Inspection on 27/01/06 for Woodside Hall

This inspection was carried out on 27th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodside Hall 29/05/07

Woodside Hall 06/06/06

Woodside Hall 28/06/05

Woodside Hall 14/01/05

Woodside Hall 19/07/04

Woodside Hall 06/11/03

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Woodside Hall Polegate Road Hailsham East Sussex BN27 3PQ Lead Inspector Debbie Calveley Unannounced Inspection 27th January 2006 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 Hall DS0000014079.V262183.R01.S.doc Version 5.0 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 DS0000014079.V262183.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodside Hall Address Polegate Road Hailsham East Sussex BN27 3PQ 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) 01323-841670 01323-845561 Premium Care Limited Mrs Elizabeth Helen Jones Care Home 59 Category(ies) of Old age, not falling within any other category registration, with number (59), Physical disability (59) of places Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That service users are sixty-five (65) years of age or over on admission. That a maximum of fifty-nine (59) service users are to be accommodated at any one time. That service-users with a physical disability can be admitted from forty-five (45) years of age. That a maximum of two service users with a terminal illness can be accommodated. 28th June 2005 Date of last inspection Brief Description of the Service: Woodside Hall is registered to provide nursing care for fifty-nine service users, who meet the registration category of elderly, physically disabled and up to two service users with a terminal illness. The service has recently negotiated a block contract with social services for twenty-four beds. Woodside Hall is a mature building with a modern extension, which has recently been upgraded and modernised. The accomadation offered is situated on two floors, comprises of forty-nine single rooms, all with ensuite facilities and five double rooms, four of which have an ensuite facility. There are two large dining areas, one on each floor and three good sized lounge areas, there is also a hairdressing room. Communal bathing facilities are provided with a mixture of shower rooms and assisted baths. The home has a selection of specialised equipment such as hoists, pressure matresses, and electric beds. It is situated on the main A22 and whilst there are no near local amenities, the towns of Hailsham, Polegate and Eastbourne are between five and seven miles away. It has large landscaped gardens, and there are car-parking facilities. The rooms and communal areas are pleasantly decorated whilst maintaining a homely atmosphere. Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 27 January 2006. It commenced at 08.30 am, and took place over seven hours. There were fiftyone residents in the home at this time. The methodology of the inspection included a tour of the building, inspection of documentation and records, the delivery of care for twelve residents and informal interviews with fourteen residents, three relatives and six members of staff. The overall quality of care provided at Woodside Hall was observed to be of a good standard and the outcome for residents living in the home is one of warmth and comfort. There were some standards not met during the inspection and these were in connection with documentation and recording and do not detract from the actual care given. The home are aware of these shortfalls and are working towards meeting the standard required. What the service does well: The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required enabling them to make an informed choice about where they live. The home is clean, safe and well maintained, which is appreciated by the residents and their relatives. The environment is comfortable and homely and residents are encouraged to personalise their rooms. The atmosphere of the home was relaxed and staff treated residents with respect and consideration. Residents are encouraged to treat Woodside Hall as their home. Complaints are handled satisfactorily and systems are in place to protect residents from abuse. There is a competent and efficient management team. Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The care planning and documentation regarding residents’ care were found improved, however there needs to be more consistent recording of fluid and nutritional records, and further development of care plans in respect of behavioural traits, communication and social needs. This will ensure that staff approach residents with a consistent plan of care, which will benefit the residents and the staff. Some areas regarding monitoring of the physical deterioration of residents needs to be more robust, to ensure that the specialist input is requested to ensure the continued comfort and safety of residents. The policies and procedures of the home in respect of the management of medication need to be followed to promote competency and good practice, which will benefit the outcomes of the residents’ health needs. The building risk assessments need to be developed with a clear action and outcome. The requirements relating to health and safety need to be addressed to ensure residents health and welfare is protected. Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 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 Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. The Statement of Purpose and Service Users Guide give prospective residents and families the information required enabling them to make an informed choice about where they live. A contract/statement of terms and conditions is given to all residents on admission, which confirms the facilities offered and care agreed. A pre-admission assessment is undertaken on all prospective residents before admission to ensure the home can offer them the care they require, however the standard of the pre-admission assessment was not consistent, which could impact on the home not being able to meet the residents needs. EVIDENCE: A Statement of Purpose and Service Users Guide, which conforms to the Care Home Regulations and National Minimum Standards, is in place. It is available to all service users and their relatives and is written in a clear and user-friendly