Inspection on 17/04/07 for Woodside Lodge Resource Centre

This inspection was carried out on 17th April 2007.

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 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 17/07/06

Woodside Lodge Resource Centre 06/04/06

Woodside Lodge Resource Centre 11/10/05

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 Mr Richard Slimm Key Unannounced Inspection 17th April 2007 10:00 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.V334825.R01.S.doc Version 5.2 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.V334825.R01.S.doc Version 5.2 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 Catherine Elizabeth Mearns 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.V334825.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2006 Brief Description of the Service: Woodside Lodge is a registered residential care home with a day centre that uses some areas of the home that used to be solely for residents. The home provides long stay or short stay residential services to older people (65 plus) living in the west and central areas of Southampton City. The home is registered to look after people with specialist older persons care needs, who may have varying degrees of dementia, also caring for people with age related physical frailty. The stated purpose of the service is to provide a person centred care approach, that will also focus on using the physical environment and multi-sensory methods to enable positive interactions and communication with people. All service users are accommodated on the ground floor in single room accommodation. The home has the resources and aims to enable service users to live on separate wings in smaller groups. The home is situated approximately 2 miles from Southampton City centre on main bus routes and adjacent to local shops. The day centre operating from within the unit, is not managed by the provider, but by the Southampton Care Association and is used to support users and carers living in the local community. Service users have only limited access and use of the facilities of the day centre based on when there are vacancies. The scale of charges are from £194.67 for short stays to £447.02 permanent stay. Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site inspection visit to the home took place between the hours of 09:00 and 17.00 hrs on the 17th April 2007. This site visit was the culmination of prefield work activities including – • A full review of the history of the service since the last inspection that was a random inspection • Gathering information from a variety of professional sources, including; • The Commission’s database • Pre-inspection information provided by the home • Surveys for the people using the service, and other contacts with families and social workers and other external stakeholders • Linking with previous inspectors who have knowledge of or who have visited the service • Interviews with people using the service The inspector was advised the people using the service wish to be known as residents. This was a key inspection, being part of a new inspection programme, which measures the service against the core and/or key national minimum standards. The last key inspection took place on the 17th July 2006; this inspection identified the service being provided at that time as poor. This was followed up by a specialist random inspection by a CSCI pharmacist on the 22nd September 2006 due to concerns regarding medication management and safe practices. In addition a further random inspection was carried out on the 21st November 2006 following CSCI management review meetings. A meeting was held with the responsible individual of the registered provider to discuss CSCI concerns. The visit of the 21st November 2006 also monitored developments and improvements required in the July inspection report, and compliance with statutory improvement notices served on the providers Southampton City Council. Conditions of registration were imposed by the CSCI to prevent further admissions of vulnerable adults at that time, until a manager had been registered, and improvements made to the outcomes for residents. The manager has now been registered, and action plans received outlining how improvements are being made, and consequently the conditions were removed following a request to do so by the authority, and a new certificate of registration was issued in February 2007 to reflect this. This inspection identified significant improvements in the quality of life outcomes for the people using the services provided at Woodside Lodge. The regulation inspector who carried out the visit was Richard Slimm. While in the home the inspector was able to meet 16 of the residents currently accommodated, carrying out case tracking with a number of people living at the home. Time was spent interviewing residents, as well as having informal Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 6 discussions with residents and observing interactions between residents, staff and others. Additional paper work where necessary was reviewed, a tour of the premises took place, and the registered manager, staff members, visiting professional and relatives were interviewed. What the service does well: The service now makes arrangements to ensure that service users needs and wishes are fully assessed prior to being admitted to the home. The service was able to provide clear evidence that the assessed needs of those people accommodated are being met. Resident’s health, personal and social care needs are identified, these are now planned in a clear and understandable fashion, that enable staff to provide a consistent or accountable level of service and support. Plans of care are now adequately monitored or reviewed, and consequently plans of care are relevant and in date. Where additional support is needed to enable residents’ to be more involved in decision making about their lives, and to be more involved in the running of their home, action is now taken to provide this support in sensitive and effective ways. Arrangements for the administration of medication at busy times of the day and/or evening has been reviewed. Staff members giving out medications are now enabled to do so without distraction or interruption. The privacy and dignity of residents was promoted