Inspection on 01/06/05 for Woodside Lodge Resource Centre

This inspection was carried out on 1st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Lodge Resource Centre 17/04/07

Woodside Lodge Resource Centre 17/07/06

Woodside Lodge Resource Centre 06/04/06

Woodside Lodge Resource Centre 11/10/05

Woodside Lodge Resource Centre 17/11/04

Woodside Lodge Resource Centre 27/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Woodside Lodge Resource Centre Wimpson Lane Maybush Southampton SO16 4PS Lead Inspector Christine Hemmens Unannounced 1 June 2005 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 Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodside Lodge Resource Centre Address Wimpson Lane, Maybush, Southampton, SO16 4PS 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) 023 8077 6141 Southampton City Council Mrs T Kimber Care Home 27 Category(ies) of DE(E) - 27 registration, with number OP - 27 of places Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: All service users admitted as from 20 October 2003 must be in DE(E) category. Date of last inspection 17/11/04 Brief Description of the Service: Woodside Lodge is a resource centre that provides a range of services to older people (65 plus) living in the west and central areas of Southampton City. The home is a specialist unit for older persons who have dementia, caring for people with progressing dementia, physical frailty and other functional difficulties. The purpose of the service is to provide a person centred care approach, one that will focus on using the physical environment and multi-sensory methods to enable positive interactions and communication with people. The home is able to accommodate both long and short-term care. All service users are accommodated on the ground floor in single room accommodation. The home is situated approximately 2 miles from Southampton City centre on main bus routes and adjacent to local shops. It has a day centre operating from the unit, which is managed by Southampton Care Association and is used to support users and carers living in the local community. Service users can access and use the facilities of the day centre on the same site when there are vacancies. Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first two day unannounced visit to the home this year. The registered manager was not available at the time of the inspection and has been absent from the since March 2005. The inspector was assisted with the inspection by the duty care coordinator and an acting manager who has been transferred from another service. The purpose of the visit was to review the fifteen requirements issued following the previous visit to the home in November 2004 and to seek the views where possible from the residents and staff. Seven of the fifteen requirements have been carried over, three of the requirements have been repeated for the third time, and a further failure to comply will result in enforcement action being taken. Serious concerns in the organisations recruitment practices and the current level of staff at Woodside Lodge has prompted a serious concern letter to be issued to the responsible individual. What the service does well: What has improved since the last inspection? Little improvement has been made to the home in terms of meeting requirements issued following the previous visit, however there was evidence that the shower room is now accessible for residents wishing to have a shower and some furniture has been purchased. The organisation has developed a system for safe guarding the financial affairs of the residents who do not have the capacity or wish to manage their own money. Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.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 Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.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 Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.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 and 2 The home fails to provide residents or their representatives with accessible and the correct information on the home and the terms and conditions of their residency. EVIDENCE: The home’s Service User Guide provides information on the facilities and what the resident and relatives can expect in respect of the health and welfare needs, however the three files the inspector viewed established that one resident had a copy of the new Service User Guide, one had an old copy and the other did not have one, this demonstrates that the home has taken little pride in informing and empowering the residents. The Service User Guide is nicely laid out and in a large print, however the home specialises in providing support for service users whose cognitive ability is failing, therefore the home must consider providing the Service User Guide in an accessible format. The inspector viewed three residents’ files to establish if the residents or their representatives had been provided with contracts that detail their terms and conditions of residency, including the fee to be paid, the room the resident will occupy, the date the resident was admitted to the home and evidence that the contracts had been signed by the manager and residents or representative. Although each resident has a contract in a personal file held in their room the Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 9 inspector observed a number of failures to comply with the previously made requirement. None of the contracts identified the room the resident will occupy or the fee they pay, others showed inconsistencies in the completion of the contracts such as the day of admission, and signing of the contract, some had been signed by relatives but not the manager and visa versa. This is very poor practice. The inspector was informed that the staff had been briefed to ensure all residents’ files were up to date with new contracts and had been given new contracts to place in residents’ files. This corresponds with the feedback and action plan from a senior manager in the organisation, which stated the requirement, would be met by the 31st March 2005. However it appears the staff had been issued with the wrong contracts and still had not completed them correctly for new residents to the home. The inspector later viewed a new contract, which had recently been finalised with all the required details on it. Therefore the organisation had not met the required timescale of the 31st March 2005 to ensure residents were issued with the correct contracts. Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.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) 7and 9 With limited staffing levels and consistency of staff the home does what it can to meet the residents current health, personal and social needs. The home in part demonstrates it respects and values the residents, however the home must ensure it finds an appropriate solution for maintaining residents confidentiality and security of records. The home has made improvements to its medication procedures, however further work is required to ensure mistakes are not made. EVIDENCE: Each resident has a personal plan that is kept in the residents’ room and provides information on the residents’ personal history likes, dislikes, strengths and needs. A member of staff with whom the inspector spoke with stated she had enjoyed completing the information with some of the residents and their families as it had given her an opportunity to get to know the person. When the staff were asked if they felt the home was meeting the residents personal identified needs as sated in their plans, they said they do their best but because of the complexities of the residents they support they often have to best guess what it is they are saying or wanting. Another member of staff stated the home does its best to help them and show them dignity and respect. All the residents with whom the inspector met with appeared clean, tidy and neatly dressed. However the home is currently very understaffed and Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 11 staff said they wished they could have more quality time to spend with the residents, to sit and chat, paint their nails or even take them for a short walk. This demonstrates the home is currently experiencing difficulty in meeting the residents’ social and emotional needs. The inspector spoke with a small number of residents who were very complimentary of the staff and the help they gave them, however they could not remember if they had a care plan and if staff shared it with them. The inspector observed behaviours identified at the previous inspection, such as repeated pacing and repeated opening of alarmed exit doors. The home was required at the previous inspection to seek advice from health care professionals on these obsessional behaviours. The home prides itself as a specialised unit for the Elderly Mentally Infirm, however neither the deputy manager, or staff on duty could confirm if the residents had been reviewed by a health care specialist, but stated it was difficult for them to manage such behaviours. The inspector observed the activity of opening alarmed doors and residents’ requesting to go home was increased late afternoon when only three care staff and one coordinator are on duty. Limited staffing levels to meet the residents needs and behaviours puts residents at potential risk, this was demonstrated recently when the home was alerted to a resident missing by a relative, which then alerted the home that another resident was also missing. However the inspector would like to give credit to the staff that she did see trying to interact and divert the residents’ obsessional behaviours in a positive manner. The inspector also observed a member of staff offering support and concern when a resident appeared unwell. Another member of staff staid she felt the home did well to meet the residents physical needs and this is further evidenced by a doctors letter stating the home did very well to meet the needs of a dying resident. The inspector met with staff who demonstrated they were aware of the core values of dignity, respect, choice and maintaining independence when supporting residents, however since the last visit to the home an alternative office space has been provided for senior staff to undertake daily administrative duties. The office which is needed as a hairdressing room twice a week, holds confidential information on the residents and discussions take place in respect of the residents. On the day of the visit the hairdresser was using the office and care staff were undertaking their administrative roles. Residents’ records are kept in a trolley that is removed from the room whenever a senior member of staff leaves the room. This demonstrates that the staff are respectful of the residents confidentiality, however it is extremely inconvenient for staff to keep remembering to remove the records and not leave information on the desk. The home must consider an alternative arrangement to ensure residents’ confidentiality is kept at all times. The requirement issued at the previous visit to the home for all residents who receive “as required” medication (PRN) have protocols in place for their use has been met. However there are still concerns regarding the administration of medication. The inspector spoke at length with the member of staff regarding the practice of not taking the medication trolley or notes to the resident when administering the medication. The member of staff gave a very Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 12 good explanation as to why she had done it the way she had on this occasion and realised what she had done was a mistake and that it would not happen again. The acting manager is advised to ensure this practice does not happen again, however further concerns are that there are currently only three staff trained to administer medication and at the time of the inspection only two members of staff the acting manager and a