Care Home: Woodside Care Home

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What has improved since the last inspection? Woodside Care HomeDS0000045053.V374917.R01.S.doc Version 5.2 Page 6Since the last inspection there has been lots of improvements to the environment. For example, bathrooms have been refurbished, some bedrooms have been decorated, and curtains and carpets have been renewed in some areas of the home. There is also a new sitting room for people to use when they have visitors, where they can make drinks and snacks. During the last inspection we said that there must be risk assessments carried out for falls, and care plans should refer to new laws about decision making. Both of these things have now been done. The care plan format has also been reviewed and changed to make the plans clearer and more detailed, and a greater choice of activities has been provided. What the care home could do better: Although we found that lots of improvements have been made to the service people receive, we said that there are still things that the home must do to make things better. We saw medication being put into a pot from the original packaging so that a person could take it at a later time. We said that this was not good practice, and the manager must talk to the local pharmacy about better ways to do this. We also saw that bedroom doors have small windows in them and a few did not have any screening for privacy and dignity. We said that they must review these arrangements and take action to make sure that people`s privacy and dignity is fully maintained. As well as the things we said the home must do, we made some suggestions to help make things better. We said that in order to make things safer for people there should be risk assessments alongside written agreements to selfadminister medication. We also suggested that staff have more regular, formal supervision so that they are well supported to do their jobs. Lastly we said suggested that they carry out more quality assurance work such as care plan and medication record audits, and write summary reports of survey outcomes and actions. This is so that they can monitor the quality of the service more effectively, and they can show that they listen to people`s views and act upon them. The manager has also told us that they are going to update the complaints policy with our new name, address and telephone number, so that people can contact us if they need to. She also said that she is also going to talk to the local fire officer about timescales for updating the fire risk assessment. Key inspection report CARE HOMES FOR OLDER PEOPLE Woodside Care Home Lincoln Road Skegness Lincs PE25 2SY Lead Inspector Wendy Taylor Unannounced Inspection 6th April 2009 09:15 DS0000045053.V374917.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodside Care Home Address Lincoln Road Skegness Lincs PE25 2SY 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) 01754 768109 01754 767810 Kodali Enterprise Limited Debra Manning Care Home 39 Category(ies) of Dementia (39), Old age, not falling within any registration, with number other category (39), Physical disability (39) of places Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE 2. Physical Disability - Code PD The maximum number of service users who can be accommodated is: 39 4th April 2007 Date of last inspection Brief Description of the Service: Woodside is a care home providing personal care for 39 older people, which is situated in the seaside town of Skegness and a short walk away from local facilities and shops. It is owned by Kodali Enterprise Ltd and has been registered since October 2004. Dr Kodali is the Responsible Individual for the company and has been the owner of the home since 1997. The building is on 3 levels with the second floor being a self-contained flat for staff. The home has 35 single bedrooms with 15 having en suite facilities and 2 double rooms. A passenger lift gives access to all floors. There is a small garden area to the front of the home and parking for up to 10 cars. Fees range from £351 to £452 with things like hairdressing, private chiropody, and newspapers as optional extras. This and other information about the home, including the latest inspection report, are available from reception. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use the service receive good outcomes. This unannounced key inspection was carried out over one day during the month of March 2009. The registered manager was available throughout the inspection. We started the process by looking at all of the information held by us, such as a self-assessment that was completed by the registered manager. Since the last key inspection we have made another visit to the home to look at certain issues. This is called a random inspection, and we wrote a report about the visit. We have used the information as part of this inspection. We then used a method called case tracking to find out more about how the home provides the care and support. We looked at care records, and we spoke to people who live there. We also watched how staff provided the care to people. We spoke to relatives, staff and other professionals who visit the home; and we looked at things like staff records, complaints and protection records, and health and safety records. Comments from people who use the service, their relatives, and staff are mentioned in the rest of this report. What the service does well: There are good assessments and care plans in place to make sure that people’s needs and wishes are identified, and met in the way they want them to be. People are able to say what they think about the service they receive, and they are encouraged to be involved in planning improvements. Staff treat people with dignity and respect. They are well trained and have a good understanding of peoples needs and wishes. They encourage people to make their own choices and decisions, and to be as independent as they can be. There are good systems in place to make sure that people are protected, including staff training, risk assessments and policies; and people who use the service told us that they feel safe living at the home. There is a wide range of activities, and social support available to people, and family and friends are welcomed into the home. What has improved since the last inspection? Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 6 Since the last inspection there has been lots of improvements to the environment. For example, bathrooms have been refurbished, some bedrooms have been decorated, and curtains and carpets have been renewed in some areas of the home. There is also a new sitting room for people to use when they have visitors, where they can make drinks and snacks. During the last inspection we said that there must be risk assessments carried out for falls, and care plans should refer to new laws about decision making. Both of these things have now been done. The care plan format has also been reviewed and changed to make the plans clearer and more detailed, and a greater choice of activities has been provided. What they could do better: If you want to know what action the person responsible for this care home is Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 7 taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 8 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 Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assured that their needs and wishes can be met at the home by way of a clear assessment process. EVIDENCE: We looked at the files for four people who live in the home. The files show us that the manager or the deputy manager go to visit people before they come to live at the home so that they can find out what needs they have and how they want to be looked after. This helps the manager to decide whether the home can meet the person’s needs. We know from information we already have that the assessment process also includes trial stays or day visits, if people want them, so that they can see if they like the home before they move in. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 10 Assessments contain information about needs and wishes in areas such as mental health, physical health, social preferences, medication, end of life arrangements, pressure area care, and nutrition. The information has lots of details about the needs and wishes identified. The manager told us that they are currently updating the assessment forms to include a section about how people make their own decisions, and a space for people to sign to say they have been involved in their assessment. The manager told us that the home does not offer intermediate care at the present time. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans assure people that their individual needs and wishes will be met in a respectful way. However some medication practices may put people at risk. EVIDENCE: Since our last key inspection we have made a visit to the home to look at issues that were raised about the standards of care. During the visit we said that there must be risk assessments in place to show how staff manage the risk of falls, and that care plans must refer to new laws about how people make their own decisions. At this visit we saw that both of these things have now been done. The manager told us that a new care plan format is currently being put in place that allows care plans to be clearly cross-referenced with risk assessments, and we saw this in some files. The new format also has space for people to sign to say they have been involved in developing the plans. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 12 Care plans contain lots of information about things like how people take their medication, how they remember things, what their sight is like, how they get around the home, how they communicate, and what they like to eat. There are also risk assessments in place for needs such as using bedroom door locks, medication, smoking, use of electric wheelchairs, and moving and handling. Plans refer to how people should be supported with their privacy, and how their dignity and independence is maintained (also see Standards 19-26). We saw that staff have a good understanding of people’s needs, and they were helping people to be as independent as they could be. Staff used people’s preferred names and discussed their personal issues in private. The care plans are supported by clear personal information and preferred daily routine information, and they are reviewed at least once every month. The personal information sheet also contains a photograph of the person and can be carried with them, for example, if they need to go to hospital. Records are kept to show when people have seen professionals such as GP’s, District Nurse’s, opticians, and chiropodists. A visiting professional told us that people are looked after very well in the home, and there is a good level of communication from staff and the manager. Relatives told us they think that people get everything they need at the home, and the care and support is very good. Medication records were completed satisfactorily, and we saw that staff gave out most medications in the right way. However they dispensed one tablet into a pot for a person to take them self at a later time. We said that this was not good practice and they must talk to the local pharmacy about better ways to do this. We also saw in records that one person has a written agreement to self administer medication when out of the home, but there was no risk assessment in place. