Inspection on 15/07/08 for Shalom Residential Home

This inspection was carried out on 15th July 2008.

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

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

Other inspections for this house

Shalom Residential Home 01/08/07

Shalom Residential Home 25/05/06

Shalom Residential Home 19/01/06

Shalom Residential Home 22/07/05

Shalom Residential Home 31/01/05

Shalom Residential Home 18/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Shalom Residential Home 147 Yarmouth Road Norwich Norfolk NR7 0SA Lead Inspector Brenda Pears Unannounced Inspection 15th July 2008 10:15 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 Shalom Residential Home DS0000046100.V368540.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. Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shalom Residential Home Address 147 Yarmouth Road Norwich Norfolk NR7 0SA 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) 01603 432050 01603 432576 lineashalom@btconnecnt.com Medicare Corporation Ltd Manager post vacant Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Old age, not falling within any other category (24) persons. Care Home only. No new admissions of service users who are wheelchair users to be accommodated on the first floor until the registered person ensures the establishment complies with regulation 23(2)(n). All service users accommodated on the first floor must have written risk assessments regarding the use of the stair lift. 1st August 2007 4. Date of last inspection Brief Description of the Service: Shalom is a large period residence located well back from the road on the outskirts of Norwich and overlooking the Yare Valley. The house has been carefully extended and adapted to provide residential accommodation to a maximum of 24 older people. There are 20 single and 2 double rooms. Two of the single rooms within the extension offer a bed sit type accommodation and the majority of rooms are spacious. Both the double rooms and 12 of the single rooms have en-suite facilities. The upstairs is accessed by a new lift. The care home has a large garden at the front though this is not very accessible for residents. A small courtyard in the middle of the building provides an area for sitting outside. There is a bungalow to the rear of the main building, which provides accommodation for the supporting night care worker who sleeps in. Current fee levels are around £380.00. There are extra charges for hairdressing and chiropody. A statement of purpose and a service user guide can be obtained from the home on request. Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection undertaken on the 15th July 20008 and started at 10.00am. The focus of this inspection was on the previous requirements, on the core national minimum standards and on the quality of life for people who receive support in the home. The methods used to complete this inspection consisted of looking at the care a service user receives and the records that support this. Information was provided to us by the home on an assessment form known as an Annual Quality Assurance Assessment (AQAA). During the visit to the home we spoke to the manager, with members of staff, three residents and two visitors. General discussions were also undertaken with a group of residents. These methods and previous findings all inform the outcomes of this report. What the service does well: Residents and visitors said that they like the home and that ‘staff are helpful and cheerful’. One visitor said that staff are very welcoming and ‘always listen if there is anything that needs discussing’. New staff have an inducted when they start work to make sure they know the residents and the routines in the home. Staff confirmed this is the case and also explained that they are fully supported by the manager. They also have regular supervision and ongoing training. Observations at this time did show that staff do consider the dignity of people living in the home. People were given choices and privacy was respected when staff needed to enter individual rooms or provide support. People have a selection of areas in which to spend their time and were seen chatting and relaxing during this inspection. Visitors were also coming and going and one visitor said ‘staff are welcoming and always on hand to speak to’. Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: More attention must be paid to the recording of information in all areas, particularly on care plans. This helps staff to provide the correct support in the way each person chooses. Any complaints received must be fully recorded with outcomes and action taken to show that people are listened to and that the home is taking appropriate action in acceptable timescales. Fuller information would show how the home has dealt with any complaint and that residents have a voice. A risk assessment for the whole premises must be completed to identify and minimise any risks around the building for the safety and well being of residents. Staff must provide the same choices to all residents, particularly with regard to a lockable area for those who have been living in the home for some years. There has to be a registered manager for the home to meet with regulations, while a manager is in place, she is not registered as manager for the home. Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 7 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. Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager does assess the needs of any new client to make sure individuals can be fully supported before an agreement is undertaken. EVIDENCE: An assessment is undertaken before any new resident moves into the home and a care plan is then developed. Residents spoken to at this time confirmed that information and discussions were carried out before agreements were signed. Shalom Residential Home DS0000046100.V368540.