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Inspection on 10/04/06 for Scarsdale Grange Nursing Home

Also see our care home review for Scarsdale Grange Nursing Home for more information

This inspection was carried out on 10th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Observations of the interaction between the service users and staff were seen to be positive and caring. Service users spoken to said that staff attended to their personal needs, giving consideration to choice, privacy and dignity. Service users made positive comments, for example, `I like living here`, `I cant grumble about living here` and `the staff are kind`. Assessments prior to admission took place for each prospective resident, to ensure the home could meet their needs. Trial visits to the home took place, to enable prospective residents and their representatives to make informed choices. Staffing levels were being maintained at the agreed levels and all service users and staff spoken to said that the manager was supportive and friendly and proactive in dealing with any concerns that may arise. Service users monies were handled safely and accurate records were maintained.

What has improved since the last inspection?

Since the previous inspection the home had expanded their menu to include a range of alternative options. Menus seen were varied and offered healthy selections. Service users spoken to were happy with the meals on offer. On the day of the inspection the lunch served was chicken pie or omelette, served with potatoes, cauliflower and carrots. Dessert was syrup sponge, yogurt or ice cream. The meal was presented nicely. The fire records showed that staff were undertaking fire practise and drills at the required intervals. All fire systems and equipment; portable appliance testing and gas appliances had been checked as necessary. The manager said that furniture had been replaced in six bedrooms and a programme of replacement had been agreed, which would replace one set of bedroom furniture each month. Service users bedrooms contained personal belongings and the main kitchen was due to be painted within the next month.

What the care home could do better:

Since the previous inspection there are a significant number of requirements that have not been actioned and are therefore carried over into this report. Many of these requirements have now been carried over through several reports, one relating to a staff training plan being developed, has been carried over since June 2003. This requires urgent action to be taken. Other requirements carried forward relate to compulsory staff training not being undertaken and incomplete information recorded in care plans, complaints and staff recruitment records. Following a recent complaint investigation, concerns were upheld, due to the lack of written evidence, it is of great urgency that the home acknowledges their lack of skill in recording full and valid information and action these requirements to fully protect the service users and staff working in the home. Environmental improvements would make the home more pleasing and help to achieve a more homely impression. It is of serious concern that there are a number of requirements in this report that raise concerns that the health, safety and welfare of the service users not being promoted and protected at all times.

CARE HOMES FOR OLDER PEOPLE Scarsdale Grange Nursing Home 139 Derbyshire Lane Sheffield South Yorkshire S8 5EQ Lead Inspector Sue Turner Unannounced Inspection 10th April 2006 8:20 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 DS0000021804.V288263.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000021804.V288263.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Scarsdale Grange Nursing Home Address 139 Derbyshire Lane Sheffield South Yorkshire S8 5EQ 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 258 3534 0114 258 0828 Mr John Martin Foster Mrs Elaine Pearl Adams Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places DS0000021804.V288263.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three service users aged 60 years and over may be accommodated at the home. 17th January 2006 Date of last inspection Brief Description of the Service: Scarsdale Grange is a purpose built home, providing care for up to 40 older people, some of who require nursing care. The home is in a residential area of Sheffield, with good access to public services and amenities, such as public transport, shops and public houses. The home has two floors, accessed by a passenger lift. Each floor has communal lounge, dining rooms and bathing facilities. All of the bedrooms are single, each with en-suite toilet facilities. The home has gardens and a car park. A copy of the previous inspection report was on display and available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. The manager confirmed that the range of monthly fees from 10th April 2006 were £410 - £475 per week. Additional charges included newspapers, hairdressing and private chiropody. DS0000021804.V288263.