Inspection on 29/05/07 for Woodside Hall

This inspection was carried out on 29th May 2007.

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

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

Other inspections for this house

Woodside Hall 06/06/06

Woodside Hall 27/01/06

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 Melanie Freeman Key Unannounced Inspection 11:55 29 and 30th May 2007 th 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.V339104.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 DS0000014079.V339104.R01.S.doc Version 5.2 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 zita.allen@woodsidehall-nh.co.uk Premium Care Limited Vacant 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.V339104.R01.S.doc Version 5.2 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. 6th June 2006 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. Woodside Hall is a converted hotel that was converted into a nursing home and has been extended with a large purpose built extension. The whole home has now been upgraded and modernised. The accommodation offered is situated on two floors and comprises of forty-nine single rooms, all with en suite facilities and five double rooms, four of which have an en suite 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 mattresses, and electric beds. The rooms and communal areas are pleasantly decorated whilst maintaining a homely atmosphere. The home is situated on the main A22 and whilst there are no near local amenities, the towns of Hailsham and Polegate are approximately 3 miles distance. It has large landscaped gardens, and there are car-parking facilities. Fees charged as from 1 April 2007 range from £715 to £750, which does not include toiletries. Additional charges are made for hairdressing, chiropody, newspapers, nail painting and outside activities such as visits to the theatre. Intermediate care is not provided. The home’s literature states the main ‘objective of the Woodside Hall Nursing Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 5 Home to provide care to all service users to a standard of excellence, which embraces the fundamental principles of good care practice’. Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Woodside Hall Nursing Home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and a further visit, which was completed via an appointment to meet individually with staff, and to cover standards not completed on the previous visit. Both visits included a meeting with the acting manager who facilitated the inspection process and received the inspector’s feedback at the end of the inspection. The inspector was able to spend time with residents, relatives and staff and observe practice in the home. In addition a visiting professional was interviewed in private. A tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose and service users guide, care plans, duty rotas, medication records, and recruitment files. The care documentation pertaining to five residents were reviewed in depth along with a number of policies and procedures and records relating to health and safety. Following the inspection visits to the home contact was made with two residents representatives and three visiting health and social care professionals. What the service does well: The atmosphere at the home was relaxed, with communication between staff, residents and visitors being positive open and friendly. The home provides prospective residents and their families, with a good level of information about what services are provided at the home. Residents All parts of the home were clean, comfortable and well maintained. All residents, relatives, visitors and visiting professionals contacted as part of the inspection process confirmed a satisfaction with the home and its services one resident saying ‘I am very well cared for the staff are nice it’s a lovely home and has good food’ Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 7 The quality and choice of meals remain good and all residents spoken with were complimentary about the food. The training for staff is good, and covers a wide variety of resident related conditions, which give the staff an understanding of the residents needs. What has improved since the last inspection? What they could do better: The home needs to confirm in writing to the prospective resident or their representative that with regard to the needs assessment completed the home can meet the needs of the prospective resident. This ensures that decisions around admission to the home are informed. The care documentation including individualised care plans and risk assessments need to be improved to ensure residents receive appropriate and person centred care that meets their assessed needs and to minimise any risks. The procedure for investigating complaints needs to be improved to ensure records demonstrate a thorough investigation process. The recruitment practice needs to be improved with the required checks being completed before they are deployed to work in the home an appropriate record of identification also needs to be retained in the home along with a recent photograph to ensure residents are safeguarded. In addition a number of health and safety issues were identified including the need for accurate record keeping, appropriate up to date policies and procedures and robust individual and environmental risk assessments. Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 8 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 DS0000014079.V339104.R01.S.doc Version 5.2 Page 9 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.V339104.R01.S.doc Version 5.2 Page 10 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): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives, with a good level of information about the home, its facilities, services and the costs involved. The admission procedures allow for the needs of prospective residents to be assessed by a competent person before admission although people are not assured in writing that their needs will be met. EVIDENCE: There is a range of well-documented information about the home and the services it provides. The home has a combined statement of purpose and service users guide and a copy of this is available along with the last inspection report and a copy of the homes terms and conditions of residency in the front entrance area. Relatives and relatives spoken to were clear on the service provided by the home and costs involved. Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 11 The registration certificate is clearly displayed and was found to be accurate. The last three admissions to the home were identified and the records relating to the admission procedures followed were reviewed. This confirmed that pre admission assessments are completed and provide a clear assessment of prospective residents care needs. These are completed by one of the deputy nurse managers and discussion with the acting manager confirmed that these are used to ensure new admissions to the home are appropriate and that the home have the staff, equipment and environment to meet their care needs. Prospective residents’ are seen either in their home or hospital before admission and the input from relatives and other professionals is used whenever possible. This approach should be more clearly recorded on the assessment documentation to demonstrate the procedure followed. Social care professionals spoken to confirm that pre admission assessments are always completed and that these were completed promptly and efficiently. It was however noted that the home does not confirm having regard to the assessment that the home can meet the assessed needs of the prospective resident. This was discussed with the manager who was advised that this should be completed in writing in accordance with the required documentation. Intermediate or rehabilitative care is not provided at Woodside Hall. Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although care documentation provides a framework for the delivery of care it needs to be developed to provide clear guidance to care staff on all the care needs of the residents, along with robust systems for risk assessment to ensure individual person centred care is delivered. The homes practice ensure resident’s medicines are stored and administered safely and residents are treated with respect and have their privacy and dignity maintained. EVIDENCE: A new computerised system has been implemented over the last month and this has required a great deal of work on the part of the senior staff in the home to input all the necessary information. Professionals reviewing the care documentation commented on its improvement and clarity. The inspection process however identified a number of short falls in the care documentation Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 13 albeit that it is acknowledged that this system has only been operational for one month. Discussion with the acting manager confirmed that she was aware of the shortfalls and confirmed that further training is planned and having regard to the issues around risk assessment specialist training will be provided as a priority Five individual plans of care were reviewed in depth as part of the inspection process and these identified that plans of care are written according to residents individual needs giving guidelines to care staff on how to care. However it was noted that the care plans did not reflect all the care needs or accurately reflect the care to be provided as generic plans are used that have not been individually tailored. For example one resident who is diabetic and has a specialised feeding regime did not have corresponding plans of care. It was also noted that resident’s social emotional and psychological needs were not assessed or addressed within the care records. Systems for assessing resident’s risk of developing pressure sores are in place although these need to be followed up thoroughly within the care documentation. There was evidence to confirm that carers are recording the care provided, and when spoken to said that they read and understood the plans of care, although having time to read them could be difficult. Staff receive a report on each resident daily and felt that their views were taken into account when planning resident’s care. There was however no evidence that the plans of care are written in consultation with residents or their representatives. It was also noted that the use of risk assessment was very limited; for example ‘bed rails’ were in use without appropriate risk assessment, the use of call bells are not documented and a resident administering her own medicines did not have a risk assessment. Those risk assessment completed for nutritional screening, falls and moving and handling need to be based on clear criteria and followed up within the care documentation. Records indicated that local Doctors are called regularly and are involved in the care of residents and three General Practitioners visited the home during the time the inspection assessment was being completed. The acting home manager and a visiting health care professional confirmed that specialist external advice is sought as necessary and included the Dietician and regular visits from a privately employed Tissue Viability Nurse. A Key worker system has not been adopted yet although the acting manager said that this was being worked on. All feedback received from residents, relatives and visiting professionals confirmed a satisfaction with the care provided and comments included ‘Every thing has been absolutely fine’ ‘ I Feel they look after mum well and choices are given around daily life’ ‘the home bent over backwards to meet the complex individual needs of one resident and managed the situation very well’. Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 14 Staff were observed when administering medicines and they were seen to be working safely. The records seen were found to be accurate and the storage areas were found to be appropriate and well managed. The medicine supplier has been changed recently and new procedures are being written. Staff were seen to be kind and pleasant to residents and a good rapport was noted between them one staff member said’ she thought of many of the residents as friends’ and one resident said ‘Staff are good to me and I am able to have some fun’. . Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities and meals continue to be creative and provide daily variation and interest for people living in the home. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. EVIDENCE: The activities provided in the home have been well received and enjoyed by residents that were spoken to. One resident said that he ‘liked the cooking’ and was able to show his potted plants completed during an activities session. The current Activity Co-ordinator has recently left and a new one has been recruited and will be providing extra time in the home. This individual has a good understanding of older peoples needs having worked as a home warden. Staff confirmed that the activities in the home have been a great benefit to residents and that celebrations are held regularly for special occasions including birthdays. Discussions with residents confirmed that they joined in activities only if they chose to do so; some residents prefer their own company and often spent their time in their own rooms. Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 16 Resident’s rooms were found to be individual and personalised and each resident has their preferred term of address recorded in their care documentation and this preference was respected. Residents were seen to have their choices respected through out the day with decisions being responded to. Visitors spoken to were all happy with the visiting arrangements and how staff who were said to be ‘very welcoming’ received them. During the inspection visit it was noted that the reception area was always manned during the day and visitors were greeted with assistance being provided if needed. The mid day meal and evening meal was observed and was seen to be organised and well managed ensuring that those residents needing assistance were given time and able to have the assistance that they needed in an unrushed manner. It was confirmed that residents had a choice at lunchtime, which included a vegetarian choice. Those residents saying they did not like the main choice were seen to have alternatives provided that they did want. Menus are used and circulated the day prior to the meals being provided and records are kept on what food is eaten by each resident. All feedback about the food was complimentary and comments included ‘good food’ ‘I have choices in the meals and the meals are good’. The dining areas are pleasant and well furnished with natural light. A catering manager is in post and when the kitchen was inspected in October 2006 the report was complimentary. Staff were seen to be following good practice when serving and distributing the meals. The meals provided looked appetising and were served in a manner that ensured it looked attractive. Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Practice in the home ensures that complaints are responded to, with residents and representatives being confident that they are listened to. However systems for recording complaints need to be improved to demonstrate a robust procedure is followed. Practice in the home ensures that adult protection issues are responded to when identified. EVIDENCE: The home has a written complaints procedure and this is displayed in the home and provided within the service users guide. The procedure followed on receipt of a complaint however does not clearly record the process and does not provide an audit trail of how the home has responded to the complaint. All records need to be clear and kept in a way that promotes peoples confidentiality. A formal complaint has been dealt with by the home and although this complaint has been resolved the records held did not clearly record what and how the complaint was received how it was investigated and responded to. Relatives and visiting professionals said that they were confident that the management of the home would respond positively to any concern raised. Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 18 Everyone spoken to confirmed that if they had any concerns or complaints they would not hesitate in talking to either the acting manager or the general manager of the home. Although the home has the local guidelines on safeguarding vulnerable adults it does not have a home policy or procedure and this needs to be provided and supported with appropriate training on this subject for all staff working in the home. Records indicated that the acting manager has received appropriate training on safeguarding adults and is able to provide staff training and the home has a whistle blowing procedure. Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, clean and safe environment for those living in the home and visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. EVIDENCE: A tour of the home confirmed that the home is well maintained and rooms are attractive with some being very personalised. Residents spoken to said that they liked their rooms one saying that the home ‘felt like his home now’. There is a large attractive garden with a seating area and although this is a bonus for the home, improved access would improve its use. The communal areas are also attractive and allow for different uses ensuring residents have choice and how they spend their time. Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 20 There are adequate communal bathrooms and shower rooms in the home, with specialist equipment to ensure all residents can have a bath or shower. The home has been assessed by an Occupational Therapist and specialised equipment is available throughout the home to promote independence. During the inspection it was noted that staff were using lifting and supporting equipment appropriately. Call bells are provided in all areas and staff were seen to be attentive and ensured residents had access to these. In addition the acting manager confirmed that she is sourcing pendant call bells for those residents who are able to use them. Good practice in respect of infection control by staff was observed during the inspection visits and there were gloves and aprons freely available in the home. Sluice and laundry areas were found to be clean and safe. Woodside Hall DS0000014079.V339104.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is sufficient staff that are suitably trained on duty to ensure that residents receive the level of care they need. The recruitment practice was found to be poor as it did not ensure all the necessary checks are completed before an individual starts working in the home. EVIDENCE: At the time of the inspection visit 49 residents were living at Woodside Hall Nursing Home. The staffing rota was viewed and the staffing levels were seen to be sufficient to meet the needs of the residents at this time. The acting manager confirmed that the staffing arrangements are flexible and respond to resident’s dependency. Staff spoken to said that there was enough staff to look after the residents to a good standard. Feedback received from residents, relatives and visiting care professionals as part of this inspection was very positive about the staff and comments received included ‘very friendly very nice staff I like it here I do what I want when I want to’ ‘I am very well cared for and staff are nice’ ‘I can not speak too highly of the staff’. Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 22 Staff training is well established and records indicated that this is well organised with new staff starting their ‘skills for care’ induction. There was evidence that core areas of training are addressed regularly with a rolling programme. Many of the staff have completed or are completing an NVQ in care. A health care professional said that she was impressed with the increased commitment to training and had noted a commitment to specialist areas like pressure area care and nutrition. The recruitment practice and records were inspected for five staff members working in the home as part of the inspection process. This review identified a number of areas of concern. • • • • • • Two staff were working in the home with no evidence that a POVA first check or a CRB check had been received. Three staff had been employed with only one reference being received. Three staff working in the home did not a recent photograph on file. Four staff had no evidence that their identification had been checked. Three staff working as care staff had not been given a copy of the GSCC code of conduct. One staff did not evidence of his right to work in this country. All these shortfalls were raised with the acting home manager. On the second visit she was able to confirm that one of the POVA checks had been received and the second member of staff was not going to be working in the home until the POVA first check had been received. She also confirmed that other issues around employment would be followed up. It was also noted that the home does not have a recruitment procedure to clarify the procedures to be followed. Woodside Hall DS0000014079.V339104.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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in an open and friendly manner with suitable quality monitoring systems. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff are generally well promoted and protected. EVIDENCE: Since the last inspection the registered manager has resigned and has been replaced by a registered nurse that has managed a nursing home before. She has completed the Registered Managers Award and has worked in the home for nine months. She advised that she had applied for registration some Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 24 months ago but when she contacted the registration team a record of her application was not on the computer system. She confirmed that she would ensure that a new application for registration was sent for processing as a priority. During the inspection visits there was no doubt that the acting manager had a good working relationship with everyone in the home and everyone spoken to said that she was approachable and responded to issues raised quickly. There is a clear management structure in the home with staff having designated responsibilities. A senior carer said that the extra responsibilities given to the senior carers allow them to supervise and monitor the standard of care more effectively. There are systems in place to monitor the quality in the home and include the use of questionnaires. The acting manager confirmed that she was waiting for further questionnaires to be returned, and then these would then be audited reported on and responded to. It was recommended that the use of questionnaires is expanded to staff and visiting professionals. The acting manager has also carried out an audited of the National Minimum Standards in the home and will be using this information to identify any shortfalls to be addressed. The general manager confirmed that small amounts of money and some valuables are held on behalf of residents although all residents have an allocated person to deal with their finances. Fees are invoiced on a monthly basis and most extras are invoiced at this time. Records relating to the monies and valuables held were reviewed and they were found to be accurate. Although it was recommended that the procedure for dealing with monies and valuables is formalised within a procedure, which includes two people checking and signing records. This will safeguard resident’s property and those staff dealing with it. Woodside Hall looked well maintained and systems are in place to report any problems to the maintenance team that need attention. Certificates relating to Health and Safety in the home were reviewed and found on the whole to be full. It was however noted that environmental risk assessments are not recorded, full records of hot water checking were not recorded, measures in place to prevent Legionnaires disease were not recorded and the health and safety policy was out of date. The acting manager confirmed that she was updating all the homes policies and procedures to ensure best practice and the health and safety of staff and residents. Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 25 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 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.V339104.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14(1) Requirement That registered person confirms in writing that having regard to the assessment made on any prospective service user that the home can meet those needs. That the care plans accurately reflect the needs of the service users in respect of their health, social and behavioural needs. That service users and/or their representatives are consulted regarding the formation of the care plans. (Previous timescale of 26/11/04, 30/09/05 30/04/06 and 30/09/07 not met.) 3. OP8 12 (1)(a) Nutritional assessments to be 01/07/07 completed for all residents and linked to the care plan. That suitable risk assessments are completed in all areas of risk and cover the use of bedrails, risk of choking and risk of falls to promote resident safety. That appropriate risk assessments are in place with an action plan for those residents Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 27 Timescale for action 15/06/07 2. OP7 15(1)(2) 12 01/07/07 4. OP16 22 5. OP29 19(1) that do not have the capacity to ring the call bell. (Previous timescale 06/06/06) That the registered person ensures that a full complaints procedure is used and that complaints are dealt with effectively and appropriate and that records are maintained to demonstrate a thorough and robust investigation. That the registered person operates a thorough recruitment procedure that includes the appropriate checks being completed before any person is deployed to work in the home. That a photograph of each staff member is retained in the home along with evidence that each persons ID has been checked. That generic risk assessments are used to ensure resident’s safety. These should include risks presented by the garden. That accurate records on check made in the home are recorded. That full accurate policies and procedures that underpin practice in the home are readily available and adhered to ensure staff and residents safety. 01/07/07 16/06/07 6. OP38 13 01/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodside Hall DS0000014079.V339104.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 DS0000014079.V339104.R01.S.doc Version 5.2 Page 29 - 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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