care coordinator were available other than agency trained staff to administer medication. The inspector established through the course of the inspection that the two permanent senior members of staff are currently doing back-to-back sleep ins and carrying out very important tasks such as the administration of medication. Over stretched and tired staff have an increased potential to make mistakes. Good practice was seen in obtaining doctors letters when there are changes to medications, however the practice of completing medication administration recording (MAR) sheets by copying from label is not considered to be best practice and where possible the staff must ensure MAR sheets are updated by the pharmacist. Changes to medication mid cycle of the MAR sheet produced by the pharmacist must where possible be authorised by the GP. Changes made over the phone must be recorded and witnessed by two members of staff and the home must ensure that short stay resident’s MAR’s are updated prior to the service user commencing their stay. The home must also ensure medication stock levels are kept to a minimum and arrangements are made to return prescribed medical aids such as catheter bags when no longer required. Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 13 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 and 13 The staff do their best to engage residents in activities and offer choices. However the home must develop an environment that assist residents to make choices and engages them in valuing and rewarding activities. EVIDENCE: The inspector observed over the two-day visit that there was very little stimulation in the form of one to one or social activity with staff, although some residents were observed socially engaging with one another. One resident informed the inspector that they didn’t do very much, however another stated they occasionally had a sing a long, did their knitting and had “the odd bus run”. This was supported by an advert for a bus trip to a garden centre for cream teas. However as previously mentioned staff stated they wished they could have more quality one to one time with residents, the inspector observed that the staff spent most of their time meeting the residents’ basic needs. The home has a sensory room which all staff have been trained to use with the residents, the inspector was informed that it is used from time to time but not as much as it could be. The inspector recalls at the previous visit that Southampton University were undertaking research into the use of sensory rooms for residents with dementia and used Woodside Lodge sensory room for their research and trained the staff, a valuable resource not to be used to its full potential. The home does well to provide an environment that assists residents to find their way around the home, coloured coded areas, names and pictures of the Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 14 residents on their bedroom doors and sign on toilets. However the requirement issued following the previous visit to the home to assist residents to be empowered to make choices in an accessible formats that meet the individual resident’s cognitive and sensory needs i.e. menu plans has not been met. Through discussion with the senior staff and care staff they demonstrated that they had not considered providing residents with an accessible format of communication that allows them to make choices, although the staff confirmed that the residents were provided with verbal choices i.e. menus the day before the meal is prepared. Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 15 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 provides little evidence that it appropriately supports residents to make complaints and protect them from potential abuse. EVIDENCE: The home has comprehensive policies and procedures on complaints and protecting vulnerable people and the home is supported by administrative departments within the organisation in dealing with complaints and allegations of abuse. Residents and their representatives are provided with information on how to complain or make compliments “Your Views Count”, however at the previous visit the organisation was advised to ensure the residents and relatives/representatives are made aware of the new title of the Commission for Social Care Inspection as the information stated the National Care Standards Commission. This requirement will be repeated as the three information packs the inspector viewed still contained old copies of the complaints procedure. One resident was admitted on the 4th July 2005 for short stay and his information pack contained an old complaints procedure. The feedback received from a senior manager in the organisation following the last visit confirmed that stickers would be issued and adhered to the complaints procedure by 31st March 2005 this has not been carried out. The staff with whom the inspector spoke with confirmed that they had received training on abuse awareness and they confidently confirmed what they considered constituted abuse and what they would do if they witnessed an abusive occurrence. However the home has failed to provide an environment for residents that fully protect them from harm or abuse. Following a recent allegation made by a resident it has been identified that the procedure for protecting vulnerable Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 16 adults had not been correctly followed, leaving the residents at continual potential risk of harm. The organisation must also ensure all its staff including administrative staff working in the area of human resources are aware of First POVA and obtain the appropriate checks before commencing newly appointed staff. Further evidence was established that staff had complained about the poor working practices of one of their colleagues, including being late for work, using inappropriate language towards residents and staff and eating residents food. No further action was taken with this member of staff other than to discuss it with them informally. Recently two residents left the home unnoticed through a side gate that had been left unlocked by gardening contractors. Procedures are now in place to minimise the risk of a similar occurrence happening again. However it was identified that the residents had left at a busy time of the day, when minimal staff are on duty and at a time when residents become restless. When viewing the area that the residents had left the home, there was evidence that there had been an attempt to open the gate, this was again observed on the second day of the visit. The home is advised to increase staffing levels at this time of the day. Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 17 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, 21,24 and 26 The staff work hard to provide a homely, clean and welcoming environment for residents to live, however further improvements are needed to improve the aesthetic appearance of some bedrooms and bathrooms and to make safe the garden. EVIDENCE: Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 18 The home has 27 bedrooms, two of which are used for short stay residents. The home is divided into three separate living areas through out, each having a lounge/dining room. The home has communal areas that can be shared by all, a hairdressing and treatment room and a sensory room. The home offers a bright clean and airy environment, a laundry facility and housekeepers who are on hand throughout the day. The residents with whom the inspector spoke with said they though t the home was nice and that they liked their bedrooms. One resident said she was very comfortable and could not ask for anything else. The home’s garden is large, mainly laid to lawn and has a path for easy access around the garden. An area of the garden which had a steep slope, seen as a potential risk at the previous visit has been made safe, however the previously made requirement to address residents wandering into the heavy undergrowth has not been met and therefore the requirement will be carried over. The registered persons are advised that a further failure to comply will result in further action being taken. The inspector was informed that on at least two occasions, one being recent, residents had wandered into the undergrowth and had fallen, they had not been discovered for some time as they could not be seen. The manager is advised that the Commission for Social Care Inspection must be informed without delay of such occurrences. The home has 3 bathrooms and 1 shower room, the inspector spoke at length with the acting manager and senior care coordinator regarding their and staff fears that residents are being placed at high risk by having unsupervised access to one of the bathrooms as the door remains unlocked and they are unable to lock the door as the absent registered manager has the key. This situation has occurred following a previous visit to the home where the manager had misunderstood the discussion around accessibility for residents to bathrooms. The inspector was informed that all residents require supervision whilst bathing and therefore would gain access with staff. However staff must ensure residents are empowered and supported to have a bath when they wish, (as far as feasibly possible to do so). The home is required to ensure all residents have risk assessments on them on accessing and using the bathroom and the door to the bathroom identified at the time of the visit remains locked. The requirement made at the previous visit to find suitable storage facilities for its moving and handling equipment has been met and the shower room is now accessible for residents wishing to shower. However the acting manager is advised to remove the boxes of unused catheter bags and the shower room must be kept clean at all times and form part of the general daily cleaning programme. Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 19 Each of the 27 bedrooms is fully furnished and residents can bring in small items of furniture and mementos if the they wish. However some rooms lack a homely, welcoming appearance and are in need of redecoration and furnishing. This was also made a requirement on the 27/07/04 and 17/11/05 and will be carried over and a further failure to comply will result in enforcement action. Room 15, a room for a female resident appeared dull, lacked colour and was without a mirror. The carpet in this room required cleaning. The inspector received feedback on the last inspection report from a senior manager in the organisation stating that a budget had been identified to enable the manager to order new furniture, bed linen and chairs for bedrooms before the end of March 2005. Although there was evidence that some chairs and covers for other chairs had been purchased, these chairs had been placed in the entrance to the home and not the bedrooms and staff could not confirm if new bed linen had been purchased. The home has ancillary staff that regularly clean the home and manage the laundry. The home is generally clean and free from offensive odours. However the home must address the unpleasant odour caused by incontinence in one area of the home. Regular thorough cleaning and alternative flooring is required. The inspector was informed that the home has purchased an aroma enhancing system but they had not had them installed as they were waiting for advice from the Health and Safety department. The acting manager is advised to chase up the health and safety officer for advice and install immediately if suitable to do so. The requirement made following the previous visit to rid the home of unpleasant odours will be repeated. Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 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 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, 29 and 30 The home provides staff with training to equip them to appropriately support the residents, however the home is poorly staffed and does not undertake correct recruitment procedures to fully protect the residents. EVIDENCE: The inspector met with three care staff at the time of the visit who confirmed that they felt fully equipped to meet the current needs of the residents. All the staff had received mandatory training and regular updates in moving and handling, fire, first aid, and food hygiene. One member of staff had just returned from an induction day where he was informed of the organisations management structure and their roles within the organisation and stated he had had a thorough induction into the home in the first few days of commencing his job. In addition the staff stated they had received service related training such as a four-day course in dementia care and medical needs related to the condition, and infection control. This demonstrates that the service takes seriously the need to train and fully equip its staff to meet the needs of the residents. However the home is currently very understaffed, at the time of the inspection the home was carrying five full time care staff vacancies, one care coordinator vacancy, one care coordinator was on long term sick and another member of staff on secondment to another home. The inspector was informed that there are four care staff one carer on duty in the morning and three one carers (Mainly agency) in the afternoon. The home is currently filling the vacancies with agency staff contracted from care agency who provide regular staff to the home. This in some way goes to Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 21 provide consistency of care, however places an additional burden on regular staff. The staff with whom the inspector spoke with stated if they could change anything about the home it would be to have more staff, more time with the residents and a settled staff team. The staff stated that the staff that are provided by the agency are good, however its not like working with your colleagues and sometimes there are language difficulties that make the job that little bit harder. This is an unacceptable level of staff and demonstrates the shortfalls in meeting the residents’ social, and emotional needs and their safety. The inspector viewed three staff files that recently commenced working in the home, two starting in May 2005 and the other on the 4th July 2005. The inspector found all records to be incomplete of the required recruitment documentation and checks. The inspector requested the acting manager to check with the organisations human resource department if “first POVA” checks and CRB’s had been carried out for the staff in question. The reply from the department was “I have never heard of a POVA check” and “I have seen proof of a an existing CRB, and I was told this was okay as long as it is less than six months old” Since July 2004 when POVA was introduced CRB’s were no longer transferable from one service to another. In addition the misconduct issues evidenced in a member of staffs file demonstrates very poor recruitment and management procedures and seriously places residents at potential risk of harm. This serious matter has been taken up directly with senior managers in the organisation. The acting manager was informed of her role in terms of recruitment. Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 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 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 and 36. The organisation has made attempts to ensure a smooth running of the home in the absence of the manager and the home attempts to support its staff. However the organisation must ensure acting managers with limited experience and care staff are fully supported to undertake their roles and responsibilities. EVIDENCE: The registered manager has been absent for approximately three months and the organisation has replaced the registered manager with a care coordinator seconded from another home within the city. The inspector met with the acting manager on both days. The acting manager showed commitment to the two day visits, coming in on one of her days off, however the inspector later established that the manager was covering the sleep in shift on her day off as the home is very short of senior staff. This appeared to be a regular occurrence and the acting manager admitted to “time taking over her”, leaving her short of time to fulfil her administrative duties. Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 23 The staff with whom the inspector spoke with said the acting manager was very good, approachable and hands on, providing support and encouragement when required. However the acting manager is very new to the post and saw herself in the role of maintaining the service until the registered manager returned. Despite being a very kind and approachable person the acting manager lacks the experience required to manage such a large service. This was demonstrated through the lack of knowledge of certain procedures and information identified throughout the report. The manager stated on a number occasions that she had sought support from her line manager responsible for another home in the city. However the responsible individual in the absence of the registered manager is responsible for ensuring the smooth running of the service. The three staff with whom the inspector met with stated they had had varying degrees of support from the manager. A new member of staff stated he had received good support through the induction process and had met with the manager on at least one occasion. Another member of staff stated it had been a long time since she had received supervision but felt confident if she had a problem she could go to the manager and another stated that they always receive very good handovers. As reported in standards 16 -18 and 27 –30 there was evidence that the manager had met with a member of staff to discuss with them their very poor work practices, all identified as misconduct issues, however the manager had failed to seek advice from personnel or a senior manager regarding the areas of concern, and had failed to obtain a signature from the member of staff on the notes she had taken. Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 1 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 x 15 x COMPLAINTS AND PROTECTION 1 x 1 x x 1 x 2 STAFFING Standard No Score 27 1 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 1 1 x x x x x x x Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 25 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 OP1 Regulation 4 Requirement The registered persons must produce a service user guide that is accessible for all residents, taking into account their cognitive ability. The registered persons must ensure all contracts are fully completed with all relevant details on the date of admission, or as close as feasibly pocssible. This requirement has been repeated. A further failure to comply will result in further action being taken. The the registered persons must seek advice from health care professionals on the obsessional behaviour /activity of those residents who repeatedly open exits and set alarms off. This requirement has been repeated. A further failure to comply with result in further action being taken. The registered persons must ensure there are sufficient numbers and skilled staff on duty at all times to meet the assessed needs of the residents. The registered persons must ensure: Medications are Timescale for action 31/10/05 2. OP2 5 31/08/05 3. OP8 OP19 12(1)(b) 13(1)(b) 31/08/05 4. OP4 OP7 OP27 12 18(1)(a) 31/08/05 5. OP9 13(2) 31/08/05 Page 26 Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 6. OP16 OP14 OP15 12(2)(3) 22(2) 7. OP16 22(6) 8. OP18 13(6) 9. OP18 13(6) 19(1) (a)(b) 10. OP38 OP19 13(4) (a)(b)(c) administered correctly at all times. Medication stock levels are kept to a minimum. That at all times there are enough trained staff to carry out the administration of medication safely. Sort stay residents medications are reviewed and up dated on the MAR by the pharmacist prior to comencing their stay. The registered persons must ensure service users are assisted and empowered to make choices in an accessible formats that meet the individual cognitive and sensory needs of the service users. i.e. Menu plans. The registered persons must ensure the complaints pamphlet produced for the residents and representatives is changed to reflect the name of the regulatory body from the NCSC to the Commission for Social Care Inspection. In the interim service users and/or representative must be informed of the change of name if they wish to make a complaint. This requirement has been repeated. A further failure to comply will result in further action being taken. The registered persons must ensure that all its staff are familiar with the procedure for evoking the Vulnerable Adults Procedure. The registered persons must ensure that all its managers and administrative staff are aware of the first POVA check undertaken on staff prior to and starting employment. The registered persons must ensure the health and safety of 30/09/05 31/08/05 31/08/05 31/08/05 31/08/05 Page 27 Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 23(2)(o) 11. OP19 OP24 OP21 23(2)(d) 12. OP26 16(2) (c)(k) 13. OP21 13(4)(a) (b)(c) the residents accessing the garden. A plan of action with timescales must be sent to the Commission for Social Care Inspection stating what action will be taken to ensure the safety and prevent the residents wandering into heavy undergrowth areas. This requirement has been carried over from the last two inspections carried out on the 27/05/04 and 17/11/04. A Further failure to comply will result in enforcement action. The registered providers must 31/08/05 provide the Commission for Social Care Inspection with an action plan detailing the aesthetic improvements to the bathrooms and bedrooms. This requirement is carried over from the previous inspections held on the 27/07/04 nd 17/11/04. A further failure comply will result in enforcement action being taken. Timescales for improvements will be negotiated and agreed with the Commission for Social Care Inspection. The registered persons must 31/08/05 ensure robust procedures are in place to eliminate unpleasant aromas effectively. Alternative flooring materials must be considered in bedrooms where there are persistent continence difficulties. This requirement has been repeated. A further failure to comply will result in further action being taken. The registered persons must 31/07/05 ensure that all residents are risked assessed accessing the bathroom, empowered to take a bath when they wish and the Version 1.30 Page 28 Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc 14. OP27 18(1)(a) 15. OP29 19(1) (a)(b) 16. OP36 18(2) bathroom door identifed at the time of the inspection is kept locked at all times. The registered persons must 31/07/05 ensure there are appropriate numbers of skilled, competent and experienced staff to meet the needs of the service users. The service must provide the Commission for Social Care Insepction with an action plan detailing how they are going to meet the shortfalls in staff. This requirement has been repeated. A further failure to comply will result in further action being taken. The registered persons must 31/07/05 ensure the home and organisation follows the correct procedures, and takes up the appropriate checks when recruiting staff. i.e. CRB and first POVA checks, references, ID and employment history. The registered persons must 31/08/05 ensure its managers and care staff are regularly supported to undertake their roles and responsibilities. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Woodside Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 29 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW 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 Lodge Resource Centre H55-H03 S39181 Woodside Lodge V218916 010605.doc Version 1.30 Page 30 - 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!