Inspection on 06/06/06 for Woodside Hall

This inspection was carried out on 6th June 2006.

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 29/05/07

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 Debbie Calveley Key Unannounced Inspection 6 th June 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodside Hall DS0000014079.V296808.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.V296808.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 Premium Care Limited Mrs Elizabeth Helen Jones Care Home 59 Category(ies) of Old age, not falling within any other category registration, with number (59), Physical disability (59) of places Woodside Hall DS0000014079.V296808.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. 27th January 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. The service has a block contract with East Sussex Social Services for twenty-four beds. Woodside Hall is a mature building with a modern extension, which has recently been upgraded and modernised. The accommodation 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 mattresses, 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 carparking facilities. The rooms and communal areas are pleasantly decorated whilst maintaining a homely atmosphere. Copies of inspection reports and the homes Statement of Purpose are made available on request. Fees charged as from 1 April 2006 range from £498 to £735, which does not include toiletries. Additional charges are made for hairdressing, chiropody, newspapers and outside activities such as visits to the theatre. Intermediate care is not provided. Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 5 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 will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. This unannounced inspection was carried out over 8 hours on the 06 June 2006. There were fifty-one residents in residence on the day, of which twelve were case tracked and spoken with. During the tour of the premises ten other residents both male and female were also spoken with. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including the service users guide, statement of purpose, care plans, medication records and recruitment files. Six members of care staff, two trained nurses, hairdresser and the cook & kitchen assistant were spoken with in addition to discussion with the Registered Manager. The pre-inspection questionnaire was received back from the registered manager on the 11 May 2006 completed in full. Comment cards received from twelve residents and four relatives were generally positive and indicated that both groups were satisfied with the services provided. Two comment cards were received from social and healthcare professionals, and eight staff surveys were received from a selection of staff. The information contained in the returned surveys has been incorporated into this report. What the service does well: 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. One resident said “ I refer to it when I need to, I find it very helpful” some residents were not aware of the meaning. The atmosphere in the home was comfortable and relaxed. All parts of the home were clean, comfortable and well maintained. The quality and choice of meals remain good and all residents spoken with confirmed this. “ The food is good” “we get a choice of food everyday” “ the food is always freshly prepared”. Systems are in place to regularly consult with residents via service users meetings and surveys. There is an open-house policy, which welcomes visitors at all reasonable times. Satisfactory arrangements are in place to safeguard residents finances. Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 6 Staff provision is well maintained with good recruitment practice being followed and appropriate numbers of staff suitably qualified working in the home. The staff group on the whole is stable. Both residents and their relatives spoke highly of all the staff saying ‘staff are always nice and kind’ ‘staff are helpful, approachable and are available to talk to’. 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: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective residents and their representatives are provided with information about the home in order to make an informed choice about whether to live at the home. The pre-admission assessment procedures ensure residents admitted can have their care needs met within the home by experienced staff. EVIDENCE: There is a range of well-documented information about the home and the services it provides. This includes a statement of purpose and service user guide. Copies of these are available in the front entrance area. A social care professional who had recently visited the home confirmed that relevant information was provided to a prospective resident. It was confirmed whilst talking to residents that the contract arrangements were clear and understood. A review of the care documentation confirmed that pre-admission assessments are completed, and are currently completed by the manager or a senior nurse. Eleven of the twelve assessments were found to be completed and were used to ensure new admissions to the home were suitable and that the home have Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 9 the staff and environment to meet the care needs of the new resident. The information contained in these assessments is then used to provide the basis of the care documentation in the home. The prospective residents’ are seen either in their home or hospital before admission and the manager confirmed that wherever possible the family or representative is involved. Two relatives confirmed that they were consulted about the pre-admission visit and were given the opportunity to attend. The manager was able to verbally demonstrate her knowledge and awareness of the different specialities required in the home and ensures that the Registered Nurses employed have attended relevant courses to deal with the needs of the elderly and also specialised courses for certain diseases. Trial visits to the home can be arranged. The manager confirmed that selffunding residents are invited to a trial period to ensure suitability of the home; this is clearly stated in the Statement of Purpose and in the statement of terms and conditions. This practice is not adopted by the social services when placing clients, but if a resident placed by Social Services is not settling in to the home, it is reviewed and an alternative placement found. Intermediate or rehabilitative care is not provided at Woodside Hall. Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Generally care plans provide a good framework for the delivery of care, however these need to provide clear guidance to care staff on all the care needs of all the residents. The home was found to be meeting resident’s health and general needs with accessed additional specialist support when needed. However medication practices at present are unsatisfactory. EVIDENCE: The care documentation pertaining to twelve residents were reviewed as part of the inspection process. These were found to include plans of care, nutritional assessment, and personal histories and risk assessments. On the whole the care documentation was full and demonstrated that the care was reviewed and evaluated, however it was noted that the plans of care did not always cover all the care needs of residents. For example one resident who has communication problems did not have any guidance in the documentation to facilitate this vital need, another resident with bilateral leg ulcers did not have a care pain for pain, which to her was a big problem. These areas were fully discussed during the inspection. There was evidence of a nutritional risk assessment being Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 11 performed on all residents, however they were not completed accurately or in full, and so were not an accurate reflection of the residents nutritional status. The use of this tool needs to be reviewed as to whether it is beneficial, and if continued to be used then all staff are to receive training in how to use and complete the tool. Staff spoken to confirmed that they received a full report on each resident daily and read the care documentation that is kept in the main office area. They felt that their views were taken into account when planning resident’s care. The clinical rooms were found clean and tidy, with all the cupboards and clinical fridges appropriately locked. The equipment was found clean and well maintained. There are policies and procedures in place for the storing, administrating, disposal and receipt of medication, they were last reviewed in 2001, and are in need of updating, especially for the disposal of medications as new procedures are now in place. The temperature of the fridge and room are recorded daily and of an acceptable temperature to maintain dressings and medications. There are medications in the fridge that need to be dated on opening, as they have a short life span. The medication administration charts were viewed and gaps were identified, medications for at least six residents were out of stock for up to 8 days and one resident had not received her medication for 25 days. This is a concern as residents were not receiving medication to meet their health needs consistently and for some, sudden withdrawal is not recommended. This was discussed and the manager confirmed that there have been problems with the supplying pharmacist. It was also discussed that the G.P should be informed if the medications are not received, so an alternative supplier or medication can be ordered. The staff also need to record and document the difficulties so there is a clear trail to follow. This area of concern will be followed up by a letter to confirm the strategies put in to place to prevent a reoccurrence of this situation. A self-administering policy is in place, but there were no residents at this time self-administering their medication. Throughout the inspection it was observed that residents were treated with dignity and respect. One relative said that “ the staff always show respect to residents and nothing was too much trouble”. A resident remarked that” she felt the staff respected her feelings and that she never felt she was a nuisance”. Two relatives said, “the care their relative received was very good and the staff were always very kind and respectful”. Another relative said the “care could not be better”. One resident and his wife said that the “staff were great”. Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, 15 and 16. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the 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 routines of daily living are flexible as possible, and residents choose their daily schedule when they are able to, including their meal times and venue. Feedback from six residents and from direct observation on the day, it was apparent that residents are given the opportunity to spend their time as they wish. Three residents said that they chose not to attend the activity sessions, even though they were always asked, they said they prefer to spend time in their room with their books and television. Residents are facilitated to maintain their independence for as long as they are able. There are no restrictions on visiting times as long as consideration is shown to all the residents. The lounges on both floors are available to residents and their visitors for private meetings if required. Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 13 Many of the residents have individualised their bedroom with items from home and residents and relatives spoken with confirmed that they are encouraged to make it homely. The home has an advocacy policy in place and the information regarding this is available to all residents. Residents are able to choose whether they wanted to join in the activities provided which are mainly available in the afternoons, and include bingo, flower arranging, singing and movement to music. The activities provided at Woodside Hall have been reviewed and information from residents suggest they offer a more varied and stimulating range. A new activity co-ordinator has just commenced employment, and so far she is proving successful and is seen as pro active and energetic by her colleagues. Activity sessions take place three times a week in the afternoon at 2.30 pm. Regular feedback from residents regarding the frequency and timing of the activities will monitor the success of the sessions and personal preferences of the residents. One survey from a resident said they “would like activities more often” another said “ not everyone likes the same things, but we get to choose so its okay”. Activities take place in the communal areas on the upper floor, the residents were positive in their verbal feedback concerning the range of activities at this time. Two relatives said that they felt that the garden areas could be used more effectively. The menus are distributed to all residents and are also on display in the dining rooms. They demonstrated choice and variety and indicated a well balanced diet. The menus rotate on a four weekly basis and change according to the seasons. Fresh fruit is available in both dining rooms. An agency cook was on duty on the day of the inspection, and it was confirmed that the new chef has recently resigned. The inspector joined the residents for lunch, and the food prepared was attractively presented and enjoyed by the residents, a choice of food was available. The pureed diet was the same as the main menu and when served to residents it was also attractively presented. The residents were forthcoming in their views of the food, and the majority said the choice was varied and the food was very good. One resident said, “ the food is very good, no complaints”. Another said “ not bad”, one resident did mention that porridge everyday was not her choice and would like bacon and eggs, however other residents confirmed that they could have a cooked breakfast everyday. The dining areas are pleasant and well furnished with natural light. The kitchen was not fully inspected at this time as the agency chef said she was not familiar with all the homes procedures. The kitchen was clean and well organised, and good practice was observed with serving up and distributing the meals. Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Procedures in the home ensure that complaints and any allegation or suspicion of abuse made would be managed appropriately. EVIDENCE: The home has a clear complaints procedure and a copy of this is readily available in the home. A system of recording complaints was demonstrated to the inspector during her visit to the home. There have however been no complaints received recently to be processed using this system. Relatives and visiting professionals spoken to confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. The home has relevant guidelines on the protection of vulnerable adults and staff have received appropriate training. The management team has a clear understanding of adult protection guidelines and have initiated this procedure appropriately in the past. Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. 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. EVIDENCE: Woodside hall provides a well maintained and comfortable environment for its residents, there has been a large amount of upgrading of the property over the last two years, which has provided all but one double bedroom with an ensuite facility. The building and upgrading is now completed. There are adequate communal bathrooms and shower rooms in the home with specialist equipment, which enables frail residents and those with a physical disability to enjoy the facilities available. Specialised equipment to encourage 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 residents in the lounge had access to a call bell and residents said that they Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 16 called out when they needed some one. This was identified at the time of the inspection. The lighting in the home is of domestic quality and there are above bed lights as well as the main ceiling lights. Beds and chairs were seen to be placed appropriately for maximum benefit of those wishing to read. Water temperatures are controlled and monitored monthly and a record kept. Random temperatures were taken and were of the recommended level. There was evidence of residents being encouraged to personalise their rooms with their own belongings and bits of furniture. The bedrooms are clean, comfortably furnished and pleasantly decorated with soft colours. One resident said “ the cleaning ladies are good, they are not intrusive” another said “the cleaning is always first class”. A relative said, “She could not fault the cleanliness of the home”. 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. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. Sluice and laundry areas were found clean and safe. The home provides a good laundry service. Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staffing arrangements are good and suitable and ensure the needs of the residents living in the home are met. