Inspection on 11/10/05 for Woodside Lodge Resource Centre

This inspection was carried out on 11th October 2005.

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

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

Other inspections for this house

Woodside Lodge Resource Centre 17/04/07

Woodside Lodge Resource Centre 17/07/06

Woodside Lodge Resource Centre 06/04/06

Woodside Lodge Resource Centre 01/06/05

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 Hants SO16 4PS Lead Inspector Christine Hemmens Unannounced Inspection 11th October 2005 09:30 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 Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 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 Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodside Lodge Resource Centre Address Wimpson Lane Maybush Southampton Hants SO16 4PS 023 8077 6141 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) Southampton City Council Mrs Theresa Mary Kimber Care Home 27 Category(ies) of Dementia - over 65 years of age (27), Old age, registration, with number not falling within any other category (27) of places Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users admitted as from 20 October 2003 must be in the DE(E) category 01/06/05 Date of last inspection 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 provide both long and short-term care. All service users are accommodated on the ground floor in single rooms. 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 DS0000039181.V250043.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced visit to the home this year it was carried out over one day by two inspectors. The registered manager was not available at the time of the inspection and has been absent from the home since March 2005. The acting manager Mrs Janet Harris who has been seconded from another Southampton City Council service assisted the inspectors with the inspection. The purpose of the visit was to review the 16 requirements issued following the previous visit to the home in June 2005, and to seek the views where possible from the residents and staff. An enforcement notice was issued as a result of poor compliance with previously made requirements and a serious concern letter regarding the home and organisation’s recruitment practices. Seven of the eighteen requirements have been carried over, three of the requirements have been repeated for the third time as a result of poor recruitment practices and a failure to meet the previous repeated requirements and address the serious concern letter issued following the last visit to the home. What the service does well: What has improved since the last inspection? There has been limited improvement since the previous visit to the home, this has partly been highlighted as the inconsistent management arrangements and lack of support provided to the acting managers. However there is evidence to suggest the newly appointed manager is doing her best to improve standards within the home. Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 6 The manager has been proactive in involving residents (where possible), relatives and staff to work in partnership and meet to assess how they can improve communication, activity and standards in the home. The homes complaint procedure and work on an introduction and to produce an accessible contract is underway and is soon to be implemented in the home. 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 DS0000039181.V250043.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 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 the following standard(s): 1 and 2 The home is making progress in developing an accessible Service User Guide and to ensure residents are issued with a contract. EVIDENCE: The inspectors saw evidence that the requirement to issue residents with an accessible Service User Guide to meet their cognitive and sensory needs is in the process of being met. The home along with a senior manager and assistance from some relatives have developed the guide in coloured picture format and large print. The Service User Guide is yet to be introduced to the residents, however the manager stated she wanted to meet with all staff and have a further meeting with relatives as the aim is to use the Service User Guide as a daily tool to support the residents to have an awareness of their environment, rights and facilities. This is seen as good practice. All but five residents have been issued with a contract that details their terms and conditions of residency, the room the resident occupies and signed where possible by the resident or the resident’s representative and manager. A copy Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 9 of the contract is kept on the residents’ personal file, and a copy is kept in the resident’s bedroom. This was observed at the time of the inspection. The inspectors were informed that work is in progress to develop the contract in an accessible format. Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 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 the following standard(s): 7,8 and 9 The home has made progress in ensuring the homes medication administration polices and procedures are followed correctly, however the care planning process is inadequate, and neither allows for the provision of planned and consistent support of residents nor the promotion of independence and the maintenance of skills. EVIDENCE: The inspector reviewed files for four residents, one of whom who had been recently admitted to the home, the others who were identified as having specific support needs through discussion with both residents and staff. There was little evidence that care plans are based on assessment of need. Individual care plans contained scant information in relation to strengths and needs, and little detail regarding the specific support needs of individual residents. The plan for the most recently admitted resident was blank, although they had spent periods of respite in the home previously. There was evidence that some plans are reviewed, however amendments are not always dated or signed. Although the home provides support for people who have dementia, there were no assessments or support plans seen for residents in relation to needs associated with dementia. There were no plans noted for the Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 11 promotion of continence. All residents are identified as having high support needs and require a consistent approach to support them to maintain their physical and mental health and welfare, however the poor approach to documenting and recording identified needs can have a detrimental affect on the overall residents care. There is evidence to demonstrate that residents are provided with support to maintain their health from primary health care professionals such as GP’s, opticians and chiropodists, however as stated earlier there is no evidence to suggest that the mental health needs of the residents are adequately assessed and met. The manager informed the inspectors that the home has a very good relationship with community psychiatric nurses and care managers who are based in the building and will assist with queries about residents mental health needs at short notice. However the home has previously been required to refer one resident to the older persons mental health team to address inappropriate and obsessional behaviors. The newly seconded manager could not confirm if a referral had been made and there was no evidence in the residents plans to support a referral. Therefore the home does not adequately meet the mental needs of the residents and will be required for a third occasion to refer the resident identified at the time of the visit. A further failure to comply will result in further action being taken. The home has made improvements to the administration of medication, especially in recording the medications administered. The manager has developed a monitoring checklist form and weekly checks the administration of medication. The manager advised the inspector that she has had recorded meetings with staff who have failed to record correctly medications administered or not administered and has placed staff on further training. This is seen as good practice and the manager is praised for her positive approach to ensure residents receive their medication as required. Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15 The home has made some progress in assisting residents to be empowered, maintain awareness and have choices and control over their daily routines and activities. However further work is required to meet the previously made requirement to ensure residents cognitive and sensory needs are taken into consideration when making choices. EVIDENCE: The manager informed the inspectors that the home is working towards providing and informative and stimulating environment to meet the residents cognitive and sensory needs to assist them to make choices about their routines and daily activites. This was evidenced by the development of a Service User Guide in an accessible format, the involvement of family and friends in developing a newsletter, information on future events, and the early stages of developing a menu plan in an accessible format with pictures and photographs. The manager also informed the inspectors that residents are supported to undertake their daily routines as they wish and a number of residents liked to have a lay in the morning and have their breakfast in bed, this was confirmed by a member of staff, however the inspectors observed a resident asleep slumped over a dining room table at 9.30am. The senior member of staff was asked as to why the resident was already asleep following breakfast and had Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 13 been allowed to fall asleep at the table. The staff member informed the inspectors that the resident was an early riser and this was her usual routine. Staff must not allow residents to fall asleep over a table and must encourage them to leave the table and find a comfortable place to sit or lay to have their usual nap. The inspectors later met with other residents who had also received breakfast, the residents said they were okay and had enjoyed their breakfast however none of them were aware of what their day was going to entail. One resident appeared apathetic stating, “nothing ever happens here” and another was upbeat and tried to make light of what they might do. The four personal plans viewed by the inspectors did not reflect the residents’ individual routines and activity, therefore staff have little information on how to support, address or work with the residents individual need. Staff must be provided with information and the tools to assist them to undertake an individualised approach. Therefore the home must ensure that personal plans reflect the resident’s routines, activity and interest and how these must be met. The development of accessible formats and tools to meet the sensory and cognitive needs of the residents has not met its previously set deadline. The inspectors recognise that the newly seconded manager and senior managers are trying to address the requirement and therefore the requirement deadline will be extended and will be reviewed during the next visit to the home, however a further failure to comply will result in further action being taken. Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has made some progress in informing residents and their relatives of how to make a complaint and ensuring the staff team are familiar with adult protection policies and procedures. However the timescale for implementing an accessible complaints procedure with the correct name of the regulatory body and for all staff to become familiar with the adult protection policies and procedures has been exceeded and therefore will be repeated. EVIDENCE: The inspectors were informed that senior managers were making progress in developing an accessible complaints procedure for residents. Reference to the complaints procedure is in the Service User Guide and the inspectors saw a draft version of the complaints procedure “Your Views Count” which clearly and simply details how the resident can complain and who they can complain to if they are unhappy including the Commission for Social Care Inspection. However following the last visit to the home the home was required to ensure that residents and their families were made aware that the name of regulatory body for eighteen months has been the Commission for Social Care Inspection (CSCI) and not the National Care Standards Commission (NCSC). The home was advised as a temporary measure to place stickers over the name. Evidence suggests that this has not been done and demonstrates that the service does not take seriously that residents and relatives may wish to complain externally and the importance of meeting requirements within the stipulated timescales. The requirement to inform relatives and residents of the Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 15 change of name of the regulatory body and produce an accessible complaints procedure will be repeated. A further failure to comply will result in further action being taken. There was recorded evidence that the majority of the staff including some ancillary staff have been made aware of the adult protection policies and procedures and abuse awareness. The manager informed the inspector that some staff still require the training. The inspectors were also informed that a senior manager had been coordinating the training and had met with some staff to reaffirm the procedures. The inspectors were informed that a recent allegation of abuse made by a resident against a member of staff was still in the process of being investigated by social services and a referral had been made to a psycho- geriatrician for an assessment of the resident. The manager informed the inspector that the home had taken measures to ensure the resident is not put at potential risk. The Commission for Social Care Inspection must be made aware in writing the outcome of the investigation. Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 16 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): 19,21,24 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 bedrooms and bathrooms, make the garden safe and provide residents with the tools to call for assistance. EVIDENCE: The home can accommodate up to 27 residents at one time, two beds 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 has 3 bathrooms and 1 shower room, some improvements have been made to one of the bathrooms since the last visit with the installation of an assisted bath. The home has an assisted shower, which is spacious and has modern shower facilities, however the shower is not used to its full potential, as staff cannot adequately support the residents with out becoming wet. The home is must purchase a shower guard in order that residents can be supported to use the shower if they wish. Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 17 The home’s garden is large, mainly laid to lawn and has a path for easy access, some work has been undertaken on the garden to make it safe, however further hazards have been identified that pose a risk to the residents, the manager has introduced regular checks of the garden at regular intervals to observe the residents whereabouts especially at times when residents become disorientated and wish to leave the home, the manager must undertake a risk assessment of the garden area and address the areas of concern identified at during the visit. The home offers a bright clean and airy environment, a laundry facility and housekeepers who are on hand throughout the day. At the time of the visit there was on housekeeper on duty who was observed to go about cleaning tasks thoroughly and interacted well with the residents. The housekeeper stated she enjoyed her job although it was demanding at times especially when her colleague is on leave or absent and when residents are unwell. The inspectors were informed that some bedrooms are to have special carpets laid to assist with the maintenance of unpleasant odours caused by incontinence, however this previously made requirement has failed to meet the set timescale. This will be brought to the attention of the responsible individual. Further improvements have been made to assist residents to orientate around the building such as pictures on toilet and bathroom doors and communal areas. One member of staff agreed that this has assisted some residents to maintain a level of independence. The home has recently had an outbreak of the Norwich bug. The home took the appropriate action in following the correct infection control procedures and notifying the appropriate authorities. The housekeeper described in detail her role at the time and the steps the home took to ensure the bug did not spread. The spread of infection was quickly eliminated and only a small number of residents and staff became unwell. There remains a considerable amount of concerns with the environment, furnishing and its décor. 