Inspection on 25/09/07 for Sandilands Lodge

This inspection was carried out on 25th September 2007.

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

Sandilands Lodge 22/04/08

Sandilands Lodge 10/01/08

Sandilands Lodge 28/02/07

Sandilands Lodge 19/04/06

Sandilands Lodge 24/11/05

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 Mohammad Peerbux Key Unannounced Inspection 25th September 2007 10:00a 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.V347535.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. Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 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 bmwilliams@btconnect.com Ms Barbara Williams Ms Barbara Williams Care Home 15 Category(ies) of Dementia - over 65 years of age (15) registration, with number of places Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2007 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 Trustee in Bankruptcy 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. It is an old property in need of refurbishment and difficult to adapt to modern standards of comfort and disability access. 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. There is no passenger lift so this home is not suitable for people with mobility problems. The home has a small kitchen and a laundry room and has recently installed a sluice. The office is also very small, too small to effectively 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. The range of weekly fees is between £417 and £455. Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2007/2008. In writing the report consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. This was the home’s first inspection for the year 2007/08. It took place over eight and half hours and was conducted by two inspectors from the Commission. Some time was spent looking at the policies and procedures, talking to staff and registered manager. Some of the residents were spoken to however due to their cognitive ability it was difficult to seek their views. A tour of the building was also carried out. They are all thanked for their time and their feedback during in the inspection process. There have also been some concerns raised as far as Adult Safeguarding is concerned and the Local Authority is carrying out an investigation presently. This service struggles to achieve National Minimum Standards. But many of the recommended policies and procedures are now in place although there is still evidence that the practice is not always consistent or well applied. What the service does well: What has improved since the last inspection? The Commission remains not confident that the registered manager has the necessary skills and competence to continue and sustain the current improvements introduced by the consultant. However it was positively noted that the manager has appointed an assistant manager to help her with the running of the home to achieve and maintain acceptable standards throughout. Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 6 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. Sandilands Lodge DS0000007207.V347535.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 Sandilands Lodge DS0000007207.V347535.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): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home undertakes an assessment of the healthcare needs of residents prior to their admission to ensure that their needs would be met. EVIDENCE: Three residents’ files were sampled at random and it was noted that prospective residents have a needs assessment carried out before they are admitted to the home. However the assessment must be considered against the statement of purpose to ensure that the service is able to meet the needs of the new resident as the home does not have a lift and will not be able to meet residents with mobility difficulties. Information from Medical staff must also be part of the assessment process, as their contribution will provide a clearer understanding of the needs of the prospective resident. For individuals Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 9 referred through Care Management arrangements, a summary of the Care Management (health and social services) assessment and a copy of the Care Plan produced for care management purposes must be obtained. All assessments must also be completed in full so that the needs of the residents could be met. The home does not offer intermediate care. Sandilands Lodge DS0000007207.V347535.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Each resident has a care plan in place however the care plans do not always cover all their care needs. EVIDENCE: Three residents’ care plans were sampled at random and it was noted they included basic information necessary to deliver the resident’s care but did not cover all the resident’s needs. For example one resident can be physically aggressive and this need was not covered in his care plan. This was discussed with the manager and assistant manager during the inspection. Residents’ care plans must cover all aspects of their health, personal and social care needs and set out in detail the action, which needs to be taken by care staff to ensure these are met. They must also meet relevant clinical guidelines produced by the relevant professional bodies concerned with the care of older people, and includes a full risk assessment, with particular attention to prevention of falls. Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 11 Although care staff and professionals write the care plans, this could be improved, as there was little evidence that the residents and their family contributed or were actively involve in the process. Care plans must be drawn up with the involvement of the resident, recorded in a style accessible to the resident; agreed and signed by the resident whenever capable and/or representative (if any). Evidence of updating information and changing actions appears on care plans however these were not consistent and there was no evidence that residents are involved in reviews in any meaningful way or encouraged to communicate their needs. The residents’ care plans must be reviewed at least once a month, updated to reflect changing needs and current objectives for health and personal care. Generally the resident’s health is monitored and appropriate action taken. The home seeks professional advice on health care issues, acts upon it. However there have been concerns raised by the local care management team that there was a delay in seeking medical advice for one resident and this is presently being investigated. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. However it was noted that the administration of antibiotics for one resident was not being administered as prescribed and the medication administration record was not completed accurately. The administration/non-administration of all medication must be recorded accurately at all times for the health and safety of residents. During the inspection it was noted that prescribed medications (creams) were left unattended and unlocked in residents’ bedrooms, which potentially places them at risk. The manager stated that “Sudocream” are left unlocked. All prescribed medication in the custody of the home must be locked according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society, the requirements of the Misuse of Drugs Act 1971,for the health and safety of residents. It is also recommended that an “O” is entered on the MAR sheet where medication has not been administered instead of leaving the space blank. Observation of the staff team interacting with the residents showed that the carers were mindful how they addressed residents, and they were seen to be polite and friendly. The home arranges for residents to enjoy the privacy of their own rooms and provides screens in shared rooms. Sandilands Lodge does however remain unsuitable for residents with mobility problems – a point Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 12 confirmed by observing how difficult it was for one resident to ascend the stairs with the help of a carer. Sandilands Lodge DS0000007207.V347535.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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home tries to be flexible and attempts to provide a service, which is as individual as possible. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: In respect of Standard 12, which is about social activities, this area is assessed as still not fully met because there was still very little indication that residents actually do have a greater choice or control about how they can spend their day - it remains the case the residents sit in the one lounge, seated with the other residents in the usual serried circle. There was little evidence that the home assists residents to sustain personal skills and abilities for as long as possible. The individual activities timetable for three residents showed that they were having activities only twice a week. This was discussed in depth with the registered manager and it was agreed that the recording of activities could be further improved; as it was difficult at times to identify what activities the Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 14 residents have been involved in. Some engagement was noted between staff and residents on the day of inspection. Family and friends feel welcome and know they can visit the home at any time. The design of the home provides seating areas within the communal areas of the home where residents can entertain their visitors, in addition to the privacy of their own room. Although the staff stated that residents are being supported to exercise choice and control over their lives in so far as they wish and are able to do so, there are concerns with regards to activities of living as mentioned above not all their needs are being identified and met. It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. The menus offer a choice of meals, and when the published menu options are not desired on the day, alternatives are offered. It was positively noted that consideration is also given to residents from ethnic minority groups as far as the menu is concerned. Sandilands Lodge DS0000007207.V347535.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are generally managed well, which should ensure that residents’ and relatives’ concerns are listened to. However there have been concerns raised with regards to the care being provided in the home, which might put residents as risk. EVIDENCE: The home has a complaints procedure which explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. The current complaints procedure is good and gives a clear step-by-step guide of how to make a complaint. It was previously required that all staff have abuse training. The manager stated that this has been met. Since the last inspection there has been concerns raised by the Local Authority which is being investigated at present, concerning the care of residents. Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment does not provide a homely atmosphere or always meet the residents’ needs. EVIDENCE: Although there is an on-going maintenance programme in place the environment does not always meet the residents’ needs. A number of the fixtures and fittings need replacing and the décor requires upgrading. A tour of the home was carried out and it was noted that most of the rooms look bare and were not always personalised. Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 17 Much of the furnishing of the home looked tired and in some cases requires to be repaired or replaced. All residents must have a means of calling for assistance, however it was noted during this inspection that the some call bells would be out of the reach of the residents if they were sitting in their bedrooms. The call bell in the ground floor toilet also needs fixing. The home is kept clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. However there were chemicals left unlocked in the laundry room (see standard 38). Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Recruitment policies are not been consistently followed resulting in residents receiving care from staff members who have not been properly vetted. This potentially leaves people who use the service at risk. EVIDENCE: Copies of the off duty rotas were seen and it was noted that the registered provider is failing to ensure that staff have adequate break time. One staff member has worked 48 hours shift, which include a waking night. Staff must not work excessive hours, as this will put residents at risk. As part of the inspection process staff records were sampled for references, criminal record checks, application forms and copies of identification. It was noted that one file did not have a photograph or an identification. Staff files must contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001 for the delivery of good quality services and for the protection of residents. Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 19 From the staff training records, it was noted that they were not always up to date and there are gaps in mandatory training. It was very difficult to ascertain if the staff were up to date with their training. There must be a staff training and development programme in place, which meets Sector Skills Council workforce training targets to ensure staff fulfil the aims of the home and meet the changing needs of residents. A training needs assessment must also be carried out for the staff team as a whole, and an impact assessment of all staff development must be undertaken to identify the benefits for residents and to inform future planning. The registered person must monitor staff competencies through regular supervision, as this will influence the need for updates with regards to training. Training and development must be linked to the homes’ service aims and to residents’ need and individual plans (for example training in dementia care). Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are shortfalls in the management of the home and the health, safety and welfare of residents and staff are not being promoted/protected and this potentially places them at risk. EVIDENCE: During the course of this inspection a large number of requirements were made and/or repeated. This reflects on the way the home is being managed and potentially has an impact on the care of the people who are using this service. This was discussed with the registered manager. Presently the manager has appointed an assistant to help her with managing the home. Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 21 However due to her lack of experience in the dementia care sector she is still learning and hoping to become the new registered manager of Sandilands Lodge. In the meantime the home must be run in the best interests of the residents and work to the basic processes set out in the NMS. It is recommended that the registered manager has access to a mentor or another professional for support and supervision in relation to her professional practice. All professionals need an element of support and supervision, including managers and owners. The manager stated that she has devised a questionnaire for resident to gain their views on the way the home is run. No copy of quality assurance report was available at the time of this inspection. This requirement has remained outstanding since 31/03/05. Three staff supervision records were sampled and it was noted that one staff member did not have any supervision record. Formal supervision sessions must be held with all care staff at least six times a year for the delivery of good quality services. This requirement has been repeated twice already. The registered provider must take action to resolve this on-going issue. A number of health and safety issues arose during this inspection and they are as follows: -Two fire doors were wedged open and two fire doors were not closing fully. Fire doors must not be wedged open unless held open by a magnetic door holder that responds to the fire warning system for the safety of staff and residents. This is very concerning to the Commission as the safety of staff and residents are being compromised. - COSHH materials were left unlocked in the laundry room and this represents serious risk to residents as the laundry room is next to the garden where it was observed one resident sitting without staff supervision. Again this is very concerning to the Commission due to the residents’ cognitive abilities. All COSHH materials must be kept locked in accordance to Control of Substances Hazardous to Health Regulations (COSHH) 1999 for the safety of staff and residents. - A number of bedside table lamps were not working. All bedside table lamps must be in working order for the safety of residents. -The radiator cover is the toilet needs to be fixed to the wall as failure could result to residents being scalded from hot surface. -The radiator pipes in room B3 must be covered to prevent residents from scalding. It is also recommended that the home carry out a risk assessment on all uncovered hot pipes in the building for the safety of residents. Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 22 Failure to comply with the aforementioned requirements represent serious breaches of the Regulations and urgent action must be taken by the registered person to address these to avoid the Commission taking further action to enforce compliance. Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X 2 X 2 X 2 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 2 X 1 X X 2 X 1 Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14(1) Requirement The needs assessment must be considered against the statement of purpose to ensure that the service is able to meet the needs of the new resident as the home does not have a lift and will not be able to meet residents with mobility difficulties. The needs assessment must be completed in full so that the needs of the residents could be met. Residents’ care plan must cover all aspects of their health, personal and social care needs and set out in detail the action, which needs to be taken by care staff to ensure these are met. (Previous timescale of 30/05/07 not met). Residents’ care plan must meet relevant clinical guidelines produced by the relevant professional bodies concerned with the care of older people, and includes a full risk DS0000007207.V347535.R01.S.doc Timescale for action 30/11/07 2. OP3 14(1) 30/11/07 3. OP7 15(1) 30/11/07 4. OP7 15(1) 30/11/07 Sandilands Lodge Version 5.2 Page 25 assessment, with particular attention to prevention of falls. 5. OP7 15(1) Residents’ care plan must be drawn up with the involvement of the resident, recorded in a style accessible to the resident; agreed and signed by the resident whenever capable and/or representative (if any). Residents’ care plans must be reviewed at least once a month, updated to reflect their changing needs and current objectives for health and personal care. (Previous timescale of 30/05/07 not met). The administration/nonadministration of all medication must be recorded accurately at all times for the health and safety of residents. All prescribed medication in the custody of the home must be locked according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society, the requirements of the Misuse of Drugs Act 1971,for the health and safety of residents. Residents need to be offered suitable forms of activity for them to enjoy a full and stimulating life style with a variety of options to choose from. All areas of the home must be maintained in good order for the health, safety and welfare of residents. There need to be a rolling programme to improve the decoration, fixtures and DS0000007207.V347535.R01.S.doc 30/11/07 6. OP7 15(2) 30/11/07 7. OP9 13(2) 02/10/07 8. OP9 13(2) 02/10/07 9. OP12 16(2)(m), (n) 30/11/07 10. OP19OP24 13(4) 16(2) c 30/11/07 Sandilands Lodge Version 5.2 Page 26 fittings. (Previous timescale of 30/05/07 not met). 11. OP22 23(2)(n) Call bells must be within the 02/10/07 reach of residents to enable them to call for help and for their safety. Staff must not work excessive hours, as this will put residents at risk. Staff files must contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001 for the delivery of good quality services and for the protection of residents. (Previous timescale of 30/05/07 not met). There must be a staff training and development programme in place, which meets Sector Skills Council workforce training targets to ensure staff fulfil the aims of the home and meet the changing needs of residents. A training needs assessment must be carried out for the staff team as a whole, and an impact assessment of all staff development must be undertaken to identify the benefits for residents and to inform future planning. The home must be run in the best interests of the residents and work to the basic processes set out in the NMS. 02/10/07 12. OP27 18(1)(a) 13. OP29 19 30/11/07 14. OP30 18(1)(a) (c) 30/11/07 15. OP30 18(1)(a) (c) 30/11/07 16. OP31 12 25/10/07 17. OP33 24(1), (2) & (3) A system must be established for 30/11/07 reviewing and improving the quality of care provided in the home for the welfare of residents.(Previous timescale DS0000007207.V347535.R01.S.doc Version 5.2 Page 27 Sandilands Lodge of 30/05/07 not met). 18. OP36 18(2) Formal supervision sessions must be held with all care staff at least six times a year for the delivery of good quality services. (Previous timescale of 30/05/07 not met). 30/11/07 19. OP38 13(4) Fire doors must not be wedged 02/10/07 open unless held open by a magnetic door holder that responds to the fire warning system for the safety of staff and residents. All COSHH materials must be kept locked in accordance to Control of Substances Hazardous to Health Regulations (COSHH) 1999 for the safety of staff and residents. All bedside table lamps must be in working order for the safety of residents. The radiator cover is the toilet needs to be fixed to the wall as failure could result to residents being scalded from hot surface. The radiator pipes in room B3 must be covered to prevent residents from scalding. 02/10/07 20. OP38 13(4) 21. OP38 13(4) 06/10/07 22. OP38 13(4) 06/10/07 23. OP38 13(4) 06/10/07 Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations It is recommended that an “O” is entered on the MAR sheet where medication has not been administered instead of leaving the space blank. It is recommended that the registered manager has access to a mentor or another professional for support and supervision in relation to her professional practice. It is also recommended that the home carry out a risk assessment on all uncovered hot pipes in the building for the safety of residents. 2. OP31 3. OP38 Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sandilands Lodge DS0000007207.V347535.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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