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this inspection, which was unannounced and took place over 7.5 hours from 8.20 am to 3.40 pm. An inspection of the environment was undertaken. Records were examined, including: 3 care plans, complaints, staff recruitment and training, menu and fire records. All CSCI’s key standards were checked. Interactions between staff and service users were observed. The inspector spoke with a proportion of the staff on duty (12), and 12 service users. Discussions with the homes manager and administrator also took place. Two relatives visiting on the day of the inspection were also spoken to. What the service does well: What has improved since the last inspection? Since the previous inspection the home had expanded their menu to include a range of alternative options. Menus seen were varied and offered healthy selections. Service users spoken to were happy with the meals on offer. On the day of the inspection the lunch served was chicken pie or omelette, served with potatoes, cauliflower and carrots. Dessert was syrup sponge, yogurt or ice cream. The meal was presented nicely. The fire records showed that staff were undertaking fire practise and drills at the required intervals. All fire systems and equipment; portable appliance testing and gas appliances had been checked as necessary. DS0000021804.V288263.R01.S.doc Version 5.1 Page 6 The manager said that furniture had been replaced in six bedrooms and a programme of replacement had been agreed, which would replace one set of bedroom furniture each month. Service users bedrooms contained personal belongings and the main kitchen was due to be painted within the next month. 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. DS0000021804.V288263.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000021804.V288263.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was not providing sufficient updated information to inform service users about their rights and choices. Assessments prior to admission took place and trial visits to the home were encouraged. This enabled staff to be aware of service users needs to ensure that they could be met. EVIDENCE: Service users spoken to said they had not received a copy of the service user guide. A copy of the guide was on display, however information within this had not been updated. This was issued as a requirement at the previous inspection, and the timescale for completion had not expired. This requirement is therefore carried forward in this report. Staff spoken to said that assessments were undertaken prior to admission to ensure the service could meet prospective service user needs. These were carried out by the home’s manager or qualified staff. Copies of care management assessments were seen on the files checked. DS0000021804.V288263.R01.S.doc Version 5.1 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 and 11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans did not truly reflect the service users health, personal and social care needs. The homes medication practices do not fully protect the service users from being administrated inappropriate medications. Service users privacy and dignity was respected. EVIDENCE: Three care plans were sampled. These contained varied information on aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs were met. Accidents were recorded and monitored. All three care plans checked had been signed by staff stating that they had been reviewed each month. The reviews verified that no changes were required to be made to the care plan. For one service user this was over a four-year period. The manager, when asked, said that the service users needs DS0000021804.V288263.R01.S.doc Version 5.1 Page 10 had changed in that four year period and agreed that the care plan should have been amended in this period. One service user was observed to have a ‘dressing’ that required changing. Staff were asked how often the dressing was changed and said it was changed several times a day, due to the severity of the wound. Records showed that the dressing had been changed twice in the last seven days. The manager was asked to ensure that the dressing was changed on the day and update the service users health care needs in the care plan. Within the service user daily recordings, some language used was inappropriate, for example, references were made to ‘nappies’ being changed. The manager was asked to investigate a statement recorded in one care plan that referred to a service user being potentially restrained. The inspectors observed staff administering medication. A nurse and student gave out medications. Service users were offered water and the inspectors observed the staff member being very patient and compassionate. Medications records were checked and a number of issues were identified. • Medication prescribed for one service user was given to another service user • Medication balance did not tally with records • One medication did not give clear administration instructions • Codes were not being used appropriately • Some medications were not being booked in appropriately • A system to check the stock of medication was not in place. Staff were observed respecting privacy by knocking on doors before entering. The interactions between staff and service users appeared respectful and caring. Service users spoken to said the staff were ‘kind’ and ‘helpful’. A requirement was issued at the previous inspection for care plans to record any wishes regarding dying and death. One of the three files seen did not have these wishes recorded. DS0000021804.V288263.