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People enjoy a wide range of activities, and a menu to suit their needs and wishes. EVIDENCE: An activity co-ordinator is employed across five days a week to support people to join in with a range of activities. Information we received before the visit showed us that there is now a defined budget in place for activities, and people who live at the home, and their relatives are involved in planning the programme. The current programme contains activities such as exercise sessions, cinema shows, and recognised therapies. We saw that each activity is centred on how the individual person wants to join in, and personal life story documents are being developed to help plan activities for people who are not able to say what they want to do. Records show what each person joins in with and whether they have enjoyed the activity. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 14 During the visit we saw people being supported to do things like use their sewing and knitting skills, make Easter baskets, and carry out household tasks that they liked to do before they moved into the home. Around the home there are also reminiscence aids such as photographs, nameplates for doors, and personal artwork. The activity co-ordinator showed that she was familiar with different approaches to supporting people who have dementia, and there are things like ‘rummage boxes’ around so that people can engage with familiar objects. People told us about a fayre that they have planned for the near future, and about the contact they have with a local school. Relatives told us that they think there is plenty for people to do at the home. We also know that the home is a member of a nationally recognised activity support organisation. Since our last visit, the home has made an extra sitting room for people to receive visitors, and it has facilities for making drinks and snacks. We also saw that a downstairs area is currently being refurbished as a relaxation room, and there is a range of equipment being provided to help people relax. There is information about advocacy support available in the reception area, and people told us that they could make their own decisions about the things they want to do. Menus are developed as a four weekly flexible plan, with choices offered for each mealtime. People are asked each day what they want to eat. We saw people choosing things that were not on the menu, and their choices were provided with no problems. We also saw that three different homemade desserts were offered from a trolley at lunchtime so that again, people could make a clear choice. People told us that the food was very good, and we saw that it was well presented. There was enough staff available to help those people who needed such. We also saw that relatives are encouraged to join people for meals. The manager told us that they are currently taking photographs of meals so that they can help people to make their choices in an easier way. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems within the home protect people from harm, and assure people that their complaints will be dealt with in the right way. EVIDENCE: People who live at the home told us that they feel safe living there, and relatives told us that staff know how to keep people safe. Staff were able to tell us what they would do if they suspected or saw any kind of abuse happening, and there was a training course about keeping people safe being held in the home on the day of the visit. Records show us that staff are regularly trained about how to keep people safe, and the home has a copy of the Local Authority guidance on this subject. We know from our records that since our last inspection there have been three alerts made to the Local Authority Safeguarding Adults Team. Records show that the manager and staff responded in the right way to the alerts and have co-operated with investigations. People who live at the home, and their relatives told us that they would feel comfortable speaking to the manager or staff if they have a problem, and they feel that things would be dealt with quickly. They said that they know about the complaints policy, and we saw that there is information about how to Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 16 complain displayed on the wall in the reception area of the home. The manager said that she would update the complaints policy to show our new contact details. Records show us that one complaint has been made about the home since our last visit, and again the manager responded in the right way. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People enjoy a generally comfortable and well-maintained environment. However the style of bedroom doors compromises people’s privacy and dignity. EVIDENCE: We know from information we received before we visited that there is an ongoing programme of refurbishment and redecoration around the home (also see Standards 12-15). During the visit we saw that ground floor bathrooms have been refurbished to a good standard, and some bedrooms have been redecorated. Bedrooms were nicely personalised, however there are small windows in the doors to these rooms. Most of the windows are covered by curtains or frosting, but a few were not and we said that this could compromise people’s privacy and dignity. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 18 We saw that things like new bed linen has been bought, and they have replaced curtains and carpets in various areas around the home. There are comfortable communal lounge areas available to people, and the owner told us that there are plans to add two further lounges to the building so that people have more choice about where to spend their time. There has also been work carried out in the garden area to make it more secure and pleasant for people to use. There are new fences, seating areas, and general planting. On the day of the visit the home was very clean and tidy, and we saw that staff used things like gloves, aprons and hand washing procedures in the right way. There are also hand sanitizers for staff to use, and the manager told us that she has just completed a training course about how to control infection. Equipment was stored so as not to cause tripping hazards, and cleaning materials that could cause harm to people were locked away. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a well-trained staff team, who are available in such numbers to fully meet their needs. EVIDENCE: Staff duty rotas clearly show the people who are on duty each day, and staff told us that there are enough of them to meet people’s needs. People who live at the home said that staff are always around when they need them, and we saw that people’s requests for help and support were met in a timely manner, including during meal times. Rotas show that there has been no need to use agency staff to cover shifts recently. Staff told us that they have a good induction and training programme, and records show us that there is a recognised core induction programme in place, as well as a clear introduction to the home. They said that they are given a training programme so that they know which courses they have been booked to attend, and they said that are able to undertake courses leading to nationally recognised care qualifications. Records confirmed this and show us that staff do training courses such as fire safety, risk assessing, medication Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 20 administration, dementia awareness, sensory deprivation awareness, and awareness of new laws effecting people’s lives. Recruitment records contain information such as criminal record bureau checks, application forms, identification, and two written references. One file for a person who has worked at the home for a long time only contained one written reference, and the manager addressed this issue straight away. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed in the best interests of the people who live there, and systems are in place to promote their health, safety and welfare. EVIDENCE: Since our last visit a new manager has registered with us. She has a background in providing care for older people and she worked at the home before becoming the manager. Since registering with us she has demonstrated that she has completed training, which helps her to keep up to date with care issues. She does not generally work as part of the care staff rota, but she does do some care shifts when necessary. She has made sure that the things we Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 22 said the home must improve upon at our last visit have been completed, and she lets us know about anything that happens in the home which effects the lives of people who live there. The deputy manager also has five hours per week allocated to completed management tasks. The manager showed us that satisfaction surveys are carried out for people who live at the home, and their relatives. She also showed us that new surveys are ready to be sent out to GP’s and District Nurses. A discussion took place with her about widening the quality assurance process to include things like care plan audits and medication record audits, and producing a summary report of the survey results. The manager told us that some people ask the home to look after their personal money for them. We saw that the money was kept securely, and we found that the amounts of money being held on the day of the visit matched personal account records, and receipts. People who live at the home, and staff members, said that the manager is very supportive, and they feel able to go to her with any issues they might have. Records show that staff have personal supervision sessions but they are not always carried out regularly. There are minutes of staff meetings that show they are kept up to date with things that are happening in the home, and they are able to say what they think about things. People who live there also have meetings, and the records show that they can say what they think about the way the home is run, and what they want to see improve. We looked at the records for things like fire safety checks, maintenance, and substances that could cause harm to people, and they were up to date. Risk assessments are in place for things like refurbishment activity, and fire safety. The manager said that she was going to talk to the local fire officer about the right time scales for updating the fire risk assessment. The home was recently awarded a three star outcome following a visit to the kitchens by the Environmental Health Officer. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 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 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 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 3 X 3 Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 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 OP9 Regulation 13 (2) Requirement Medication must not be secondarily dispensed from its original packaging. This to ensure that people’s health, safety and welfare is maintained. The management/use of windows in bedroom doors must be reviewed, and action taken to ensure that people’s privacy and dignity is fully maintained. Timescale for action 07/05/09 2 OP19 12 (4) 07/05/09 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 OP9 Good Practice Recommendations It is recommended that risk assessments accompany written agreements to self administer medication. This to ensure that people’s health, safety and welfare is maintained. DS0000045053.V374917.R01.S.doc Version 5.2 Page 25 Woodside Care Home 2 OP36 3 OP33 It is recommended that staff receive formal supervision sessions at least six times per year. This is to ensure that they are supported to carry out their job roles effectively, and they are enabled to develop their skills and knowledge. It is recommended that quality assurance processes include activities such as care plan and medication record audits, and summary reports of survey outcomes and actions. This is so that the quality of the service can be monitored more effectively, and people are assured that their views are listened to. Woodside Care Home DS0000045053.V374917.R01.S.doc Version 5.2 Page 26 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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