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: The staffing rota was viewed and the staffing levels were seen to be sufficient to meet the needs of the residents at this time. It was confirmed by the manager that there is flexibility of the staffing levels and they are adjusted according to the changing needs of the residents. It was noted on the day of the inspection that the morning shift was slow and some residents were having their mid morning coffee just before lunch, the manager said that she had noticed this and would look in to it. Staff spoken to said that the levels of staff on duty were sufficient to give the care required, they also said that the trained staff always helped out. Residents also confirmed that they had no complaints regarding the amount of staff, one resident said the “staff are always helpful, they look after me very well”. Another said, “ The staff are really nice, always take time to talk to me”. Staff files of five employees were viewed and evidenced that the home management team follow robust procedures when employing staff. They contained the required information and demonstrated that the appropriate induction training had been completed in respect of the job they were to undertake in the home. Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 18 Staff interviewed confirmed a high satisfaction with the training provided and stated that recent training was interesting and informative. Eight staff surveys received stated that they were satisfied with the standard of training provided. Staff and records seen confirmed that they had undertaken compulsory training such as manual handling, adult protection, first aid, and food hygiene and fire safety. In addition specialist training in understanding dementia, palliative care, stroke care updates are also provided. NVQ training is available and staff are encouraged to complete this, at present only 25 of staff have an NVQ qualification, some staff employed have made a decision that they do not want to do a qualification at this stage of their life. Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The overall management of this home is good with effective systems in place to protect residents. EVIDENCE: The Registered Manager is a Qualified Registered General Nurse and has the experience to run the home effectively with support from the general manager. A deputy manager completes the management team. The management structure of the home is strong, competent and has clear lines of accountability. The feedback from residents, relatives and staff indicated that they felt supported and were able to approach the management team at any time. The ethos of the home is to focus on the residents and the staff were observed doing this. Regular staff meetings and resident/relative meetings are held and records of the meetings are kept. The staff surveys mentioned the staff Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 20 meetings and how beneficial they were and the staff felt that areas of improvement they put forward were acted for the benefit of the residents. These form part of the quality assurance systems in the home. One resident mentioned that they attended the resident meetings and thought it gave them the opportunity to discuss the running of the home and areas that could be improved. Residents’ financial interests are safeguarded by the homes policies and procedures. All staff spoken with were aware that they must not be involved in any financial matters of the residents, they also said that they would not accept money or gifts from residents. The residents spoken with said they had no worries regarding their financial status, and felt they were supported in managing their affairs efficiently. 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. Evidence was seen of regular supervision sessions and all staff spoken with and those that completed staff surveys confirmed that they receive regular supervision. Throughout the inspection good practice was observed in regards to ensuring the safety and well being of the residents when being moved around the building, however all staff are to be reminded of the moving procedures of residents when moving up a chair. The accident forms were seen and had been correctly completed with appropriate referrals made as necessary. As mentioned previously staff need to ensure that all residents have access to a call bell facility in communal areas. Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 21 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 ENVIRONMENT CHOICE OF HOME Standard No Score 1 2 3 4 5 6 Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)(2) 12 Requirement That the care plans accurately reflect the needs of the service users in respect of their health, social and behavioural needs. 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 and 30/04/06 not met.) That the care plans and tool regarding nutrition are reviewed. 2. OP9 13 (2) Medication administration record charts must reflect current medication profile and must be a true and accurate record. That all verbal orders for controlled medication follow the homes procedures with dates and signatures of the persons responsible for taking the order. Medication that has a short life span needs to be dated on opening. Woodside Hall DS0000014079.V296808.R01.S.doc Version 5.2 Page 23 Timescale for action 30/09/06 06/06/06 That an audit of the medication charts is continued. (Previous timescale 21/01/06 not met) 3. OP22 13(4)(c) 23(2)(n) That call bells are in good working order and accessible to service users at all times. (Previous timescale of 28/06/05 and 30/04/06 not met) That appropriate risk assessments are in place with an action plan for those residents that do not have the capacity to ring the call bell. 06/06/06 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 OP38 Good Practice Recommendations That staff are reminded of safe moving techniques as discussed. 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