Inspection on 21/06/05 for Woodside Home for the Elderly

This inspection was carried out on 21st June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodside Home for the Elderly 20/08/08

Woodside Home for the Elderly 05/09/07

Woodside Home for the Elderly 30/05/06

Woodside Home for the Elderly 14/02/06

Woodside Home for the Elderly 11/12/04

Woodside Home for the Elderly 15/08/04

Similar services:

Chirnside House

Keer Sands Residential Home

Sunny Bank (P.R.S.) Ltd

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Clover House

Langrigg House

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

CARE HOMES FOR OLDER PEOPLE Woodside Home for the Elderly Burnley Road Padiham Burnley, Lancashire BB12 8SD Lead Inspector Julie Playfer Announced 21 June 2005 09:00 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 for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodside Home for the Elderly Address Burnley Road Padiham Burnley Lancashire BB12 8SD 01282 772306 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) Lancashire County Care Services Care Home (CRH) 43 Category(ies) of Old age, not falling within any other category registration, with number (OP) - 30 of places Dementia - over 65 yerars of age DE(E) - 9 Mental Disorder, excluding learning disability or dementia over 65 years of age MD(E) - 3 Learning Disability over 65 years of age LD(E) - 1 Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The following staffing levels must apply at all times: Units A,C and D - 2 care staff to be on duty on each Unit. 20:00 - 22:00 - 1 care staff to be on duty on each unit Unit B - 08:00 -22:00 2 care staff to be on duty Night Care Staff - 22:00 - 08:00 1 waking care staff - B Unit 1 waking care staff - A Unit 1 waking care staff - C and D Units. In addition to the care staff there will be a manager on duty throughout the waking day and a member of staff will be designated during the night. Date of last inspection 11th December 2004 Brief Description of the Service: Woodside is registered to provide personal care and accommodation for a total of 43 people. The home is owned and operated by Lancashire County Care Services and has been recently reopened after extensive building work and refurbishment. The home stands in its own grounds close to Padiham town centre. Public transport is accessible from Burnley Road. There are car parking facilities at the front of the building. Accommodation is provided in 42 single rooms and 1 double room. 19 of the single rooms have an ensuite facility. The home comprises of four units, Alder, Beech, Cedar and Damson. Each unit is self contained with lounges, dining rooms, bedrooms and bathroom facilities. There is a large conservatory on the ground floor and a smoking room. Beech unit provides care for older people with a dementia. The home has been decorated and furnished to a high standard throughout. Staffing levels form part of the conditions of registration. (See above). Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over two days and a total of 14.5 hours were spent on the premises. During the visit the inspector looked at written information including records, policies and procedures and spoke with the people who live at the home and some their relatives. The inspector also talked to the manager of the home and the staff on duty. A full tour of the building, both inside and outside, took place. At the time of inspection a total of 38 people were living at Woodside, with an additional person in hospital. Prior to the inspection service users and their relatives were invited to complete comment cards. Two cards were returned to the inspector. What the service does well: What has improved since the last inspection? The home reopened in March 2004 after being closed for approximately 18 months for extensive building work and refurbishment. This section is therefore not applicable. Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 6 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 for the Elderly F57 F07 S35069 Woodside V225065 210605 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 for the Elderly F57 F07 S35069 Woodside V225065 210605 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 - 6 The admission procedure was well managed. Residents were informed about the services and facilities in the home and their rights were protected by means of a written contract. Systems were in place to carry out an assessment of needs and residents were encouraged to visit prior to admission, to assess the quality, facilities and suitability of the home. EVIDENCE: Written information was available for residents in the form of a statement of purpose and service users guide. Both documents were presented in a suitable format and had been issued to all residents. Both the statement of purpose and service users guide provided the residents with useful information about the home and details about the services and facilities provided. However, the statement of purpose did not include the arrangements for dealing with complaints. All residents had been issued with a contract at the point of moving into the home and a copy was included in the service users guide. The contract set out Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 9 the terms and conditions of residence, including information about the level and payment of fees. The majority of residents living at Woodside had transferred from other homes operated by Lancashire County Care Services (LCCS), which were due for closure. A new assessment of needs had therefore not been carried out for all residents prior to admission. Previous assessments carried out under care management arrangements were seen on files and staff had completed internal assessment documentation in the residents’ former homes. However, it was noted the latter did not cover all elements listed in the National Minimum Standards. It was evident residents referred since the reopening of the home, had an assessment of their needs prior to moving into the home. Residents and their relatives/representatives were offered the opportunity to visit the home prior to admission. All prospective residents were invited to visit the home to meet other residents and staff and partake in a meal. A relative was spoken to during the inspection, who had visited several times prior to his wife’s admission to the home. Woodside does not provide intermediate care. Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 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 - 10 There was no clear system of care planning to adequately provide staff with the detailed information they need to ensure the residents’ needs are met. The management of medication was poor and in order to safeguard the residents record keeping and some aspects of practice must be improved. EVIDENCE: There were two systems in place to address the care needs of the residents. The first system was based on the residents’ social, physical, intellectual, cultural and emotional needs. However, the assessment information did not readily correspond to these categories and the format was difficult for staff to understand, consequently the plans were incomplete in all case files seen. The second system was based on the residents’ daily routines; however there was no evidence to indicate that the residents had been consulted or involved in devising the plans. Neither system addressed the residents’ health care needs nor provided clear guidance to staff on how resident’s needs were to be met. Reviews had been carried out once a month, but care plans had not been updated. The care plans were supported by daily care records and personal profiles. Records were also made of personal care provided and risk assessments had been carried out as necessary in relation to falls and mobility, however risk Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 11 assessments had not been carried out in respect to nutrition. A record of weight was not kept on a regular basis for all residents. Policies and procedures were available in respect to the handling of medication, but these were not specific to the home. The home operated a monitored dosage system for the administration of medication, which was dispensed into individual blister packs. Appropriate records were maintained of the receipt, administration and disposal of medication. However, not all medication was administered in line with the prescriber’s instructions, eye drops were not dated on the day of opening and there were some omissions on the medication administration record. Also not all information from the prescription label had been transferred to the medication administration record and on one occasion during the inspection the medicines trolley was left unattended with the keys in the lock. Residents spoken to felt their right to privacy was respected by the care staff and personal care was carried out with respect to their dignity. All residents were referred to by their preferred mode of address, which was documented on the care plan. Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 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 -15 The routines were primarily designed around the needs and wishes of the residents and as such the residents were able to exercise choice and control over their lives in respect to daily living. Residents were encouraged to engage in pastimes and leisure activities of their choice. Residents were able to maintain good contact with their families and friends. Residents were served with a good choice of meals throughout the day in pleasing surroundings at times convenient to them. EVIDENCE: Residents had a range of opportunities to engage in leisure interests. Activities were arranged on the separate units and for the whole home in the conservatory. A variety of activities were arranged on Beech unit, which provided care for older people with a dementia, these included music and singing, reminiscence, balloon games, reading stories, jigsaws and dominoes. The residents living on Beech Unit often joined other residents in the main conservatory with staff support. Staff on all units confirmed they had sufficient time to spend with residents to pursue leisure pastimes or sit with residents for a chat. Activity records were maintained on all units. Residents were also involved in activities outside the home for instance one resident attended a local day centre and other residents enjoyed walks in the surrounding area. Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 13 The routines in the home were flexible and residents had a choice in the times they went to bed and got up in the morning. Hence breakfast was served to suit the wishes of the residents. Residents’ meetings were held on a regular basis and minutes were displayed on notice boards. Some residents spoken to, said they enjoyed the meetings and confirmed they were able to discuss all aspects of life in the home. The residents were able to receive visitors at any time and were able to entertain their guests in private. All the visitors spoken to during the inspection expressed satisfaction with the standard of care provided. One relative said he thoroughly enjoyed visiting the home, the staff made him feel very welcome and he often partook in a meal. Residents were encouraged to exercise choice and control over their lives. As such residents were supported to manage their own finances. Residents were also able to bring in personal belongings and arrange their rooms how they wished. Residents were mostly satisfied with the quantity, quality and variety of food. However, one concern was raised on a comment card. This concern related to the serving of tinned hot dog sausages. This issue was discussed with the manager during the inspection and the menus were seen. It was evident this type of food was served once during a five week cycle of menus and there was a choice offered at all mealtimes, hence systems were in place to enable all residents to select a choice of meal or request an alternative. The menu was displayed on each unit, but not in all dining areas. Drinks and snacks were served at set times throughout the day and other times on request. Each unit was equipped with a kitchen area and staff were able to prepare drinks and small snacks. Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 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 and 18 Residents were provided with sufficient information should they wish to raise a concern about their care. Policies and procedures in respect to the protection of vulnerable adults must be updated to ensure a proper response to any allegation of abuse or inappropriate practice. EVIDENCE: Two complaints procedures were included in the service users guide. The procedures differed slightly and could therefore be confusing. One procedure set out the timescales of the complaints process and stated complaints can be directed to the Commission for Social Care Inspection, the other did not. There was also information about the complaints procedure included in the contract/statement of terms and conditions and statement of purpose. The manager maintained a record of complaints. A copy of No Secrets in Lancashire (The Joint Strategy for the Protection of Vulnerable Adults) was available, along with a specific procedure setting out the required response in the event of any allegations or suspicion of abuse. However, the procedure did not set out the roles and responsibilities of the registered manager, who under the Care Homes Regulations 2001 would have the responsibility to instigate the adult protection procedures. All staff had been issued with the ‘whistle-blowing’ procedure. Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 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 The residents were provided with a clean, comfortable and well- maintained environment, however, the residents felt the layout of the home did not meet their needs. EVIDENCE: Woodside is a purpose built two storey building, which has recently undergone extensive building work and refurbishment. The accommodation within the home is split into four separate units. Each unit is self-contained and provides lounges and dining areas along with bedrooms and bathrooms. The home has been refurbished and decorated to a high standard throughout. However, the residents, who participated in the inspection, strongly disliked the layout of the home. They felt the lounges were too far apart and as a result they found it very difficult to visit or make friends in other parts of the home. Two residents in particular felt isolated on their unit. Residents on Cedar Unit also commented that the passenger lift was a significant distance from their accommodation and it was “hard to get to”, if they wished to go downstairs to use the conservatory. This meant that one resident, who was able to walk with a frame, had to consider using a wheelchair. Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 16 Residents were able to smoke in a designated room on the ground floor. This room was an extra facility in the home and was not intended to be a lounge. Comments were received from relatives before, during and after the inspection to express concern about the type of seating provided in this room and the level of ventilation. Following discussions with the manager of the home and the area manager, it was evident that the room was not intended to form part of the residents living space and it was seen that the type of seating was suitable for its planned purpose. Residents were encouraged and supported to use the room for short intervals to smoke and then use other facilities available to them on their unit or conservatory. There was an extractor fan fitted in the room and the window could be opened. None of the residents expressed a concern about the smoking room. The grounds of the home were extensive and there were several sitting areas for the use of residents. Beech unit had a large enclosed garden, which the residents were able to freely access at any time. There was an assisted bath and shower on each unit and nineteen of the single rooms had an ensuite facility. Residents were provided with appropriate aids and adaptations to assist their mobility and independence, these included three Oxford hoists, a stand-aid hoist, grab rails in toilets and bathrooms and raised toilet seats. There was a call facility in every room. The doors to residents’ bedrooms had been fitted with appropriate locks and residents had been issued with keys. It was evident from a tour of the building that residents had bought in their own belongings and personalised their rooms in accordance with their own tastes and preferences. All residents and relatives spoken to were very pleased with the size and standard of furnishing and décor in the bedrooms. Radiators had a guaranteed low temperature surface and preset valves had been fitted to all water outlets to minimise the risks of scalding. There was a good standard of cleanliness throughout the home. A small laundry was located on three of the units with a main laundry on the ground floor. Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 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 - 30 The recruitment and selection of new staff was not robust and must be improved to safeguard the welfare of the residents. Staff had good training opportunities and a significant proportion of the staff team had achieved NVQ 2. EVIDENCE: The staffing levels provided were in line with the conditions of registration. Wherever possible existing staff covered shortfalls on the rota, but on the occasions when this was not possible the home employed agency staff. Lancashire County Care Services operated a recruitment and selection procedure, which was underpinned by an Equal Opportunities policy. However, on inspection of three staff files there were a number of shortfalls identified in the recruitment process. Some staff had not provided a full employment history and there was no satisfactory written explanation of gaps. One person commenced work in the home prior to the receipt of a second reference and a CRB check was not obtained for one person who had a gap in service of less than a month and day. Some references were unsigned and undated. Arrangements were in place for the induction of new staff, which covered the “Skills for Care” standards. The induction programme provided underpinning knowledge for NVQ training. At the time of the inspection, 17 staff had achieved NVQ level 2 or above and an additional 4 members of staff were waiting for accreditation. This equated to a ratio of 53 of trained members of staff. Staff had also completed courses on positive dementia care, food hygiene, first aid, infection control, health and safety compliance and adult Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 18 protection. Staff interviewed during the inspection had found the training provided useful and applicable to daily practice. Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 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 - 38 The approach and attitude of some staff must be monitored to ensure the residents’ right to dignity and respect is maintained at all times. Appropriate policies and procedures were in place to safeguard the residents’ health and safety and financial interests. EVIDENCE: The manager was not registered at the time of the inspection. However, Ms O’Neill had submitted an application form to the Commission and had almost completed the registration process. The manager had a job description and there were clear lines of accountability within the home and the organisation. The overall atmosphere of the home was open and friendly. Systems were in place to consult staff and residents about life in the home. Positive interactions were observed between the staff and the residents, with many of the staff sitting with residents for a chat or playing a tabletop games. However, the residents had mixed views about the staff. They said the majority of staff were Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 20 “kind and caring, but there were one or two who were ignorant”. These comments were discussed with the manager, who will investigate this matter. The quality assurance system was being developed in line with Lancashire County Care Council’s policies. The manager explained a satisfaction survey will be carried out over the next few months. The Council had appropriate insurance in place to cover against loss or damage and business interruption costs. Sound financial procedures were in place to assist residents with their financial affairs. Written transactions were maintained and a random check of the money deposited on the premises for or on behalf of residents corresponded accurately with the records. There was an established programme in place for the supervision of staff, with each manager being delegated the responsibility of supervising a group of staff. It was noted the supervision format covered the elements listed in the National Minimum Standards. The manager maintained appropriate regulatory records, however a number of records required attention for example the care plans, medication records and the collation of staff records. Staff training records indicated staff had received periodic training on moving and handling, food hygiene, fire safety and first aid. Systems were in place to record accidents and the home had a comprehensive set of policies and procedures relating to health and safety. The electrical installations, gas central heating and fire equipment were tested when the home reopened in March 2004 and all relevant certificates were seen at the time of registration. Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 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 3 2 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 4 3 3 STAFFING Standard No Score 27 3 28 4 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 2 3 3 3 3 2 3 Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 22 No 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. 2. Standard 1 7 Regulation 4 15 Requirement The statement of purpose must include the arrangements for dealing with complaints. A service user plan must be generated for all residents based on a comprehensive assessment of need. The plans must cover all aspects of personal, social support and healthcare needs and include details of how these needs will be met. The plans must be drawn up with the involvement of the resident and reviewed once a month. Any agreed changes must be recorded and actioned. The service user plans must all health care needs and provide clear guidance to staff of how these needs are to be met. A record of weight must be maintained as necessary and nutritional risk assessments must be carried out as appropriate. All medication must be administered in line with the prescribers instructions. Eye drops must be dated on the day of opening and discarded in line with the pharmacists instruction. F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Timescale for action 15th August 2005 15th August 2005 3. 8 15 15th August 2005 1st August 2005 4. 8 15 5. 9 13 Immediate and ongoing from the date of inspection. Page 23 Woodside Home for the Elderly Version 1.30 6. 9 13 7. 9 13 A separate bottle of eye drops must be used for each eye and labelled appropriately. The medication administration record must be signed by the member staff administering medication to residents, to avoid omissions on the records. All information on the prescription label must be transferred to the medication administration record. The medication trolley must not be left unattended and medication must be kept securely at all times. All complaints procedures must provide consistent information. The procedure must state that a complaint can be directed to the Commission for Social Care Inspection at any stage. The registered person must ensure there are robust procedures for responding to suspicion or evidence of abuse or neglect. The procedures must include contact details of local agencies and the Commission and set out the roles and responsibilities of the registered manager and staff. All records and documentation relating to the recruitment of new staff must be collated and maintained in line with the requirements of the Regulations. Appropriate Police checks must be carried out and received before a person commences work in the home or has any access to the residents. The responsible individual must update the recruitment procedure to ensure all staff receive a CRB check after a Immediate and ongoing from the date of inspection. 8. 16 22 Immediate and ongoing from the date of inspection. 15th August 2005 9. 18 12 1st August 2005 10. 29 18, 19 Immediate and ongoing from the date of inspection. 11. 29 18, 19 Immediate Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 24 break in service of any length. 12. 32 12 The attitude and approach of some staff must be monitored to ensure the residents rights to dignity and respect are maintained at all times. All regulatory records must be kept complete and up to date at all times. Immediate and ongoing from the date of inspection. Immediate and ongoing from the date of inspection. 13. 37 17, 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 3 9 9 15 Good Practice Recommendations The assessment tool should cover all elements listed under standard 3. The medication policies and procedures should be specific to the home. Information transcribed from the prescription label to the medication administration records should be signed and witnessed by two members of staff. Menus should be displayed in all dining areas. Woodside Home for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Unit 4, Petre Road Clayton Business Park Accrington Lancashire BB5 5JB 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 for the Elderly F57 F07 S35069 Woodside V225065 210605 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!