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were able to make choices about daily living and social activities. A range of activities was offered to service users. To improve choices and maintain interests activities on offer should be on display. The home had an open visiting policy, which assisted in maintaining good relationships with service users representatives. A varied diet was provided, a ‘routine’ early morning drink should be offered to all service users. EVIDENCE: Service users said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Two relatives spoken to said they were able to visit at any time and were made to feel welcome. Staff were seen to ask service users about their preferences regarding clothes, meals and bath times. An activities worker was employed, for three mornings per week. She offered a range of appropriate social opportunities both in and outside of the home. Service users were free to join in any organised activities. Service users spoken with said they enjoyed the range of activities offered, DS0000021804.V288263.R01.S.doc Version 5.1 Page 12 and said enough were provided. On the day of the inspection service users were looking forward to the weekly bingo session. Up to date information regarding the activities available was not circulated or on display, which would assist service users in deciding if they wished to participate. All service users spoken to said that they were satisfied with the food served. They said they were offered choice and variety. Three service users spoken to at breakfast time said they had not had a drink since teatime of the previous day. Staff said that drinks were served at suppertime, but did accept that some service users may be in bed by this time and therefore not have one. As breakfast wasn’t served until after 8:30 am (even later upstairs) this meant that some service users had gone over twelve hours without a drink. DS0000021804.V288263.R01.S.doc Version 5.1 Page 13 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 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The homes record of complaints was not clear and accessible and did not evidence that appropriate action was taken following any concerns raised. Staff had not been provided with essential training to ensure service users were safe, and to inform staff of the procedures to follow if an allegation was made. EVIDENCE: The homes complaints policy was on display in the entrance area of the home. It contained relevant information and informed the reader who to contact external to the home, should the complainant wish to do so. The homes record of complaints was not well organised, as a consequence information was difficult to obtain. CSCI was aware of a complaint about the home made to social services. The home were also aware of this complaint but had not recorded any information about the complaint. The complaints record would benefit from reorganisation in order that complaints can be monitored efficiently and information more easily retrieved. The form used to record complaints did not detail the action taken or the outcome of the complaint. Staff had been made aware of the form to use to record complaints, to ensure all relevant information had been sought. A supply of forms had been made available to staff so that they could access these when needed. DS0000021804.V288263.R01.S.doc Version 5.1 Page 14 Since the last inspection a complaint was made to CSCI regarding the care of a service user. The provider was asked to investigate the complaint and give feedback to both CSCI and the complainant. Following receipt of the investigation the inspector issued two requirements in relation to service user care plans. These requirements (2 and 5) are incorporated into this report and the timescale for completion has been extended, in agreement with the manager in recognition of the work involved in ensuring the care plans are comprehensive. The homes adult protection policy included information on local procedures. Staff spoken to said that they would report any allegations of abuse to their senior manager. Staff said they had not received any training in adult protection procedures, however they were able to describe types of abuse that service users could be susceptible to. The requirement for staff to attend adult protection training has been required since 1st March 2005. DS0000021804.V288263.R01.S.doc Version 5.1 Page 15 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, 21, 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 within the home was not maintained to an adequate enough standard to provide a comfortable home for service users. EVIDENCE: There were no unpleasant odours noticeable in the home. Service users said that their rooms were kept clean. Bedrooms seen were comfortable and homely. The manager said that a rolling programme had commenced to replace bedroom furniture that was worn, and replace bed linen and curtains. Six bedrooms had benefited from this and the plan was to continue the programme at one bedroom per month. Grounds around the home were kept tidy and accessible. The home had sufficient bathing, washing