Inspection on 28/06/05 for Woodside Hall

This inspection was carried out on 28th June 2005.

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 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 29/05/07

Woodside Hall 06/06/06

Woodside Hall 27/01/06

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 28 June 2005 7:10 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 Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodside Hall Address Polegate Road Hailsham East Sussex BN27 3PQ 01323 841670 01323 845561 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) Premium Care Ltd Mrs Elizabeth Helen Jones Care home with nursing 59 Category(ies) of Old age 59 registration, with number Physical disability 59 of places Terminal Illness 2 Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That service users are sixty-five (65) years of age or over on admission. 2. That a maximum of fifty-nine (59) service users are to be accommodated at any one time. 3. That service users with a physical disability can be admitted from forty-five (45) years of age. 4. That a maximum of two service users with a terminal illness can be accommodated. Date of last inspection 14 January 2005 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 a block contract with East Sussex Social Services for twenty-four beds. On the day of the unannounced inspection there were fifty-nine service users in residence. 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 H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 28 June 2005 at 7.10 am and took place over 7.5 hours. Two inspectors inspected the home and conducted informal interviews with twenty-four residents, three relatives and six members of day staff and three members of night staff. The inspection process consisted of a tour of the building, inspection of documentation and records and looked at the delivery of care for ten residents. What the service does well: What has improved since the last inspection? What they could do better: The care planning and documentation in respect of the residents has been identified on previous occasions as a concern as it does not reflect accurately the work staff do to meet the residents needs. The danger of not maintaining accurate records is always that staff may not provide safe and consistent care and that changes in needs cannot be tracked. The wording used in the daily log for individual residents was found in some cases to be inappropriate and training and supervision in this area is required. At the present time the activities provided are not well attended and do not stimulate the residents, it has since been discussed of ways to provide activities that will be enjoyed and looked forward to by the residents. Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 6 The breakfast service was found to be inefficient as the residents were receiving cold toast and porridge, and residents were found asleep with their breakfast placed in front of them. A review of the service is needed to ensure that all residents receive a warm and edible breakfast. Prescribed medication was found to have been out of stock for four weeks which could have a detrimental effect on the resident and subsequently affect their health. Regular auditing of the medication charts is required to prevent this from occurring and the staff should ensure that all medication is ordered before it runs out. Staff need to be vigilant and regular checks by senior staff would be beneficial in ensuring that all residents have access to a call bell and that call bells are all in working order. Some Health and Safety issues were identified throughout the inspection process and these were left as Immediate Requirements as they impact on the safety of the residents. 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 H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 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 Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 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, 4 & 5 The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required to enable 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. Four residents were aware of the service users guide and had their own copy. Two residents were not aware, but did say that their family had all the paperwork about the home. Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 9 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 the staff completes a pre-admission assessment using the assessment tool with the new care plan system introduced in December 2004. Six assessments were seen fully completed, but four were incomplete and did not give a full explanation of reasons for admission. It was confirmed by two residents that their family were involved in the assessment. The assessment is undertaken at the residents’ place of residence, and input from other relevant professionals is sought when and as required. From information in the pre-admission assessment there was evidence of residents being admitted to the home with the main diagnosis of dementia, this needs to be reviewed as the registration category of the home does not include dementia and the physical layout of the home is not suitable for residents who may wander due to a large of amount of stairs throughout the building. Eight of the twenty-four residents spoken with said they remembered visiting, the home before admission, which had made them feel they had the choice. One resident said that it had helped her “make her choice by visiting three homes in the area and that she had liked the friendliness of the staff at Woodside Hall best.” Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 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 & 10 Care plans did not set out the needs of the residents in an individual plan of care. Care plans do not contain sufficient information to evidence that the health, personal and social care needs of individual service users are being met. The risk assessments in place for individual residents are inadequate so residents are not safeguarded. Personal support is not offered in such a way as to promote and protect service users’ privacy, dignity and independence EVIDENCE: Ten care plans were viewed and whilst the format of the care plan system has improved, it was noted that the positive outcomes observed at this time are still dependent upon staff knowledge and memories rather than full and detailed recording. The admission profile in these care plans were incomplete and have not been signed or dated. This was previously highlighted at the last inspection and remains outstanding. The care plans did not identify all aspects of the individual’s needs in respect of wound care, identified nutritional problems and social needs. Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 11 In one residents daily log it said ‘dressing applied to left hip’, but there was no care plan for staff to follow as to what dressing was required and how often it required changing/checking and if the wound was improving or deteriorating. The same resident was noted to be screaming constantly, especially when left arm moved by staff but no care plan was in place for managing this problem. Omissions of this nature were found in the majority of the care plans seen. From the poor quality of the care plans it is not evident that the health needs of the residents are being fully met. In one care plan it was identified that a urine test was required as the resident was confused and not eating, it was still recorded as “ still for urine test” three weeks later. One resident was identified pre-admission, as requiring a dynamic mattress, three months following admission it was still not in place. Two residents were seen being assisted with their meal in bed in an inappropriate flat position. On tracking their care it was not found to be identified as a problem or to have a care plan for staff to follow. One resident had been seen by a speech and language therapist, who had written and requested that an upright position be maintained for eating and drinking, however a care plan had not been formulated and instructions not followed by the care staff, therefore not ensuring the safety of those residents. Inappropriate wording was used in individual care plans and this was discussed in full at feedback and on a subsequent visit. There was no evidence in the care plans inspected to suggest that residents or their representatives were consulted about the care process. Four of the residents spoken too, did not remember discussing the care plans with the staff. The relatives spoken to said they were kept informed of the care given but were had not been involved in any aspect of the care planning. The clinical rooms were tidy and well stocked. The medication charts were correctly completed, however there was medication prescribed for one particular resident that was out of stock for four weeks, this is not acceptable practice and needs to be followed up with the G.P and pharmacist. During the course of the inspection, staff were seen interacting positively with the residents, however it was found that the dignity and respect of some service users were not upheld whilst personal care was been given, examples were discussed with the staff during the inspection. Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 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) 12, 13, 14 & 15. The arrangements for leisure and social activities inside and outside of Woodside hall provide limited opportunity for mental or physical stimulation. The homes encourages and enables residents to maintain contact with their families and friends, by having an open door policy and a welcoming reception. Not all residents are helped to exercise choice and control over their everyday lives. 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, however the breakfast service was not efficient or adequate for the needs of the residents. EVIDENCE: There is evidence of an activity programme, which is displayed in the dining areas of the home. There were no activities planned on the day of the inspection. Two residents said they enjoyed the activities when they went to them, but would like the opportunity of going out. Another said “she chose not to go to the sessions, and preferred to stay in her room”. One resident said that she “spent a lot of time on her own, but she had her television for company”. Four Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 13 others were non-committal in their view of the activities in the home and three were not aware of the activities. One resident said that “activities took place twice a week and were boring”. There are three lounge areas and residents were seen sitting on their own waiting for lunchtime with little interaction seen. One visitor commented that “not very much went on”, whilst another said that her relative “rarely left her room, and that it would be nice to see her in the lounge occasionally”. It was evident from the comments received that residents would benefit from a more robust plan of activities, which should take place both inside and outside of the home. At present they consist mostly of board games and the occasional ‘pot luck’ session. The programme of activities needs to be more prominently displayed so all are aware of when and where they are happening. On arrival at the home at 7.15. am, the staff were busy getting residents up in their chairs ready for breakfast. It was observed that many of the residents were asleep/dozing in their chairs. The night staff spoken to said it was “unfair to residents as they don’t get a choice as to when they get up”, another staff member said “if the resident is really unhappy, they are left in bed”. It was not evident from care plans as to residents’ preferences in this area. Three residents said that they like getting up early, eight were unaware of the time, and six said they were told to get up for breakfast. This routine did not give the impression that the residents were able to choose for themselves their daily routine. From speaking to four residents’ they conveyed that they were not given the opportunity to exercise choice and control over their everyday lives. Woodside Hall promotes an open door policy during the day. Residents spoke of visitors they had received and the home maintains a register of the visitors received in the home. Two visitors said the “staff are very nice and always ask me how I am and make sure that I know everything that is happening”. The breakfast service