Inspection on 30/05/06 for Woodside Home for the Elderly

This inspection was carried out on 30th May 2006.

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 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 for the Elderly 20/08/08

Woodside Home for the Elderly 05/09/07

Woodside Home for the Elderly 14/02/06

Woodside Home for the Elderly 21/06/05

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 Mrs Julie Playfer Unannounced Inspection 09:45 30th May 2006 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 Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 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 Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 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 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) Lancashire County Care Services Miss Pauline O`Neill Care Home 44 Category(ies) of Dementia - over 65 years of age (10), Learning registration, with number disability over 65 years of age (1), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (3), Old age, not falling within any other category (30) Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitably qualified manager who is registered with the Commission for Social Care Inspection The following staffing levels must apply at all times: Waking Day Care Staff - 08:00 to 20:00 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 Unit. 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 in charge during the night. The home is registered to take people in the following categories: OP- Older age not falling within any other category - 30 DE(E) Dementia over 65 years of age - 10 MD(E) Mental disorder, excluding learning disability or dementia over 65 years of age - 3 LD(E) Learning Disability over 65 years of age - 1 14th February 2006 3. Date of last inspection 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 was extensively refurbished in 2005. 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 Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 5 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 good standard throughout. Staffing levels form part of the conditions of registration. (See above). At the time of the inspection the scale of charges was as follows: standard rate £313.00, higher rate £352.50 and self-funding residents £364.00. Additional charges were made for hairdressing, toiletries, magazines, newspapers, holidays and private chiropody. The registered manager made information available to prospective residents by means of a statement of purpose and service users guide. These documents were usually given to relatives and/or prospective residents on viewing the home or at the point of assessment. In addition, all residents accommodated in the home had been issued with a personal copy of the statement of purpose and service users guide. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over nine and a half hours on 30th May 2006. The previous statutory inspection was carried out on 14th February 2006. There have been no additional visits made to the home since the last inspection. On the day of inspection there were 42 residents accommodated in the home. Information was obtained from care records, staff records and policies and procedures. The inspector undertook a partial tour of the premises and spoke to the residents, the staff on duty and the registered manager. Four residents were involved in the case tracking process. Prior to the inspection the registered manager completed a questionnaire, which provided useful information for the inspection. Questionnaires and comment cards had been sent to the home for residents and their relatives, 8 questionnaires were returned from residents and 9 cards were received from relatives/visitors to the home. What the service does well: The admission procedure was well managed. Residents’ needs were properly assessed and they received written information about the services and facilities provided in the home. Residents were able to maintain good contact with their family and friends. Relatives and visitors were made welcome in the home. Routines were flexible and residents were able to exercise control over their daily lives. Residents were consulted about their choice of activities. All the residents spoken to said they enjoyed the meals provided and there was always plenty of choice. The residents had access to a clear complaints procedure and felt confident their views were listened to and acted upon. The home was decorated and furnished to a high standard throughout and provided the residents with safe and comfortable accommodation. The residents also had access to extensive grounds, which were attractive and well-maintained. A significant proportion of the staff team had obtained NVQ level 2 or above and were provided with opportunities to pursue various training courses pertinent to the care of older people. Comprehensive written policies and procedures were in place to safeguard the residents’ health and safety. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 7 The overall atmosphere was open and friendly. The management style was consultative and residents’ and staff meetings were held on regular basis. What has improved since the last inspection? What they could do better: Following the initial assessment of needs the registered manager must inform the residents in writing that the home is suitable for meeting their needs, so prospective residents can be confident that the home will be able to care for them appropriately. The registered manager must ensure a care plan is generated for each resident, which covers all aspects of the residents’ health and well-being. The plans must be based on a comprehensive assessment of needs and drawn up with the involvement of the resident and/or their representative. This is to ensure that staff are provided with clear guidance on how to meet the needs of the residents. The residents’ weight must be recorded on a regular basis for monitoring purposes. Such records would alert staff to significant fluctuations in weight and possible health problems. In order to minimise the potential for errors and safeguard the residents, improvements must be made to the management of medication in the home. The vulnerable adults procedure should be updated to align with local protocol, to ensure a correct and consistent response is taken in response to any allegations or suspicions of abuse. