Inspection on 22/05/07 for Shedfield Lodge

This inspection was carried out on 22nd May 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Shedfield Lodge 14/05/08

Shedfield Lodge 24/05/06

Shedfield Lodge 26/01/06

Shedfield Lodge 13/07/05

Shedfield Lodge 05/01/05

Shedfield Lodge 13/09/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Shedfield Lodge St Annes Lane Shedfield Southampton Hampshire SO32 2JZ Lead Inspector Anita Tengnah Unannounced Inspection 22 May 2007 10:00 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 Shedfield Lodge DS0000012320.V336141.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. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shedfield Lodge Address St Annes Lane Shedfield Southampton Hampshire SO32 2JZ 01329 833463 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) Mr Robert Barrie Geach Mrs Christina Geach, Mr Andrew Robert Geach Position Vacant Care Home 33 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (33) Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The additional room registered 9C must not accommodate any service user with dementia on admission. Two named service users over the age of 60 may be admitted in the MD category. 21st December 2006 Date of last inspection Brief Description of the Service: Shedfield Lodge is a residential care home. It is registered to provide support and accommodation for up thirty-three people over the age of sixty-five. Within this number, up to twenty people can have dementia on admission and up to ten can have a mental disorder, excluding learning disability or dementia. The home is situated on the outskirts of Southampton. It is a large period house in its own grounds and gardens. Communal areas include a dining room, two lounges and a conservatory. The layout of the home is such that some of the bedrooms would not be suitable for any person with mobility problems. Twenty-three of the bedrooms are single. Six of these have en suite facilities. The remaining five bedrooms are double of which three have en suite facilities. The provider makes information available about the service, including the commission’s reports to prospective residents on request and copies of this information are available at the home. The current fee charged is £385-£480 per week. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit was undertaken on the 22nd of May 2007 as part of the inspection process. The process included a tour of the service where a number of the bedrooms, communal areas, kitchen, and bathrooms were viewed. As part of case tracking 6 staff, 7 service users and a visitor’s views were sought and care records were looked at. Information gained from the Annual Quality Assurance Assessment (AQAA) was also used and included in this report, as was information gathered by the commission since the last inspection to contribute in assessing judgements in this report. References and findings from the random visit in December 2006 will also be included in this report. Positive comments were received from the service users regarding the care that they were receiving at the home. The commission has not received any comment cards from the service users or relatives. Care practices observed at the time of the visit showed that staff developed good relationships and care was provided in a respectful manner. What the service does well: What has improved since the last inspection? Some of the bedrooms have been refurbished. The chairs in the communal lounges have been replaced and were appropriate to the service users’ needs. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre admission assessment process is good and ensures that service users’ needs are assessed and the home should be able to meet them. The home does not provide intermediate care. EVIDENCE: The care records of two recently admitted service users were looked at as part of case tracking. Details in the pre admission assessments included personal care needs, mobility and falls history. The staff reported that a care manager’s assessment is also sought as part of the assessment process and this was available in a service user’s record seen. The manager or a senior staff member undertook the home’s assessments. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 9 Comments received indicated that the home offers the service users a choice of visiting the home prior to admission. A service user spoken with reported that she visited the home and “took to the home first time”. Staff reported that usually the family visited due to the frailty of the service users. There was no evidence that the service users/relatives were involved in the assessment process. This should be further developed as appropriate in order to ensure that all care needs are identified prior to admission. The home does not provide intermediate care. Shedfield Lodge DS0000012320.V336141.