Inspection on 24/11/05 for Sandilands Lodge

This inspection was carried out on 24th November 2005.

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

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

Other inspections for this house

Sandilands Lodge 22/04/08

Sandilands Lodge 10/01/08

Sandilands Lodge 25/09/07

Sandilands Lodge 28/02/07

Sandilands Lodge 19/04/06

Sandilands Lodge 23/11/04

Sandilands Lodge 17/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sandilands Lodge 228 Carshalton Road Sutton Surrey SM1 4SA Lead Inspector Michael Williams Unannounced Inspection 24th November 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sandilands Lodge Address 228 Carshalton Road Sutton Surrey SM1 4SA 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) 020 8643 6291 020 8642 3788 BMWilliamstconnect.com Miss Barbara Williams Mr Richard Trusty Miss Barbara Williams Care Home 15 Category(ies) of Dementia - over 65 years of age (15) registration, with number of places Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2005 Brief Description of the Service: Sandilands Lodge was co-owned by Mr Richard Trusty and Miss Barbara Williams, however, Mr Trustys interest in the business is at present represented by a receiver but the home is still registered with the CSCI and remains in full operation. Miss Williams is the registered manager. The home is registered to provide residential care for up to fifteen older peoples (aged 65 and over) with dementia. The home is a large detached house situated on the Carshalton Road close to local shops and bus routes between Wallington and Sutton. There are three single and six double bedrooms located over two floors. The home has a separate lounge and dining room on the ground floor. There are bathrooms and toilet facilities located on both floors but these facilities have not been assessed by an Occupational Therapist as suitable for people with disabilities or mobility problems. The home has a small kitchen and small laundry room. The office is also very small, too small to effectivelly manage the home. A small patio area and raised garden is to be found at the rear of the property and parking space to the front. Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 27 requirements were made by the CSCI in July and this inspection visit was to monitor compliance. Whilst many requirements are ‘in the process’ of being addressed few are fully implemented and 17 requirements arise on this occasion. In addition to those outstanding matters a number of new requirements are made. As advised previously, it is vital that the owner/manager develops a sound and viable business plan to address these shortcomings without further delay. It is acknowledged that despite the difficulties of one partner being subject to bankruptcy proceedings the remaining proprietor is working hard to keep the business viable so that care can continue to be provided. A ‘Trustee in Bankruptcy’ represents the interests of one partner and he has confirmed the continuing viability of Sandilands Lodge. The manager has appointed an architect to make improvements to the building, which is rather old and not to modern standards. What the service does well: What has improved since the last inspection? What they could do better: In view of the number and range of requirements not fully complied with since November 2004, as well as the number of new requirements identified during the inspections of July and November 2005, it is clear that robust action is required by the owner/manager to improve various aspects of this home. In order to improve the general running of the home, such as administration and record keeping; care planning; staff training; maintenance of the home and so forth, is it strongly recommended that a suitable management team is put in place including perhaps a Deputy Manager. Such a person could oversee the care of service users and assist in the paperwork which Miss Williams acknowledges can be daunting at times; a housekeeper is suggested to oversee hotel service such as laundry, catering, maintenance and safety Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 6 certificates, and an administrator to assist in the increasing volume of administration and recording-keeping which can be very onerous for small businesses like Sandilands. During the inspections in July and November 2005 a number of hazards were identified and a number of these are still not fully dealt with but the manager assures the CSCI that action will be taken to deal with all hazards and other shortcomings. The CSCI will continue to monitor these matters. Safety matters that must be attended to include unprotected hot radiator; unsafe digital locks on fire and final exits; fire doors wedged open; fire doors with a locks that would prevent egress in the event of an emergency; hazards in the garden such as builder’s equipment stored on the fire escape route; lapses in window security on the ground floor. 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. Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 New service users are now being admitted after an assessment is undertaken by a care manager and the home’s manager. This involves the service user or, in most cases, their representative. So service users and their families will be assured that their needs will be met. The service user remains in complete. EVIDENCE: A sample of case files was examined with the assistance of a member of staff and the manager. The information is stored in several files for each service user and whilst this is not an unusual arrangement the information the staff took some time to identify the documents requested. However, the preadmission documentation was eventually located in the files so this standard is, on this occasion, assessed as met but it is suggested a more methodical, and indexed, file system is needed. The manager states that she had yet to complete the work on the home’s Service User Guide so as to ensure it contains all the matters listed in NMS 1. Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 9 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 None of these standards were fully met in July so they were re-evaluated again in November. Care plans are now in place and the home is in regular contact with Doctors and Nurses to ensure the social and health care needs are being met. Medication is now more safely administered using a dosette system so as to ensure the safety of service users. No lapses in privacy or respect were identified during this inspection. EVIDENCE: A sample of care plans was checked to confirm they are in place for each service user and that they are reviewed and updated monthly to confirm they remain relevant and annually to review more thoroughly. In the small sample checked this was the case. As indicated in standard 3, the case files need to be set out in a more methodical and accessible manner. Although the exact causes for bruises to two residents is unclear both were the result of accidental injury by staff suggesting the need for staff training in safe techniques for moving and handling service users to ensure their health and well being is protected. Where staff were previously transferring medication into alternate packs this is now done by the pharmacist in line with good practice. A doctor was on site to check the well being of several service users and therefore confirms that medical cover is in place. During the course of the inspection no lapses were observed in the manner in which service users were assisted, staff were kind and caring in their attitude to residents. Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 10 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 15 It was not possible to discern directly from service users whether or not their lifestyle, their social, cultural and religious interests and wishes were being met but they appeared content with life in Sandilands Lodge. Visitors are welcomed and in so far as service users are capable of making their choices known these are respected. No record of food was available but the meal on the day was wholesome and plentiful and service users said they enjoyed it. EVIDENCE: In respect of standard 12 which is about social activities this standard is assessed as not fully met because there was very little indication that service users have a great deal of choice about how they can spend their day - it is usually in the one lounge, seated with the other service users in the usual serried circle. Nor is it clear that the home helps service users to sustain personal skills and abilities for as long as possible. During the course of the two visits for this Autumnal inspection little evidence of social/recreational activity was seen; for example, mid afternoon on 24th November and again in the morning of 5th December. There were even occasions, up to about 20 minutes, when the service users sat without staff support and supervision, they sat unattended listening to music. The manager states that social activities such as Bingo and manicures as well as conversation with staff are available. A recommendation to improve leisure, recreational activity and opportunities for stimulation is made; in particular staff are trained so as to Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 11 offer opportunities for stimulation and activity including contact with the wider community. Only key standard 15, about meals, failed to be fully met last time and once again the manager has not put in place a record of meals provided – this needs to be in sufficient detail so that the nutrition of each service user can been evaluated if and when the need arises. A requirement for this record is therefore repeated. Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 12 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 The home has a clear and simple procedure for dealing with complaints so service users’ are confident their concerns will be dealt with promptly and effectively but the procedures for reporting allegations or suspicions of possible abuse were not clear to all staff, this would compromise the well being of service users if effective referral procedures are not in place and known to all. EVIDENCE: The record of complaints was in place following a requirement made in the previous inspection. No complaints have been recorded for many months; the manager states that no complaints have been received but it may also mean that key workers have not been helping service users, (who have limited capacity to make known their feelings), to make known any concerns they may have. An incident warranting referral to the local authority Social Services arose during the course of the inspection and demonstrated that the manager had some confusion about the respective roles of the CSCI and Social Services and she had not already referred the matter as indicated. A requirement is made to ensure all staff including the proprietors are aware of the distinction between the CSCI and the Social Services and to be familiar with the Local Authority’s procedures for dealing with allegation or suspicions of abuse. Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 13 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 20 21 22 23 26 This is not a well maintained care home but improvements are being so as to provide a more comfortable, suitably adapted and safe environment for service users with bedrooms that will suit their needs. EVIDENCE: This is a relatively small care home, 15 beds in all, and it provides a homely and comfortable setting although there is just a single lounge for all the service users to spend the day so they have little choice about where and with whom they sit each day. The home was clean and tidy when inspected. At present this home is not providing a safe and well maintained environment in all areas. A number of hazards have the potential to put service users at risk or to reduce their comfort such as digital locks on doors, wedges used to prop open fire doors, an unprotected hot radiator in a small toilet. With such a vulnerable client group in residence such hazards must be more closely monitored by the staff themselves and dealt with in a timelier manner in future. The home has yet to arrange for an Occupational Therapist to assess the premises for suitable aids and adaptations to meet the various disabilities of service users including visual, hearing and mobility problems. At this stage it Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 14 therefore appears the home does not have the equipment needed for the correct moving and handling of service users and this is also a potential risk for both residents and the staff. As most rooms in this home are shared rooms (double bedrooms) there is little scope for service users to choose with whom they share and little scope to move to a single room if they no longer wish to share. Clinical waste was seen to be stored in the alley next to the home and was therefore both a fire hazard (because this is an external