and toileting facilities. DS0000021804.V288263.R01.S.doc Version 5.1 Page 16 The inspectors carried out a full environment check and found a number of areas within the home to be in need of decoration, cleaning and tidying. Observations of the environment were: • A number of bedrooms had broken, scratched and marked furniture • Bathroom floors were stained and marked • Bathrooms checked were quite stark and clinical and were poorly decorated and furnished. • Paint on the walls in the bathroom was peeling • No blinds or curtains were fitted to the bathroom windows • The floor in both dining rooms was stained and marked • Diffusers on strip lights required cleaning • Communal areas in the home were untidy and cluttered • The main kitchen was in need of painting • The bed linen on one bed was not clean • Soiled linen had been left on the floor in the corridor. DS0000021804.V288263.R01.S.doc Version 5.1 Page 17 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff were employed in sufficient numbers to meet the service users needs. Recommended levels of NVQ trained staff had not been achieved, so did not ensure staff had the competencies to meet the service users needs. There remained a number of shortfalls in the details held and recorded in staff recruitment files, therefore not ensuring the protection of service users. The lack of staff training records may not ensure that all staff receive the relevant training. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained to meet the needs of service users. Service users and relatives spoken with felt that enough staff were provided. Of the 26 care staff, 6 staff had achieved NVQ level 2 in care, a further 10 staff were undertaking the training. Whilst this is an improvement, the numbers of NVQ trained staff did not meet the recommended 50 of the care staff trained to NVQ level 2 in care by 2005, to ensure the staff team was qualified and competent to carry out their duties. Three staff records were checked. There had been a general improvement in staff recruitment records, CRB’s had been completed, Identities had been checked and appropriate references obtained. However in all three files a gap DS0000021804.V288263.R01.S.doc Version 5.1 Page 18 in CV’s had not been explained, there was no evidence of qualifications and in one file there was no photograph. The manager said that the previous requirement relating to a staff training programme had not been actioned and is therefore carried forward to the next inspection. DS0000021804.V288263.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager’s leadership approach benefited service users and staff. The lack of quality assurance audits means that the home cannot be run in the best interests of the service users. Service users monies were safely handled, however not all files were securely stored. The health, safety and welfare of service users were not fully promoted due to the number of concerns around health and safety requirements. DS0000021804.V288263.R01.S.doc Version 5.1 Page 20 EVIDENCE: All of the service users, staff and relatives spoken with said the manager was approachable and supportive. The manager was a qualified nurse and had commenced NVQ 4 in management. Recorded quality assurance visits by the registered provider had not been carried out. Three service users monies were checked. Receipts, records and money all tallied and all were kept securely. The majority of staff spoken to on the day of the inspection said that their line manager did not give them formal supervision. Whilst undertaking a tour of the premises, the inspectors saw a number of service users files insecurely stored. A number of records checked were also found to be disorganised and out of date. During the inspection the inspectors observed a number of concerns relating to the health, safety and welfare of the service users. • Cupboards, bedrooms and bathrooms had hazardous substances insecurely stored. This was a requirement at the previous inspection and is carried forward in this report. The manager was instructed to make sure that all substances hazardous to health were securely stored immediately. • The machinery room door was unlocked. The manager was instructed to lock the door immediately. • The floor covering in the lift had ‘raised’ causing a potential tripping hazard. • Many of the service users beds had metal frames. One relative spoken to said that the bed had caused bruising to the service users legs, whilst being transferred from bed to chair. • Service users were using wheelchairs without footplates fitted. Not all service using without footplates had a completed risk assessment. Fire records were up to date and stated that weekly testing of the fire alarm system and fire drills had occurred. A sample of records showed that staff were receiving fire safety training. Records of mandatory training did not include all aspects of training. Some staff required training in food hygiene, COSHH in order to maintain safe standards. DS0000021804.V288263.R01.S.doc Version 5.1 Page 21 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X 2 X X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 2 1 DS0000021804.V288263.