on a daily basis, at every given opportunity, at the home. The service now actively plans to provide daily opportunities to residents that will meet their needs or match their expectations, satisfying social, cultural, religious or recreational interests or needs. The service supports residents to maintain contact with their families and/or friends within the local community and the home itself. Residents were observed being supported to journey out safely from their home. The service has improved the degree and amount of opportunities to support and encourage residents to exercise as much choice and control over their daily lives as possible. The service has reviewed how people with short-term memory loss are enabled to make informed choices about the food they eat. Residents confirmed a more flexible approach to this area of daily living is now adopted at the home. The home has a written complaints procedure. The home investigates complaints in line with the complaints procedure. Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 7 The service has a variety of arrangements in place that protect service users from potential harm. Externally the home is not well maintained and appears to be neglected. The registered organisation has advised the CSCI that this matter, including the replacement of rotten window frames and windows will be addressed over the next three financial years. The service now provides adequate and appropriate aids and adaptations that promote service user independence and/or safe moving and handling practices at the home. The home was cleaned to a good standard, and domestic staff members consult and involve residents as much as possible in the running of their home in this area of the service. The service now ensures that the number and skill mix of staff meets the needs of service users’. The provider organisation has improved the quality of staff and management supervision and support at the home. The percentage of staff trained to NVQ level 2 exceeds 50 national target. The service is now managed and run to fully benefit the people living in the home. There was evidence that residents are now more seriously considered in the context of how the home is run or how the service is to be developed. The new manager is now receiving support from senior management and indeed the registered body to achieve the changes needed at the home. Arrangements for handling residents’ monies are now compliant with the legal requirements on the registered persons, and enable each resident to have a separate interest baring account. The health, safety and welfare of service users and staff are now promoted and protected. What has improved since the last inspection? The action plans from the registered provider outlining how they intend to comply with the requirements of the last three inspection reports were used to inform some judgements made following this inspection. The following areas of progress were noted during this key inspection – • Outcomes for people using the service in the area of “Choice of home” had improved from poor to good • Outcomes for people using the service in the area of “Health and personal care” had improved from poor to good Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 8 • • • • • Outcomes for people using the service in the area social activities” had improved from poor to good Outcomes for people using the service in the area protection” had improved from poor to good Outcomes for people using the service in the area improved from poor to adequate Outcomes for people using the service in the area improved from poor to good Outcomes for people using the service in the area administration” had improved from poor to good of “ Daily life and of “ Complaints and of “ Environment” had of “ Staffing” had of “ Management and 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. The summary of this inspection report can be made available in other formats on request. Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 was assessed Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The service makes arrangements to ensure that service users needs and wishes are fully assessed prior to being admitted to the home. The service was able to provide evidence that arrangements are in place to ensure the assessed needs of people using the service are being met. EVIDENCE: Standard 6 was not assessed, as the home does not provide intermediate care services. Case tracking identified that • • Each resident has a contract that forms terms and conditions of residence. These contracts identify the specific bedroom to be occupied. Each resident has a welcome pack to the home that contains information about the home’s aims and objectives, a guide for the new resident and other information such as complaints procedures etc. DS0000039181.V334825.R01.S.doc Version 5.2 Page 11 Woodside Lodge Resource Centre The following evidence was obtained in respect of standard 3 Needs assessment – • • • • • • From a case tracking exercise of a sample of residents it was evident that residents are assessed prior to admission to the home Assessment information included personal profiles about the person’s life and history before admission Key information was also obtained as part of the assessment process and included key people such as next of kin; friends; advocates; GP; nurse etc Assessment paid attention to issues of risk as well as needs and wishes Residents had been involved in their assessments as far as possible. Trained staff from within the care service had carried out assessments. Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were assessed – Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s health, personal and social care needs are identified, these are planned in a clear and understandable fashion, that enable staff to provide a consistent or accountable level of service and support. Plans of care are monitored and reviewed, and are relevant and in date. Action is taken to provide support in sensitive and effective ways where additional support is needed to enable residents’ to be more involved in decision making about their lives, and to be more involved in the running of their home. Arrangements for the administration of medication are safe. The privacy and dignity of residents is promoted. EVIDENCE: The following evidence was obtained in respect of standard 7 service users Care Plan – Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 13 • • • • • • • • • Each resident had a plan of care set out within a standard document and based on the outcome of the care assessment of the resident concerned Daily notes and chronologies are maintained in a “daily log system”. The quality of information being kept was variable and provided some evidence that staff may benefit from further training in this area, but in general information was being captured in sufficient detail about daily interventions with residents Reviews are carried out regularly and recorded appropriately. Once more the quality of information varied, but in general relevant information was being captured with regard to daily care needs of residents Dementia mapping had taken place identifying areas of success and areas of shortfall in quality of life for residents. Action had been taken to address any areas of shortfall. Care plans and records identified residents health care needs and ensured that prompt action is taken to meet these needs with the support of local community health care teams, including GP’s district nurses and other specialists when needed. The home has an identified community psychiatric nurse who acts as the specialist link to the older person mental health care team. Residents interviewed said they were happy with the quality of support the received at their home Residents were observed to be contented and calm. The atmosphere in the home was pleasant, informal and relaxed. Staff were observed to support residents in a flexible, sensitive and kindly manner, in line with recorded plans of care The following evidence was obtained in respect of standard 8 Health Care – • • Residents see their GP on request, or where staff identify the need for referral to a GP A community nurse was evident visiting a number of patients at the home at the time of this visit. The nurse confirmed the recent improvements that had been made at the home, to the benefit of her patients Care plans and records identified residents health care needs and ensured that prompt action is taken to meet these needs with the support of local community health care teams, including GP’s district nurses and other specialists when needed Staff confirmed there were good relations with visiting health care professionals. This was also confirmed by a visiting nurse. • • The following evidence was obtained in respect of standard 9 Medication – • Given the particular needs and general frailty of residents medication practice in the home are not set up to enable residents’ to self medicate, Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 14 • • • • • • as no residents are assessed as able to maintain their own medicines safely. Medications were found to be managed by the home safely Residents spoken to said they were happy with the arrangements made for the management of their medications The home uses a dossette system with medicine administration records (MAR) sheets used to record and keep an audit trail of medicines administered. The inspector was advised of plans to change the system to a monitored dosage system in the future. All staff will be trained in the new system before introduction Medicines were being stored safely Staff members involved in any aspect of medication administration are trained to do so Staff induction is based on Skills for Care industrial occupational standards and includes familiarisation with the home policies and procedures concerning medication and drugs administration Other staff training is provided in regard to safe medication practices The following evidence was obtained in respect of standard 10 Privacy and Dignity – • • • • • • • All residents are accommodated in single bedrooms with privacy locks provided Residents interviewed said they felt staff respected their privacy and dignity Staff were observed to knock on bedroom doors before entering All private bedrooms had been provided with suitable privacy lock facilities. Communal toilets and bathrooms are provided with privacy locks Residents’ had been consulted in regard to the choice of colour schemes in the newly upgraded lounge / diner Staff members were observed to meet the needs and respect the wishes of residents in age appropriate and respectful ways Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were assessed – Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service actively plans to provide daily opportunities to residents that will meet their needs or match their expectations, satisfying social, cultural, religious or recreational interests or needs. The service supports residents to maintain contact with their families and/or friends within the local community and the home itself. The service provides opportunities to support and encourage residents to exercise as much choice and control over their daily lives as possible. The service has reviewed how people with short-term memory loss are enabled to make informed choices about the food they eat. Residents confirmed a more flexible approach to this area of daily living is now adopted at the home. EVIDENCE: The following evidence was obtained in respect of standard 12 Social Contact and Activities – • Residents interviewed said they were happy with arrangements made at the home in respect to their lifestyles Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 16 • • • • • One resident has said she did not get out much but this was fine for her, another resident was being supported by an old friend to go out, and other residents are able to journey out with support. There are far more entertainments and activities going on in the home, residents’ were found to be quite happy with arrangements, and taking part in those activities the home provides that include; entertainers; pub lunches; trips to the local common to feed the ducks; games and dancing / singing. There is also a visiting hairdresser twice a week. Residents get involved in reminiscence activities with staff as well. In better weather residents can get involved in gardening type activities within the enclosed private grounds of the home Residents were free to come and go around communal areas of the home as they pleased based on their needs and abilities The manager explained that