Inspection on 06/07/05 for Woodside Home

This inspection was carried out on 6th July 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 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 Home 13/06/06

Woodside Home 10/03/06

Woodside Home 26/10/04

Woodside Home 08/06/04

Woodside Home 29/04/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE WOODSIDE HOME Baxendale Whetstone London N20 0EH Lead Inspector Tom McKervey Announced 6 & 7 July 2005 @ 09.30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodside Home Address Baxendale, Whetstone, London N20 0EH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8445 1127 020 8343 8324 Brian M Hosier for The Board of Trustees of The Woodside Home Miriam Kajencki (in process of registration) PC Care Home only 49 Category(ies) of OP Old Age registration, with number of places WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26 October 2004 Brief Description of the Service: Woodside Home is a care home registered to provide care and support for up to 49 older people, all of whom are female. The home is run by a charitable trust and is managed through a board of trustees. The home, which is purposed-built, has 49 single bedrooms, located on the ground, first and second floor. None of the bedrooms have en-suite facilities. There is a passenger lift, which serves all three floors. There is a large communal lounge area and dining room on the ground floor. An additional lounge space is provided elsewhere in the building. There is an attractive garden and lake within the grounds as well as a large conservatory. Woodside Home is close to the shops, services and transport links of Whetstone, and is easily accessible by public transport. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out over two days and was completed in fifteen hours. Two members of the Trust board were present at the start of the inspection, and the manager, who fully cooperated with the inspection, was present throughout the process. The inspection consisted of a tour of the premises, speaking to the residents and visitors to the home, and interviewing staff, all of which was conducted independently of the manager. The inspector also read samples of residents’ case files and staff records. In addition, documents pertaining to the management and running of the home were also examined. A new manager had been appointed in March 2005. However, this person was unable to take up post until the end of the year. Consequently, at the time of the inspection, an interim manager was in place, and was in the process of applying for her registration. Prior to the inspection, the inspector received twenty four comments from service users, seven from relatives and one from a care manager. The majority of comments from service users and the care manager, indicated a high level of satisfaction with the service. However relatives’ comments indicated. concerns about the new manager. These comments were fed back to the manager during the inspection, and have been further addressed in the body of this report. What the service does well: The quality of care is very good, and service users live in a safe and wellmaintained building. The home has a particularly pleasant environment, where residents and visitors can enjoy very attractive gardens and lakes. There is a strong commitment to train and develop staff to equip them to meet service users’ needs. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 6 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 HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, & 3. Standard 6 does not apply. There is good information available for service users and/or their representatives about the service to enable them to decide on the suitability of the home to meet their needs. However, the contracts of terms and conditions of the service, which safeguard both the service users’ and the home’s interests, are not always completed properly. EVIDENCE: The Statement of Purpose contains all the information required by the standard. However, a requirement is made to amend the Statement of Purpose and Service Users Guide, to show the new management structure. The inspector examined six contracts of residents who were most recently admitted. Only one contract contained all the information required in Standard 2, and had been signed. A requirement is made regarding this matter. Comprehensive assessments were in place from care managers, (where appropriate), and the home staff. In one instance, an assessment of a specific resident, indicated that the home was no longer able to meet their needs, and appropriate steps were being taken to find a more appropriate placement. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 9 There was evidence in the case files, of trial visits being available for service users before moving to the home. This was also confirmed in discussion with residents and relatives. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, & 10 Service users have good access to a full range of healthcare and are well supported by staff in their personal care. However, residents’ needs, as set out in their care plans, are not being regularly monitored. EVIDENCE: The manager stated that she is introducing more comprehensive care plans in the home. Four care plans were sampled, including one that was written in the new format. The assessments in the current care plans did not always relate to the care objectives, and it would be better practice to have the assessments on the same page as the rest of the plan. It was noted that care plans were not being monitored monthly, and a requirement is made to address this. The inspector was informed that the concept of key-working had been introduced, and it is the key worker’s responsibility to write the care plans. The case records showed that all service users were registered with the GP. A separate form was seen in each case file, where health care appointments were recorded. These ranged from chiropody to dentists, opticians etc. Charts were also seen for the recording of service users’ blood pressure and weights. There were records to show that medicines were being administered safely and stored securely. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 11 Staff were observed interacting with residents. The staff were respectful and addressed residents appropriately. Service users told the inspector that they were happy with the way the staff cared for them and the manner in which they were given personal support with bathing and toileting. The wishes of service users in the event of their death were recorded in the case files. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 14 & 15 Service users enjoy a good quality of life in the home, and there is an appropriate range of activities that they can choose to participate in. Service users are provided with sufficient, wholesome and well-presented meals. EVIDENCE: The activity programme includes musical movement, art classes, sing-a-long sessions and outside entertainers monthly. A hairdresser also attends weekly. The inspector observed an art class and sing-song taking place during the inspection. Residents told the inspector that they were happy with the activities provided. The visitors’ book showed that there were regular visits to the home by family and friends. The inspector spoke to four relatives during the inspection. In discussion with service users, it was confirmed that they were able to make their own decisions about joining in activities and about meal choices. There were records of minutes of residents’ meetings, which indicated that they were encouraged to make suggestions about service improvements. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 13 The inspector joined residents for the three-course lunch, which is the main meal of the day. The food was well cooked and attractively presented. The inspector noted that where service users required help with eating, this was done sensitively and in an unhurried manner. Service users stated that they can choose to dine in their rooms if they wish. The menus showed evidence of choice of main meals. Special diets, including ethnic dishes were provided as necessary. An inspection of the kitchen, confirmed that food was stored safely. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 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 standard(s) 16 & 18 Service users’ best interests and welfare are protected by appropriate complaints and adult protection procedures. EVIDENCE: There is an appropriate complaints procedure in place. Eight complaints had been made in the last year, four of which were fully, and two partially substantiated. There were records to show that staff were being trained in adult protection, and in discussion with a group of staff, it was evident that they were knowledgeable about issues of abuse. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24 & 26 Service users benefit from living in a clean and attractive home, which is safe and well-maintained. EVIDENCE: A tour of the premises was carried out. The building was generally well maintained and the standard of décor was very good. The large gardens were very attractive and provide a pleasant amenity for the residents. Appropriate risk assessments were in place pertaining to the building and accommodation. There are three spacious lounges and an attractive conservatory on the ground floor as well as a smaller lounge on the first floor. There are sufficient toilet and bathing facilities, which have appropriate adaptations for people with mobility problems. Five bedrooms were visited and they were all very comfortably furnished and nicely decorated. There was evidence of personal possessions in the rooms. Residents told the inspector that they were very satisfied with their accommodation. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 16 A team of cleaning staff keeps the home looking very clean and odour free. There is a control of infection policy in place, and care staff are provided with disposable gloves and aprons when supporting residents with personal care. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 There is a good programme of training for staff to meet service users’ needs. However service users’ welfare is not being fully safeguarded because of, (a) poor staff recruitment practices, and (b), incomplete records to provide evidence that there are always sufficient staff on duty to meet residents’ needs. EVIDENCE: The staff rotas were examined. Although service users who were spoken to, stated that they were satisfied with staffing levels during the day, there was some concern expressed about night-time levels. It was not clear from the rota what shifts were actually worked at night. Furthermore, it is not acceptable for staff to be identified on the rota only by their first names. The manager, deputy and second officer’s, duties were not recorded on any rotas. A requirement is made to address these issues. Staff records showed that they receive training in mandatory and other appropriate subjects to support them in meeting service users’ needs. There is a commitment by the Trust Board to train care staff on the National Vocational Qualifications, (NVQ) programme. The inspector was informed that current job descriptions were not available for all staff who work at the home, and a sample of the records of recently recruited staff, showed that, in some instances, a current Criminal Records Bureau, (CRB) certificate had not been obtained. It was also noted that some staff references were not from the person’s last employer. A requirement is made regarding this matter. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 18 WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 36 & 38 Staff are now receiving regular supervision to support them in caring for service users. However, although appropriate changes are being introduced to meet the National Minimum Standards that will ultimately benefit service users, the pace of change is having a detrimental effect on staff morale. EVIDENCE: The inspector was informed that a manager had recently been appointed, who was unable to immediately take up post. In the interim, another manager has been appointed on a fixed term contract, is well-qualified and experienced at managing care homes. During the inspection, the inspector spoke to residents, relatives and other visitors, team leaders and staff, about the leadership and management style in the home. These discussions were held independently of the manager. The inspector was concerned to find that the majority of people who were interviewed, expressed strong concerns about how the home was being run. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 20 Relatives stated that the manager appeared “distant” from themselves and the residents. There appeared to be a consensus among the staff that, while the changes being introduced were necessary, there were too many happening at the same time, and that there was a lack of communication and negotiation with them. The manager stated that she had fully discussed these issues with the team leaders, the staff and relatives at various meetings; evidence of which, the inspector saw in minutes. Although the inspector found that there was poor morale among the staff team, there was no evidence that this was directly affecting the residents. The inspector made some recommendations to the manager and a member of the Trust Board about adopting a strategy to manage service changes. This recommendation is included in this report. The inspector was informed that a quality audit of the service has not yet been undertaken and a requirement is made regarding this. A programme of supervision is now in place, with an appropriate structure and process. The inspector saw records regarding the safety of gas, fire and electrical installations. Fire alarms were tested weekly and drills were carried out. The fridge and freezer temperatures were recorded, and cleaning materials were stored securely. There were records to show that the water supply was regularly tested to exclude the presence of legionella. Portable electrical appliances had not been tested, and a ventilation pipe that protrudes from the boiler room, needs to be padded to prevent injury. A requirement is made to address these health and safety issues. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 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 CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 3 x 2 WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 6(a) Requirement The registered person must ensure that the Statement of Purpose and Service User guide include the recent changes in the management structure. The registered person must ensure that service users contracts contain all the information outlined in Standard 2. The registered person must ensure that service users care plans are reviewed each month to reflect residents changing needs. The registered person must ensure that all staff working in the home have an up to date job description. The registered person must ensure that the shift rotas include staffs full names, and properly record the actual shifts worked. The registered person must ensure that all staff have a current CRB clearance and a reference from their last employer. The registered person must ensure that a quality audit of the Timescale for action 30/9/05 2. 2 5(1)(b) 30/9/05 3. 7 15(2)(a) 30/9/05 4. 27 17(2) Sch 4 18(1) 30/9/05 5. 27 31/8/05 6. 29 19(1) Sch 2 31/8/05 7. 33 24(1) 31/12/05 Page 23 WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 8. 38 service is carried out to reflect views of service users and other stakeholders. This requirement is restated. The previous temescale was 31/12/04 13(4)(a)(c The registered person must 30/9/05 ) ensure that the ventilation pipe is padded and that portable electrical appliances are tested by a qualified electrician. 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 32 Good Practice Recommendations The registered person and the manager should develop a strategy that enables staff to implement changes to the service and engages them fully in the process. WOODSIDE HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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 HOME G59 S10528 Woodside Home V230855 6.7.05 Stage 4.doc Version 1.30 Page 25 - 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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