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 8 The registered manager must ensure all records are maintained and kept up to date to ensure the residents’ rights and best interests are safeguarded. 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 DS0000035069.V291767.R01.S.doc Version 5.1 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. 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. 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. A resident new to the home was familiar with the statement of purpose and service users guide and said he looked at it “now and again”. A copy of the contract/individual service agreement was included in the service users guide. All residents involved in the case tracking process had been Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 11 issued with a contract and one resident recalled signing the agreement, which he said had been explained to him. It was evident that residents had their needs assessed prior to admission to the home by the registered manager and social worker, where applicable. The preadmission assessment covered the residents’ personal, social and health care needs. However, there was no evidence seen to indicate the registered manager had informed residents in writing that having regard to the assessment the home was suitable for meeting their needs. Residents and their relatives/representatives were offered the opportunity to visit the home prior to admission. As such, all prospective residents were invited to visit the home to meet other residents and staff and partake in a meal. None of the residents spoken to could recall visiting the home, but two people said their family had a look round and chose the home for them. A relative spoken to said that she visited the home and was impressed by the welcome she received and the “good standard of the home”. Woodside does not provide intermediate care. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff had a good understanding of the residents’ needs and promoted their rights to privacy and dignity. However, the care planning systems were unclear and lacked sufficient guidance to staff on how to meet health care and cultural needs. The overall management of medication was not robust and had the potential for error. EVIDENCE: There were two concurrent 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 this section had not been completed 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 fully 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 not all the plans had Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 13 been updated. Charts detailing the personal care provided by staff were incorporated into the care documentation, however, it was evident some residents’ weight was not recorded on a regular basis. The care plans were supported by records of personal care, which provided information on changing needs and any recurring difficulties. All records seen were detailed and the residents’ needs had been described in respectful terms. Appropriate risk assessments had been carried out in respect to the potential risks associated with general well-being, mobility, falls, nutrition and pressure sores. The assessments included management strategies in order to minimise or eliminate any identified hazards. Whilst staff interviewed demonstrated a good understanding of the equalities and diversity needs of individual residents, there was no evidence that such needs were reflected in the care plans in the areas of race and ethnicity. The residents spoken to felt the staff respected their right to privacy and all made complimentary remarks about the staff, for instance one resident said the staff would “do anything to help you”. The staff were observed to interact with the residents in a positive manner and they referred to the residents in their preferred term of address. Since the last inspection, the policies and procedures relating to medication had been reviewed to reflect the practices in the home. The storage arrangements had been revised and as a result medication for Cedar and Damson Units had been moved to locked trolleys on the first floor. It was also noted that two members of staff had signed the controlled drugs register and instructions for the application of creams had been included on a separate form kept in the residents’ rooms. 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, there were shortfalls in the overall management of medication. These included shortfalls in record keeping and the administration of medication. All staff designated to administer medication had received accredited training. The registered manager and staff demonstrated a sensitive approach towards the needs of residents, who were in the last days of their life. The preferred wishes of residents about the arrangements after death were recorded in their care plan and families were encouraged and supported to spend time with their relative. One relative wrote on the comment card that the care given to her mother “has been wonderful and the staff have been very caring, offering words of comfort”. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 14 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were able to choose their life style and social activity and were supported to keep in contact with their friends and family. Residents received a healthy and varied diet according to their assessed requirement and choice. 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. Records were maintained of activities undertaken on each unit and these included dominoes, quizzes, listening to music and watching films. Residents were observed to be playing with a balloon on Beech Unit and having a conversation with staff on Damson Unit. Several residents enjoyed going to the local shops and walks around the grounds and to the nearby National Trust property. Staff spoken to confirmed they had sufficient time to spend with residents to pursue leisure pastimes or sit with residents for a chat. The residents spoken to as part of the case tracking process said they were aware that activities were available and one person said she liked to play dominoes, however, other people said that they either preferred to sit in their own bedrooms or rest in the afternoons. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 15 The residents were supported to follow their chosen form of religious worship and representatives from local churches visited the home for prayers and communion on a regular basis. 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. The residents felt they had an active choice in their daily lifestyle, one person said “I always wake up early and get up early and I go to bed when I want, depending what is on the television”. Residents’ meetings were held on a regular basis and minutes were seen during the inspection. All the residents were invited to participate in the meetings and they were able to discuss any aspect of life in the home. The residents were able to receive visitors at any time and were able to entertain their guests in private. The visitors spoken to during the inspection expressed satisfaction with the standard of care provided and stated that they felt involved with the care of their relative. One relative said the staff were “great – very caring and approachable ”. All the relatives who returned a comment card were satisfied with the overall care provided and one person wrote “I am completely satisfied with the personal care my mother receives” and another person said “I am very pleased with Woodside”. 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. All residents spoken to were complimentary about the meals, which they described as “good home cooked food”. The residents said the food was a good quality and there was always plenty to eat. A menu was displayed on each of the units and the residents were asked their choice of meal. On the day of the visit, the meal looked appetising and was well presented. Drinks and snacks were served at set times throughout the day and other times on request. Residents were observed asking for drinks during the inspection and were served promptly by the staff. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents had access to a clear up to date complaints procedure and staff had access and an awareness of the adult protection procedure. EVIDENCE: Since the last inspection the complaints procedure had been updated to inform residents, they could direct a complaint to the Commission at any point of the complaints process, if they wished to do so. The procedure set out the time scales and incorporated the contact addresses of managers within the organisation and the Commission. The residents spoken to were aware of the complaints procedure and said they would speak to a member of staff or the manager if they had any concerns. All the residents spoken to were confident their views would be listened to and appropriate action would be taken in the event they had a complaint. The registered manager maintained a record of complaints, which indicated the home had received four complaints within the last 12 months, all the complaints had been resolved and responded to within 28 days. 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. The internal procedure did not set out the roles and responsibilities of the registered manager, who under the Regulations for Care Homes would have the responsibility to instigate the adult protection procedures. However, it was clear throughout all discussions that the registered manager and staff had a Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 17 good understanding of the Vulnerable Adults Procedure and were aware of the relevant agencies involved. Staff confirmed they had been given specific information on the procedure and had watched a training video. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The residents were provided with a safe, comfortable and well-maintained environment, which encouraged independence. EVIDENCE: Woodside is a purpose built two storey building, which reopened in 2005 following 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. With the exception of one resident, all residents spoken to liked the layout of the home. The grounds of the home were extensive and there were several sitting areas for the use of residents. Since the last inspection new garden furniture had been purchased for the patio outside the main conservatory. Beech unit had a large enclosed garden, which residents were able to freely access at any time. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 19 One resident on this unit particularly enjoyed walking round the garden on his own. The conservatory on Beech Unit added considerably to the communal space and provided the residents with a choice of where to sit and spend their time. In addition to the communal space provided on each unit the residents had access to a large conservatory on the ground floor. 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. As such, all residents spoken to described their rooms as “lovely” and “really nice”. One person said “how could you get better than this?” Radiators had a guaranteed low temperature surface and preset valves had been fitted to all water outlets to minimise the risks of scalding. All residents said there was plenty of hot water and the home was maintained at a comfortable temperature. 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 DS0000035069.V291767.R01.S.doc Version 5.1 Page 20 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 using available evidence including a visit to the service. Staff were provided with appropriate training and were deployed in sufficient numbers to meet the needs of the residents. The residents were protected by the home’s recruitment policy and practices. EVIDENCE: A recorded staff rota was completed in advance, which indicated which staff were on duty and how many hours they had worked. All staff providing personal care were aged over 18 and all staff left in charge of the building were aged over 21. The level of staffing was in line with the conditions of registration. Lancashire County Care Services operated a recruitment and selection procedure, which was underpinned by an Equal Opportunities Policy. The file of one member of staff, who had recently commenced working in the home, was seen during the inspection. It was evident from looking at this file that the procedure had been followed and all relevant checks had been carried out. 