Inspection on 31/08/05 for Woodside Hall

This inspection was carried out on 31st August 2005.

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

The inspector 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 16/02/07

Woodside Hall 06/01/06

Woodside Hall 09/03/05

Woodside Hall 21/07/04

Woodside Hall 30/01/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Woodside Hall Woodside Wootton Bridge Isle Of Wight PO33 4JR Lead Inspector Mark Sims Unannounced Inspection 31st August 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodside Hall DS0000012570.V250435.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 DS0000012570.V250435.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodside Hall Address Woodside Wootton Bridge Isle Of Wight PO33 4JR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01983 882415 01983 884578 Colville Care Limited Mrs Deirdre Lynn Shortt Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability (2), Terminally ill (5) of places Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The category PD (female) relates to current resident only and will not apply when this person is no longer resident. Date of last inspection Brief Description of the Service: Woodside Hall is located at the far end of New Road and is approximately 1.5 miles from the amenities of the local town. The premises is a large period property set within its own substantial grounds, the front of which has been given over to parking and the rear which has been laid mainly to lawn. Service user accommodation is mainly single occupancy, although several multiple occupancy rooms are available for people who wish to share. The accommodation is divided between two main floors accessible via the passenger lift, although the first floor is split-level with the latter half of the floor accessible via a chairlift or stairs. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out unannounced and lasted 4.5 hours, during which time the inspector spoke with the service users and their relatives, inspected key documents, met with staff and discussed operational issues with the manager. What the service does well: What has improved since the last inspection? What they could do better: On returning to the office the inspector noticed that reports required under Regulation 26 of the ‘Care Homes Regulations 2001’ are not being received, which is an important issue, as the Commission for Social Care Inspection has previously raised it as a requirement. The company directors must therefore Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 6 ensure that the visits and reports are undertaken and copies of the reports sent to the local area office. 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 DS0000012570.V250435.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 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 the following standard(s): Standards 3 & 5 The statement of purpose documentation is clearly and readily accessible within the front entrance hall and contains all relevant information and a copy of the most recent Commission inspection report. The management team ensure all prospective service users are assessed prior to the offer or declining to offer accommodation at Woodside Hall is made. EVIDENCE: Whilst undertaking a brief tour of the premises the opportunity arose to review the home’s statement of purpose documentation, which was accessible within the front entrance hall. On reading through the statement of purpose the inspector could easily identify all those areas of the document created in accordance with the recommendation of the national minimum standards and also the date of review, 5 March 2005. In addition to the information contained directly within the statement of purpose the management had also provided access to copies of previous Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 9 Commission inspection reports, those available being the reports for 21 July 2004 and 9 March 2005. On talking to service users’ relatives it was apparent that the management had provided the service users with ample information prior to admission and that people knew generally that the statement of purpose documentation was available, although it seemed most people had not taken the opportunity to read the document. The pre-admission assessment plans of three service users were reviewed during the inspection. The plans having been completed by the management team during visits to the prospective service user and contained information pertinent to the person’s current needs and wishes. A copy of the pre-admission assessment is maintained on the service user file and is used in the production of initial care plans, these are used in the delivery of a service to the patient, until a fuller and more detailed assessment can be undertaken and more detailed and comprehensive plans produced. In conversations with service users and their relatives it was clear that they felt the home met their needs and confirmed that prior to moving into the home a member of the management team had visited them and in some cases they or their relative had visit the home to ensure it would meet their immediate needs. In addition to the information gathered during the visit to service users the management is also obtaining information from professional sources, mainly hospital staff and care managers. One particular pre-admission assessment reviewed also contained discharge information from the discharging hospital ward. Whilst this information is useful, the details provided were scant or sparse and offered little insight into the person’s progress since admission to hospital. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 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 the following standard(s): Standards 7, 8, 10 & 11 The manager has introduced a comprehensive and individualised care-planning package for service users, which is maintained within their bedrooms for accessibility. A multi-disciplinary team recording system is used to maintain details of all health and social care professional contacts. Service users and their relatives felt the staff were respectful and conscious of people’s rights to the promotion of dignity and privacy. As part of the comprehensive care-planning programme details of people’s funeral wishes, in the event of their deaths whilst resident at the home are gathered and documented. EVIDENCE: At the previous inspection it noted that the home’s care planning programme had been fully reviewed and revamped with far greater emphasis being placed on the creation of individually written care plans that identified the specific needs and wishes of the service user. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 11 It was pleasing to note at this visit how well the new system of care plans had bedded in, with each service user aware of the location of their individually produced and agreed care plan and able to confirm that the content of the plans more or less reflected their needs as they perceive them. It was also evident that the plans are kept under regular review and are updated as and when the person’s needs or personal circumstances change or alter. As identified previously the care planning process and assessment process are closely linked with care plans generated from the full and comprehensive preadmission assessment and updated as appropriate on re-assessment. The staff and management also appear committed to ensuring changes in people’s health care needs, etc. are fully documented and reflected through the care planning process. Generally all health and social care contacts are documented within a multidisciplinary record, which is individualised and documents all professional contact, including general practitioners, care managers and allied health services. Whilst undertaking the inspection the opportunity to meet briefly with a visiting general practitioner arose, his comments being very positive about the environment and the staff and his overall impression of the service good. Over the past few years the company directors have worked steadily on developing and improving the accommodation available at Woodside Hall, culminating in only one shared bedroom remaining. In addition to decommissioning many of the shared bedrooms the directors have also extended the home with all new bedrooms including en-suite facilities and alterations being made to several existing bedrooms so they can incorporate en-suites. The obvious benefit of single occupancy bedrooms is the level of privacy they afford service users, which several people spoken to during the day highlighted. The fact that the home has no specific quiet lounge appeared not to be an issue for either visitors or service users during conversations, with ample communal space allowing for relatively private interactions and meetings. It was also noticeable, whilst located in the lounges, that the relationship between the service users, their relatives and staff are mutually respectful, amiable and friendly. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 12 People are often referred to by their first name, both on the part of the staff and the service users, and people happy to engage in conversation or friendly banter when the opportunity arose. In talking with both service users and their relatives it was evident that they appreciated the relaxed and friendly atmosphere created within the home but were quick to point out that regardless of the situation staff always remained professional and polite. This particular theme was also repeated within comment cards returned to the Commission, where people described staff as welcoming and friendly and where they confirmed that they are able to meet with their relatives in private. Another aspect of the home’s practice, which underpins their commitment to ensuring service users’ health and personal care needs are met consistently, involves their approach to caring for dying service users. In the past it has been reported that the manager prefers to identify at point of admission or during the pre-admission assessment process any specific funeral arrangements a service user might have in case they die whilst staying at the home. This information, if volunteered, is documented on the admissions sheet, although it is kept under review and is useful when supporting relatives dealing with the deceased’s wishes regards funeral directors. Policies and procedures are available to staff when caring for dying service users and supporting relatives and training is a mix of experiential learning and education gained during National Vocational Qualifications and Professional courses. At this inspection further evidence was seen of the home’s approach to the supporting of service users and their relatives when death is expected, with care plans being produced to guide staff through the process of care for a dying patient and contact with the families observed to be sensitive and respectful. Woodside Hall DS0000012570.V250435.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): Standards 12, 13 & 14. Discussions with service users supplied evidence of their satisfaction with the home’s social activities programme. Service users are supported in the maintenance of community contacts and are welcome to receive visitors to the home at anytime. The care planning process and running record are used to evidence that people are supported in exercising and retaining control over their own lives. EVIDENCE: Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 14 At the time of the last inspection the role of the activities co-ordinator was relatively new to the home, although the person appointed had already established a variety of activities and entertainments for the service users, including letter writing, card games, Scrabble, reading, etc. He had also developed records for the specific purpose of documenting the activities people participated in and enjoyed, these records on inspection were noted to be well structured and informative documents. The activities co-ordinator’s position was also a hit with the service users, who enjoyed the additional social outlet and often one-to-one interactions that the position allows. At this visit it was pleasing to find out that the position of the activities coordinator was continuing to prove popular and that the service users were still very pleased with the entertainments provided and the additional support available. The person employed to provide the additional social stimulation unfortunately is only available to the home for six hours each week, however the evidence from the service users is that this time is well used and that they appreciate the opportunity to participate in activities often on a one-to-one or small group basis. Independent Arts also continue to visit the home on a weekly basis, although during conversations with service users they appeared to gain more enjoyment from the array of wildlife that visit the grounds which included squirrels, rabbits, a variety of birds and foxes. The position of the home, best described as rural, allows for sweeping views across the Solent and accompanying countryside and is a panoramic combination popular with the people spoken to during the visit, several of whom were sat outside enjoying the sunshine. Whilst talking to this small band of sun worshippers, it was established that throughout the summer the staff had been very supportive and regularly came to check they were alright and did not require anything, provided a bell for summonsing help between check visits, ensured there was ample shade, sunscreen, fluids, etc. The service users also stated that staff assist them in moving around the garden as the sun moves and that often in the afternoons the numbers of people taking in the fresh air and sunshine increases. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 15 Visitors to the home, relatives, friends, etc., supported the views of the service users and stated that their mother/father or friend enjoyed a varied and interesting social life at Woodside Hall, although one person pointed out that the ability of people to participate in some of the entertainments, etc. were limited by their physical and mental capacities. Relatives and/or visitors were all clear that the home’s visiting arrangements met both their and their relation’s/friend’s needs and that the home’s location posed no problems with regards to access, as people were generally aware of where the home was situated prior to agreeing placements. From the prospective of the service users it was again clear that families and friends visit regularly and that their visitors are always made welcome by the management and staff, a statement supported by the returned comment cards (information questionnaires distributed by the Commission prior to inspections), which clearly indicate that staff and the management of the home are welcoming and friendly. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16. The complaints process established by the home is well set out and structured and provides clear information on the role of the home and the Commission in investigating and resolving people’s complaints/concerns. EVIDENCE: Details of complaints made to the home are recorded using the home’s complaints logging system, which also documents outcomes and resolutions to complaints addressed. In conversations with several of the patients it was clear that their understanding of the complaints process was rudimentary, people stating that they would speak to the manager or nurse in charge if they had any issues to raise or complaints to make. This willingness to approach senior staff members or the manager, etc. should ensure that the right people are informed of any concerns held by service users and should ensure appropriate action is taken in remedying the situation. The comments of relatives also confirmed that people generally understood the complaints process, ‘mother would notify me and I’d speak with Dee (manager) if she was upset’, etc. The role of the Commission in resolving or investigating complaints appeared less well understood by either the service users or their representatives, although details of our role and contact address are clearly displayed within the Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 17 Statement of Purpose documentation, which is available within the main entrance hall. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 22, 23, 24. The tour of the premises evidenced that the home is well maintained and that a good decorative standard is continued throughout. The communal facilities both internal and external are well maintained, safe and accessible to service users. A wide range of specialist moving and handling equipment is available at Woodside Hall. The service users met during the visit were happy with their personal space / bedrooms. Bedrooms visited during the inspection had clearly been personalised by the occupant in accordance with their own wishes. EVIDENCE: The tour of the premises evidenced that the home is well maintained and that a good decorative standard is continued throughout. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 19 A maintenance person is employed to undertake routine repairs and remedial works, as well as tackling larger jobs, as evidenced by the recently completed refurbishment of an upstairs bathroom, the bathroom having been completely retiled and a new bathroom suite installed. In addition to the work undertaken to improve the appearance of the upstairs bathroom, a new tracking hoist had been installed within the ground floor bathroom, with a view to improving disabled access, although this was obviously professionally installed. The tour of the premises also evidenced that work to improve the environment was constantly ongoing, with several windows to the rear of the property having recently been replaced and plans to renew the remaining windows in hand. Several service users, as mentioned earlier, were enjoying the gardens during the inspection, the inspector spending time sat out with people discussing the merits of fresh air and sunshine. Whilst in the gardens, it was obvious that the main grounds are very difficult for most patients to access, due to mobility issues and the large majority of the garden being laid to lawn, which is difficult for wheelchairs to traverse. However, a large path or patio style area has been created around the perimeter of the home and this enables people in wheelchairs or those less steady on their feet to get out of the home and wander around taking in the fine views and abundant wildlife that exists. One service user spoken with discussed how he and his wife use the path outside of his bedroom to exercise, the gentleman describing how he can access the path via his patio door and how he wanders with his wife to the end of the path and back, providing both exercise and stimulation. Whilst talking to this patient and several other people met during the tour of the premises, it was evident that efforts to personalise their private accommodation had been made, with pictures, photos, ornaments and small pieces of furniture used to create a sense of belonging and familiarity. However, one person did comment that it was impossible to get a house full of furniture into one room and that it had been a difficult decision choosing what to keep and what to let go when moving into the home. The person was quick to point out that this was not a criticism of the home but an observation on the difficulties associated with aging generally. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 20 Within the home the problems associated with ageing are fully appreciated and efforts to minimise their impact through the provision of equipment and alterations to the property, etc. have been made. Ramped access is provided to both the front and rear of the property, a passenger lift and chairlift are provided to overcome the obstacle posed by stairs, hoists (including the new tracking hoist). Standaids and wheelchairs, etc. are readily available, although storage is a problem and height adjustable beds and a range of pressure relieving mattresses and cushions supplied. Comments from relatives of the service users indicate that they feel it is often the care and attention provided by the staff that ensures their relatives’ health and wellbeing is so well maintained, this obviously including the provision of suitable equipment. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 29 & 30. Sufficient staff are available to meet the needs of the service users. The manager of the service should have access to staff files and details of the recruitment and selection process completed. Access to suitable and appropriate training is being provided to members of the staff team. EVIDENCE: The duty rosters indicate that sufficient staff are employed across the twenty four hour period to meet the needs of service users, with between seven and eight staff working each morning, six staff working each afternoon and three staff working at night, although these are all wakeful staff. The home’s shifts are: 08.00hrs to 14.00hrs 1 qualified plus 4 auxiliary nurses. 