format. Copies of these documents were found in the reception area and also in the residents’ rooms. Six residents were aware of the service users guide Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 10 and had their own copy. Three residents were not really aware of the service users guide, but said they had a brochure. There is a fully comprehensive statement of terms and conditions in place, which includes the services covered by the fees and the room to be occupied. All service users receive the statement of terms and conditions prior to admission to the home. A senior member of staff completes a pre-admission assessment using the assessment tool with the new care plan system introduced in December 2004. The pre- admission assessments viewed were of an improved standard, however there is a need to ensure that they are signed and dated on completion. The assessment is undertaken at the residents’ place of residence, and input from other relevant professionals is sought when and as required. It was confirmed by three residents that they were included in the assessment and that their families had been involved. Four of the twenty residents spoken with said they had visited the home before making a choice to live there, three residents could not remember how they came to live at the home, but they had been in hospital, one said she had moved to Woodside from a rest home in Eastbourne and her family had chosen the home for her. Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Residents would benefit for a more comprehensive care planning system that guides staff in all aspects of personal and health care and that all risks are identified and planned for. Systems for the recording, handling and storing of medication need to improve to protect residents. Personal support is offered in such a way as to promote and protect service users’ privacy, dignity and independence EVIDENCE: A selection of care plans were viewed and were found to have improved in content since the last inspection, however it was identified that that some residents’ behavioural and social needs still need to be developed in terms of care plans. This will guide staff to deliver the care required consistently and therefore benefit the residents. Fluid charts were found to be inconsistently completed and in respect of three residents had not been completed for two days. These were tracked with their care plans, which still identified the need to monitor their intake. It was discussed that if the fluid charts are not required any more, the staff need to Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 12 update the care plan and not wait till the monthly review. There is still a need to continue to try to involve the resident and/or their representative in the formation of the care plan, only one resident spoken with had a knowledge of the care plan and very few had signatures that evidenced involvement from their representative. One relative said she had not been involved, but did speak to the staff on a daily basis. One residents’ physical disability was seen to be in need of specialist physiotherapy intervention in regard to her positioning in her wheelchair, her difficulty in swallowing and eating her meal. This was discussed in full with staff during the inspection. This particular resident’s care plan was seen and did not fully reflect her changing needs. The clinical rooms were found clean and tidy, with all the cupboards and clinical fridges appropriately locked. A recommendation of good practice is that the clinical room should be kept locked when not in use and the first aid boxes should be located in areas accessible to all first aiders not just trained nurses. The fridge was found very overstocked with eye drops prescribed for individual residents and liquid emulsions for dietary problems need to be dated on opening as they have a restricted life span. The medication administration charts were viewed and some gaps were identified. Nurses need to be pro-active in following up gaps and checking that the residents have received their prescribed medication. A regular audit of the medication charts performed by a designated person needs to be instigated to ensure good practice. Residents who refuse medication important for their health needs, e.g. digoxin and bumetamide, need to be discussed with their G.P without delay and their vital signs monitored to detect any changes in their health. The procedures in place for controlled medication orders received over the telephone need to be followed with evidence of dates and signatures. Throughout the inspection it was observed that residents were treated with dignity and respect by the staff in all aspects of their care. Six of the residents spoken with were complimentary regarding the care and respect shown by the staff. One resident said, “the staff are wonderful, I could not ask for better care”, another said that “everyone is very kind, they treat me very well”. Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. The arrangements for leisure and social activities inside and outside of Woodside hall now provide opportunity for mental or physical stimulation. The home encourages and enables residents to maintain contact with their families and friends, by having an open door policy and a welcoming reception. The dietary needs of residents are well catered for and offer a balanced and varied selection of food that has been updated in line with the personal likes and choices of residents. EVIDENCE: The activities provided at Woodside Hall have been reviewed and now offer a more varied and stimulating range. Activity sessions take place three times a week in the afternoon at 2.30 pm. Regular feedback from residents regarding the frequency and timing of the activities will monitor the success of the sessions and personal preferences of the residents. Activities take place in the communal areas on the upper floor, the residents were positive in their feedback concerning the range of activities. Five residents spoken with were enthusiastic about the craft sessions, one proudly showing a box she had decorated and now used herself. The activity coordinator also spoke of the ideas she has to promote more participation from Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 14 residents, she also visits