Inspection on 16/02/07 for Woodside Hall

This inspection was carried out on 16th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodside Hall 06/01/06

Woodside Hall 31/08/05

Woodside Hall 09/03/05

Woodside Hall 21/07/04

Woodside Hall 30/01/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Woodside Hall Woodside Wootton Bridge Isle Of Wight PO33 4JR Lead Inspector Liz Normanton Unannounced Inspection 16th February 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodside Hall DS0000012570.V326871.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 Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodside Hall Address Woodside Wootton Bridge Isle Of Wight PO33 4JR 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) 01983 882415 01983 884578 Colville Care Limited Mrs Deirdre Lynn Shortt Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability (2), Terminally ill (5) of places Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The category PD (female) relates to current resident only and will not apply when this person is no longer resident. 6th January 2006 Date of last inspection Brief Description of the Service: Woodside Hall is located at the far end of New Road and is approximately 1.5 miles from the amenities of the local town. The premises is a large period property set within its own substantial grounds, the front of which has been given over to parking and the rear which has been laid mainly to lawn. Service user accommodation is mainly single occupancy, although several multiple occupancy rooms are available for people who wish to share. The accommodation is divided between two main floors accessible via the passenger lift, although the first floor is split-level with the latter half of the floor accessible via a chairlift or stairs. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 16/02/07 with a brief return visit on 21/02/07 and focussed on what the commission considers to be core standards for a care home for older people as defined in the Department of Health (DOH) National Minimum Standards. The information in this report has been collected from a variety of sources, which includes a pre-inspection questionnaire completed by the manager, nine resident’s feedback comment cards, ten relative comment cards, a GP comment card, a visit to the home, discussion with several residents, the manager, and two staff. Three residents’ care files and three staff files were audited. The information provided indicated that the majority of people are extremely satisfied with the service. Two requirements have been made one in relation to the safe storage of controlled drugs and the other in respect of regulation 26 visits to be made by the company directors. What the service does well: Prospective residents and their representatives can be assured that the home will not admit a person until it is satisfied that an individuals care needs and nursing needs can be met. Residents have commented that the home provides them with the nursing care that they need and they are extremely satisfied with the service. Visitors are welcome at the home and residents can make choices about how they live their lives within a residential setting. The home provides residents with a nutritious, well balanced diet and can cater, for specialist dietary needs. The home provides a clean, safe, warm, comfortable, homely environment. Qualified nurses and nursing auxiliaries are employed in sufficient numbers and have the experience and training in caring for older people with nursing care. The home is well managed and administrated. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. Prospective residents and their relatives benefit from the professionalism of the manager who will only admit people into home when they are satisfied that the home can meet an individuals assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In discussion with the manager they reported that the majority of prospective residents are admitted from hospital. Prior to admission the manager visits prospective residents at hospital to gather as much information about their health and care needs as possible to inform the needs assessment. As part of this process the manager consults with prospective residents, care managers, relatives and nursing staff. There was evidence on resident’s files that the manager obtains when possible the care managers care plan and ward details. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 9 The manager does not consult with staff with regards to prospective residents as they reported they are aware of the staff capabilities and can see no benefit from this. As well as undertaking the needs assessment the manager advises relatives to visit the home and also to look at as many other nursing homes as possible in considering whether the home is the right place. The manager will only take admissions when they are satisfied that the home is able to meet and individuals needs. One resident who has recently moved to the home was not able to discuss their admission as they were showing signs of confusion when asked questions. In feedback from nine residents they all stated that they enjoyed living at the home. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. The health and personal care, which a resident receives, is based on their individual needs. There have been improvements in the homes medication procedures, however it has been discovered that although the storage of controlled drugs is reasonably safe it does not meet with legislation. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We viewed three care plans and found them to contain comprehensive care details, which had been drawn up from the needs assessment. Each resident keeps their care plan in their room and has signed a consent form to that effect. The care plans are easily accessible to both nursing staff and carers to enable them to meet a persons needs using a consistent approach. