Inspection on 16/10/06 for Sheldon Lodge

This inspection was carried out on 16th October 2006.

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 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

Sheldon Lodge 18/12/07

Sheldon Lodge 23/02/06

Sheldon Lodge 15/09/05

Sheldon Lodge 12/01/05

Sheldon Lodge 05/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Sheldon Lodge 150 Sheldon Road Chippenham Wiltshire SN14 0BZ Lead Inspector Alyson Fairweather Key Unannounced Inspection 10:00 16th October 2006 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 Sheldon Lodge DS0000028697.V301217.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. Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sheldon Lodge Address 150 Sheldon Road Chippenham Wiltshire SN14 0BZ 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) 01249 660001 Mr Sateeam Arithoppah Mrs Jayne Arithoppah Care Home 9 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (9) of places Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 2 service users over the age of 65 must be accommodated for intermediate care at any one time. 23rd February 2006 Date of last inspection Brief Description of the Service: Sheldon Lodge is registered to care for nine older people, two of whom may have dementia or associated illnesses. It is a detached property which is located within a residential area of Chippenham and is within close proximity to a public house and convenience store. The home is privately owned and the proprietors are Mr and Mrs Arithoppah who live on the premises and undertake many shifts as part of the working care roster. The home offers five single and two shared bedrooms which are located on the ground and first floor and a stair lift is installed to access all parts of the building. There is a large, well developed garden and on-street parking is available. Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection took place over one day in October. The manager and several residents, relatives and members of staff were spoken to. We received written feedback from seven relatives and friends, one GP and one care manager. The inspector toured all the building and observed a lunch-time meal and an activities session. A range of records were reviewed, including staff training records, staff employment records, medication records, care plans, and risk assessments. Fees range from £367 - £420 per week. What the service does well: Residents’ healthcare is well managed. All residents are registered with a GP whilst living in the home, and all other medical professionals are seen as and when required. The home has good links with the local older people’s community team, and can call for support if any crisis periods arise. Care plans contained details of medical appointment made for residents. Great care is taken over maintaining healthy skin for those residents who may be immobile, and to ensure tissue viability each resident has been issued with a comfortable support mattress. One GP who responded to our questionnaire said that the home “communicated clearly and worked in partnership with him” and that if “any specialist advice was given, it was incorporated into the residents’ care plan”. One family member said “My mother has been close to dying. I have been impressed with the consideration to her and my feelings at such a time by all the staff”. Staff training continues to be of a high standard. All new staff receive induction training and staff are supported to undertake a variety of training to equip them to perform their duties. Training includes mandatory courses, such as first aid, manual handling, food hygiene, health and safety, dementia and NVQ training. Other training includes Protection of Vulnerable Adults, medication administration, and advanced first aid. Seven staff members, as well as the two proprietors, have done a VRQ in Dementia Care, and were awaiting their certificates. A study day on Conflict Management is planned. All four of the health and social care professionals who responded to our questionnaire said that staff demonstrate a clear understanding of the care needs of residents, and were satisfied with the overall care of residents. All seven of the relatives Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 6 and friends who responded to our questionnaire said they were satisfied with the overall care provided. Mr and Mrs Arithoppah are both registered nurses and have many years experience of various health settings and working with older people. Mrs Arithoppah has the Registered Manager’s Award and is also an NVQ Assessor. Mr Arithoppah has undertaken training to undertake the testing of portable electrical appliances and to facilitate training within the home. He also takes responsibility for the home’s medication systems. Both have recently taken their VRQ in Dementia Care. One resident’s friend said “I am impressed by the nice “family” feel about Sheldon Lodge. As a very close friend of the resident I am very happy that she is here at Sheldon Lodge in such good care”. Of the two staff members interviewed, one said that she would go to either of the proprietors if she needed advice, and the other said she was “able to talk to Mrs Arithoppah about anything – she is always very approachable”. What has improved since the last inspection? What they could do better: Residents’ safety has in the past received significant attention. However, during the inspection one of the emergency call bells in a bedroom failed to work, and thus there was no response from any staff member. When the emergency call bell was activated in another room, the sound could clearly be heard throughout the home, and two staff members responded very quickly. The proprietors explained that the call bell must have been faulty, and because it was seldom used, it had escaped notice, although it had been regularly serviced. They have therefore been asked to make sure that all call bells are maintained in good working order, so that residents or staff are able to summon help in an emergency. On examination of the emergency call bell panel, it was noted that one sign simply stated “Room 8”. When asked which room this represented, both proprietors were unclear. They have been asked to make sure that the emergency call bell panel is clearly labelled, so that staff might immediately identify in which room assistance is needed. Sheldon Lodge DS0000028697.V301217.