fire escape route) and it was a waste hazard (because it was not be stored in a suitable and locked container). The home has a small garden; it has a raised lawn and at this time of the year (Winter) would offer little attraction to service users it also rather hazardous as builders are at work in the area and clinical waste and other rubbish is left accessible to any residents who may wander into the garden. The home has large cellar, which the manager intends to use more effectively. During the inspection one area was being used for food storage and the freezer was heavily encrusted with ice and the food partially defrosted – this was a potential food hazard and the manager was advised to dispose of the food which she could not guarantee was being maintained at below -180 C. The CSCI have been invited to review plans to improve the premises, for example by reducing the number of shared bedrooms, and such proposals are commended but must comply with the accommodation standards and in particular must not provide less individual space (bedrooms) than previously provided before March 2002. Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 15 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 The staff team has still yet to achieve its full potential and is not always the number and skill mix of staff, nor completed recruitment checks, required to meet service users’ needs so as to ensure they are in safe hands. EVIDENCE: The proprietor concedes that not all the documentation required to demonstrate that safe recruitment practices are in place but are ‘in process’ and near readiness. In particular, the manager is still waiting for the return of some CRB (Police) checks. Pending the completion of those checks staff must have a POVA-First (the list of ‘unsuitable’ workers) check in place and must be supervision until the full CRB is received and found acceptable. The home’s programme of training has yet to be fully implemented but is underway. On the second day of inspection neither a dedicated cleaner nor cook was on duty and the proprietor/manager was also absent. At that point three staff were providing care as well as undertaking cleaning and cooking duties – this falls below the numbers required to meet the care needs of service users in this home. During the course of the inspection the proprietor returned thus freeing other staff to undertake ancillary duties. The manager conceded that there are staffing difficulties and is exploring options to increase the staff establishment in her home. Training for staff is underway but the lack of clarity about protecting vulnerable adults from abuse as outlined in standard 18 indicates the need for continued training. It is also evident that staff need to be reminded of their responsibilities to maintain a safe environment by noting hazards and dealing with them in a more timely manner, the hot radiator for example, door locks Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 16 and the use of door wedges. Two residents were seen to have bruises to their face and this was followed up by the CSCI at the time of inspection; the social service care manager is satisfied that these were accidents and not deliberate injuries but they do indicate the need for staff to be trained in the safe moving and handling of service users. In general the staff team needs to be better trained and supervised if standards are to be maintained. Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 17 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 32 33 34 36 37 38 The proprietors are very caring people but the management and leadership in this home needs to be strengthened if the various shortcomings identified in other sections of this report and previous reports are to be effectively dealt with so as to ensure the home is run in the best interests of the service users. EVIDENCE: The owner/manager is registered with the CSCI and was assessed as fit person to do so at the time. This home is run by a business partnership of two persons and the second person in this partnership has been adjudged bankrupt so his interest in the business is represented by a Trustee in Bankruptcy (pending appeals) and he is to play no part in the running of the home. This will inevitably affect the running of the home although shortcomings in the management of this home were evident before his absence. In view of the range of requirements outstanding and the new ones that arise the management of this home need to be improved. For example, record keeping and administration does not meet the necessary standards. A number Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 18 of potential hazards have again been identified. The various shortcomings outlined in this section are all likely to adversely affect the safety, comfort or well being of service users. Of the 27 requirements, issued in July 2005, 7 are assessed as met, 14 not fully met and 6 partially met or not reassessed during this inspection. A number of care issues and hazards were identified, including unsafe practices in respect of the care of service users and their moving and handling leading to bruises on two occasions; lack of stimulation and supervision of service users; unsafe digital locks on internal and external fire/final exits; fire doors wedged open; hazards in the garden such as clinical waste stored on the fire escape route; refrigerated food stored in the cellar inadequately monitored; the laundry and boiler room were both unlocked and unattended at the point of inspection. The manager concedes that record keeping and general administration is not her strong point and prefers ‘hands on care’ - so she has employed a part time administrator, but still there are deficiencies in record keeping and the management of documentation in the home such as the Service User Guide, police checks, safe storage of service users’ personal files, food records and so forth. In order to improve the general running of the home - its administration and record keeping; care planning; staff training; maintenance of the home and so forth – it is strongly recommended that a suitable management team is put in place including perhaps a Deputy Manager to oversee the care of service users and the documentation required to demonstrate that good care is being provided; a housekeeper is suggested to oversee hotel services such as laundry, catering, maintenance and safety certificates, and an administrator with some responsibility for ensuring better control of paperwork. In discussion with the manager it is clear she is aware of shortcomings and is striving to attain a quality care home but without an effective management team in place the owner/manager will need to demonstrate that she can herself successfully run the home and meet National Minimum Standards in all areas. Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 19 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 1 3 1 3 X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 2 X 2 2 1 Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? 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 5 Requirement Service User Guide: this must be kept up to date and must include all the matters listed in NMS 1 and Regulation 5. This is outstanding from 23/11/04. Data Protection: confidential information, including personal documentation and computer screens, must be maintained secure, private and confidential. Food records: must be maintained in accordance with Schedule 4:13. Staff Training: Training must be implemented for all care staff including training in Dementia care; First Aid; Moving and Handling; Medication; Fire Safety; protection from abuse procedures. A record of this training must be maintained and be available for CSCI inspection. This is outstanding from 31/3/05 Protection: all staff, including the manager, must complete training, and periodic refresher training, in the procedures for dealing with allegations of abuse, this must include training in the DS0000007207.V267731.R01.S.doc Timescale for action 30/03/06 2 OP37OP14 12(4) 30/03/06 3 4 OP37OP15 OP8OP30 17 18 30/03/06 30/03/06 5 OP32OP30 OP18 13(6) 30/03/06 Sandilands Lodge Version 5.0 Page 21 6 OP22 23(2)n 7 OP19 23(2) 8 OP20 23(2)o local vulnerable adult protection procedures; each member of staff to be given a summary. Each member of staff to be given a copy of the homes whistleblowing policy and each member of staff to be given a copy of the GSCC (General Social Care Council) Code of conduct. Written evidence must be provided of these various requirements. Vulnerable Adult Protection training remains outstanding from 31/3/05. Adaptation of premises: the 30/03/06 registered person must demonstrate that the premises and facilities have been assessed by suitably qualified person, such as an Occupational Therapist, to ensure that suitable aids and adaptations have been installed to meet the needs of service users. A copy of that assessment must be supplied to the CSCI. Outstanding from 30/9/05 Premises: the premises must be 30/03/06 maintained in good order throughout; old and broken furniture must be replaced. A schedule of work must be submitted to the CSCI to include details of programme of replacement and redecoration. This requirement, to prepare a programme of maintainance, of reiterates a requirement from November 2004 in view of the condition of some areas. 30/03/06 Garden: the garden must be suitable, safe and well maintained. Rubbish must be cleared and the grounds kept safe, attractive and accessible to service users. This is outstanding from 23/11/04. Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 22 9 OP34OP33 OP32 24 25 10 OP34 25(2) (3) 11 OP37 17 12 OP38 23(4) 13 OP38 23(4) Quality of care: The registered person must establish a system for reviewing and improving the quality of care provided and must submit a report, including the annual business plan, to CSCI. Results consultations must be included in the service user guide. This remains an outstanding requirement from 31/3/05 Finances: The registered person shall provide the CSCI with the information listed Regulation 25(2) including the annual accounts; a bank reference; information as to the financing of the home and a certificate of insurance. It is noted that some of this documentation was supplied at the time of inspection. Records: the registered person must maintain all those records listed in the Schedules 1 to 4 as they apply to this home and shall maintain them complete, up to date and accurate; including staff recruitment records and service user case files. Fire safety: Digital lcoks must not be used on fire doors, fire exits and final exits, or any other location that would impede egress, unless they have a electro-magnetic device connected to the fire warning system and with a local override device adjacent to the lock (which must then be tested monthly). Fire Safety: No fire doors, including bedroom doors, are to be propped open unless held by a magnetic door holder that respnds to the fire warning system and all doors, including those with magnetic door DS0000007207.V267731.R01.S.doc 30/03/06 30/03/06 30/03/06 30/03/06 30/03/06 Sandilands Lodge Version 5.0 Page 23 14 OP38 23(4) 15 OP38 13(3)(4) 16 OP26OP38 13(3) & 16(2)j 18 17 OP28OP27 18 OP19 23(2)c 16(2)j holders, must close fully to their stops. Fire Safety: all fire exit routes must be kept free of obstruction such as clinial waste and any builder’s equipment. Clinical waste: the home must make suitable arrangements for holding clinical waste safely until it is collected by an authorised contractor; it must be contained within a suitably large and locked container. Infection control: The home must have suitable sluicing facilities. This is an outstanding requirement from 31/3/05 Staffing levels: The home must ensure that at all times there are staff in sufficient numbers to meet the needs of service users and must be no less than the staffing levels provided for in the guidance issued under the previous registering authority. Food hygiene: Food stored in the cellar, including chilled food must be monitored to ensure suitable temperatures are maintained and that freezers are kept clean and with minimum frost. Frozen food that cannot be guaranteed as being held below –18 degrees must be disposed of. 30/03/06 30/03/06 30/03/06 30/03/06 30/01/06 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 Refer to Standard 12 Good Practice Recommendations Activities: It is recommended that the range of activities DS0000007207.V267731.R01.S.doc Version 5.0 Page 24 Sandilands Lodge 2 7 be reviewed and revised so as to meet the specilalist needs of people with dementia. The revised schedule of opportunities for fulfilling and social activities to be made known to service users and their visitors. Care notes: Service users case notes must contain, as a minimum, all those items listed in NMS 3 and Schedule 3. Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Sandilands Lodge DS0000007207.V267731.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!