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. One member of staff said that the induction programme was very detailed and covered all aspects of good care practice, including the promotion of the residents’ rights to privacy, dignity, choice and independence. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 21 At the time of the inspection, 19 staff had achieved NVQ level 2. This equated to 53 of the staff group. Staff training records seen during the inspection demonstrated that the staff had also completed courses on positive dementia care, food hygiene, first aid, infection control, health and safety compliance and adult protection. Staff interviewed during the visit had found the training provided useful and applicable to daily practice. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 22 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, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. A means had been established to formally consult both residents and staff and systems were in place to monitor the quality of the service. The ethos of the home was open and friendly and the staff benefited from regular supervision. The health and safety of residents was promoted and protected, however, certain aspects of the record keeping must be improved. EVIDENCE: The registered manager had achieved a Registered Manager’s Award and an NVQ level 4 in management as well as an HNC in Social Care. At the time of the inspection the manager was working towards an A1 assessor’s award. There were clear lines of accountability within the home and the organisation. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 23 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. All residents spoken to said the staff were “very good” and “very kind and nice”. Arrangements were in place to consult both residents and staff and appropriate meetings were held on a regular basis. 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. The supervision format covered the elements listed in the National Minimum Standards. All staff also had an annual appraisal of their work, which focussed on their work performance and identified any future training needs. Since the last inspection, the residents and their relatives had been given the opportunity to complete satisfaction questionnaires. The results had been collated and analysed and feedback had been given to all interested parties. At the time of the inspection the registered manager was working on the annual development plan. Systems were in place to monitor the quality of the service, received by the residents. Appropriate arrangements were in place for handling money, which had been deposited with the home by or on behalf of a resident. A random check of monies was found to be correct. Records were also maintained in respect to the amount of fees charged and received. The registered manager maintained appropriate regulatory records, however a number of records required attention for example the care plans and medication 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. Documentation was seen during the inspection to indicate the electrical installations, electrical appliances and fire equipment were tested on a regular basis. However, the gas safety certificate was not seen during the inspection. Health and safety checks were carried out on the building and risk assessments were carried out as appropriate. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 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 X 18 2 4 4 3 3 3 4 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 2 2 Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 25 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 OP4 Regulation 14 (1) (d) Requirement The registered manager must confirm in writing to the resident that having regard to the assessment the care home is suitable for the purpose of meeting the resident’s needs in respect to his/her welfare. A clear system of care planning must be developed. 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 following the monthly review; any agreed changes must be recorded and actioned. (Previous timescale of 15/08/05 and 30/04/06 - not met). The service user plans must include all health care needs and provide clear guidance to staff of how these needs are to be met. (Previous timescale of 15/08/05 and 30/04/05 - not met). DS0000035069.V291767.R01.S.doc Timescale for action 30/05/06 2. OP7 15 30/07/06 3. OP8 15 01/08/06 Woodside Home for the Elderly Version 5.1 Page 26 4. OP8 15 5. 6. OP9 OP9 13 (2) 13 (2) 7. OP9 13 (2) 8. OP37 17, 18 9. OP38 13 (4) (c) A record of weight must be maintained for monitoring purposes. (Previous timescale of 01/08/05 and 15/03/06- not met). All prescribed medication must be administered in line with the prescriber’s instructions. The medication administration record must be signed contemporaneously to avoid omissions on the records. An appropriate key must be used whenever the resident does not take medication. Whenever medication is changed or discontinued the medication administration record must be clearly marked with the date and all other relevant details. All regulatory records must be kept complete and up to date at all times. (Previous timescale of 14/02/06 – not met). A gas safety certificate must be produced to provide evidence the gas installations have been checked and are safe. 01/07/06 30/05/06 30/05/06 30/05/06 30/05/06 30/06/06 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. 2. 3. Refer to Standard OP8 OP9 OP18 Good Practice Recommendations A record should be consistently maintained of the residents’ weight. A protocol should be devised for the administration of all medication prescribed “as necessary”. The vulnerable adults procedure should include the contact details of the relevant agencies and set out the roles and responsibilities of the registered manager and staff. Woodside Home for the Elderly DS0000035069.V291767.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington 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 DS0000035069.V291767.R01.S.doc Version 5.1 Page 28 - 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!