14.00hrs to 20.00hrs 1 qualified plus 3 auxiliary nurses. 20.00hrs to 08.00hrs. 1 qualified plus 1 auxiliary nurse, both positions are wakeful. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 22 The evidence from both the people spoken with during the visit and the remarks provided via the comment cards is that people are well cared for and that staff are deployed in sufficient numbers to meet people’s needs. It had been the intention of the inspector to review the recruitment and selection procedures of the home during the inspection visit. However, the director of nursing who oversees this process was not available and the manager has no access to these files in the absence of the director. This is a strange situation, as normally the Commission would expect managers of services to have access to this information, especially at times when directors or proprietors are absent. It is suggested that the manager and relevant director(s) discuss this issue in an attempt to ensure information required for inspection purposes is readily accessible in the future. Fortunately the manager did have access to the training files and records, which were used to evidence that access to core training such as moving and handling, infection control, etc. were being provided, as well as more specific training events such as Parkinson’s Updates, Adult Protection Updates and National Vocational Qualifications (NVQ’s) courses. The manager is also continuing to ensure that new staff complete a period of induction and foundation training, as recommended within the National Minimum Standards for Older People, although the manager is still finding that staff prefer to complete a National Vocational Qualification once they have undertaken the induction, as apposed to progressing onto the foundation programme, this picture is actually being reflected nationwide and is presently being reviewed. The director of nursing supplied copies of the training files with the preinspection or annual return data collected by the Commission, which demonstrated not only the training attended but also the hours of training paid for by the employer. In discussion with the staff it appeared that they were happy with all aspects of the their employment at Woodside Hall and that staff training is made readily available, and that NVQs are being completed by or have been completed by a large number of the auxiliary nurses. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 36, 37 & 38. Staff are receiving appropriate levels of formalised supervision. The home’s records are well maintained, clear and concise documents that are produced and managed in the best interests of the service users. Health and Safety requirements are appropriately addressed, with both service users and staff’s health and wellbeing promoted. EVIDENCE: Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 24 The manager is ensuring that all staff receive regular supervision and guidance in accordance with their roles and responsibilities. Supervision records for two staff were seen, although not read in depth, as supervision where possible should remain confidential. The records inspected indicated that supervisions are undertaken as part of a quick fire résumé of the person’s performance, with a more intensive and extensive appraisal occurring annually when the individual is asked to appraise their own performance before attending an interview with the manager. Presently the manager says she is managing to deliver supervision sessions bimonthly, which given the addition of the appraisals and team meetings, should ensure staff are well supported and supervised. As indicated earlier within the report the management has developed good working practices when it comes to the creation and maintenance of records. The service users’ plans being personally written and well maintained, as well as regularly reviewed, updated and accessible to service users. The assessment tools are clearly used to underpin decisions on a person’s suitability for admission to the home and where they are admitted this information is used in the development of their initial care plan. The statement of purpose document and copies of previous inspection reports, etc. are made available to visitors and patients alike and training records are up to date and demonstrate that a commitment exists to ensuring staff access appropriate levels of training. In addition to the positive approach the management team and staff take with regards to records and record keeping the home were also found to be acting responsibly when storing information and limiting access to sensitive information to authorised personnel only, although the issue of the recruitment files and access for the manager needs clarification. The proprietary company provide the manager with a full set of health and safety guidelines, which in turn is made available to staff within the nursing office and key locations around the premises. The maintenance person is responsible for overseeing large aspects of the home’s environmental health and safety, including fire alarm checks, emergency lighting checks and routine maintenance, records for these systems were inspected and found to be appropriately maintained. The maintenance person is also asked to adjust water regulators on baths, etc., although the responsibility for checking bath temperatures comes down to the staff member running the bath, again records of water temperatures are maintained. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 25 On checking this particular record the inspector noticed that the water is often being delivered at source at about 38º to 39º centigrade, which could be a little cold for some people. As the range of recommended water temperatures goes from 38º to 43º centigrade it might be worth considering adjusting the thermostatic valves slightly. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 3 3 X 3 3 3 X X STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 3 3 3 Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 27 Are there any outstanding requirements from the last inspection? No 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 2 Standard OP29 OP33 Regulation Regulation 17 Regulation 26 Requirement Records required for inspection purpose must be accessible. The company must undertake Regulation 26 visits and forward copies of the visit reports to the Commission. Timescale for action 04/11/05 04/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP29 Good Practice Recommendations The manager should discuss with the directors the issue of accessing information required for inspection purposes in their absence. Woodside Hall DS0000012570.V250435.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 DS0000012570.V250435.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!