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 adequate. This judgement has been made using available evidence including a visit to this service. The care plans and records of care given were available. Further developments of care plans and pen pictures and life history would benefit the service users. The health care needs and access to external agencies was satisfactory. The medication management was inadequate and put the service users at risk. The service users are treated with respect and their right to privacy maintained. EVIDENCE: The care records of 4 service users were looked at as part of case tracking. These contained details of assessments such as mobility, dietary needs, continence. Daily records of the care given consisted mainly of “washed Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 11 dressed and padded”. A few contained details of meals taken. The manager reported that a new care planning system had been introduced since the last visit. There were some improvements in the care planning as care plans seen included dressing, washing, toileting and diet. The home has a large number of service users with varying degrees of dementia. The care plans did not reflect how specific needs associated with dementia would be met. Discussion was held with staff that assessments should include a baseline that reflects the service users’ life history, interests and promotion of well-being, and care plans must be in place to say how any identified needs would be met. The staff confirmed that further development of care plans were needed. The falls risk assessments and care plans must also be further developed to reflect the current needs of the service users. There were no night care plans in records seen and staff confirmed that these would need to be developed. The mental health care plan for one service user seen was detailed and included information on challenging behaviour. Two of the service users spoken with said that they were diabetics. There was a diabetic care plan for one of them but none for the other service user. The chef was aware of the dietary needs of these service users and confirmed that they are offered diabetic diets. The deputy manager reported that all the service users are registered with the local surgery. The GP visited the home on request and staff reported that the GP and other healthcare professionals were supportive to the service users. The doctors’ visits and treatments were recorded in the service users files. The home has a procedure for the management of medication, the lunchtime medication administration was observed and medication handling was appropriate. The manager reported that only staff who have received training in medication are responsible to administer medication. Information received from the AQAA indicated that the drug administration system had changed to a blister pack. Staff reported that training in the new system remains outstanding although the staff have been using this for the past three months. The medications were stored in the medicine trolley that was kept in the kitchen and secured to the wall. A sample of the Medication Administration Record (MAR) sheets was looked at as part of the inspection. These showed considerable numbers of gaps on the MAR sheets for prescribed medication. Medication had either not been given or not signed for as required. This was an issue raised at the last inspection in May 2006 and remains an area of concern. During the Random visit in December 2006 the manager reported that she would be monitoring this. Some of the medications possibly missed included antibiotics and anti coagulants which has a detrimental effect for the service users. The MAR Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 12 sheets records must also contain records of variable dosages as administered to the service users. A system to record ointments/ creams that are administered to the service users must be put in place. Four of the service users who were able to contribute to the inspection reported that they were treated with respect and their rights to privacy respected. Comments included “the girls are all right” and “staff are good and kind”. It was noted that two service users had keys to their bedrooms and said that they kept these locked as some of the service users did wander into their rooms. They confirmed that staff knocked prior to entering their rooms. A screen was available in one of the shared rooms seen. However a comment card received from a relative indicated that the service user’s dignity was not always protected as she is dressed with no under garment on when the family takes her out. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some recreational facilities for the service users are available, however this needs further development to meet all the care needs of the service users. The service users are supported to maintain links with their family and friends. The service users are treated with respect. The meals are good and well managed, meeting with the satisfaction of the service users. EVIDENCE: The home has some activities for the service users and information received indicated that these included music and movement for an hour a week. This session took place on the day of the visit and the service users appeared to be enjoying this. The ‘patsy’ day care centre attended the home on Mondays and Fridays for an hour and an external entertainer came in on a fortnightly basis for a sing song. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 14 The home did not have an activity coordinator and the service users spoken with reported that the activities could be improved, as at present activities are dependent on the carers’ availability. Comments from the service users were that “not much goes on”. A service user said that he liked walking and relied on the staff to accompany him. He was accompanied for his walk in the afternoon after requesting for the door to be opened so that he could go out. Two of the service users said that they preferred not to take part in the activities and staff respected this. One service user in particular was found walking throughout the time of the visit and trying doors to get out and at times in a distressed state. The home has a number of service users with dementia and their assessment and care plans lacked information such as life history, their strengths, abilities, interests and promotion of well-being. This was discussed with staff as further development of