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. Sheldon Lodge DS0000028697.V301217.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 Sheldon Lodge DS0000028697.V301217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Prospective residents have their needs, hopes and goals assessed and recorded before they move in to the home so that staff know how best to support them. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to this service. EVIDENCE: Residents of Sheldon Lodge can be referred by Wiltshire County Council, by their families or by means of self-referral. The manager makes a detailed assessment, at which stage residents are able to say what they feel their needs and goals are, and to assess whether the home might be able to help with these. Potential residents make several visits to the home, and can spend time getting to know staff and other residents. This allows further assessment of their needs to take place. The format is detailed, comprehensive and contains sufficient information to enable a clear plan of meeting individual need. All assessments viewed were completed in detail. Sheldon Lodge DS0000028697.V301217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Residents have all their health, personal and social care needs set out in care plans, and their health needs are fully met. They are protected by the home’s medication policies and procedures. Residents feel they are treated with dignity and respect. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to the service. EVIDENCE: Each person has a care plan which is drawn up with them and signed with help from their families if necessary. These plans include details of any personal care needs, medical and physical health, mobility and communication skills. The care plans also highlight people’s likes and dislikes, and what activities they like to pursue. These plans are reviewed regularly every two months, but are also done so if there are any changes in the person’s situation. Staff record the activities residents undertake as well as their general wellbeing on a daily basis. There is a monthly review of all night time needs of all residents. Risk assessments were in place for those residents who need them, and these included people’s mental health deterioration, risk for someone of wandering Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 11 off, and risk of choking for someone else. The action taken to minimise these risks was recorded and reviewed at the same time as the care plan. It is recommended that the format of the risk assessment is changed so that each risk is on a separate sheet and is linked to the care plan. All residents are registered with a GP whilst living in the home, and all other medical professionals are seen as and when required. This varies according to the needs of individuals. The home has good links with the local older people’s community team, and can call for support if any crisis periods arise. Care plans contained details of medical appointment made for residents. Great care is taken over maintaining healthy skin for those residents who may be immobile, and to ensure tissue viability each resident has been issued with a comfortable support mattress. One GP who responded to our questionnaire said that the home “communicated clearly and worked in partnership with him” and that if “any specialist advice was given, it was incorporated into the residents’ care plan”. One family member said “My mother has been close to dying. I have been impressed with the consideration to her and my feelings at such a time by all the staff”. Mediation is currently stored within a locked kitchen cupboard. The Nomad system of administration is used. The pharmacy dispenses the medication into dossette boxes although the home uses its own printed administration sheets to document administration. Each record has a photograph of the resident. All medication records were accurately signed and all staff have undertaken drug administration training. These were no residents who were self-medicating at the time. The care manager and the GP who responded to our questionnaire both stated their opinion that residents’ medication was appropriately managed in the home. All residents spoken with confirmed their satisfaction with staff members and expressed that his or her privacy and dignity were respected at all times. Staff were observed knocking on doors and residents were spoken to with their preferred form of address. Residents confirmed that all personal care was given appropriately and staff respected residents’ wishes of wanting to spend time in their room. Two district nurses, the care manager and the GP who responded to our questionnaire said that they were all able to see the residents in private when they needed to. There are two shared bedrooms in the house. One family member spoken to reported that her mum was “very happy” to share a room, but that she was given privacy in her room when it was needed. Sheldon Lodge DS0000028697.V301217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 14 and 15 The home has developed regular activities provision that links with residents’ individual interests and capabilities, including provision for religious observance. Residents are encouraged to follow their preferred routines and make their own choices. People can have as much or as little contact with family and friends as they wish, and are supported to do so by staff. Residents receive a wholesome, appealing, balanced diet. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to the service. EVIDENCE: Many of the activities for residents take place inside the home, and include art therapy, a cooking group, bingo two or three times a week, a music & singing group, games & puzzles, church services and garden tea parties in summer. An art therapist and a piano player both give their time to entertain residents. The home’s owners have purchased a keyboard so that it can be used at any time in the home. A group of residents were singing to song-sheets on the afternoon of the inspection, and the inspector was very happy to join in for a brief period. One particular resident has one to one art therapy sessions. This same resident enjoys classical music, and has accumulated a wide variety of CDs. When not undertaking arranged activity, some residents reported Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 13 enjoyment with reading, newspapers, crosswords and the television. One resident has a free-view box which gives television access to many different channels. For those people who wish to attend outside activities, there are church tea parties, outings to various places, including horse world, the garden centre, tearoom visits and a fireworks party in the winter, arranged by an exresident’s family. Residents also are encouraged to go out with their relatives, and one relative had just returned from lunch out with her mother. Observations and discussions with residents confirmed that they can exercise personal autonomy and choice within their capabilities. Residents can and have brought items of furniture and personal possessions to make their bedrooms more homely, they can choose how and where to spend their time, and what activities to participate in. Residents are able to meet with their visitors within the main communal areas or in private accommodation as required. Although many residents do not generally stay up after 9 pm, records showed that some did not actually go to sleep until quite late, and preferred to watch TV in their own rooms. A satisfactory and varied four weekly menu is in operation, which provides a choice at breakfast and at teatime with the option of a cooked breakfast at weekends. The main meal of the day is held at lunchtime providing a set meal or the option of a vegetarian meal, although the latter is rarely taken up. Supper is made available for residents and this is served at about 19:30. The Mrs Arithoppah undertakes the majority of the cooking duties, although her husband and other staff contribute. Drinks and snacks are available at other set times of the day, and a pot of coffee is available in the lounge all day for any visitors. Mealtimes are flexible to take into account residents’ appointments and this was evident during the inspection. Residents were seen to use the dining room to eat lunch, which was chicken with potatoes, carrot and swede, with custard and jam sponge to follow. One resident was seen to be offered a salad instead. Health eating is positively encouraged and a good selection of fresh fruit and vegetable is made available. Residents commented positively about the quality of food provided and they confirmed that they receive plenty of it. Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents’ views are listened to and acted on. The policies and procedures the home has in place, and the staff training in Protection of Vulnerable Adults, ensure that residents are safeguarded from abuse and harm. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to the service. EVIDENCE: There is a complaints procedure in the home which outlines the steps to take if any one has a complaint. This gives details of how residents and families can contact the Commission for Social Care Inspection (CSCI) if they prefer to complain to an outside person. All seven relatives and friends who responded to our questionnaire said they were aware of the home’s complaints procedure, and all said they were satisfied with the overall care provided. Two residents spoken to said that they would be able to talk to staff if they had any concerns. No complaints have been received by the home or by the CSCI. The home has copies of the “No Secrets” document, as well as the organisational policy and procedure on responding to allegations of abuse. Staff spoken to confirmed that they had received training in the protection of vulnerable adults. All staff members are encouraged to report any incidences of poor practice, and a “Whistle Blowing” procedure is also available. There have not been any incidents requiring a vulnerable adults’ referral. Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Residents live in a homely and comfortable environment, which is suitably maintained and is clean and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Sheldon Lodge is located within a residential area of Chippenham within close proximity to local amenities. All areas are homely, comfortable and well maintained. There are two twin and five single bedrooms, which are on the ground and first floors, with a stair lift which residents use with staff assistance. Residents’ bedrooms were homely and each contained individual personal items. Communal areas consist of a sitting room and separate dining room. The kitchen floor has been replaced, and the environmental health officer was reported to be very pleased with it. ‘Door guards’ have also been fitted to all doors on the ground floor so that they can be safely held open as required. A great deal of work has been done by the provider in fitting radiator covers in the home. At the front of the building there is a large, wellSheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 16 maintained garden. One resident was seen to be enjoying the afternoon sun outside in the garden. The home was clean and hygienic, with policies and procedures in place for the maintenance of the building. Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Residents’ needs are met by the numbers and skill mix of staff. They are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their job. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to the service. EVIDENCE: The home provides the minimum levels of staff, which comprises of two care staff on duty throughout the waking day and commences at 08:00 and finishes at 21:00. A cleaner is employed for five afternoons a week and a music therapist and an art therapist also provide support for activities in the home. There are no waking night staff employed at night but Mr and Mrs Arithoppah provide the necessary sleeping in duties. Mrs Arithoppah reaffirmed that she or her husband make regular checks during the night, and a monthly review of residents’ night time needs is recorded. All residents have access to a call bell and are encouraged to ring for assistance if required. The call would then be heard within Mr and Mrs Arithoppah’s private accommodation. All seven of the relatives and friends who responded to our questionnaire said they were satisfied with the overall care provided, and all thought there were sufficient staff on duty. The home has a clear system for recruitment and selection of