the less able residents on a one to one basis, and keeps records of the involvement she has with the residents. The routines of daily living are flexible, and residents choose their daily schedule when they are able to, including their meal times and venue. Feedback from the residents and from direct observation on the day, it was apparent that residents are given the opportunity to spend their time as they wish. Four residents said that they did not attend the activity sessions, even though they were asked, they were content to spend time in their room with their books and television. Residents are facilitated to maintain their independence for as long as they are able. There are no restrictions on visiting times as long as consideration is shown to all the service users. The lounges are available to residents and their visitors for private meetings if preferred. Many of the residents have individualised their bedroom with items from home and residents and relatives spoken with confirmed that they are encouraged to make it homely. The home has an advocacy policy in place and the information regarding this is available to all residents. The menus are distributed to all residents and are also on display in the dining rooms. They demonstrated choice and variety and indicated a well balanced diet. The menus rotate on a four weekly basis and change according to the seasons. Fresh fruit is available. The residents were forthcoming in their views of the food, and the majority said the choice was varied and the food was very good. One resident said, “ the food is very good, no complaints”. Another said “ its not bad, but not as good as my cooking”, one resident did mention that porridge everyday was not her choice and would like bacon and eggs, however other residents confirmed that they could have a cooked breakfast everyday. The dining areas are pleasant and well furnished with natural light, residents were seen enjoying their meal, the choice of the day was various forms of fish, fried and baked, served with vegetables and potatoes, a vegetarian alternative was also offered. The pudding was chocolate pudding also with an alternative. The kitchen was not inspected at this time. Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The complaint procedure is clearly detailed in the Statement of Purpose and Services Users Guide and is available to residents and their families enabling them to share their concerns formally and confidentially. Staff interviewed had a good understanding and knowledge of Adult Protection policies and procedures, which protect the residents from harm and abuse. EVIDENCE: There are appropriate policies and procedures in place and it was confirmed that these are followed when investigating any concerns raised at the home. No complaints been received by the CSCI since the last inspection. The complaint book was viewed and this demonstrated that all complaints are recorded, along with the outcome and action taken by the home to resolve the complaint. The staff interviewed were knowledgeable of the complaint procedure and of how to start the process if the manager is not available. One of the residents referred to the Service Users Guide when asked if they knew how to make a complaint, whilst one resident said she had been given a guide and was sure she had the necessary information to raise a complaint if she needed to. One resident said she would talk to the nurse in charge if she had a problem. The Adult Protection policy in the home was found to be up to date and staff interviewed were knowledgeable about the systems in place to protect Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 16 vulnerable service users. There is on-going training for all staff in adult Protection. Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. The home provides a comfortable, clean and safe environment for those living there and visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. There is specialist equipment in the home for residents’ use to maximise their independence, however call bells need to be in reach of residents and in working order at all times to ensure the safety of all residents. EVIDENCE: Woodside hall provides a well maintained and comfortable environment for its residents, there has been a large amount of upgrading of the property over the last year, which has provided all but one double bedroom with an ensuite facility. The building and upgrading is now completed. There are adequate communal bathrooms and shower rooms in the home with specialist equipment, which enables frail residents and those with a physical disability to enjoy the facilities available. Specialised equipment to encourage Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 18 independence is provided e.g. handrails in bathrooms, hoists, wheelchairs and lifts to all areas of the home. Call bells are provided in all areas, however not all were in a position that the resident could call for assistance and many were found broken. These were identified at the time of the inspection. The lighting in the home is of domestic quality and there are above bed lights as well as the main ceiling lights. Beds and chairs were seen to be placed appropriately for maximum benefit of those wishing to read. Water temperatures are controlled and monitored monthly and a record kept. Random temperatures were taken and were of the recommended level. There was evidence of residents being encouraged to personalise their rooms with their own belongings and bits of furniture. The bedrooms are clean, comfortably furnished and pleasantly decorated with soft colours. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. Two residents said that the cleaning was good and they had no complaints. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. Sluice and laundry areas were found clean and safe. Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29. The staffing levels are sufficient to meet the assessed needs of the residents. There is a robust recruitment process in place, which protect and supports residents. EVIDENCE: The staffing rota was viewed and the staffing levels were seen to be sufficient to meet the needs of the residents at this time. It was confirmed by the management team that there is flexibility of the staffing levels and they are adjusted according to the changing needs of the residents. Staff spoken to said that the levels of staff on duty were sufficient to give the care required, they also said that the trained staff always helped out. Residents also confirmed that they had no complaints regarding the amount of staff “ they always answer the bell when I ring, sometimes I do have to wait to go to the dining room, but that is because they are taking everyone at the same time”. Another said, “ The staff are really nice, always take time to talk to me”. Staff files were viewed and evidenced that the home management team follow robust procedures when employing staff. Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The Registered Manager has the necessary experience and qualifications to run the home effectively. Clear professional leadership is apparent in the home. The ethos is one of kindness and caring. EVIDENCE: The Registered Manager is a Qualified Registered General Nurse and has the experience to run the home effectively with support from the general manager. The management structure of the home is strong, competent and has clear lines of accountability. The feedback from residents and staff indicated that they felt supported and were able to approach the management team at any time. The ethos of the home is to focus on the residents and staff were observed doing this. Regular staff meetings and resident/relative meetings are held and Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 21 records of the meetings are kept. These form part of the quality assurance systems in the home. Two residents mentioned that they attended the resident meetings and thought it gave them the opportunity to discuss the running of the home and areas that could be improved. Residents’ financial interests are safeguarded by the homes policies and procedures. All staff spoken with were aware that they must not be involved in any financial matters of the residents, they also said that they would not accept money or gifts from residents. The manager confirmed and the staff training records show that all staff are kept updated on the Health and Safety policies, the manual is available to all and clearly defined. Staff were able to discuss the training they received and said that they were kept up to date with changes to policies in connection with fire safety and health and safety. The staff are issued with certificates yearly for Manual Handling, twice yearly for Fire Safety and Food and Hygiene. The home has a comprehensive set of policies and procedures, which govern the running of the home. All relevant legislation and procedures are in place in respect of Health and safety. There were some areas of concern identified during the inspection regarding health and safety that are requirements and these were discussed during feedback; The building risk assessments need to be developed to show clearly the action taken to promote the safety and well being of residents. In particular the fire escape routes in the basement. The call bells need to be in good working order and in reach of all residents at all times. The position and use of identified stair gates. That all staff are reminded of the moving and handling guidelines to ensure the safety and comfort of residents. That residents’ on continuous oxygen therapy have the appropriate sign on their room door to advise all of the fact that there is oxygen in that room. That the first aid kits are accessible at all times and checked on a regular basis to ensure that the correct items are available. The use of door wedges in fire doors needs to be discontinued immediately as per the fire service instructions. Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 22 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1)(2) 12 Requirement That the care plans accurately reflect the needs of the service users in respect of their health, social and behavioural needs. Timescale for action 30/04/06 2 OP8 That service users and/or their representatives are consulted regarding the formation of the care plans.(Previous timescale of 26/11/04 and 30/09/05 not met.) 30/04/06 14(1)(a) 2 That records pertaining to (a) (b) nutrition/fluid input are accurate. That documentation regarding communication and behavourial traits are developed. That assessments regarding physical disability are reviewed and monitored and expert sought when required. Medication administration record charts must reflect current medication profile and must be a true and accurate record. That all verbal orders for controlled medication follow the homes procedures with dates 3 OP9 13 (2) 27/01/06 Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 24 and signatures of the persons responsible for taking the order. Medication that has a short life span needs to be dated on opening. That an audit of the medication charts is commenced. 4 OP22 13(4)(c) 23(2)(n) That call bells are in good working order and accessible to service users at all times. (previous timescale of 28/06/05 not met) 30/04/06 5 OP38 23(4) 6 OP38 23(4) That appropriate risk assessments are in place with an action plan for those residents that do not have the capacity to ring the call bell. That the practice of propping 27/01/06 open doors ceases in line with the latest guidence from the fire service. That the building risk 27/01/06 assessments are developed to include the action taken and implemented by the home to ensure the safety of residents in respect of: The fire escape route in the basement. The stairgates in use, throughout the building. The use of Oxygen in residents rooms. That all staff are appropriately trained and supervised in the safe moving and handling of residents. 27/01/06 7 OP38 13 (5) Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 25 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 OP3 OP9 Good Practice Recommendations That all pre-admission assessments are signed and dated on completion. That the overstocking of eye drops is reviewed. That the clinical room doors are locked when not in use. 3 OP38 That first aid boxes are accessible and checked regularly Woodside Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Hall DS0000014079.V262183.R01.S.doc Version 5.0 Page 27 - 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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