residents are consulted on a regular basis, both formally and informally. Residents interviewed also confirmed that the manager and the staff check with them that everything is ok, as well as regular meetings The following evidence was obtained in respect of standard 13 Community Contact – • • • • Residents confirmed they received their guests when and where they wished Friends / Relatives confirmed they could visit at any reasonable time and did not need to pre-plan this with the home The home has a clear visiting policy Residents are free to choose who they see The following evidence was obtained in respect of standard 14 Autonomy and Choice – • Practice in this area was observed. Staff were seen to promote the rights of residents to autonomy, and provided opportunities for residents to make informed choices. Residents who were making choices to remain in their bedclothes were respected. Staff monitored this matter at regular intervals offering support to the resident, but backing off when the resident made it clear she did not want their assistance There was recorded evidence that residents were being supported in such activities as baking cakes and cooking Residents confirmed that they were able to make choices about their daily lives in an adult and age appropriate manner There was no evidence of restrictive practices at the home, and the staff interviewed said they would be able to challenge poor practices, and would be fully supported by the manager The home has appropriate systems in place for dealing with residents’ personal or financial affairs safely. Where appropriate these matters are managed by residents families/advocates DS0000039181.V334825.R01.S.doc Version 5.2 Page 17 • • • • Woodside Lodge Resource Centre • • Due to the needs of the people living at the home residents were not found to be aware of their personal records Residents are consulted by the home The following evidence was obtained in respect of standard 15 Meals and Mealtimes – • • • • • • • Residents confirmed that the quality of the food was good, comments included “the food is good”; “I look forward to my meals here”. Food menus offered a full varied and nutritious diet. Daily food menus are written up on the lounge picture/communication boards The chef confirmed she is provided with the resources needed to keep the residents happy Residents have choice and control over the food they eat, and where they eat The inspector was given the opportunity to join residents at lunch, which is the main meal of the day. All residents said they enjoyed their meal. The meal included a choice of two main courses and a dessert or cheese and biscuits Staff were discreetly attentive to residents support needs throughout the lunch serving period Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed – Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home deals with any concerns or complaints. The home investigates complaints in line with the organisations complaints procedure. The service has a variety of arrangements in place that protect service users from potential harm. EVIDENCE: The following evidence was obtained in respect of standard 16 Complaints • • • • • There had been no complaints recorded since the last key inspection Residents are all given a complaints procedure in the organisations welcome pack for the home. Residents knew who to speak to if they had any concerns Residents said the manager is very approachable and would deal with any problems The home has a quality assurance system that monitors complaints and/or comments about the service The following evidence was obtained in respect of standard 18 Protection – • There had been no reported protection of vulnerable adults (POVA) case at the home since the last key inspection DS0000039181.V334825.R01.S.doc Version 5.2 Page 19 Woodside Lodge Resource Centre • • • • • • The manager was aware of her responsibilities with regard to POVA The home has a copy of the local social services policy and procedure with regard to POVA Staff interviewed were able to demonstrate an awareness of what may constitute abuse of adults and/or older persons Staff confirmed they had been trained in POVA Residents confirmed that they felt safe living at the home Staff members had all had full POVA and CRB checks carried out (See section six Staffing) Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 22 and 26 were assessed – Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Externally the home is not well maintained and appears to be neglected. The service provides adequate and appropriate aids and adaptations that promote residents’ independence and/or safe moving and handling practices at the home. The home was cleaned to a good standard EVIDENCE: The registered persons have advised the CSCI that they intend to invest in the external environment over the next three financial years in order to bring the home up to modern standards – The following evidence was obtained in respect of standard 19 “Environment” - Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 21 • • • • • • The manager advised that a representative of the landlord of the building had come and surveyed the outside of the home and has identified those windows that need to be replaced as a matter of urgency due to wood rot. This will need to be monitored and kept under review by the manager of the home, and progress will need to be measured during future CSCI inspections, based on a clear plan of action The registered organisation has advised the CSCI that these matters, including the replacement of rotten window frames and windows will be addressed in three phases over the next three financial years. Action had been taken to clean old and dead climbers from the brickwork The lounge / diner has been upgraded with a total redecoration and new facilities/furnishings. Residents had been consulted with regard to choice of colour schemes, and were very proud of this area of their home The manager is aware of the shortfalls at the home due to a history of neglect and under investment, and is drawing up plans to address these issues. The home’s latest newsletter identifies the need to upgrade the small front lounge as a matter of some urgency. There is a need to provide residents with bedroom carpeting and for the communal areas of the home to be upgraded to