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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. While care plans contain clear information in some areas, there is insufficient detailed information in each file to enable staff to fully meet individual needs. Medication is handled and stored correctly for the safety and well being of those living in the home. EVIDENCE: Any special healthcare needs are met with appropriate infection control procedures and routines are in place that include special wipes and clinical hand sprays that are used regularly by staff in the home. The medication storage unit is fixed to the wall in a locked room. Medical record sheets were up to date and fully completed. The manager has not yet checked that the fixings meet with current guidelines set by the Royal Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 11 Pharmaceutical Society. The key to the medication is stored separately and is not held on the general staff key ring. There is signage in words, pictures and specific colours on doors around the home to prompt and remind people of areas such as toilets, bathrooms as well as their own rooms. Four care plans were looked at and these now contain fuller information with sections of information including moving and handling, communication, weight, daily records and healthcare. One file contained information about a skin tear that was dressed by the district nurse but this information was not written on the district nurse healthcare sheet and there was no information about how this had occurred. Another record indicated that the person was now ‘unsteady on their feet’ and the care plan stated that staff were to ‘assist with balance’. However, there was no indication as to when or in what situations this support should be given. One care plan stated ‘can be aggressive in morning’ but had no further information as to how staff would deal with such aggression. Another file had information of a person having a hearing aid but no information stating which ear or if both ears. Communication would be vital and there was no indication as to which ear had better hearing or how to communicate effectively. Care plans did have dates where regular reviews are undertaken and ‘no change’ was recorded if care plans were not adjusted. However, some letters for hospital appointments dated back to 2005 and filled the care plan with unnecessary paperwork, making files bulky and difficult to find relevant sections. One file showed that deterioration in mobility had been identified and a more detailed care plan was written to support this resident. Residents clearly have access to healthcare professionals when needed and appointments and outcomes are recorded. Pressure areas are monitored and appropriate pressure relieving mattresses are provided. Observations and comments on questionnaires confirm that staff do treat service users with respect and with due consideration for dignity. One person said that ‘staff are wonderful’ and ‘I get help if I need it’. Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 12 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in a range of leisure activities, to maintain contact with family and friends and are offered a variety of healthy meals that they have chosen. EVIDENCE: Residents have a choice as to when they eat their meals and to also stay in their rooms if they choose to do so. Staff do encourage some contact with other residents when possible. If a person wishes to remain in their room for the day, the manager explained that a member of staff would pop in and chat from time to time. The inspector saw that this was the case with two people who chose to stay in their rooms on the day of the inspection. One visitor said ‘staff do keep an eye on people and are always available if we need to speak to them’. The manager stated that the chef would meet any specific cultural needs regarding food and mealtimes. There is a choice of meals available and Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 13 residents are asked daily what they would like for their meals. Food choices are also discussed at resident meetings and people are given what they would like to eat, not just one alternative meal. Any specific dietary needs are also catered for and staff record the amounts that have been eaten to monitor nutrition levels. The different needs of residents is recognised and alternative religious services are being provided to discover exactly what spiritual support is required by individuals. Some services already provided have not been very successful, so the manager is offering alternatives to see if these meet religious needs even if people do not request them. One person has specific needs due to dual sensory loss and staff have considered the quality of life experience of this person. Contact has been made with social services, with the local deaf/blind club and additional assessments have been carried out. Individual communication has been developed that suits the person and information is provided in the correct format. Regularly asked questions have been set out on laminated sheets and this has proved to be helpful for the person concerned. Appropriate support is also provided at resident meetings to allow full inclusion. Staff do not currently inform this person directly when meetings are being held. The manager stated that this would be done in future. Residents have meetings every six months and family or visitors can attend if people wish. A notice is put up in the home announcing when the meeting is planned to inform all visitors. Minutes are kept of resident meetings and of any actions that are to be undertaken. A record book provided by the food standards agency is followed for temperature checks of foods, fridges and freezers. The cleaning schedule is also recorded and the kitchen was clean, tidy and orderly at this inspection. The whole home is disturbed a great deal by the ringing of the call bell that is old and sounds very loudly in a high-pitched tone for a lengthy period of time. One call indicator panel is on the ground floor and a second is in the staff only area. Pictures of special events are on display in the home and family and friends also join in on these occasions. All money raised from a garden fete last summer was put towards funds for other entertainment in the home such as a firework display. Residents also have trips out to local places of interest, such as a recent coach trip to Great Yarmouth that is planned. Residents also enjoyed tea dances, bowls on lawn area and a sweepstake was held for the Grand National. Minutes of the last residents meeting are on display in the entrance hall. These showed that various trips and outings had been discussed and following a request for drinks, squash is now available for Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 14 people to help themselves in various areas around the building. Other activities in the home include music sessions, food tasting and nail manicures. One resident said that ‘You just entertain yourself and it is just the boredom’. When asked if the home does take people out another resident said ‘yes we have outings and parties, we are going on a trip out very soon’. Residents then had a chat and discussed previous trips out and how they had enjoyed the fireworks the previous year and the food. They said ‘we are looking forward to the trip out’. Shalom Residential Home DS0000046100.V368540.