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 11 There was evidence that care plans are reviewed monthly and changes are also made as required. In discussion with the manager they reported that wherever possible residents are encouraged to take part in the review of their care plans. In written feedback provided in nine resident comment cards all stated that they were well cared for. In written feedback from ten relatives they stated that they were consulted about their relatives care. Three people took the time to make written comments and said: “ My friend is well looked after and the staff are very kind. The home is a pleasant place to visit, very clean and hygienic”. “ More then happy with the standard of care. All the staff always friendly and helpful” “ I haven’t had much experience with Nursing Homes etc, but as far as I can see this home is run with as much care and efficiency as is possible”. All residents are registered with a general practice. In discussion with the manager they reported that the trained nurses are responsible for the nursing needs of the residents however the home would consult with the District Nurse team if they needed advice. The residents were observed to be being well cared for by all staff on duty throughout the inspection visit. In written feedback from a doctor who visits patients living at the home they have confirmed that the home communicates clearly and works in partnership with them and they were satisfied with the overall care provided to residents. A chiropodist visits the home every six weeks to provide a foot care service for those that require it. Since the last inspection the manager reported that they have now taken responsibility for counting all tablets in to the home against the prescription to try to prevent medication errors in medication numbers. There was also evidence that a separate record of why a medication has not been taken is now appropriately recorded. In discussion with the manager they reported that they have purchased a specialist kit for destroying controlled medications and a contract has been set up with an environmental agency who now deals with the homes returned medications. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 12 In respect of controlled drugs the home stores them in a metal cabinet which is bolted inside a larger metal cabinet however this does not meet the legal requirement for nursing homes which stipulate that the cabinet should be bolted to a solid interior wall. Controlled drugs are recorded on to the Medication Administration Record (MAR) sheet and also recorded in to a separate CD register, which is double signed, to demonstrate that a second member of staff has witnessed the medication being given. We counted three residents medications against records kept in the MAR sheets and found them to be accurate except for one in which one Aspirin was missing. The manager was clearly concerned about this and believed it was down to human error as she has taken every effort to ensure medication practices in the home had improved. The manager agreed to talk with staff responsible for giving medication to ascertain where this tablet had gone. All personal care and health care needs are given in the privacy of resident’s own rooms. In written feedback from residents they confirmed that they feel that their privacy is upheld. A doctor informed us that they visit their patients in private and relatives and friends confirmed that they could visit their residents in private. In discussion with two residents they confirmed that the staff always treat them with dignity and respect and one said “I like to have a bit of banter with them”. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 Quality in this outcome area is good. Residents are able to choose their life style, social activity and keep in contact with family and friends. The activities provided by the home generally meet with residents cultural and social expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has employed an activities co-ordinator (this person had previously been a carer at the home). In discussion with the activities co-ordinator they explained that they were still developing their role and would introduce new activities as time goes on. A list of weekly activities is on display in the reception area and activities are scheduled four days a week and are in the afternoon. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 14 At the inspection visit several residents had chosen to join in the activity, which was based around art and crafts. It was noted that some residents had visual impairments and needed assistance to participate in the activity. In discussion with the activities co-ordinator they reported that they had not done any training in working with people with visual impairments. It would be beneficial to the residents for the activities co-ordinator to have training in this area to enable them to develop some more meaningful activities for those residents with visual impairments. Other activities at the home include, playing scrabble, card games, jigsaws, listening to music, watching films and sing –along. In discussion with the manager they reported that the residents prefer gentle past times, which are not too noisy. In feed back from nine residents comment cards we know that eight residents think the activities are suitable with only one, displaying dissatisfaction. Residents have the benefit of seeing visitors during the course of the week, which include relatives, friends, the hairdresser, chiropodist and doctor. There are no restrictions on visiting times, and those relatives/friends that have returned comment cards tell us that they are always made to feel welcome. Residents that are able can go out with relatives and friends. In discussion with the manager they reported that those residents, who observe religious beliefs are visited by various representatives