Inspection on 10/05/06 for Hallamshire Residential Home

This inspection was carried out on 10th May 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hallamshire Residential Home 23/04/08

Hallamshire Residential Home 11/10/05

Hallamshire Residential Home 30/11/04

Hallamshire Residential Home 24/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Hallamshire Residential Home 3 Broomhall Road Sheffield South Yorkshire S10 2DN Lead Inspector Shirley Samuels Key Unannounced Inspection 10th May 2006 09:00 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 Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 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. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hallamshire Residential Home Address 3 Broomhall Road Sheffield South Yorkshire S10 2DN 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) 0114 266 9669 0114 266 9669 None Hallamshire Old People`s Residential Home Limited Ms Beverley Jane Ward Care Home 32 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (32) Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 32 beds 10 can be used for dementia elderly (DE/E) or mental disorder elderly (MD/E) The service can admit three service users between the age of 60-65. Date of last inspection 11th October 2005 Brief Description of the Service: The care home provides care to 32 older people (10) of the places are for older people with dementia or mental health problems. Three beds can be used for service users between the age of 60 and 65. The home is situated in the Broomhall area of Sheffield. Accommodation is provided on three floors. There are 4 lounge areas one of which is used mainly for activities. There are three dining areas one that is separate while the other two are integrated into the lounge areas. The home is surrounded by a mature garden, which can be enjoyed by the service users and is near to local shops and accessible bus route. Written information about the home is provided to all service users prior to admission and copies displayed in service users bedrooms. Available in the entrance to the home is a copy of the last inspection report and details of how to make a complaint. The manager stated in written information provided prior to the inspection, that the fee charged at the home ranged from £303-£341 per week. There are additional charges for hairdressing, chiropody, toiletries, trips and outings. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over eight hours from 8:30 – 16:30. The inspector spoke with seven service users; seven members of staff including the cook, team leaders, domestic staff and the activities coordinator the manager and a professional visitor. Observations were made of the care provided, attitude and approach of staff and of the interaction between staff and service users. Questionnaires were completed by five service users (with the assistance of the activities coordinator). At the time of the inspection there were 28 service users living at the home, there were 4 vacancies and no waiting list. A selection of records were examined including three service users files, pre inspection questionnaire completed by the manager prior to the inspection, staff recruitment and training records and records of health and safety checks. What the service does well: Service users were issued with a contract detailing the terms and condition of their stay. Admissions were not made to the home whether the staff having the information they needed to make a judgement about wither or not they could meet their needs. Care Plans were in place, which in the main detailed the needs of the service users and the action staff needed to take to meet their needs. Service users received visits from health care professionals and were satisfied with the service they received. Records were kept of visits and the outcome. In the main the medication procedures met the standards and service users, where appropriate were able to administer there own medication. Service users said they were treated with dignity and their rights were promoted and their privacy respected. The home employed an activities coordinator and a variety of activities were arranged. Service users were encouraged to maintain contact with family and friends and visitors were made welcome. Service users were in the main happy with the food provided and records were kept of food preferences. Service users were encouraged to drink and refreshments were offered in between meals. Service users were aware of how to make a complaint and said they had someone to talk to if they were unhappy. There have been no complaints made about the home since the last inspection. The majority of staff had received training on the protection of vulnerable adults and was aware of the action to take if allegations were made. There have been no allegations of abuse made at the home. There was sufficient domestic staff employed to maintain hygiene standards. The staffing levels agreed at the time of registration were being maintained, the staff said these were sufficient to meet the needs of the service users. The service users said that staff attended to their calls for assistance in a timely manner. The manager is qualified and competent to manage the home and staff said she was approachable and managed the home effectively. Procedures were in place Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 6 to promote the health safety and welfare of service users and staff were aware of their responsibilities for maintaining safe working practices. What has improved since the last inspection? 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. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 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 Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 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): 1,2 & 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users were provided with information prior to moving into the home, this enabled them to make an informed choice about moving into the home. Contracts were issued, giving service users details of the terms and conditions of their stay. Service users were not admitted to the home without first having their needs assessed. This ensured that staff had the information they needed to make a judgement about how they could meet needs. EVIDENCE: The majority of the service users said via the questionnaires and those spoken to that they were provided with information about the home. Some service users did not recall being given information but said information may have been given to their relatives. In each service users bedroom there was posted a service user guide, which gave them information about the home, staffing, mealtimes, activities etc. A copy of the last inspection report was available in the entrance to the home along with copies of the statement of purpose, Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 9 service user guide and leaflets about the work of the commission for social care inspection. It was not clear when the statement of purpose and the service user guide were last reviewed. Some of the information provided in service users bedrooms was not in a format, which might promote understanding as some of the service users were in differing stages of dementia. Three service user flies were checked. There was a copy of the contact and terms and conditions including the fee, room to be occupied and details of additional charges. In the three service users files checked, assessments were in place, these were carried out by a social worker or by the manager for service users who were self funding. The staff said that service users were not admitted to the home without an assessment. They added that in the main the information provided prior to admissions was accurate and reflected the needs of the individuals, if gaps were noted in the information further details would be obtained. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 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): 7,8,9, 10 &11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users health personal and social care needs are set out in a plan of care. This provided staff with the information they needed to meet the needs of the service users. Service users received visits from health care professionals; this ensured that their health care needs were met. Where appropriate service users were able to administer their own medication, this promoted their independence. Service users feel they are treated with respect and their right to privacy is upheld, this promoted a feeling of wellbeing and dignity. The action to take on the death of a service user was not consistently recorded in service users files. This meant that staff were not aware of the wishes of service users regarding their wishes following their death. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 11 EVIDENCE: Three service users files were checked in the main they contained details of service users health social and personal care needs. Service users spoken to were aware that records were kept and they said that staff did talk to them about their preferences, likes and dislikes. There was evidence that care plans were reviewed monthly and daily records, in the main gave very brief overview of the care provided and activity for each day. One of the three care plans checked showed details of who had contributed to the development of the care plan. Service user records did not contain a photograph. Records were kept of appointments and treatments carried out by health professionals. Service users said they received the medical support they needed. “The doctor attends when I need him” “Dentist visits now and again” “the home arranged for me to have some new specs” “the doctor is available when necessary”. The GP who attends the home gave feedback about the home and said the staff had a very caring attitude; the manager was effective and the home made appropriate call outs for visits to service users. There was a treatment room where medication trolleys were kept securely. Medication requiring refrigeration was stored appropriately. The pharmacist made regular monitoring visits and records were kept of the checks made, the outcome and any action required by the home. There was an effective system in place for the recording of medication received into the home. In the main records of administration were correct and signed at the time of administration. One tablet was found in a pot in the medication trolley the records showed that the tablet had been refused the day before, the staff member said it was to be disposed of. There were two examples of medication that had been administered and not signed for. Observations were made of medication administration showing that service users were appropriately supervised and encouraged to take their medication. The manager said via the pre inspection statement that designated staff received medication training and details were provided of the staff competent to carry out this task. Service users said they were treated with dignity and that their right to privacy was respected. They said “the staff are always polite” “staff always there when you need them” “ always a speedy response to bell call and that makes me feel secure” “staff are always kind” “need to give and take on both sides always treated like an adult”. Observations were made of staff giving information and offering choices. The staff spoken to were able to give examples of how they respected the rights of service users and promoted their dignity on a daily basis. Staff made sure they had the information they needed to meet the needs of service users by talking to service users about their preferences and wishes, making sure that care is provided in a way that service users prefer. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 12 Three service users files were checked, details of service users wishes following their death was recorded in one of the files. Staff said that some service users and families were not always willing to discuss. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users were informed of activities provided; this enabled them to make choices about taking part. Visitors were made welcome this encouraged service users to maintain contact with family and friends. Staff gave service users information and promoted their independence. This encouraged service users to make choices and have control over their lives. Service users were provided with a varied diet including fresh fruit and vegetables and a choice of hot and cold drinks. This ensured that they received a balanced diet. EVIDENCE: Service users were consulted about the activities they would prefer; they were able to choose how to spend their day and were able to take part in religious ceremonies. This meant that service users social, cultural and religious needs were met. Service users records detailed some of the pastimes they enjoyed and what action staff needed to take to try and maintain this. There was an activities coordinator employed at the home that worked 16 hours. A variety of Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 14 activities took place including trips out, bingo, film shows and various entertainers came into the home. The manager said for some activities there was an additional charge. In line with the wishes of individual service users they received visits from local church members. Service users said, “I am quite happy with the arrangements” “ I play bingo and join in reminiscence sessions watch films, Its alright”. “ I think we do very well here there is always something to do”, “Not really interested in activities I’m not really a joiner”. Service users said they were able to see visitors in private and that their visitors were made to feel welcome. The entrance to the home was welcoming easy chairs were available and information about the home was displayed. The manager submitted a copy of four weeks menus. Service users were provided with a variety of food the menu included, meat, fish, fresh fruit and vegetables. Meals were served at convenient times and arrangements were in place to ensure that service users who needed assistance and encouragement to eat received this in a respectful manner. The GP who visited the home said that care is provided to some very fail individuals, some in advanced stages of dementia. The GP observed that staff encouraged service users to eat and drink and felt that service users received a nutritionally balanced diet. Service users said “nice hot and varied”, “I have a small appetite, my food needs to be tempting and it is” “sometimes varies but mostly good”, “I always enjoy the food”, “its quite good I am satisfied”, “ I think they do a pretty good job decent food I’m not faddy”. One service user said they would prefer a glass to drink from rather than a plastic beaker, another said they would like tablecloths on the tables. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home had a written complaints procedure, which was displayed in the entrance to the home and explained to service users. This ensured that service users and their families had details of how to make a complaint and could be confident that they would be listened to. The home had policies and procedures in place on adult protection, this promoted the safety of service users protected them from abuse and informed staff of the action they must take. EVIDENCE: Service users said they had someone to talk to if they were unhappy. Some said they did not like to complain but if the need arose they would talk to a relative and ask them to deal with it. Other service users said they would talk to carers or the manager. None of the service users had any concerns on the day of the inspection. In each bedroom there was written information on how to make a complaint. There have been no complaints about the home since the last inspection. Service users said they felt safe. Staff were able to verbalise the action they would take following any allegations of abuse. Some staff had received adult protection training and training was ongoing for others. There have been no allegations of abuse reported at the home. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 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 & 26. Quality in this outcome area is adequate with further improvements needed regarding the environment. This judgement has been made using available evidence including a visit to the service. A requirement is carried forward from 20/12/04 for easy chairs in the lounges to be replaced; as yet this has not been completed. In places the décor is shabby. This resulted in the environment not being well maintained. Sufficient domestic staff were employed and staff were aware of there responsibilities regarding the control of infection. This ensured that service users lived in clean hygienic surroundings. EVIDENCE: The décor in some areas of the home including service users bedrooms were in a poor state of repair, in other places the décor was “tired” and “dull”. The easy chairs in the ground floor lounge were stained and in very poor condition. The dining tables were uncovered and looked “stressed”. Since the last Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 17 inspection the carpets in the lounges and corridor areas have been replaced. Decoration had commenced and the manager said new chairs and replacement furniture including dining tables were ready to be delivered. The kitchen was last inspected by the environmental health officer in August 2005, and was issued with a very good standard. At the time of this inspection the ceiling was discoloured, the strip lights needed cleaning and the cook had some concerns about the grouting in-between the tiles and the need to replace tiles. The window frame was damaged and the paint discoloured. Service users said, “the home was always clean”, “ the home smells nice”, “Pleasant”, “ I feel comfortable here that’s everything”, “good sanitation never smells bad”. The laundry facilities are sited away from food preparation areas. Service users said they were satisfied with the way their clothing was treated. One service user said, “Laundry is speedy and satisfactory”. Staff were provided with gloves and aprons and were able to verbalise what steps they took to control the spread of infection. Special bins were provided for the disposal of clinical waste. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 18 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): 27,28,29 & 30. Quality in this outcome area is good; with further improvement needed. This judgement has been made using available evidence including a visit to the service. Staffing levels were maintained to ensure that the needs of service users were met. Agency staff were not used at the home this ensured that consistency was maintained for the service users. The recruitment procedures in the main included thorough checking of applicants this ensured that service users were supported and protected. Staff received the training they needed to make sure they were competent to do their job. EVIDENCE: Staff rotas were checked; these showed that the staffing level agreed at the time of the inspection, was being maintained. Staff said the staffing levels were in the main sufficient to meet the needs of the service users. Service users said “the staff are always available when I need them”, “usually around” “good response to my needs”, “perhaps a few minutes wait but its nothing”. The manager stated via the pre inspection questionnaire that 55 of the care staff had obtained NVQ level 2 in care. Since the last inspection staff have received training in fire safety, moving and handling, food hygiene, adult protection, first aid, food hygiene, and the safe handling of medication. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 19 Staff said that training was ongoing. Adult protection training and training on report writing was outstanding. Three staff files were examined in the main they included all the information required by the regulations. There were two examples where gaps in employment history were not explained. On one file there was no photograph of the staff member. Some staff felt they needed further training in dementia care. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 20 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): 31,33,35,37 & 38. Quality in this outcome area is good, with some further improvement needed. This judgement has been made using available evidence including a visit to the service. The manager is qualified and competent to run the home this ensures that the service users live in a home that is well managed. The manager communicates clear leadership and direction of the staff team this promoted an ethos, which service users benefited from. Monthly visits are made to monitor the conduct of the home and to obtain the views of the service users and staff, this enables service users and staff to have a say in how the service is run. There were policies and procedures in place to ensure that service users financial interests were safeguarded. The manager and staff understand their responsibilities for observation, reporting and taking action regarding, health and safety issues. This promoted the health safety and welfare of service users and staff. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 21 EVIDENCE: The manager is experienced and has completed the registered managers award. The manager has demonstrated a good understanding of the Care Homes Regulations and the responsibilities of as registered manager. Staff spoke positively abut the manager and said she was approachable and they were able to comment on the service and influence change for the benefits of the service users. Staff said communication systems were effective and they felt informed about the changing needs of the service users. The Responsible Individual, who speaks with service users and staff visits the home monthly and obtains their opinion about the service and views on how the service could be improved. Service user and relative surveys have previously been carried out and a satisfaction rating displayed. This however has not been done recently. Two service user finance records were checked. The records included income and expenditure and copies of receipts were kept for all transactions. Service user care plans did not detail who controlled service users finances. For one service user the arrangements were unsatisfactory. The balance sheets and the monies stored did correlate and there were procedures in place for regular checking of service users accounts. Accidents were recorded however some incidents had not been reported to the CSCI as required by the Care Home Regulations. Staff had received moving and handling training. Staff were observed using appropriate moving and handling techniques and written risk assessments formed part of service users care plans. Via the pre inspection statement the manager said that appliances were serviced and appropriate checks were made of the gas, electric and water supply. Staff understood their responsibilities regarding the safety of themselves and others and for the reporting of any hazards. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 22 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 2 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 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 x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 x 2 3 Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement The statement of purpose and the service user guide must be kept under review and produced in formats which best responds to the needs of the service users There must be a photograph on each file of the service user. There must be procedures in place to ensure the safe disposal of medication that has been refused. Medication administration records must be signed immediately following administration of medication. Service users wishes following their death must be recorded in their care plan. Where service users and their NOK do not wish to discuss this must be noted. The kitchen ceiling and strip lights must be cleaned. The kitchen window must be repaired or replaced. The easy chairs in the lounge must be replaced. Previous timescales of 20/12/04 and20/01/06 not met. Timescale for action 10/10/06 2 3 OP7 OP9 Schedule 3 13 10/10/06 10/06/06 4 OP9 13 10/06/06 5 OP11 12 10/10/06 6 7 8 OP19 OP19 OP19 23 23 16 10/10/06 10/10/06 10/10/06 Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 24 9 OP19 23 All areas of the home used by 20/07/06 service users must be reasonably decorated. As part of the recruitment procedures, gaps in employment history must be explained and recorded. Each staff file must contain a recent photograph of the staff member. Staff must receive training appropriate to the job they are to perform. Therefore all staff must receive adult protection training, report writing and dementia care. Service users care plans must include details of financial arrangements. The CSCI must be notified of all events referred to in Regulation 37. 10/06/06 10 OP29 19 11 12 OP29 OP30 19 Schedule 2 18 10/10/06 10/10/06 13 14 OP35 OP37 12 37 10/06/06 10/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP15 OP15 OP19 OP33 Good Practice Recommendations Service users should be provided with a glass to drink from instead of plastic beakers. The service users wish to have tablecloths on the dining tables should be taken into consideration and appropriate action taken. To promote healthier standards in the kitchen an impermeable splash back should be provided above all the work surfaces. Service users and relatives should be surveyed and the results published. Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hallamshire Residential Home DS0000002966.V292757.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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