources. Staff training records include details of fire safety, first aid and refer to staff awaiting Food Hygiene and Adult Protection training. There were limited records to confirm staff have received recent Manual Handling training, further gaps in training were identified in standard 26 of this report. Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 18 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) 32, 35, 36, 38 The management and administration is effective to ensure that residents and relatives are involved in running the home. Health and safety practices are generally good and staff and relatives are provided with appropriate support. EVIDENCE: Relatives were positive that the management team are effective in their duties, communicated well and are available to discuss care and concerns. Resident money management was assessed. Records indicate that systems are safe; they include receipts for all transactions and signatures of two staff. Sampled balances of residents money was counted and found to be correct. The local authority is the appointee for one resident. At the time of inspection staff supervision records were not fully available, however since inspection the manager has advised and provided evidence that staff supervision is frequent and provides appropriate support. Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 19 The service, testing and maintenance of equipment and utilities in respect of health and safety is generally good. Risk assessments for fire safety, premises and staff are in place and are regularly reviewed. Fire records do not reflect that all staff attend fire drills and instruction at regular intervals. Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 20 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 3 3 3 x 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 2 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 x x 3 3 x 2 Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 21 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 OP7 Regulation Requirement Timescale for action 30/11/05 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. Manual handling risk assessments must be reviewed and where needed updated following any incident of concern. Fall risk assessments must be developed for residents who are identified as at risk. All frozen foods items must be appropriatley labelled. All recruitment documents including application forms and references must be available at the home.. 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 attend a minimum of two fire drills annually, records to evidence this must be available. 2. OP8 12(1) 13(4) 30/11/05 3. 4. 5. OP8 OP15 OP29 12(1) 13(4) 13(3) 13(4)(c ) 19(1)(b)(i ), schedule 2. 18(1)(c )(i) 30/11/05 31/10/05 31/12/05 6. OP30 31/12/05 7. OP38 13(4)(c ) 23(4)(e) 31/12/05 Woodside E54 S33612 Woodside V245385 061005 AI Stage 4.doc Version 1.40 Page 22 Previous timescale of 30/6/05 not met, this requirement is carried forward. 8. 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 V245385 061005 AI Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Birmingham & 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 V245385 061005 AI Stage 4.doc Version 1.40 Page 24 - 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. 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