1. Bedrooms are dull, poorly furnished with institutional style furniture, worn bed linen, curtains and nets. 2. Some bedrooms are without mirrors, vanity units to place toiletries and washbasins are old with tired tiles and mouldy grout. The home has been required on three previous occasions to supply the Commission for Social Care Inspection with an action plan detailing when environmental improvements especially to the residents bedrooms and bathrooms will be made. The home has failed on a fourth occasion to provide the Commission for Social Care Inspection with an adequate action plan which details the schedule of work and timescales. Therefore it was agreed that the issue would be brought to the attention of the responsible individual of the service. Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 18 Further areas of concern that must be addressed are: 1. Ensuring that all residents have access to call bells in all rooms including communal rooms. It is unacceptable for residents to have to call out when needing assistance. 2. The manager must consider moving the care co-ordinators office to a more appropriate location. It is unacceptable to share an office with the hairdresser as there is the potential to breach residents confidentiality. 3. Guiding handrails situated in corridors must be repainted as they are worn and tacky to touch. Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 19 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 and 29 The home remains under staffed and does not carry out the correct recruitment procedures. This has the potential to seriously affect the health and welfare and safety of the resident. Enforcement action will be taken in respect of the failure to comply with correct recruitment procedures. EVIDENCE: The home remains understaffed and relies heavily on the use of agency. There is evidence to suggest the service is trying to address the problem of staffing levels and efficiently deployment of staff whilst on duty. The inspectors were informed that some staff have increased their hours and the service is holding recruitment days. The manager has taken steps to deploy staff efficiently in order to ensure staff are available at times when residents may become restless and need extra support. The manager also said she is encouraging staff to spend more quality time with the residents. This was picked up as an area concern by staff during a previous visit to the home. The home has a pool of regular agency staff who have become aware of routines and residents needs and who are included in staff meetings and some training. However a continued failure to equip the home with sufficient numbers of skilled staff could have a detrimental effect on the residents’ health, welfare and safety. Staffing levels will be continuously monitored during subsequent visits to the home. The home has introduced a thorough induction process and a care coordinator mentors newly appointed members of staff. Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 20 Enforcement action will be taken in respect of the homes recruitment procedures, following serious concerns in recruitment practices and the lack of understanding demonstrated by the previous acting manager and the services human resource department in respect of criminal record checks (CRB’s) and the protection of vulnerable adults checks (POVA) the home was issued with a serious concern letter and requirements to address the concerns. The manager demonstrated that the home and service were taking steps to meet the previously made requirements. However following the review of three staff personal files the inspectors established that the appropriate checks had not been fully complied with. The acting manager was also informed that until such time all checks were in place a member of staff would need to be removed from contact with residents. Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 21 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 and 36 The long-term absence of a registered manager has had a detrimental affect on the smooth running of the home, however the service has appointed a competent acting manager. Staff receive support and supervision, however the home must ensure staff receive a minimum of six supervision sessions a year. EVIDENCE: The home has been without a registered manager for approximately a year, the home has had several acting managers who have done their best to maintain a smooth running of the home, however the differing styles of the managers, their differing competency levels, lack of support and their remit to maintain minimum standards and meet requirements has not allowed the acting managers to develop their potential and move the home on. There is evidence to suggest the managers have done their best to maintain a smooth running of the home and the current acting manager has made attempts to meet the sixteen previously made requirements, however the inconsistent Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 22 management arrangements has had a detrimental affect on the smooth running of the home and the residents. The registered persons must make application to the Commission for Social Care Inspection to register a manager. There is evidence to demonstrate that staff receive support and supervision, the manager is responsible for supervising senior staff and the admin team and senior staff supervise care staff. This demonstrates a good deployment of management time and duties, however records showed that not all care staff have been regularly supervised. The acting manager must ensure all staff receive a minimum of six supervision sessions a year. This will be reviewed during the next visit to the home. Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 23 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 X X 1 1 3 STAFFING Standard No Score 27 1 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X X 2 X X Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP12OP7O P14 Regulation 15(1) 12(1) (a)(b) Requirement The registered persons must ensure that the residents’ personal plans reflect their strengths, health and welfare needs, routines, hobbies and interests. The registered persons must ensure the residents personal plans detail “how” their support needs must be carried out. The registered persons must ensure the mental health needs of residents are assessed, recorded and their personal plans reflect “how” they are to be supported. The registered persons must seek advice from the health care professionals on the obsessional behaviours/activity of those residents who repeatedly open exits and set alarms off. This requirement has been repeated on three occasions. A further failure to comply will result in further action being taken. DS0000039181.V250043.R01.S.doc Timescale for action 31/12/05 2 OP7OP12O P14 15(1) 31/12/05 3 OP8OP7 13(1)(b) 15(1) 31/12/05 4 OP8 12(1)(b) 13(1)(b) 31/12/05 Woodside Lodge Resource Centre Version 5.0 Page 25 5 OP14OP15 OP16 12(2)(3) 22(2) The registered person must ensure residents are assisted and empowered to make choices in an accessible formats that meet the individual cognitive and sensory needs of the residents. I.e. menu plans. This requirement has been repeated. A further failure to comply will result in further action being taken. The registered persons must ensure the complaints pamphlet produced for 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 residents and/or representatives must be informed of the change of the 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 person must ensure the Commission for Social Care Inspection is informed in writing of the outcome of the investigation into an allegation of abuse made by a resident. The registered persons must ensure a recorded risk assessment is undertaken to minimise the risk of residents falling in the area of the garden identified as a hazard. The registered persons must ensure residents can be DS0000039181.V250043.R01.S.doc 31/12/05 6 OP16 22(6) 31/12/05 7 OP18 13(6) 31/12/05 8 OP38OP19 13(4) 31/12/05 9 OP21 12(2)(3) 23(j) 31/12/05 Version 5.0 Page 26 Woodside Lodge Resource Centre 10 OP19OP21 OP24 23(2)(d) supported to use the assisted shower if they wish. The registered providers must provide the Commission for Social Care Inspection with an action plan detailing the aesthetic improvements to the bathrooms and bedrooms. This must include areas of concern identified in the body of the report. This requirement has been carried over from the previous inspections held on the 27/07/04, 17/11/04 and 01/06/05. A further failure to comply will result in enforcement action being undertaken. This will be addressed with the responsible individual. Timescales for improvements will be negotiated and agreed with the Commission for Social Care Inspection. The registered providers must ensure all residents have access to call bells at all times. Including communal areas. The registered providers must relocate the care coordinators office to an appropriate location. The registered providers must repaint or make good worn and tacky handrails. Details of when the work will be undertaken must be sent to the Commission for Social Care Inspection by the stated timescale. The registered persons must ensure there are appropriate numbers of skilled, competent and experienced staff to meet the needs of the residents. The DS0000039181.V250043.R01.S.doc 31/12/05 11 OP22 ????? 31/12/05 12 13 OP37 OP19 12(4)(a) 17(1)(b) 23 31/01/06 31/01/06 14 OP27 18(1)(a) 31/01/06 Woodside Lodge Resource Centre Version 5.0 Page 27 15 OP29 19(1) (a)(b) 16 OP29 19 17 OP31 8 and 9 18 OP36 18(3) service must provide the Commission for Social Care Inspection by the stated times scale an action plan detailing how they are going to meet the shortfalls in staff. This requirement has been repeated on three occasions further failure to comply will result in enforcement action. The registered persons must ensure the home and the organisation follows the correct procedures, and takes up the appropriate checks when recruiting staff, i.e. CRB and first POVA checks. Enforcement action has been taken in respect of this requirement as the home has failed to comply appropriately on two consecutive occasions, placing residents at risk. The registered persons must remove from duty the member of staff identified at the time of the visit as not having all the appropriate recruitment checks in place until such time the checks are in place. The acting manager must notify the Commission for Social Care Inspection when the checks are in place. The registered persons must make application to the Commission for Social Care Inspection to register a suitable manager. The registered persons must ensure all staff receives a minimum of six supervisions a year. 30/11/05 30/11/05 31/12/05 30/11/05 Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. OP21 Refer to Standard 23 Good Practice Recommendations The registered persons are advised to purchase a shower guard in order to prevent staff from becoming wet when supporting residents in the shower. Woodside Lodge Resource Centre DS0000039181.V250043.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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. 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