their care plans would assist in meeting the social needs of the service users. The home has an open visiting policy and the record of visitors to the service maintained at the home supported this. A relative spoken with said that he visited at various times and “this is not a problem”. Two service users confirmed that they could see their relatives in private. Comments included “the staff always make you feel welcome”. All spoken with said that they felt safe and the staff treated them with respect. Interaction observed at the time of the visit showed that the staff have developed good relationships with the service users. Information from the AQAA indicated that all the service users were from a Christian denomination. The person in charge stated that the home had a visiting clergy and undertook a service in the lounge for some of the service users. Two of the service users said that they attended church service every Sunday. The church provided transport for both of them and they looked forward to seeing their friends and prayer was an important part of their lives. The home has a planned menu that is rotated on a regular basis. The menus indicated that the meals were balanced and the chef reported that alternative choice was available. The service users spoken with said that the meals were “very good” and “plentiful”. Two of the service users showed the inspector the facility for making hot drinks in their rooms. The chef was aware of the likes and dislikes of the people living at the home including special diets, although the list in the kitchen was not up to date. A record of meals taken was maintained and included food temperatures. Some of the service users were able to choose from the menu however the staff reported that not all of them were able to do so. Further development of how meal choices are offered to people with dementia should be considered including involvement of family and advocates. Shedfield Lodge DS0000012320.V336141.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 adequate. This judgement has been made using available evidence including a visit to this service. The record of complaints received and action taken are inadequate. The staff have knowledge of adult protection and action that they must take in reporting any allegation of abuse. EVIDENCE: The home has a complaint procedure and staff spoken with said that they would report complaints to the manager. The three service users spoken with said that they would be happy to approach the manager and “things would be sorted”. Two service users said that they were happy with the care and “there is no problem”. The staff in charge said that the home had not received any complaints since the last visit. The Local Authority adult services had received a complaint in March 07 that was investigated as adult protection. The investigation was completed in April 07 and action had been agreed by the home to resolve some of the issues. Adult services would be carrying out further reviews in June 07. The complaint log seen did not contain record of this complaint. The provider must ensure that all complaints received are recorded as required, including any action taken. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 16 The home has the Hampshire adult protection procedure and staff spoken with said that they were aware of the whistle blowing procedure and would report any concerns to the manager. Staff said that training in adult protection was available. Shedfield Lodge DS0000012320.V336141.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): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is homely, though ongoing refurbishment of the service would improve the environment. The infection control procedure for dealing with soiled laundry is poor. EVIDENCE: A tour of the building was undertaken and a number of bedrooms were looked at. The staff said that some of the bedrooms had been refurbished. The home was clean and no adverse odour was detected except for an area on the first floor. The deputy manager said that they were aware of this and thought that it came from under the floorboard. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 18 The two communal lounges on the ground floor were in a good state of repair and the furnishing was clean and appropriate to the service users’ needs. Four of the service users said that they were satisfied with their rooms and were able to personalise them. The manager said that bedrooms are refurbished as they become vacant. Various bedrooms were noted to have worn carpets and scratched/ worn paintwork and a full programme of refurbishment needs to be put in place to address these issues. Consideration should be given to the environment to meet the needs of people with dementia such as clearly visible and signed toilet doors and communal areas. The provider should seek advice from a relevant professional as necessary. A Random visit in December 2006 found that disposable hand towels and liquid soap were available in the communal toilets seen and all had a good supply of toilet paper. No bars of soap were seen in the communal bathrooms during this visit. This was following a requirement at the last visit which has been met. The home has an internal laundry and the deputy manager reported that some of the laundry such as bed linen and towels were sent out to an external agency. However other staff spoken with said that they washed all the sheets and towels prior to these being sent out. There was personal clothing found in the laundry area that did not have names of the service users. A comment received from a relative indicated that concerns had been raised on several occasions about the service users wearing other people’s clothing. Another issue raised was the lack of clean clothing in the service user’s drawer. The laundry area had two industrial washing machines and a dryer that were in use at the time. The staff said that gloves and aprons were available in the kitchen area. Staff were observed to use different coloured aprons for the serving of meals and care tasks. However practices observed in the laundry indicated that the management of soiled laundry was poor and posed an infection control risk through unnecessary handling of soiled laundry. This was brought to the attention of the manager and must be addressed. Shedfield Lodge DS0000012320.V336141.