from different denominations which includes Catholic Church, Church of England, Salvation Army and the Jewish society, on a regular basis. Five residents rooms were viewed and were observed to contain some items of resident’s furniture, which they had brought from home. All rooms seen had been individualised to represent the individual’s personality. There was evidence that resident can choose to have alcohol in their rooms. In discussion with two staff they reported that residents can make choices on when to awake and retire, choice of clothes, what to eat, whether to join in activities etc. In discussion with the manager they reported that one resident manages their own finances. Eight of the nine residents who gave feedback on comment cards told us they liked the food provided by the home with only one being dissatisfied. The manager was observed visiting a resident in their room to let them know the lunch and teatime menu and asked them for their choice. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 15 We observed people having different choice of meals at lunchtime. As it was a Friday the residents were traditionally offered fish and the choice at the inspection visit was Scampi or Haddock with chips. One resident who does not eat fish was offered egg, chips and beans as an alternative. There was evidence that the home uses fresh produce as well as frozen and preserved foods. In discussion with two staff one reported that food which is liquidized is all put in together and does not look appetising, this was discussed with the manager who agreed to discuss the matter with the cook. The home can cater for specialist diets as required. Residents were observed eating their meals in various settings throughout the home, which included sitting to the dining table, in their rooms or in lounge area with side table provided. One resident was observed being assisted to eat by a member of staff and this was done in a dignified manner. Woodside Hall DS0000012570.V326871.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. Residents have access to a robust, effective complaints procedure, are protected from abuse and have their legal rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information supplied in the pre-inspection report returned to CSCI indicates that the home has not had any complaints since the last inspection. There was evidence that the home would use a complaints log in the event of a complaint being made. In discussion with two staff they reported that they would take any complaints to the manager. Details of how to make a complaint are available in the Statement of Purpose/Service user guide, which is available on the stand in the reception area of the hall. In written feedback from nine residents they all confirmed that they knew who to talk to if they were not satisfied with their care. In returned relative/visitor comment cards eight people told us that they were aware of the complaints procedure whilst two were not familiar with it. All ten stated that they had never made a complaint about the service. In comments returned by GP they Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 17 reported that they had never received any complaints about care provided at the home. In discussion with the manager they reported that there had been an allegation made about the home since the last inspection and this was fully investigated by the social services adult protection team and was unsubstantiated, however the complainant refused to return to the home. The home is in receipt of the Isle of Wight Adult Protection Procedural Policy and staff, have been provided with the General Social care Council code of Conduct. In discussion with two staff they were able to demonstrate that they knew how to identify abuse and would use the homes “whistle-blowing” policy if necessary. Information provided in the pre-inspection questionnaire indicated that staff, have received adult protection awareness training. Information retuned in the ten residents comment cards informs us that residents feel safe and well cared for. In discussion with one resident they said, “the staff are fantastic and the manager is wonderful”. Woodside Hall DS0000012570.V326871.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. The physical design and layout of the home enables residents to live in a safe, comfortable, homely, environment, which encourages independence. The home is generally well maintained but there were some areas identified that required improvements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the premises was undertaken and included four residents bedrooms and all communal areas. The home is well laid out and residents are able to access all areas independently. All areas of the home were clean and the furnishings and Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 19 decoration provided a very homely and comfortable environment. Residents are able to bring items of furniture from their own homes and bring their personal possessions. The lounge areas offer residents a panoramic view across the Solent over to Portsmouth and due to the home being situated in natural woodland the grounds are teaming with wildlife. In discussion with one resident they said, “people sit out in the gardens in the better weather and they have al-fresco meals”. We observed that one bedroom viewed did not have any seating as required in the national minimum standards. In discussion with a member of staff they reported that the room was not big enough to accommodate two chairs and when the resident had guests chairs would be provided as required. A residents room had continence pads stacked on the floor against their wash basin, this was felt to be inappropriate storage and did not afford the resident any dignity when having visitors to their room. This matter was discussed with the manager who agreed to install small chest of drawers for the purpose of