and mid-day meal were observed. The breakfast service commenced at 8 am, where the food were placed on trays uncovered and meals was still being served at 9 am, the breakfasts were not kept warm, and the residents were eating barely warm porridge and cold toast. A free standing fan was seen blowing cool air on the cooked food prior to leaving the kitchen. Residents were seen asleep in their chairs with their breakfast untouched. The porridge ran out and a carer was heard saying “the others are feed, they can have weetabix”. Residents that had a cooked breakfast of bacon and eggs were seen enjoying it and it was served to them hot and covered. Three residents commented that the porridge was cold and lumpy and two were seen having difficulty in eating the toast. One resident said “it arrived when I was dozing and I did not know it was there” This indicates that the breakfast service needs to be urgently reviewed to ensure that all residents get choice and an edible breakfast. Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 14 It was confirmed on a follow-up meeting with the manager that this has now been reviewed and changed. It will be monitored on a regular basis. The mid-day meal was seen to be nutritious and attractively served, residents were complimentary regarding the choice of food available and looked forward to eating with their friends. The menu rotates on a four weekly basis and changes according to the season. The soft diet was seen to be of a good consistency and colourful. The chef has done research on diabetic meals to enable a wider choice for those requiring a sugar free diet. The dining areas on both floors were clean and the furniture was of a good standard. Staff were seen offering assistance to those less abled in a quiet and dignified manner. The atmosphere was inclusive and service uses were seen interacting with each other and enjoying the company. One resident said” food is pretty good”, another said “ I enjoy the food, dinner and supper are quite good”. Other comments included “good with plenty of variety”, “meals are much better now and always tasty”. Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 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 standard(s) 16 & 18 Policies and procedures are in place for dealing with complaints which are assessable to service users and their representatives. Arrangements for protecting service users are not satisfactory at this time, placing them at possible risk or abuse. EVIDENCE: A policy and procedure is in place for dealing with complaints and this is also outlined in the statement of purpose and service users guide. The manager is aware of the timescales set down for dealing with complaints and a complaints register is available. 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 vulnerable service users. There is on-going training for all staff in Adult Protection. However there was documental evidence to suggest that staff need further guidance on whistle blowing and of the need to share with the manager allegations made by residents of possible abuse or incidents that have occurred during a shift against residents by residents. Staff recorded events in the daily log, but did not take it through the Adult Protection systems in place. Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 16 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, 20, 21, 22, 23, 24, 25 & 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 is 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. 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 Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 17 encourage 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 one was found broken in the lounge. The response to call bells at times was slow. The corridors are wide enough for the self propelling of wheelchairs. 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 items 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. One resident said” everyone is very nice and the place is kept clean”. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. It was noted that some staff need to be reminded to adhere to the policy regarding the correct usage of gloves. Sluice and laundry areas were found clean and safe. The beakers were found badly stained and this was discussed with the kitchen staff. Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 18 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 & 30. The staffing levels at night are insufficient to meet the complex needs of the residents and the current night/morning routine of the home. The staffing levels during the day were sufficient to meet the needs of the residents. Staff are provided with training pertinent to meeting the needs of the residents and to do their jobs competently. EVIDENCE: There were six members of night staff on duty, two trained nurse and four carers for fifty-nine residents, many of whom have complex needs. The care staff on duty said “that it was a struggle to complete their duties and felt they were rushing and not giving residents the time they need” and “its very hard work and unfair to the residents”. The trained staff “felt that the staffing levels at this time were sufficient, but when some residents are poorly it’s difficult to finish all the work”. This conflict of views regarding staffing levels needs to be reviewed and assessed against the needs of the residents and the current night routine. The ratio of staff to residents also indicate insufficient staff are provided in respect of the residents documented needs. One resident said he felt that the night staff were at times “disrespectful to him because they were too busy”, another said “that the mornings were always rushed to get her up for breakfast”. A resident also said that she was “got up at 6.30. am and at 11.30. am was still waiting to get washed and Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 19 dressed” and “couldn’t see the point of rushing her to get up and then leave her for hours”. The day staffing levels were seen to be sufficient to meet the current needs of the residents, four trained nurses and nine carers for the morning shift, and four trained and five carers for the afternoon shift. The nurse in charge said that “ the staffing levels increase if