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 poor. This judgement has been made using available evidence including a visit to this service. The care staffing hours are eroded by non- care duties to the detriment of the service users. The recruitment process is poor and puts the service users at risk. There is a satisfactory training programme. The record of training such as mandatory training for staff was inadequate. EVIDENCE: A random inspection visit in December 2006 looked at staffing levels. Rotas seen at that time indicated that six carers were on duty in the mornings, four in the afternoon and evening and two awake and one sleeping staff at night. The manager or deputy manager were on duty each day and the manager said that she was on call and could be contacted when not on duty. At weekends only four carers were on duty during the day. The deputy manager said that she worked each weekend but this was not recorded on the rota. The manager said at the last visit that she was in the process of recruiting staff. Although the home does not usually employ agency staff, the manager said that she had had discussions with agencies to employ temporary staff Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 20 until sufficient staff could be recruited. The manager said that staffing levels would increase from the beginning of January 2007 and that the levels would be adjusted to meet the needs of the service users. A sample of the duty roster was looked at as part of this visit. This indicated that there are 6 carers on the morning shift and 4 carers in the afternoon. The staff in charge confirmed that night duty had two waking carers and an additional sleeping carer when there are 31 service users and above. Although the home has 6 carers on duty on the morning shift, it was noted that the carers were responsible for the kitchen work and the service users laundry. Care hours were being eroded by non- care duties. The home has a chef who works until one in the afternoon and a kitchen assistant from 5-8pm week days. At weekends there is a kitchen assistant from 8-1 pm. The carers prepared the weekend teas and suppers and afternoon teas daily. The service users were observed in the lounge unattended on several occasions through out the day, as the staff were busy in the kitchen and laundry. The provider must ensure that staffing levels are appropriate to meet the needs of the service users. The home must also have sufficient number of domestic staff so that care hours are not eroded by non- care duties. Information received from the AQAA indicated that there are 10 staff who have completed NVQ level 2 or above and 4 staff were working towards this level. Staff said that there is a training programme and regular training is available. A sample of records for the 4 recently appointed staff was looked at as part of this visit. This showed that although staff completed an application form, this did not contain a full history of their past employment and references were not always sought from the previous employer. Some staff records had only one reference. Another staff member who had started in January 07 did not have any evidence of a Criminal Record Bureau Check, POVA first check or references. These issues were brought to the attention of the deputy manager. The registered persons must ensure that staff records are up to date and all necessary checks must be completed prior to employment. There was no evidence on file of whether the staff had completed an induction although staff said that there is induction in place. The manager reported that she was in the process of putting in place an induction programme in line with ‘Skills for Care.’ The manager confirmed that a training programme was in place and planned training included dementia care for 10 staff in June 07. 10 staff are booked for moving and handling training in July 07 and first aid training for 10 staff in August 07. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 21 Some staff records seen contained information about training such as food safety, dementia, moving and handling and infection control. However this information was not available for all staff. It was difficult to ascertain if all the staff had completed basic food hygiene. All staff were involved in food preparation. The deputy manager said that the computer was out of order and could not print out the certificates. It could not be confirmed who had completed the training. The staff also reported that a carer provided the manual handling training for all staff as she had completed the “train the trainer“ course. The deputy manager was unable to provide any evidence of this person’s qualification, as the record could not be found. Discussion was held with staff that the development of a training matrix would ensure that any gaps in training are identified and action taken. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 22 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): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a manager who is in day-to-day control of the service. The auditing system at the home is satisfactory. There is a good servicing programme for equipment at the home. The lack of fire drills and poor management of hot water delivery put the service users at risks. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home has a manager who has been appointed within the last 6 months. An application is required to register with the Commission. The manager confirmed that she is in the process of submitting this application. Some service users and a relative spoken with said that they would approach the manager if they had any concerns. Comments were “we can go to her office anytime”. Staff reported that they felt supported and would go to the manager if they had any issues. Comments were that there is a good staff team and “we all work well together”. The staff reported that an audit of the service users views was undertaken in June 06 but the outcome of it was not known. The provider completes monthly reviews and copies of reports had been sent to the commission. The manager discussed that she would be introducing service users/ relatives meetings and staff meetings. The staff in charge reported that the provider deals with the moneys of two of the service users. The service users signed for their money. A record of the personal allowance was kept at the home. However the inspector was unable to check the money as the staff member in charge said that she did not have access to it. This raises issues that the service users would not be able to access their money if they needed to. Staff reported that one of the service users did not understand money matters and staff helped her with her money. It would be good practice to look into accessing an advocacy service for this service user to help her with her finances. A sample of servicing records seen indicated that there is a system in place for the regular servicing of equipments. A record of weekly fire alarm testing was available. A fire risk assessment was completed in June 06 and a risk assessment for the building was dated July 07. Although records showed that 7 staff had completed fire training in March 07, there was no record of staff fire drills. This was brought to the attention of the manager. Records showed that the monitoring of the hot water temperature was being undertaken. Records also showed that in October the hot water temperature in one room measured was 63 degrees centigrade and there was no record of any remedial action taken. The record of hot water temperature was not maintained at regular intervals and staff were unsure about the correct temperature for hot water delivery. The provider must ensure that the hot water is delivered at the correct temperature for the safety of the service users. The home’s handyman stated that not all the taps were fitted with thermostatic control valves and would be bringing this to the attention of the provider. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 24 It was noted that care staff were in the kitchen throughout the day as the medicine trolley was kept there and gloves and aprons. They also used the kitchen for their meals and staff reported that they all use the kitchen a lot as the call bell panel is also situated there. On a number of occasions service users were also seen walking in and out of the kitchen. The kitchen was clean and the chef reported that she kept her area in order. However some parts of the kitchen was in need of upgrading such as flooring and cupboards. The fridge for defrosting meat was rusty and posed an infection control risk, as this could not be adequately cleaned. The two fridge freezers had some rust on them too. A risk assessment for the kitchen must be in place and the provider must ensure that the service users are not put at risk. The manager reported that she would be looking into a different area for staff to have their meals and restricting access to the kitchen area. Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 25 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 17(1) (a) Schedule 3 13(2) Requirement An accurate record of all prescribed medication, and when these have been administered to the service users, must be maintained. A system for recording ointments/ creams administered to the service users must be put in place. The service users must be provided with suitable activities to meet with their assessed needs. A complaint log must be maintained and records of all complaints and actions taken must be recorded. The home must ensure that there are sufficient numbers of staff on duty at all times to meet the needs and promote the dignity of residents. This is an outstanding requirement of 30/06/06 and 28/02/07. Staff must not be employed until all appropriate checks have been DS0000012320.V336141.R01.S.doc Timescale for action 15/07/07 2 OP9 15/07/07 3 OP12 16(2)(m) (n) 17(2) Schedule 4 (11) 18(1)(a) 15/07/07 4 OP16 15/07/07 5 OP27 15/07/07 6 OP29 19(1) 15/07/07 Shedfield Lodge Version 5.2 Page 27 7 OP38 23(d) (e) 8 OP38 13(4) (a) (c) completed. Records of these must be maintained. Regular fire drills for staff must be in place as required for the protection of the people living at the home. The hot water temperature must be monitored and hot water delivered at the correct temperature for the safety of the service users. 15/07/07 15/07/07 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 Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Shedfield Lodge DS0000012320.V336141.R01.S.doc Version 5.2 Page 29 - 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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