Inspection on 23/04/08 for Hallamshire Residential Home

This inspection was carried out on 23rd April 2008.

CSCI found this care home to be providing an Adequate service.

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

Hallamshire Residential Home 10/05/06

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 17/12/2008.

CARE HOMES FOR OLDER PEOPLE Hallamshire Residential Home 3 Broomhall Road Sheffield South Yorkshire S10 2DN Lead Inspector Ramchand Samachetty Key Unannounced Inspection 09:50 23 & 24th April 2008 rd 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.V364317.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. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 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 None Hallamshire Care Home Ltd Manager post vacant Care Home 32 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (8) of places Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2006 Brief Description of the Service: The care home provides care and accommodation for up to 32 older people. Twenty-four places are for older people with dementia or mental health problems. Three beds can be used for people who are from 60 to 65 years old. The home is situated in the Broomhall area of Sheffield. It is close to local shops and it is accessible by public transport. It is surrounded by a mature garden, which can be enjoyed by the people living there. Accommodation is provided on three floors. There are three lounge areas and three dining areas. One dining area is separate while the other two are integrated into the lounge areas. A statement of purpose and service user guide is provided to people using the service. Copies were available at the home. The manager stated that the fee charged at the home ranged from £369.00 - £395.00 per week. There are additional charges for hairdressing, chiropody, toiletries, trips and outings. Further information can be obtained from the home manager. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. Since the inspection CSCI has met with the owner and manager and they have demonstrated a commitment to improve. This key unannounced inspection was carried out on 23 and 24 April 2008, starting at 09.50 on the first day and finished at 12. 30 pm. On the second day the inspection started at 9.30 and finished at 17.00hours. the manager Mr Scott Melville was present throughout this inspection. The service is registered to provide accommodation and personal care for up to 32 older people, 24 of whom may be people who suffer from dementia. There were 28 people in residence at the time of this inspection. All the key national minimum standards for ‘Care Homes for Older people were assessed. The inspection included a tour of the premises, examination of care documents and other records, including those pertaining to complaints, staff employment, staff rota, medicines management, maintenance of equipment and quality assurance methods. We looked at the information contained in the ‘Annual Quality Assurance Assessment’, which was submitted to us before this inspection. We also considered the views we received from a survey that we carried out for people who use the service and their relatives and these have been included in the report. We would like to thank all the people living at the home, their relatives and staff who helped with this inspection. What the service does well: People who use the service and their relatives said that they were satisfied with the care being provided. They stated that staff were very caring and friendly. There is a good staff team, which works well together to ensure the continued wellbeing of people living at the home. People who use the service have good access to community health care services and to other care professionals. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 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.V364317.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 does not apply to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. People who use the service and their relatives said that they were given sufficient information to help them make their choice of care home. Assessment of needs were carried out before people were admitted to the home, in order to make sure that their needs could be met. EVIDENCE: A statement of purpose and service user guide was available at the home. Staff stated that copies of these documents were given to people who live at the home and their relatives. These documents were also given to people who came to view the home for possible admission. Relatives told us that they were given sufficient information and this helped them make their choice. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 9 The home had changed ownership in December 2007. The statement of purpose that was issued by the previous owner did not contain sufficient information on how the service caters for the specific needs of people who experience dementia. However, we noted that efforts were being made to revise these documents to reflect the changes that had taken place and to improve their overall quality. We looked at the care files of two people who had been admitted in recent months. They showed that an assessment of their needs had been appropriately carried out before their admission and this ensured that their identified needs could be met at the home. The home does not provide an intermediate care service. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. People who use the service and their relatives were satisfied with the care being provided, which they felt was meeting their needs. However, there was insufficient planning, recording and reviewing of assessed care needs and risks. EVIDENCE: We spoke to a few people who use the service and three relatives who were visiting their loved ones. They told us that the care being provided was generally good. The relatives told us that the some care staff ‘worked very hard’ and were ‘ experienced and very committed to their work’. They also stated that personal care was always provided to their loved ones in a discreet manner and therefore their privacy and dignity were respected and promoted. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 11 We looked at the care documentation for three people who live at the home. There was an assessment of need for each individual. There were brief records of a monthly review of the care needs of each person in their individual file. There was no care plans to show how the assessed care needs of each person would be met. Staff made daily entries about the care provided to people but these were kept separate from their care files. We noted that the records of care consisted mostly of generalised comments like ‘had a good afternoon’ and ‘full assistance given’. One relative stated that she had not been offered the opportunity to ‘get involved in the care review’ of her loved one and could not share her views on the care being provided. One of the three people whose care we looked at, had an advanced stage of a pressure sore. Appropriate referrals had been made to a specialist nurse dealing with pressure sores and to other health care professionals. Staff had also taken appropriate steps to acquire a recommended pressure mattress and an adjustable bed. However, there was no care plan to guide staff in providing care and in following the guidance of the professionals involved. No risk assessment was undertaken and recorded in the care file. We spoke to a few care assistants who provided care to this person. They confirmed that they were providing pressure relief by regularly changing the position of the person. There was little information in the care records to assist in the evaluation of the care being provided with regards to the management of this pressure sore. In discussion, we noted that the responsibility for the management of pressure sores was mostly left to the district nursing team. In another instance, a ‘kirton’ chair had been used for one person to refrain her from walking around. Staff explained that she was ‘unsteady on her feet’. However, this use of restraint was not appropriately planned and recorded in her care documents. Staff had little guidance on how this form of restraint should be managed. We also found that continence problems, affecting one person whose care we looked at, had not been planned. It was therefore difficult to ascertain what actions were to be followed by staff to address this aspect of care. At the meeting with the provider and manager after the inspection the manager explained that a majority of the care plans were now transferred to a new ‘superior’ model. Advice was also given and discussed re record keeping and informed choice regarding rstraint, the manager confirmed he will action this. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 12 We looked at the storage, handling and administration of medicines. The receipt of medicines was appropriately recorded. The medicines administration records were well maintained. The photographs of people for whom medicines were administered, were kept in the front of the medicines record file and this helped with their proper identification and avoided any possible errors. Overall, we found the management of medicines to be satisfactory. Hallamshire Residential Home DS0000002966.V364317.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. People using the service were able to benefit from some of the recreational activities that were available to them. This helped them in maintaining their quality of life. EVIDENCE: People who live at the home and their relatives said that they felt routines at the home were flexible. This enabled some people to choose, with staff support, how they spend their daytime. At this inspection, we noted that people were spending most of their time sitting in the lounges. There was a television playing in the main lounge and some people were watching it. A care worker sat with three people and was helping them make greeting cards. Staff said that there were no other activities planned for the day. We noted that there were about seven people in a small lounge and they spent time mostly on their own, except if they needed support with their care. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 14 In discussion, staff explained that they carried out some recreational activities on a regular basis. There was a record of such activities being undertaken. It included games like dominos, cards, jigsaws and crafts and a ‘pat a dog’ scheme. We noted that the few participants in these activities were mostly the same on most occasions. In discussion, the manager stated that he was reviewing the provision of social and recreational activities. He was also planning to make use of the large garden areas, particularly as the summer season approaches, for the benefit of the people living at the home. Relatives told us that they were always welcomed at the home. They could see their loved ones in private if they wished. There was a small quiet lounge, which they could use for that purpose. Relatives said that there was good communication between themselves and staff and this contributed to the wellbeing of their loved ones. People using the service and their relatives said that meals served at the home were generally good. Staff explained that where people could not choose their preferred meals, they helped them to indicate their preferred food by getting to know their ‘likes and dislikes’. We observed lunch being served. It was the main meal of the day and it consisted of scrambled eggs, sausages, beans, tomatoes, bread and butter and mashed potatoes. One care worker was observed assisting one person with eating her meal. Nutritional needs assessment was not consistently undertaken. However, a small number of people had been appropriately referred to the dietician for support in meeting their specific nutritional needs. Hallamshire Residential Home DS0000002966.V364317.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. People living at the home and their relatives were satisfied that they could express their concerns to staff and that these would be dealt with. Policies and procedures were in place and were used to protect people from potential harm. EVIDENCE: There was a complaints procedure in place and it gave information on how to make a complaint and who would deal with it. It also gave the timescale within which a complaint would be investigated and concluded. The complaints procedure was displayed at the home and was included in the statement of purpose and service user guide. Relatives who we met on the day told us that they were aware of the complaints procedure and would use it if necessary. However, they felt confident that staff would address any concerns that they had in a prompt manner and so making it unnecessary to invoke the complaints procedure. The manager confirmed that no complaints had been received since the last inspection. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 16 There was an adult safeguarding policy in place to promote the safety and welfare of people living at the home. However, it did not include information and procedures to be followed concerning the local Social Services’ adult safeguarding team. Staff were aware of the home’s safeguarding policy and had received training on safeguarding vulnerable adults. The acting manager confirmed that there had been one allegation of adult abuse at the home and that this had been appropriately referred to the local adult safeguarding team for investigation. Hallamshire Residential Home DS0000002966.V364317.