storing the pads. In discussion with one resident they reported that they were not happy with their bed as they slid down the mattress at night and had to be moved by staff, which disturbed their sleep. This was discussed with the manager who explained that the bed had been recently purchased due to previous problems and that the home, are aware of the situation and are looking at ways to improve matters. There was evidence of some wear and tear to the cushion seats of the dining chairs in the second lounge/dining room this was discussed with the manager who agreed to make arrangements for these to be upholstered. The underneath of a bath chair was found to have a build up of scum, which can be a health hazard, this was brought to the managers attention and they agreed to get the cleaners on to the matter immediately. A small tile was also coming away from the wall, which could have posed a risk to health and safety, and the manager agreed to have it replaced by the maintenance person. One bedroom did not have an overhead light or bedside lamp as required by the national minimum standards and in another bedroom a light bulb was missing from the overhead light in discussion with the manger they explained that this had been reported to the maintenance person and they are waiting for a specialist bulb. To prevent the risk of spread of infections in a care home it is advisable not to have any items for communal use however it was noted that there was a bar Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 20 of soap in one of the communal bathrooms. The manager was informed and asked a member of staff to remove it immediately. The laundry is sited away from food preparation areas and has a concrete floor covering and the housekeeper had put a piece of carpet on the floor to prevent their feet from getting cold. The housekeeper was advised to remove the carpet, as it could be a risk to health and safety. Residents clothing is marked with initials to prevent people from wearing the wrong clothes. The washing machine has a disinfection programme to kill harmful bacteria and also has a sluicing programme. The home provides staff with protective wear to help to minimise the spread of infection. All staff had been trained in infection control and the home has an infection control policy. The home was described by residents and visitors as always being clean. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 21 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 & 30 Quality in this outcome area is good. Staff in the home are trained, skilled and experienced and supplied in sufficient numbers to fill the aims of the home and to meet the changing needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager supplied CSCI with copies of the staff roster prior to the inspection visit, which indicated that the home supplies sufficient staff on duty to meet the care needs of the residents. A registered nurse is employed on each of the three shifts and is supported by nursing auxiliaries. The manager works in the home Monday to Friday and has close contact with the residents and supports the staff team. The home also employs a deputy manager and there is a clear line of accountability within the staff team. In feedback from the GP they indicated that there is always a senior member of staff on duty to confer with. In the returned comment cards from ten relatives they all felt that there are sufficient staff on duty. Evidence provided in the pre-inspection questionnaire indicated that the home has met the governments target as 63 of the nursing auxiliaries have now Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 22 completed the National Vocational Qualification (NVQ) in care at level 2 or above. In discussion with the manager they reported that two additional staff are due to commence NVQ level 2 training. We looked at three staff files and found them to contain the relevant evidence of recruitment documentation as required by legislation. The homes application forms did not have much space for a person to write their full employment history and they would be advised to review and revise the application form in this area. There was evidence of additional curriculum vitas supplied in respect of two of the files seen. In discussion with the manager they reported that the home does not usually employ people until the Criminal Record Bureau (CRB) had been returned. In the event of someone being employed sooner then the CRB being returned the home would request a Protection of Vulnerable Adults (POVA) check first. Information supplied on the pre-inspection questionnaire submitted prior to the inspection indicated that staff had undertaken training relevant to their roles and responsibilities over the past twelve months. Training included, adult protection, end of life pathway, continence, supra pubic catheterisation, syringe driver, palliative care, fire safety manual handling theory and MAST training. Future training includes infection control, manual handling practical skills sessions, and health & safety updates. In discussion with two staff they confirmed that they had received training whilst employed at the home and evidence of training certificates were viewed in staff files. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 23 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): 31,33,35 & 38 Quality in this outcome area is good. The management and administration of the home is based on openness and respect and has an effective quality assurance systems developed by a qualified and competent manager. The company directors are visiting the home but have not been recording these visits as specified in regulation 26. This judgement has been made using available evidence including a visit to this service. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 24 EVIDENCE: The home has been managed, by Deidre Shortt for five years she is a skilled and competent leader, who possess, both a managerial qualification, ‘The Registered Managers Award’, and relevant professional nursing qualification ‘Registered Nurse’. In discussion with several residents and from written feedback from residents and their families it was established that the manager, and staff, are considered approachable, supportive and caring. With regards to Quality Assurance the residents are consulted annually using a service user satisfaction questionnaire used to gather information about people’s opinions of how the service is meeting their needs. In discussion with the manager they reported that in addition to the surveys they have developed an infection control audit and have also had further consultation with residents in respect of meals provided by the home. The home has an annual renewal programme and the manager reported that there were plans to re-decorate one of the lounges. The information provided in the pre-inspection questionnaire indicated that the home regularly reviews and the updates policies and procedures in line with changing legislation and Department of Health, good practice recommendations. At the last inspection and previous inspections going back to 2005, it was required that the company directors undertake monthly regulation 26 visits and send copies to CSCI. In discussion with the manager they reported that one company director does visit the home several times a week and a second visits at least once a week. There was no evidence that any of these visits had been used as a formal regulation 26 visit. Those directors involved in visiting the home must record such visits from at least one visit per month in accordance with Regulation 26 of the Care Homes Regulations. In discussion with the manager they reported that the home prefers not to become involved in the direct management of residents finances, offering instead to support people through the provision of a tick system, the home purchasing all items required by a resident and billing or invoicing them at the end of the month. One resident presently manages their own finances with several others being supported by their families or representatives, although the majority opt to use the system highlighted above. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 25 The manager ensures that staff adhere to heath and safety procedures within the home buy setting an example and providing mandatory training which includes health & safety in the workplace, food hygiene, manual handling, fire safety and infection control. Some areas of the kitchen were not clean the cooker hood was covered in grease and had a build up of debray on its surface which was a potential health hazard. A cupboard for the storage of plates needed cleaning as the grooves in which the doors slid had remnants of old food particles stuck inside. Food preparation chopping boards needed replacing, as there was evidence of over use. One item of glass ovenware was damaged and was a health hazard to both residents and staff. The paintwork on the kitchen windows was peeling off and looked unsightly and could be a potential health hazard. With respect to the above the manager agreed to deal with the matters and on a short return visit to the home on 22/02/07 to read staffing documents the work had been undertaken to clean the kitchen and remove dangerous items. The manager also reported that the directors have arranged for the windows to be replaced. We looked in the fridges to ascertain that food was being stored in accordance to food hygiene standards and found a used cooked chicken and some other items, which had been used and although they had been covered had not been dated. This was discussed with the manager and the “stand in” cook was asked to destroy the items immediately. The home has a locked storage facility for substances considered hazardous to health (COSHH) and a COSHH risk assessment had been undertaken. The manager has undertaken a generic risk-assessment of potential hazards throughout the home and has taken action to minimise or eliminate these hazards. In discussion with two staff they demonstrated that they knew the homes fire procedures and would know what action to take in the event of a fire. The manager ensures that boilers and central heating systems are serviced regularly. Portable electrical appliances are checked annually. All accidents, injuries and illness or communicable diseases are recorded and those of a serious nature are reported to CSCI. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 26 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 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 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 27 NO 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 OP9 Regulation Requirement Timescale for action 30/07/07 2. OP33 Regulation The Controlled Drugs cupboard 13 must be correctly secured to a solid wall in order to comply with the Misuse of Drugs (Safe Custody) Regulations 1973. Regulation The company must undertake 26 Regulation 26 visits and keep copies of the visit reports at the home available for inspection. 30/04/07 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. Refer to Standard OP29 Good Practice Recommendations It would be advisable for the home to review its application form in respect of gathering a full employment history and obtaining in addition a curriculum vitae in respect of all new employees to evidence if there have been any gaps in their employment history. Residents with visual impairments would benefit if the activities co-ordinator had some training from the blind society to enable them to facilitate activities which would DS0000012570.V326871.R01.S.doc Version 5.2 Page 28 2. OP30 Woodside Hall better meet the needs of the residents. Woodside Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Hall DS0000012570.V326871.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!