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know who to complain to and feel they will be taken seriously and procedures are in place, including staff training, to provide protection from abuse. EVIDENCE: The complaints procedure is on display in the main hall with updated timescales and details of how the matter will be dealt with. The complaints records did have information about some matters that have been raised by residents and family members. However, the outcomes were noted as ‘matter sorted with family and resident’ but with no additional details or timescales. Staff are trained to recognise abuse and how to deal with such a situation. Discussions with staff showed that they do understand how some actions can be seen as abusive and were confident that the manager would deal with such a situation appropriately. Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 16 When talking to people living in the home, they did say that they feel comfortable talking to the manager or staff about any problems and that they felt action would be taken. There are appropriate routines and procedures regarding the handling of money for residents. The home has a safe for security, all receipts are kept for each transaction and services such as the hairdresser have an accounts book. The chiropodist does provide a full list of clients who use the service, providing information for any audit that may be undertaken. Some families deal directly with money for residents, others have support from social services, appointed courts, solicitors and others have a power of attorney. Photocopies of all accounts held are regularly provided and keys are held by nominated persons only. Some residents have a lockable area in their own rooms. However, not everyone who has been living in home for a long time have been asked if they would like a lockable area for their personal use. Complaints have been received by the Commission since the last key inspection regarding poor staffing levels and poor quality of food. The home now has a stable staff team and fresh food is available daily and residents said the food has improved since the new chef has been appointed. Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does provide a comfortable, clean environment, however, the lack of risk assessments and maintenance puts residents at risk. EVIDENCE: The home welcomes all visitors and some people were relaxing in various lounge areas while others were in their rooms at the start of this inspection. Staff were welcoming to all visitors and dealt with residents in a calm and unhurried manner. Rooms are comfortable and residents can bring their own possessions where space allows. The home has various areas in which residents are able to relax, watch television or just sit quietly if they wish. On the day of this inspection the Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 18 whether was very hot and while people were enjoying sitting in the conservatory to watch television, this area was particularly hot. Windows were open, a large ceiling fan was on and other fans were also available for use. A gardener now regularly maintains the external grounds and all areas were clear and tidy on the day of this inspection. There is a main television room, a sitting area with a radio and a large landing space with armchairs as well as the conservatory. The manager explained that an external space that is not currently used is being considered for sectioning off to provide another external area in which to sit quietly. Discussions were also undertaken about the use of an alternative area as a laundry because the current laundry space is tiny, is not suitable as a laundry area and does not have hand washing facilities. There is very little space in this area to sort clothes out or move about and high shelving is currently used to separate items when clean. Any ironing is done on the large landing area, in the conservatory when empty or by night staff. The laundry area is very dimly lit and is not fit for purpose. The laundry is currently not locked but the manager explained that a new keypad is on order for the laundry door. The energy saving lighting in this area is very low, providing a dull and dim glow. There is an external lawn area that is used for functions such as fetes and a garden party was enjoyed last year. A handrail has been put along side a steep set of stairs and a ramp is planned to allow direct access for people who use wheelchairs or walking frames. There is currently access through one side of this lawn area but as this has to be reached by a stone covered driveway, the alternative ramp will provide safe, direct access for all residents. There is another external area with a fountain, chairs and tables that is used by residents and provides a safe, enclosed area in which to chat and relax. New units have been installed into the kitchen, replacing previously old and damaged units, but areas of the floor are broken and are in need of replacing. Stair carpet is worn and frayed quite badly in one place, posing a risk to the safety of residents, visitors and staff. A risk assessment is needed until this carpet and flooring is made safe. A full environmental risk assessment has not been undertaken to identify and minimise risks to residents. Such areas as windows that did not have