modern standards and with colour schemes and furnishings that are in keeping with the wishes and choices of residents accommodated, and that provide a valuing environment At the time of the site visit a new washing machine was being fitted in the laundry area, and a new sluicing facility is to be provided in order to bring the laundry area up to standard for a modern care home. The following evidence was obtained in respect of standard 22 “Aids and Adaptations” – • • • • • The correct type of equipment is now in place to enable staff to support higher dependency service users safely at the home. Staff members confirmed they had received manual handling and moving training Adaptations have been made to some aspects of the environment to reflect the needs of older persons suffering from dementia and memory/communication deficits. Pictures of residents with their key carers had been placed on bedroom doors to aid residents to find their rooms Dementia mapping had been introduced to enable the home to find out what is does well and where it needs to improve The following evidence was obtained in respect of standard 26 “Hygiene and control of infection” – • Action is being taken to upgrade the laundry area Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 22 • • • • • Domestic staff interviewed confirmed they were supported to do their jobs, and also confirmed the improvements that have recently be made at the home The home was being kept clean and there were no offensive odours throughout the home at the time of the visit. The home employs separate domestic workers who work hard to keep the home fresh and well presented for residents Staff members are provided with appropriate resources, such as disposable gloves, aprons and cleaning materials to do their jobs safely Residents’ confirmed that their home is always kept clean and tidy by the dedicated domestic staff Residents confirmed that domestic staff members consult and involve them as much as possible in the running of their home in this area of the service. Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were assessed – Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff meets the needs of service users’. The manager monitors the quality of staff supervision and support at the home that benefits residents. Over 50 of the staff team are trained to NVQ level 2 exceeding national targets. EVIDENCE: The following evidence was obtained in respect of standard 27 Staff Complement – • • • • Staffing levels were sufficient to meet the needs of residents, with four care staff on duty on arrival unannounced to the home, with the manager, laundry, domestic, kitchen assistant and cook in addition. Residents confirmed that staff are very attentive and if they have to call for staff assistance they do not have to wait long before staff arrive The staff team are well trained and receive good induction into working at the home in line with Skills For Care standards The manager is working hard to develop a good team of staff at this home Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 24 The following evidence was obtained in respect of standard 28 Staff Qualifications – • One staff member interviewed was qualified to NVQ level 2. Another was employed at the home via a care agency and was studying to obtain a qualification in a non-care related area, but did confirm he had received all basic training for his role. Over fifty of care staff members have been supported to get their NVQ level 2 qualifications that meet the government benchmark for the care sectors. There was evidence of a commitment to the ongoing training and development of staff working at the home, and this was confirmed by staff members interviewed There was documentary evidence of training audit taking place and linking to supervision of professional staff, as well as the needs of the resident group • • The following evidence was obtained in respect of standard 29 Staff Recruitment – • • An audit of staff records were inspected, including the most recently employed person The organisation is carrying out the necessary employment checks to ensure the safety of residents. CRB or POVA 1st check had been carried out as required The following evidence was obtained in respect of standard 30 Staff Training – • • • • Care staff receive induction that uses the industries occupational standards and follows standards produced by Skills for Care, and provides a good standard of familiarisation for new staff joining the team The home has a training programme Staff interviewed said they were well trained and received good induction, and regular supervision Staff training has included – POVA; Infection Control; Health & Safety Awareness; Life Support; Safe Handling of Medicines; Nutrition, Health and Food Hygiene; Manual Handling and Moving; Health and Safety Risk Assessment; Dementia; First Aid, with 6 permanent care co-ordinators and one relief care co-ordinator staff holding a First Aid certificate, providing 24 hour cover and Fire Training. Most of the staff had infection control and food hygiene training prior to July 06. Since 2006 four new care staff have had infection control/safety at work as a part of their skills for Care course. A new carer to start at the end of April 2007 has been nominated and will commence the Skills For Care course in May 2007. New housekeeper/kitchen assistant has undergone food hygiene and ‘COSHH’ training. Six care staff members have attended Food Hygiene training since July 06. The temporary cook is waiting to undertake her intermediate food hygiene course in June. Four new care DS0000039181.V334825.R01.S.doc Version 5.2 Page 25 Woodside Lodge Resource Centre staff are to be nominated for food hygiene training as dates of courses become known. In-House COSHH training was undertaken in December 06 with eight staff attending both care and housekeepers. Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 26 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 were assessed Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is managed and run to benefit the people living in the home. Residents’ views are considered in the context of how the home is run or how the service is to be developed. The new manager is now receiving support from senior management and indeed the registered body to achieve the changes needed at the home. Arrangements for handling residents’ monies enable each resident to have a separate interest bearing account. Arrangements are in place, which ensure the health, safety and welfare of service users, and staff are promoted and protected. EVIDENCE: The following evidence was obtained in respect of standard 31 Day to Day Operations – Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 27 • • • • • • • The registered manager is a trained and registered social worker who has experience working with older persons, and attending college to achieve the NVQ level 4 in management / RMA qualification The registered manager is committed to ensuring that the best possible services are provided to residents and that residents are fully consulted about the sort of services provided The organisation has improved the commitment to the support for the manager of the home The home provides a staff structure including senior care staff to whom the manager can safely delegate duties and tasks, as well as having an on-call emergency arrangement in place Residents confirmed the manager was approachable and does a very good job Staff members interviewed confirmed that they felt valued and supported by the manager of the home who provides them with regular meetings, supervision and annual appraisals Staff members all commented on the improvements that had been made at the home over the past 8 months, since the registered manager took over her role The following evidence was obtained in respect of standard 33 Quality Assurance – • • • • • • • The manager arranges to hold regular meetings with both staff and residents about the running of the home There are also now carers meetings to provide support to relatives and loved ones of residents suffering from age related mental health problems The organisation have provided a plan of action about upkeep and maintenance, with extensive decoration and maintenance planned to the external aspects of the home this year, and the following two years The main lounge / dinner has benefited from upgrading, and residents were consulted in this The manager is committed to the promotion of resident, consultation and involvement in ongoing developments and the overall improvement of the service provided Feedback is actively sought from service users in a variety of ways including, meetings, surveys and informally The manager is aware of the need to continually look at new and innovative ways of developing and improving consultation with the residents group, and the need to use different media to aid and promote better communication with people who have dementia related communication deficits The following evidence was obtained in respect of standard 35 Service Users’ Money – Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 28 • • • • • The organisation have developed safe and legal systems for supporting confused service users’ in managing their personal or financial affairs Residents interviewed said they were happy with the way the home supported them in this area of daily living Where the home nor the resident manage the residents affairs the support of their relatives, or other advocates external to the home is sought with the permission of the resident The manager is aware of the new Mental Capacity Act 2005 and the need to ensure the code of practice is made available to staff, and the principles of the act inform practice at the home The home is also aware of legal arrangements for more vulnerable residents under such arrangements as court of protection The following evidence was obtained in respect of standard 38 Safe Working Practices – • A fire officer last inspected the home on the 30/5/06. Fire equipment was tested on the 14/12/05. Fire drills take place at regular intervals, and include fire lectures/training for staff. The fire alarm is tested on a weekly basis. Residents confirmed fire/emergency bells are tested regularly The environmental health officer last inspected the home on the 20/2/06 Tests are routinely arranged with appropriate contractors to ensure all systems in the home are maintained safely and to manufacturers recommendations. Baths, hoists and wheelchairs were all serviced on the 10/4/06. There is a contract for the disposal of soiled waste and sharps The emergency alarm call system was last serviced on the 22/2/06, the alarm call system does not extend to the dining room The home has clear policies and procedures in respect of the maintenance of health and safety related topics at the home The laundry is currently in the process of being upgraded • • • • • • Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 29 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 X X X 3 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 3 X 3 X 3 X X 3 Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 30 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 OP19 Regulation 12-13-1623 Requirement The registered persons must identify those windows to be replaced during financial year 2007/08 – those to be replaced during 2008/09 and those to be replaced during 2009/10. All other works planned both externally and internally to the premises during this year 2007/08 will also need to be clearly identified in a work plan in order to enable progress to be measured. A copy of the plan is to be sent to the Commission. Timescale for action 25/05/07 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 OP12 Good Practice Recommendations It is recommended that the organisation and the home DS0000039181.V334825.R01.S.doc Version 5.2 Page 31 Woodside Lodge Resource Centre OP14 OP33 continue to look at ways of developing and improving methods of consultation with the people using the service, in ways that address communication needs of service users as well as promoting age appropriateness and adult status. It is essential that such areas as activities; food menus; service development and other areas related to the daily running of the home are fully informed by the views, wishes and needs of the people living in the home. Woodside Lodge Resource Centre DS0000039181.V334825.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000039181.V334825.R01.S.doc Version 5.2 Page 33 - 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. 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