CARE HOMES FOR OLDER PEOPLE
Scarsdale Grange Nursing Home 139 Derbyshire Lane Sheffield South Yorkshire S8 5EQ Lead Inspector
Janis Robinson Unannounced 17 May 2005 09:00 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 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. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Scarsdale Grange Nursing Home Address 139 Derbyshire Lane Sheffield South Yorkshire S8 5EQ 0114 2583534 0114 2580828 None Mr John Martin Foster Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Elaine Pearl Adams N Care home with nursing 40 Category(ies) of OP Old age (40) registration, with number of places Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 8 December 2004 Brief Description of the Service: Scarsdale Grange is a purpose built home, providing care for up to 40 older people, some of whom require nursing care. The home is in a residential area of Sheffield, with good access to public services and amenities, such aspublic 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. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 6 hours from 9am to 3pm. The inspector carried out a tour of the environment, sampled records and observed interactions between staff and residents. 6 service users, 6 staff and 1 visitor to the home were spoken with. Discussions with the homes administrator and senior nurse on duty also took place. The homes manager was not present during this inspection and the homes administrator, alongside senior nurses, was in charge of the home. As a consequence of the manager’s absence, a proportion of records were unable to be located, and requirements made at the last inspection were unable to be checked. These have been carried forward and will be checked at the next inspection. What the service does well:
The interactions observed between residents and staff appeared patient and respectful. The visitor spoken with was `very happy with the care provided’. Residents said most staff were respectful and caring. Each resident was provided with a contract, which informed them of their rights and obligations. Trial visits to the home took place, to enable prospective residents and their representatives to make informed choices. Care plans were in place for all residents. These set out in detail the personal, social and health care needs of the individual, and the staff action required to ensure these needs were met. An activities worker was employed at the home, and all residents said they enjoyed the activities provided. The home had an open visiting policy, to support residents to maintain contact with relatives and friends, and the visitor spoken with said that she was able to visit at any time and was always made to feel welcome. The routines at the home were flexible, to enable residents to have some control over their lives. Staff were observed to offer assistance with eating to those residents that required this. On the day of the inspection the home was very clean and odour free. The environment was well decorated, in the main. Communal areas contained homely touches to provide a comfortable environment. Residents’ bedrooms contained personal belongings. Sufficient bathing facilities were provided to ensure residents personal care needs were met. The home had a central laundry and kitchen, which provided for residents needs. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 6 Agreed levels of staff were being maintained. All of the staff and residents spoken with said the manager was supportive and approachable. The home had a quality assurance system, which sought the views of residents and their representatives. What has improved since the last inspection? What they could do better:
The home did not have a service user guide, to provide information about the home, containing all of the information outlined in the National Minimum Standards. The homes current guide could not be located, and none were available. The homes resident group had become more dependent, assessments of needs needed to take place to ensure appropriate levels of staff were provided to meet the additional demands resulting from this. Whilst individual care plans were in place, not all contained information on the residents wishes regarding dying and death, to ensure these were carried out. The home did not have a menu to inform residents of food being provided, and choices offered to residents were not available until meals were being served. Whilst the home had a complaints procedure, staff were unaware of the homes pro-forma to record complaints, to ensure all relevant information was recorded. The homes record of complaints was unable to be located during this inspection. Whilst the homes adult Protection policy had been updated to include further detail, staff had not received training on this, to familiarise themselves with the updated policy. In the main the environment was well decorated and well maintained. One dining room had a stained carpet. Several pairs of protective gloves had been discarded and left to the side of the car park, which were unsightly and did not follow control of infection procedures. Some of the bedroom furniture provided was worn and aged. All of the staff spoken with informed the inspector that further aids to support moving and handling of residents was required, as a result of increased dependency.
Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 7 The recommended 50 of care staff trained to National Vocational Qualifications (NVQ) at level 2 in care had not been achieved. The administrator was in the process of obtaining proof of identification on all staff, to ensure appropriate checks had been carried out and appropriate information retained. A staff training plan and individual training records were unable to be located during the inspection. Staff supervision did not take place, to ensure staff were supported and developed skills. Some records required for inspection, and for the smooth running of the home were not accessible. Records appeared ill organised. The homes policy and procedure file did not contain all of the required documentation to ensure the home was safely run. The homes current fire records were not available, fire records available had not been maintained up to date. The staff interviewed confirmed that they had undertaken fire training. Staff had not undertaken food hygiene training. The majority of residents were mobilised in wheelchairs without footplates in use. Staff informed the inspector that wheelchairs were not serviced, and as a result some were not in good working condition. 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. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 9 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 standard(s) 1,2,4 and 5. Whilst the home had a service user guide, no copies were available at the home to provide residents and their representatives with information about the services provided. Contracts had been undertaken with each resident, to inform them of their rights and obligations. Trial visits to the home were encouraged, to enable prospective residents and their relatives to make informed choices. Assessments of the changing needs and further dependency of residents must take place to ensure the home meets residents’ needs and the conditions of registration. EVIDENCE: No service user guide was available at the home and staff were unable to locate further copies. Therefore residents were not provided with the detailed information about the home needed to support and inform them of their rights choices. Contracts were in place, which informed residents of all of the information needed. Staff undertook periodic training to keep them up to date, and could give examples of good practice. Staff spoken with had caring attitudes. Access to specialist services, such as chiropody, opticians and
Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 10 dentists was provided to ensure residents individual needs were met and supported. The visitor spoken with said they had been able to look around the home prior to their relative being admitted. The residents spoken with said most of the staff cared for them well. All of the residents said their needs were well met, and they were `very happy’ with the care provided. All residents were well groomed and appropriately dressed. Staff stated that the needs of some residents had become more complex, some showing signs of dementia, confusion and related conditions. A number of residents spoken with showed signs of confusion. The home must ensure assessments are undertaken by appropriate professionals in order to ascertain that individual needs can continue to be met, and the conditions of registration are adhered to. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 11 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 standard(s) 7,8,10 and 11 Each resident had a care plan, to ensure his or her opinions had been sought and needs assessed. These provided staff with the information needed to fully care for individuals. Health care needs were monitored and met. Resident’s privacy and dignity was respected. Care plans did not contain information relating to residents wishes regarding dying and death. EVIDENCE: The inspector examined 2 care plans. These contained specific information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs were met. The residents had signed their plans. Residents spoken with were aware of their right to access their records, but chose not to do so. The plans contained detail of all health care contacts, appointments and treatments, and the home supported access to these to ensure health was maintained. On the day of the inspection one member of staff accompanies a resident to a hospital appointment. Accidents wee recorded and monitored. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 12 Staff were observed respecting privacy by knocking on doors before entering. The interactions between staff and residents appeared respectful and caring. Residents spoken to felt `well looked after’. The visitor spoken with said they were `very happy’ with the care provided at the home. They told the inspector that they were kept well informed by the home, and had no concerns. Care plans did not record any wishes regarding dying and death. These must be sought to ensure they are carried out. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15. Residents were able to make choices about how they spent their time. A range of activities were offered to residents, to improve choices and maintain interests. The home had an open visiting policy, in order to develop and maintain good relationships with residents’ representatives. The home did not have a written menu, to assist residents to make choices. EVIDENCE: Residents 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. The home employed an activities worker, to provide a range of appropriate social opportunities both in and outside of the home. Residents were free to join in any organised activities. All of the residents spoken with said they enjoyed the range of activities offered, and said enough were provided. One resident told the inspector that they were looking forward to a trip to the seaside, which had been organised. Residents confirmed that they were able to see their visitors in private. Two residents spoken with said that a relative visited them every day. The visitor spoken with said they were able to visit at any time, and were `always made to feel welcome’. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 14 Staff were observed offering assistance with eating to those residents that required this support. All of the staff and residents spoken with said that choices were offered at mealtimes, and staff had `access to food at all times to cater for residents needs. The home did not provide a written menu, to inform residents of their choices, and monitor the food provided. Some residents’ said that they were not aware of the meals provided, or the different choices until the meal was being served. This practice potentially restricts choices. Residents must be informed of tier choices prior to the meal being served, and a written menu to assist this must be provided and displayed. One resident informed the inspector that she liked to eat her meals in her room and the home respected this. Bedrooms contained a range of personal possessions, enabling residents to make their room comfortable and homely. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Te home had a clear and accessible complaints procedure, to ensure residents’ rights were protected and any concerns listened to and taken seriously. The homes complaints record was unavailable for inspection. Staff were unaware of the homes system to record complaints. An adult protection procedure was in place, to ensure residents safety was promoted. Since the last inspection this had been updated. Staff had not undertaken training to familiarise themselves with the updated information. 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 inspector was unable to evidence whether the action taken and outcomes of complaints were recorded, as the homes record of complaints was unavailable and could not be located. The homes complaints policy stated that staff should record any complaints received on the homes pro-forma provided for this. However, staff spoken to were unaware of this and stated they would take notes and pass these to the homes manager. The homes complaints procedure must be correctly followed to ensure relevant details are recorded and appropriate action taken. Since the last inspection the homes adult protection policy had been updated to include further information, and include the procedures for Sheffield City Council. Staff had not been provided with training to inform and familiarise them of the more detailed information. Six staff had undertaken adult protection training since the last inspection.
Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 26. The home was clean and generally well maintained. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and residents’ bedrooms were well decorated and personalised. Sufficient bathing facilities were provided. Insufficient aids to meet the moving and handling needs of residents were provided. Some bedroom furniture required replacing and grounds required clearing of debris in one area, to maintain standards. The home was free from odours. A central laundry and central kitchen served the home. EVIDENCE: Since the last inspection the homes corridor areas had been redecorated and recarpeted to improve the environment. All of the residents spoken with said the home was comfortable and they were happy with their rooms. The home was well decorated. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 17 Some bedroom furniture was worn and aged and in need of replacement, and one dining room carpet was stained and required cleaning to eradicate marks or replacing in order that the environment was maintained. Several pairs of disposable gloves had been discarded to the front side of the building. This was unsightly, did not create a positive impression of the home and did not follow control of infection procedures. All of the staff spoken with said the homes current aids for moving and handling residents did not meet the increased needs of residents. The home had, in the past, hired a stand aid, to assist with moving and handling. This was no longer available at the home. Staff reported that this equipment was required to ensure personal care needs could be fully met. The majority of residents were mobilised in wheelchairs without the use of footplates, posing a possible hazard. Staff reported that some wheelchairs were in poor condition; tyres were flat and footplates did not fit properly. Staff informed the inspector that wheelchairs were not routinely serviced. This must take place as a matter of priority, to ensure the safety of residents. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. Agreed levels of staff were being maintained. Some staff undertook NVQ training. Recommended levels of NVQ trained staff had not been achieved. The homes recruitment practices were being improved, to ensure a thorough procedure was in operation. Staff undertook periodic training to keep them up to date. The homes training plan and records were not accessible during this inspection. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained to meet the needs of residents. Residents and the visitor spoken with felt that enough staff were provided. Of the 31 care staff, 1 staff had achieved NVQ level 2 in care, a further 3 staff were undertaking the training. This 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. At the time of this inspection the homes administrator was collating proof of identification to keep in all staff files, to ensure that all of the required information was sought and a thorough procedure was followed. The inspector was unable to evidence whether individual training records, and a training plan had been developed, as these were not available during the inspection due to the manager’s absence.
Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37 and 38. The manager’s leadership approach benefited residents and staff. The home had a quality assurance system in place, to seek the views of residents and their representatives. Formal staff supervision to develop and support staff, did not take place. There was no formal process for staff meetings. The homes records were stored securely, to respect residents rights. Records to evidence that fire systems were checked at the required frequency could not be located. Records of staff fire training were out of date, current training records could not be located. Some staff mandatory training had not been provided, posing a potential risk. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 20 EVIDENCE: All of the staff spoken with said the manager was approachable and supportive. The manager was a qualified nurse. Since the last inspection she had registered to commence NVQ 4 in management. The home undertook surveys with residents and their relatives to obtain their views and inform practice. Staff supervision, to develop, inform and support staff did not take place on any formal basis. Staff said that whilst some staff meetings took place, these were called in response to need, rather that formal, pre-arranged meetings to regularly update staff and inform care practices. Staff confirmed that they had undertaken fire training and participated in a drill within the recommended timescales. However, fire records of staff training and fire alarm checks could not be located. Failure to undertake, record or monitor these could compromise residents’ safety. All of the staff spoken with said they had not undertaken food hygiene training, in order to maintain safe standards. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 3 x 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2
COMPLAINTS AND PROTECTION 2 3 3 1 3 2 3 3 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 Standard No 16 17 18 Score 2 x 2 3 2 3 x x 1 2 2 Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 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 1 Regulation 4 Requirement Timescale for action 01/08/05 2. 4 12 3. 4. 11 15 15 12 A service user guide must be produced which contains all of the information outlined in the National Minimum Standards. (Previous timescsale of 01/02/05 not met. This requirement has been outstanding since June 2003) The homes current service user guide must be available to residents at all times. Assessments of residents 01/08/05 showing signs of dementia or other related conditions must be undertaken by relevant professionals to ensure the home can meet the changed needs of these residents, comply with the conditions of registration and provide appropriate staffing levels and training. (Previous timescale of 8/12/04 not met). Residents wishes regarding dying 01/08/04 and death must be sought and recorded in care plan. Residents must be asked in 01/08/05 advance of meals preferred choice. (Previous timescale of 01/02/05 not met). Residents must be consulted about food choices and
J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Scarsdale Grange Nursing Home Page 23 5. 16 22 6. 18 18 7. 19 23 8. 9. 22 22 13 13 preferences. (Previous timescaale of 01/02/05 not met. This requirement has been outstanding since June 2003.) A menu, reflecting the food provided and the choices offerred, must be undertaken and made available to residents. The outcomes of complaints must be recorded and detial whether the complainant was satisfied. (Previous timescale of 01/03/05 not met) The homes pro-forma to record complaints received must be available to staff at all times. Staff must be made aware of these and informed how to complete them. All staff must be trained in the homes updated adult protection procedures. (Previous timescale of 01/04/05 not met) The environment must be well maintained at all times; The identified dining room carpet must be cleaned to eradicate marks, or replaced. The discarded disposable gloves at the front side of the home must be removed. Staff must be instructed to discontinue this practice. A standing hoist must be provided. All wheelcairs must be fitted with footplates. Staff must use footplates at all times unless a written risk assessment has` been undertaken and placed in the individual residents care plan. All wheelchairs must be regularly serviced. Written confirmation of the servicing of all wheelchairs must be forwarded to the CSCI within one month of this inspection date.
J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc 01/08/05 01/08/05 01/08/05 01/08/05 17/05/05 Scarsdale Grange Nursing Home Version 1.30 Page 24 10. 24 23 11. 29 19 12. 30 18 13. 36 18 14. 37 17 15. 16. 38 38 18 13 All worn bedroom furniture must be replaced. (Previous timescale of 01/04/05 not met. This requirement has been outstanding since October 2003) Copies of proof of identity must be kept on each staff file. (Previous timescale of 01/02/05 not met. This requirement has` been outstanding since June 2003) A staff training plan, which meets the National Training Organisation workforce training targets must be developed. Individual training profiles must be kept. (Previous timescale of 01/04/05 not met. 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 retreived. (Previous timescale of 01/03/05 not met) A formal system of staff supervision must be introduced. Staff must receive supervision a minimum of 6 times each year. (Previous timescale of 01/02/05 not met. This requirement has been outstanding since October 2003. Regular staff meetings must be organised. All records required must be available for inspection. These must be kept up to date, well organised, and monitored. All staff must undertake food hygeine training. Records of all fire training and fire equipment testing must be available and maintained up to date. Systems must be put in place to ensure such checks take place when the manager is not present.
J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc 01/11/05 1/09/05 1/09/05 01/08/05 01/09/05 01/11/05 01/08/05 Scarsdale Grange Nursing Home Version 1.30 Page 25 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 28 31 Good Practice Recommendations 50 of the care staff should be trained to NVQ level 2 in care. The manager should be trained to NVQ level 4 in management. Scarsdale Grange Nursing Home J55 S21804 Scarsdale Grange v218794 170505 UI Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 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
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