restrictors have no risk assessment in place. Two window catches were also broken and discussions were undertaken with the manager regarding regular maintenance check Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home have their needs met by a consistent staff team who are well trained and regularly supervised, providing stability and continuity of care. EVIDENCE: Staff training is now ongoing and includes moving and handling, first aid and health and safety. One person has almost completed NVQ level three, one person is about to start NVQ level two and another three are about to start NVQ level three. New staff have been recruited to provide adequate staffing levels in the home. Staff have an induction programme when starting work that includes health and safety, where first aid kits are kept and general fire awareness on the first day. Staff are supervised on shift by a senior carer and when competent and a clear criminal record check is received, they then work alone. During this induction period, any training needs are identified and core training is booked. Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 20 Most staff have now completed training for the protection of vulnerable adults and the two remaining staff who missed this training are to be booked on the next course. At the start of this inspection staffing consisted of four members of care staff, the manager, a chef, domestic staff and a maintenance person is also employed Monday to Friday. There is also domestic cover over the weekend period. Training has been undertaken regarding eye conditions, three staff have been trained in optical awareness and the manager is a trainer for this subject. Staff files contain appropriate information for the recruitment of staff and checks are in place to protect residents such as a criminal records check. Discussions with staff at this time showed they have a sound knowledge of procedures in the home and of individual routines and care needs. Staff also described what to do in certain situations such as finding signs of abuse and meeting individual care needs. One resident said ‘it is good in this home with good staff and good food’ another said that ‘staff always come when I need them to help me’. Another person commented that ‘some staff help more than others but they all help you’. Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 21 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): 31,33,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the ethos of the home reflects that resident’s best interests are considered, the lack of risk assessments puts them at risk. EVIDENCE: The manager has 25 years experience in care, has previously worked in nursing homes, an EMI unit, A & E psychiatric unit and was previously a deputy manager. She has now been a manager for almost three years but is not yet registered as manager of Shalom residential home. Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 22 There is an open and inclusive management style in operation and the manager is always available for discussions. This was confirmed by two visitors and through discussions with residents and staff at this time. The manager explained that staff also have a weekly chat with the manager and supervision is regularly undertaken, records and staff discussions confirmed this. The results of a recent quality assurance survey carried out by the home are on display in the entrance lobby. These results show that most responses were favourable and between good and excellent, one response was not favourable. The manager explained that quite a small number of replies were received, it is hoped that the next redesigned surveys will promote a better response. There is a COSHH folder with information and how to handle materials safely. A full fire risk assessment has been completed and updated this year. Certain aspects of this assessment showed that regular testing and maintenance is carried out on relevant equipment. Electrical testing has been competed as has testing of fire extinguishers. Two new smoke detectors have been installed and fire exit signs are to be renewed with larger signs for clearer identification. As identified in the main body of this report, certain areas of the home have not been risk assessed to identify if there are risks to people. Shalom Residential Home DS0000046100.V368540.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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 1 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (c) Requirement Care plans contain full and appropriate information in all sections to meet the needs of the individual. A check must be made to ensure controlled drugs are correctly secured to meet the safety and welfare of residents. Timescale for action 31/10/08 2. OP9 13 (2) 31/10/08 3. OP16 22.8 All complaints are recorded along 06/09/08 with investigation details and any actions taken, to show that they have been satisfactorily dealt with. All residents are provided with choices, in this instance, regarding having the use of a lockable space in their own room for safety. The kitchen floor is made safe for the health and safety of those using this area. The carpet in all areas of the home, particularly on the stairs, is free from damage. Providing DS0000046100.V368540.R01.S.doc 4. OP12 OP24 (7) 23 (2) m 31/10/09 5. OP19 23 (2) b 30/11/08 6. OP19 13 (4) a,c 23 (2) b 30/11/08 Shalom Residential Home Version 5.2 Page 25 a safe environment for residents, staff and visitors. 7. OP26 (26.3) OP38 12 (1) a Hand washing facilities are available for use in the laundry area for the control of cross infection. An alternative area be identified for the laundry as the currently small area is not fit for purpose. A full environmental risk assessment is completed for the safety of residents, staff and visitors. That a registered person is in place to manage the home. 08/12/08 8. OP38 16 (2) e,f 23 (1) a 23 (1) a 08/12/08 9. OP38 (38.6) OP19 03/11/08 10. OP31 8 (1) 31/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Shalom Residential Home DS0000046100.V368540.R01.S.doc Version 5.2 Page 27 - 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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