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. People living at the home were satisfied with the standard of accommodation and its facilities, which made the place comfortable and pleasant. However, there health and safety measures were not consistently followed. EVIDENCE: People living at the home and their relatives were satisfied with the standard of accommodation provided. They described the home as being ‘very cosy’ and ‘genuinely warm’. They commented that both the communal and private areas were always kept clean and tidy. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 18 We undertook a tour of the premises in the company of the acting manager. The main entrance at the front was wheelchair accessible. The building comprised of three floors and there were two passenger lifts to facilitate access between them. The communal areas comprised of two lounges and a small ‘quiet’ room and two dining areas. The kitchen and laundry facilities are located on the ground floor. There was a public telephone along the main corridor. We noted that there were a number of ‘easy chairs’ placed along this main corridor, facing the kitchen door. We observed people who were sitting on these chairs, getting up from time to time and going to the kitchen door, which was wedged open. The staff in the kitchen had to take them back to their seats. We had also observed other fire doors being wedged open. We advised against the wedging of fire doors to keep them open and staff immediately removed the wedges. The use of the corridor as a seating area was potentially obstructive and hazardous, in particular, with regards to fire safety. It also posed a safety risk to people, who experience dementia, to be able to wander near and in the kitchen. We noted that there was no proper signage throughout the home to assist people with communication difficulties to find their way to various areas, including toilets and bathrooms. All external doors were provided with keypads and locking system to ensure the security and safety of people who have dementia. There were three bathrooms and no separate shower facility. The acting manager said that the provision of a shower facility was being considered. This would provide people with a choice of bathing facilities. One of the bathrooms was being completely refurbished in order to make it more pleasant and homely. Another bathroom had parts of the bathtub panels removed and staff told us that it was also under repair. Two bathrooms had fixed bath hoists fitted to provide assisted bathing. However, we noted that the hot water at some outlets, used by people at the home, was ‘very hot’ and could cause scalding. The laundry was sited away from the food preparation areas. We noted that dirty and soiled linen was kept in open baskets and some of the linen was left on the floor. This could lead to cross infection. We viewed a few bedrooms with the permission of people who lived in them and their relatives. We found them to be clean, tidy and odour free. There were four ‘double’ bedrooms. Two of these bedrooms, were shared by married couples. The two others were occupied by people of the same sex. We checked one of the Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 19 ‘double’ bedrooms. It had a privacy screen in the middle of the room, to ensure privacy to the occupants. The provider and manager have stated there has been ‘massive improvement’ to the physical environment – new carpets, new bathroom equipment and redecorated bedrooms. The surrounding grounds included a lawn, which was well maintained for the time of the year. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. People living at the home and their relatives were satisfied with the staff team, which they found to be very committed and conscientious. Although the number of care staff deployed appeared sufficient, its deployment in relation to the lay out of the building meant staff were not able to supervise groups of people as necessary. This could lead to people missing out on care and attention. Staff recruitment and selection was inadequate in ensuring the protection and safety of people living at the home. EVIDENCE: The home was registered to care for up to 32 older people. At the time of this inspection, there were 28 people in residence, 27 of whom had dementia. The care staff on duty, besides the acting manager, comprised of the deputy manager and four care assistants. There were three care assistants on duty after 6.00 pm in the evening and three were scheduled to work during the night. Other support staff included a domestic, a cook and a kitchen assistant and a laundry worker. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 21 We noted that some people living at the home were often left without staff supervision or interaction for some periods, except if they needed care. During the inspection, we found that a group of seven people had been sitting in one of the small lounge on their own for quite some time. Staff were observed near the main lounge and dining area. Given the lay out of the building, care staff explained that they had to respond to calls for assistance at different areas of the home. We spoke to a few relatives and they said that ‘staff were hardworking but that ‘there was not enough of them’. They said that there were often fewer care staff during the weekends and at the evenings. One relative said that she visited her loved one regularly and tried to ‘pamper’ her a bit because she often felt ‘lonely’. She added, ‘I don’t think staff could spend time with her as they are so busy’. We spoke to care staff about the training they had received to help them provide care to people with dementia. They said that they had received training on ‘Dementia Care’ from a Social Service team (POPPS) and this lasted for about three hours. They had also received training on other topics like continence care, adult safeguarding, moving and handling, fire safety and first aid. The deputy manager said that she had undertaken an accredited course in the safe administration of medicines. In discussion, staff indicated that they understood adult safeguarding policy and procedures. The ‘Annual Quality Assurance Assessment’ (Aqaa) states that refresher training on a number of ‘mandatory’ training was being organised. There were twenty members in the care team and six of them had completed their National Vocational Qualification (NVQ) level 2 in care. Three others were currently following their NVQ level 2 courses. We noted that, commendably, the staff group at the home was from a diverse background in terms of gender and ethnicity. We looked at the files of three care staff, who had been more recently recruited to work at the home. In all three instances, the required preemployment checks, including the relevant disclosures and work references had not been sought and obtained before the staff member started to work at the home. Gaps in employment history had not been checked and explained. The lack of appropriate pre-employment checks could put people who use the service at risk. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. Management arrangements were in place and people who use the service, their relatives and staff were satisfied with them. EVIDENCE: A new manager was in post. He joined the home in December 2007. He stated that he had experience in the management of residential care, in particular, for older people with mental health problems. He also stated that he had completed the NVQ level 4 and the ‘Registered Manager’ Award (RMA). The manager confirmed that he would be submitting his application for registration as manager of the home to CSCI. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 23 People living at the home, relatives and staff were satisfied with the way the home was being managed. They were very complimentary about the new manager in terms of his attitude and commitment to the service. We looked at quality assurance methods that were being used to get feedback from people who use the service and their representatives about the quality of the service. The manager confirmed that a satisfaction survey of people using the service had been organised. Questionnaires had been sent out in January and the manager said that he would be collating the answers and producing a report on the matter. We noted that the management of medicines and of personal monies of people was appropriately monitored. However, there was no audit of care documentation and of health and safety checks, including the temperature of the ‘hot’ water at all outlets used by people living at the home. Such audits would have assisted in rectifying the shortfalls that we identified in parts of the service. We saw a copy of the report of the provider’s monthly visit to the home, in which management issues were being identified and addressed. Arrangements were in place to support people living at the home with the management of their personal monies. All financial transactions undertaken on behalf of the people concerned were appropriately recorded, witnessed and signed for and receipts were kept. The manager stated that he and a member of staff undertook a regular audit of each individual ‘s account and they had all been satisfactory. These procedures ensured that the financial interest of people concerned was safeguarded. A few members of the care team told us that they felt that the new manager was providing them with appropriate support. However, they stated that they had not received the recommended number of supervision sessions yet. In discussion, the manager confirmed that he had started to plan the supervision of all his staff. Information about the maintenance of equipment and of other systems like gas, electrical appliances and water supply and heating, was provided in the ‘Annual Quality Assurance Assessment’ that was submitted before this inspection. Health and safety issues were discussed with the manager and a sample of the records was checked. We also checked compliance with the last fire department’s recommendations. They were found to be satisfactory. We drew the attention to the need to stop using wedges to keep fire doors open. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 24 We noted that accidents happening at the home were appropriately recorded and addressed. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15 Requirement Individual plans of care must be appropriately developed and implemented and reviewed for people living at the home. This will ensure that all identified needs are addressed. Timescale for action 27/06/08 2. OP7 15 The use of any form of restraint 27/06/08 must be appropriately planned, recorded and reviewed, to make sure that it justifiably contributes to the welfare of the person to whom it applies. Fire doors must not be kept open 27/06/08 by using wedges. Advice from the fire officer must be sought where such doors need to be kept open. The seating arrangement in the 27/06/08 corridor facing the kitchen must be reviewed in order to improve the safety of people, who have dementia and who live at the home. Advice must also be sought from the fire officer about the fire safety implications of this seating arrangement. DS0000002966.V364317.R01.S.doc Version 5.2 Page 27 3. OP19 23 4. OP19 23 Hallamshire Residential Home 5. 6. OP26 OP29 16 18 7. OP38 13 Dirty and soiled linen must be 27/06/08 kept in appropriate bags to avoid any possibility of cross infection. The recruitment and selection of 27/06/08 staff must be improved to make sure that the required preemployment checks are appropriately undertaken. This will help to protect people who use the service from any potential harm. Health and safety checks must 27/06/08 be carried out and action taken to address any shortfalls identified. An audit of such checks must also be put in place to maintain good practice and to improve the overall quality of the service. 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 The social care needs of people using the service should be more appropriately assessed to reflect their preferences and capabilities. This should help in increasing opportunities for their social stimulation. The nutritional needs of people should be consistently undertaken and catered for. This should help with their overall health and wellbeing. The adult safeguarding policy of the home should be improved to include information about the local multidisciplinary safeguarding team. This should facilitate the use of the procedures. Appropriate signage should be used in the home in order to guide and facilitate people with communication difficulties to find their way to various facilities and areas. The number and deployment of care staff should be reviewed to ensure that all the needs of people living at the home are effectively met. DS0000002966.V364317.R01.S.doc Version 5.2 Page 28 2. 3. OP15 OP18 4. 5. OP19 OP27 Hallamshire Residential Home 6. OP36 A plan for the regular supervision of staff should be developed and implemented. Hallamshire Residential Home DS0000002966.V364317.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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