Inspection on 01/09/05 for Woodside House

This inspection was carried out on 1st September 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 House 07/12/06

Woodside House 05/04/05

Woodside House 13/09/04

Woodside House 28/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Woodside House Woodside Road Norwich Norfolk NR7 9XJ Lead Inspector Ruth Hannent Announced 1 September 2005 9.30am st 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 House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodside House Address Woodside Road, Norwich, Norfolk, NR7 9XJ 02073 522224 02073 422229 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) Barchester Healthcare Homes Limited Ms Vanessa Snow Care Home 56 Category(ies) of Dementia (30), Old age, not falling within any registration, with number other category (14), Physical disability (12) of places Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Fourteen (14) Older People, not falling into any other category, may be accomodated Thirty (30) Service Users under the age of 65 years who have dementia may be accomodated Twelve (12) Service Users under the age of 65 years who have a physical disability may be accomodated Total number accomodated not to exceed fifty-six (56) Date of last inspection 5th April 2005 Brief Description of the Service: Woodside House is a care home providing nursing care and accommodation for 56 service users. The home is separated into three units, Willow can accommodate 12 service users with a physical disability, Sycamore can accommodate 14 older people and these two units are managed as one, with Elm accommodating 30 older people with dementia and managed as the second unit.The company of Barchester Healthcare owns it.The home is situated on the outskirts of Norwich close to local shops and GP surgery. It was opened in 2002 and consists of a single storey building within its own grounds. All the home’s bedrooms are single with en-suite facilities. There are two enclosed well-maintained gardens with ample car parking at the front of the premises. Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place over 6 hours. Residents were spoken to along with staff and relatives. A tour of the home took place with all three units inspected. Some records were inspected such as health and safety, complaints, care plans, medication and personnel/training files for staff. Two comment cards and the pre inspection questionnaire were discussed. What the service does well: What has improved since the last inspection? What they could do better: The Home needs to look at its recording practise to ensure information is not repeated and that continuity of care is recorded in one place for relevant staff to read and record. Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 6 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 House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 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 House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 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) EVIDENCE: These standards were not inspected on this occasion. Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 9 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 and 11 Information for care plans is available but it does not cover the whole persons needs in one format which makes it difficult to ensure all areas of care are met. The health care needs of residents are met well by a multi professional approach. The residents are assisted with their medication by a qualified staff member and procedures are followed with one reservation regarding the safety of medication when not in view. Residents are treated with dignity and respect. The Home is very sensitive to the needs of the resident and family at the time of death. EVIDENCE: The residents care plan and information is held in a clinical style system that records all information but on various sheets of paper. For staff to gain a full Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 10 picture of the person each sheet needs to be looked at, taking time and effort to collate all the information to ensure the correct care is happening. This plan of care should also be signed by the resident or residents’ representative to show involvement and agreement. (Recommendation) This care home has qualified nurses who over see the health care needs of the residents. The GP’s are actively involved and records were seen of chiropody, continence programmes and specialist advice in two care plans looked at. Residents are assessed to ensure all their nursing needs can be met. On walking around it was noted that the specialist care one resident was receiving was appropriate. The nursing staff are responsible for the administration of medication. This process was observed and each stage was carried out correctly from the chart check for name, medication, dose and time to the ensuring of ingestion before the chart was signed. Each recording chart had the residents photo on the front and all areas of the chart had been signed for in with the appropriate code or signature. One concern was the trolley was not always in vision of the staff member when entering to offer medication, leaving the trolley unlocked. This is not part of the procedure of the home and needs to be addressed. (Requirement) The controlled drugs are stored in a double locked cabinet in the medical room. The recording for these drugs were seen and accurate according to the names, dates, medication, dose and double signature of amount administered and amount remaining. Throughout the day the staff’s approach to residents was noted. Doors were knocked upon before entry and residents were asked before any action/assistance was taken. It was also noted the staff induction pack contained information on the way residents should be addressed and the respect of privacy and dignity. Although this was apparent most of the day, one resident had their door ajar and her catheter bag on a stand by the bed was on full view for all passers by. (Recommendation). The Home has a policy on ensuring that residents who are dying are treated with respect and dignity. The Manager will discuss with the family and resident their wishes and will invite any family members who live far away to stay in the accommodation available within the Home to be close on hand. Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 11 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 and 15 This Home works hard to achieve stimulation and recreational interests to fulfil the lives of the residents. Residents are encouraged to maintain links with families and friends by visitors at the home or out in the community. It needs to be made clear that residents are offered choice especially where and it what they would like to sit. Meals are served that are attractive, wholesome and well balanced. EVIDENCE: The Home is very active in trying to accommodate all the interests of the residents. On the day of the inspection a theme of the ‘sea’ was creating a buzz throughout the building. The activities staff were busy helping create colourful fish with eight residents. Some had Nelson style hats on that they had ready for the afternoon boat trip out from the Broads. Some residents were taking an early lunch in preparation for the outing with anchor shaped pastry covers to the pies on their plates. (A special menu had been created with a nautical theme for the day). Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 12 Jigsaws are in place in the atrium for people passing to and fro to place the odd piece in and one residents’ daughter was reading a book of memoirs to her father. In the back of each care plan is a format ready to ask questions of all people involved with each resident so a life book can be created to aid staff in a more individual approach when planning stimulation for each person. These are to be completed shortly. Visitors were seen coming and going throughout the day with staff greeting each one appropriately. Some went directly to the bedrooms, some in the lounge and one in the atrium. A concern shared with senior staff was the choice of residents being offered a more comfortable seating when they are relaxing. It was noted throughout the inspection that people were left in their wheelchairs with some falling asleep in what appeared uncomfortable positions. (Recommendation) The meal times are set in different dining areas with residents having space to move about and for not to many people to be sat together. It was noted that staff were available to assist with meals without having to move around the room. The meal was on the nautical theme and appeared to be enjoyed by most people. The tables were set to attract the eaters with a picture of Nelson’s flagship ‘The Victory’ as a centrepiece. The atmosphere was relaxed and unhurried with the people who were booked for the trip already eaten and ready to go. One lady commented “I am always ready for my meals as they are so good and I enjoy everything”. The menu’s seen with the pre inspection questionnaire appeared balanced and nutritional with liquidized or fortified extra drinks available for those requiring it. Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 13 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 The Home has a robust complaints system and will act upon and take seriously any concerns addressed by all parties involved. Policies and information shared in induction of new staff should ensure residents are protected from abuse but a full training programme will make sure all staff are clear and understand the protection of vulnerable adults. EVIDENCE: The Home has a comprehensive complaints procedure. This is offered to residents in the form of a welcome pack placed in each bedroom and a picture frame display is also in the entrance where all information is available for any visitors. Two records of complaints were seen. Each complaint was seen as dealt with appropriately by sharing the content with Barchester Healthcare Regional Director. All action taken is recorded and copies of letters are retained. A comment card received from a relative prior to the inspection will be looked at and discussed with the resident and their family member with guidance from the Regional Director. The senior staff team members have all received the appropriate POVA training and the rest of the staff team are about to have this training cascaded to them. The plan is to cover all staff over the next few months. (Recommendation) The Home has a whistle blowing policy that is introduced to staff along with all other relevant policies as part of their induction. Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 14 Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 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 and 25 The environment within this Home is well maintained with high standards both indoors and outside that are seen as suitable for the residents. Records are available and all areas are seen as safe. The exception are the door thresholds in the atrium which present a potential tripping hazard for service users. EVIDENCE: Woodside House has just had many of the areas freshly painted. The whole building is light and spacious. The furniture and curtains are of good quality with many areas for people to sit and relax in. The Home is only a few years old and the standards required of a new building are all in place. The grounds around the building are well kept with neat garden beds, seating areas and a gazebo for shade on the lawn. All bedrooms have a toilet and hand wash basin facility with adequate bathing facilities in each unit. Four were viewed in different areas of the Home and were noted to be clean and tidy. Two residents spoken to in their rooms told Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 16 how much they loved the Home and their own bedroom. “ I am very happy here and love my room” was one comment. Residents are assessed for the correct adaptations and equipment they may need with hoists and specialists beds and mattresses for those requiring them. The communal areas are large with plenty of space for freedom of movement for wheelchair users. The thresholds in the Atrium are still raised and need to be re-designed to prevent a potential accident, which is an outstanding requirement from the previous inspection. If this is not feasible a risk assessment needs to be carried out and recorded. (Requirement) The Home has a health and safety officer employed by Barchester Healthcare who visits the Home to cover all areas of Health and Safety. Records were seen of the water temperature checks of the hot and cold water taps in all areas. The hot taps all varied between 42 and 46 degrees. This was checked again by hand on the day of the inspection and it was noted to be comfortable at hand hot. Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 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 and 30 There is a good skill mix with adequate numbers of staff at Woodside House. The Home is working hard towards all care staff obtaining the NVQ 2. to ensure residents are in safe hands. There is a robust procedure in place for recruiting staff to ensure the residents are supported and protected by appropriate staff. Staff at Woodside House have the offer of good all round development and training to give them the competences to do their job. EVIDENCE: The Home has a suitable ratio of staff to residents. The job roles are clearly defined to ensure all task carried out are of quality such as seen were the activities staff concentrating on the stimulation for residents or the waitress who was setting tables and serving regular drinks to ensure residents were taking in enough liquids. A copy of the rota for the week of the inspection showed a mix of skills of both qualified and unqualified care/nursing staff throughout the day and night. The Home has recently had a problem with vacancies for both domestic staff and nursing staff for the Elm unit. The recent recruitment drive has nearly covered all these vacancies and the Home is on the way to ensuring consistency of staff to the residents. Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 18 The Home has a designated training co-ordinator who will oversee all the inductions, which follow the direction of the TOPSS training programme. Each staff member will complete the induction and will then use some of the knowledge gained to cross reference with some NVQ units. This was seen on a few staff files that are held in the resources room. At present there is 56 of the staff who have a recognised qualification. (The majority of this is the qualified nurses). The Home has been recruiting staff recently and some of these personnel files were looked at. Each one had a tracking sheet to ensure all relevant paperwork had been received or where it was in the process if not returned. Noted were the application forms, POVA and CRB checks with two references, copies of the person’s I.D. and work permits for those who need to have one. All CRB’s were held in the safe, checked on the day of inspection and then disposed of with only a copy of the name and CRB number held on file. Certificates for training recently undertaken are copied and held with all training achieved in an manual for each staff member. All statutory courses are covered by the training co-ordinator who is an assessor for NVQ, a trainer for first aid, a moving and handling trainer and a qualified nurse. On talking with this member of staff it was clear the Barchester group are keen to help develop the skills of the co-ordinator to enable the cascading of training within the Home. (Recently completed was a four day health and safety course, which senior staff attended). One carer spoken to was full of praise of the amount of training and support she is given and has in the past three years attended as many as she could, which included all the statutory courses. Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 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, 35 and 38 Woodside House is run by a Manager who is able to carry out the duties responsibly. The residents’ money is not handled by staff members at Woodside House, which will ensure their finances are safeguarded. The health and safety of all at Woodside House is promoted to ensure everyone is safe and protected. EVIDENCE: The Manager of Woodside House has been the Registered Manager for over two years and is both a qualified psychiatric nurse and holds the NVQ 4 Management qualification. (Certificate seen on display in the office). The senior team within the Home are competent and understand the conditions associated with old age and are very experienced with the needs of the younger residents within the Home. On talking to the recently appointed Matron it was evident Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 20 her knowledge of the people who live at Woodside is understood and with her experience of running a residential home in the past would be a compliment to the management structure. The Home holds no money for any resident. All expenditure for the resident is sent to the families via an invoice such as hairdressing, chiropody or newspapers. Some residents hold small amounts of money for small items and some residents control all their own money but nothing is held by the Home and no cash is handled. The Manager takes a lead in ensuring all health and safety areas within the Home are covered. All the health and safety training is planned with the training co-ordinator for safe working practise. The health and safety file is accurate and constantly being updated. Clear records of maintenance are stored and all checks under this category, such as fire alarm checks, emergency lighting and water temperatures were seen. Accidents within the home are recorded and RIDDOR forms sent as appropriate. The most recent accident report was seen, which are then logged with Barchester Healthcare who collate all the information to identify if any of the accidents could have be prevented. (Over the months this identified times when staff are required to be in the lounge to hopefully prevent falls and this led to an increase in staff for this particular area). Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 3 2 x x 3 x STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x 3 x x 3 Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 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 9 Regulation 13(2) Requirement The Registered manager must ensure the medication trolley is locked at all times when not in full view of the member of staff administering medication OUTSTANDING REQUIREMENT. The raised thresholds in the atrium need to be changed to ensure safe movement for all residents or as a minimum a full risk assessment needs to be in place. Timescale for action Immediate and ongoing 30th Novemeber 2005 2. 22 23.2 (a) and 13 (4) 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 7 10 14 18 Good Practice Recommendations It is recommended that all care plan documents are signed by the resident or representative to agree care needs. It is recommended that any resident who requires specialists equipment such as catheter bags has some fway of hiding it from public view. It is recommended that residents are offered choice as to where they would like to sit and not assume by leaving them in their wheelchairs that this is what they prefer It is recommended that all staff are POVA trained as soon I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 23 Woodside House as possible. Woodside House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 3rd Floor, Cavell House St Crispins Road Norwich NR3 1YF 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 House I55 s32205 woodside v240348 010905 stage 4.doc Version 1.40 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. 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. 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