there are admissions or if there is a terminally ill resident that needs more individual care”. The staff informally interviewed were able to discuss the training they had received whilst working in the home. One carer said she had had training in moving & handling, infection control, fire safety, food and hygiene and also study sessions on different illnesses that they care for in the home. She had had her induction training and she felt “well supported by the senior staff and that the training and supervision she had received had enabled her to give a good standard of care”. Another carer said “she felt that the standard of care in the home was good and that they were committed to providing relevant training. Another carer said that, “the induction training she received was a good introduction to the home and the job”. One member of staff said “there was too much training and took up too much time” another staff member said “there have been many changes for the better over the past eight months including access to training”. There is on-going enrolling on the NVQ programme and all staff receive encouragement and support to enrol. The current percentage of staff with an NVQ qualification is 35 . One carer said she was going to enrol shortly, and that she had been “hesitant at first, but feels with the support given she will be able to do it”. One resident said “ I like the attitude of the day staff, nothing is too much trouble” another said “ the day staff are very helpful” and ”they know how to look after me”. Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 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 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) 36 & 38 All staff receive formal supervision at least six times a year and this promotes good practice and provides a support system for staff. EVIDENCE: The home runs a training programme that is suitable for the staff and for the needs of the residents. Training events are displayed on key notice boards in the home to ensure all staff are aware of the planned days. Staff are supported by the manager and the training manager on a daily basis and more formally through supervision. Staff spoken to confirmed they received supervision and annual appraisals. They are in a written format and copies are kept in the staff files. An observation that was relayed to the manager during feedback, that some relatively new staff still need supervising as they were seen assisting residents to eat in an inappropriate position. Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 21 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 regarding health and safety that were issued as Immediate Requirements and these were; • That all call bells are in reach of service users and in working order. • That wheelchairs are used with the correct footrests in place. • That the use of free standing fans are reviewed in the corridors and kitchen are reviewed. • That the fire exits/routes in the basement, are reviewed with the Fire Service. • That the clinical room doors are kept closed and not inappropriately propped open with oxygen cylinders. • That the accident book is correctly completed and corresponds with the residents daily log. Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION 4 3 3 2 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x 3 x 2 Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 23 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 7 Regulation 15 (1) (2) 12 (1) (a) (b) Requirement That the care plans accurately reflect the needs of the service users and are updated on a regular basis. That service users and/or their representatives are consulted regarding the formation of the care plans.(Previous timescale of 26/11/04 not met.) That records pertaining to nutrition, wound care, continence and communication are developed and accurately reflect the service users needs.(Previous timescale of 26/11/04 not met) That an activity programme be developed and that facilities are provided for recreation and fitness.(Previous timescale of 31/01/05 not met.) Medication prescribed for service users, must not be out of stock for more than 24 hours. That all service users are enabled to make choices and exercise their personal autonomy within a structured risk assessment framework. ( Previous timescale of 26/11/04 not met.) Timescale for action 01 September 2005 2. 8 14 (1) (a) 2 (a) (b) 13 (1) (b) 12 (1) 16 ((1) (2) 16 (1) (2) (n) 01 September 2005 3. 8 & 12 01 September 2005 28 June 2005 01 September 2005 4. 5. 9 14 13 (2) 12 (2) (3) Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 24 6. 18 7. 8. 22 27 9. 38 10. 11. 12. 13. 38 38 38 38 That all staff receive training in the prevention of abuse, and are aware of the multi-discilpinary guidelines and the different categories of abuse. 13 (4) ( c) That call bells are assessible in 23 (2) (n) all areas and in working order. 18 (1) (a) That staffing levels are appropriate to the assessed needs of the service users, the size, layout, and purpose of the home at all times. 23 (4) That the practice of propping open doors ceases in line with the latest guidence from the fire service. 23 (2) (4) That footrests are in place on wheelchairs when in use to prevent injury to service users. 23 (4) That the fire routes in the basement are reviewed with advice from the fire service. 23 (2) That the free standing fans used in corridors and the kitchen are risk assessed as to their safety. 17 (1) (a) That the accident book is Schedule correctly completed, and 3. corresponds with the residents care plan. 13 (6) 01 September 2005 28 June 2005 28 June 2005 28 June 2005 28 June 2005 28 June 2005 28 June 2005 28 June 2005 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. 3. Refer to Standard 26 26 22 Good Practice Recommendations That all beakers are cleaned with a stain remover. That all staff are reminded of the approprite use of gloves. That the response time to call bells are monitored. Woodside Hall H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 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 H59-H10 S14079 Woodside Hall V222901 280605 Stage 4.doc Version 1.30 Page 26 - 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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