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The service user guide must be updated to ensure all of the information included is up to date. Copies of the guide must be provided to current and prospective residents. Information within all care plans must be reviewed and updated to reflect each service users current health, personal and social needs. Staff must receive information/training regarding appropriate language to be used within service user information. The registered manager must investigate the incident of potential restraint and take appropriate action. Timescale agreed on the day of the inspection. All service users assessed health needs must be promoted and maintained. Timescale agreed on the day of the inspection. There must be arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines DS0000021804.V288263.R01.S.doc Timescale for action 30/04/06 2. OP7 15 01/08/06 3. OP7 15 01/08/06 4. OP8 12 11/04/06 5. OP8 12 13 11/04/06 6. OP9 13 11/04/06 Version 5.1 Page 23 7. OP11 15 8. 9. OP15 OP16 16 22 received into the home. Timescale agreed on the day of the inspection. Service users wishes regarding dying and death must be sought and recorded in their care plan. (Previous timescale of 01/08/05 and 30/04/06 not met) Hot and cold drinks must be offered regularly to all service users The outcomes of complaints must be recorded and detail whether the complainant was satisfied. (Previous timescales of 01/03/05, 01/08/05 and 31/03/06 not met) The homes pro-forma to record complaints received must be expanded to include action taken and outcomes. All staff must be trained adult protection procedures. (Previous timescales of 01/04/05, 01/08/05 and 30/04/06 not met) All areas of the home must be well maintained therefore: Dining room floors must be thoroughly cleaned. Diffusers on the strip lights must be thoroughly cleaned. Communal areas in the home must be tidy and uncluttered. The main kitchen must be repainted. All areas of the home must be well maintained therefore: Bathroom floors must be thoroughly cleaned. Bathroom walls must be repainted. All areas of the home used by the service users must be well maintained therefore: DS0000021804.V288263.R01.S.doc 01/06/06 01/06/06 01/06/06 10. OP18 18 01/08/06 11. OP19 16 23 01/08/06 12. OP21 16 23 01/08/06 13. OP24 16 23 01/08/06 Version 5.1 Page 24 14. OP26 16 23 15. 16. OP28 OP29 18 19 17. OP30 18 The programme of replacement of bedroom furniture must continue. All areas of the home must be kept clean and hygienic therefore: All bed linen must be changed as required. Soiled linen must not be left on the floor. Timescale agreed on the day of the inspection. 50 of the care staff must be trained to NVQ level 2 in care. A thorough recruitment procedure must be in operation, therefore: All gaps in employment history must be explored. (Previous timescale of 17/01/06 not met) A photograph must be placed on each file. Evidence of qualifications must be placed on file. A staff-training plan, which meets the National Training Organisation workforce training targets, must be developed. (This requirement has been outstanding since June 2003). All staff must receive statutory training, records must be accessible and organised so that information can be easily retrieved. (Previous timescales of 01/03/05, 01/09/05 and 31/03/06 not met) The manager must be trained to NVQ level 4 in management. The provider or their representative must carry out visits to the home as detailed in Regulation 26 of the Care Homes Regulations. DS0000021804.V288263.R01.S.doc 10/04/06 01/08/06 01/08/06 01/08/06 18. 19. OP31 OP33 9 26 01/12/06 01/06/06 Version 5.1 Page 25 20. 21. OP36 OP37 18 17 22. OP38 18 23. OP38 18 24. OP38 13 Staff must be given formal supervision. All records must be kept securely, kept up to date, well organised, and monitored. (Previous timescale of 01/09/05 not met) All staff must undertake food hygiene training. (Previous timescale of 01/11/05 not met) All staff must undertake COSHH training. An audit of staff mandatory training must take place. Where gaps are identified, training must be provided. The health, safety and welfare of all service users must be promoted and protected at all times, therefore: All substances that may be hazardous to health must be securely stored at all times. (Previous timescale of 17/01/06 not met) The machinery room door must be kept locked. The floor covering in the lift must be made safe. Individual risk assessments must be carried out, for each service users who has a metal bed frame. Appropriate action must then be taken to reduce any risks identified. Footplates must be used on all wheelchairs, unless there is a risk assessment stating that using footplates would not be appropriate for the individual. Timescale agreed on the day of the inspection. 01/06/06 01/06/06 01/08/06 01/06/06 10/04/06 DS0000021804.V288263.R01.S.doc Version 5.1 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP38 Good Practice Recommendations Up to date information about activities should be circulated to all service users in formats to suit their capabilities. A mandatory training matrix should be developed. DS0000021804.V288263.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000021804.V288263.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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