staff. All prospective staff complete an application form and supply two referees, one of Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 18 which is from their most recent employer. The home verifies proof of identity and performs Criminal Records Bureau (CRB) checks. As part of this, since 2004, people’s names are checked against the Protection of Vulnerable Adults register (POVA). One staff member who had been employed for several years had no POVA check, as a CRB check had been done prior to 2004. This individual is well known to the proprietors, who believe they would have been aware of any misconduct. A discussion was held with Mrs Arithoppah about how to manage this situation. It is therefore recommended that the staff member in question signs a declaration that she has not been placed on the POVA register and that Mrs Arithoppah completes a risk assessment regarding the continued employment of this individual with vulnerable people. All new staff have received induction training and staff continue to be supported to undertake a variety of training to equip them to perform their duties. Training includes mandatory courses, such as first aid, manual handling, food hygiene, and health and safety, dementia and NVQ training. Other training done includes Protection of Vulnerable Adults, medication administration, and advanced first aid. Seven staff members, as well as the two proprietors, have done a VRQ in Dementia Care, and were awaiting their certificates. A study day on Conflict Management is planned. All four of the health and social care professionals who responded to our questionnaire said that staff demonstrate a clear understanding of the care needs of residents, and were satisfied with the overall care of residents. Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 38 The home is managed by a registered nurse who has been in post for many years, and hold the relevant managerial qualifications. There are systems in place for reviewing quality of care, to ensure that the home is run in the best interests of the residents. Residents’ moneys are safely managed. The home has systems in place to ensure the health, safety and welfare of residents and staff. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to the service. EVIDENCE: Mr and Mrs Arithoppah are both registered nurses and have many years experience of various health settings and working with older people. Mrs Arithoppah has the Registered Manager’s Award and is also an NVQ Assessor. Mr Arithoppah has undertaken training to undertake the testing of portable Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 20 electrical appliances and to facilitate training within the home. He also takes responsibility for the home’s medication systems. Both have recently taken their VRQ in Dementia Care. One resident’s friend said “I am impressed by the nice “family” feel about Sheldon Lodge. As a very close friend of the resident I am very happy that she is here at Sheldon Lodge in such good care”. Of the two staff members interviewed, one said that she would go to either of the proprietors if she needed advice, and the other said she was “able to talk to Mrs Arithoppah about anything – she is always very approachable”. The views of residents have clearly been sought as part of the annual consultation. This questionnaire had also been sent to families/friends, to staff and to visiting professionals. The replies had been collated and the proprietors’ responses had been disseminated to all the people who had responded. Overall, there was a very positive response to the quality assurance exercise. The home does not have any involvement with residents’ finances. Residents are encouraged to manage their own financial affairs with the assistance of their family members or representatives. As a result the home does not undertake the role of appointee or hold any money for the residents’ safekeeping. Any expenditure such as hairdressing is raised as an invoice by the home and given directly to the residents’ or their representative. Residents’ safety has in the past received significant attention by installing individual fail-safe devices to all hot water outlets. Risk assessments have also been developed in order to address key areas. The fire log book was well maintained demonstrating a high level of fire safety. All checks have been undertaken as required and a number of fire drills had taken place during each identified period. Staff were up to date with their fire instruction. However, during the inspection one of the emergency call bells in a bedroom was pulled. This failed to work, and there was no response from any staff member. When the emergency call bell was activated in another room, the sound could clearly be heard throughout the home, and two staff members responded very quickly. The proprietors explained that the call bell must have been faulty, and because it was seldom used, it had escaped notice, although it had been regularly serviced. They have therefore been asked to ensure that all call bells are maintained in good working order, so that residents or staff are able to summon help in an emergency. On examination of the emergency call bell panel, it was noted that one sign simply stated “Room 8”. When asked which room this represented, both proprietors were unclear. They have been asked to ensure that the emergency call bell panel is clearly labelled, so that staff might immediately identify in which room assistance is needed. Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 22 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 OP38 Regulation 13 (4) (c) Requirement All call bells must be maintained in good working order, so that residents or staff are able to summon help in an emergency. The emergency call bell panel must be clearly labelled, so that staff might immediately identify in which room assistance is needed. Timescale for action 18/10/06 2 OP38 13 (4) (c) 18/10/06 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 OP7 OP29 Good Practice Recommendations The format of the risk assessment should be changed so that each risk is on a separate sheet and is linked to the relevent care plan. The staff member with no POVA check should sign a declaration that she has not been placed on the POVA register. The proprietor should complete a risk assessment regarding the continued employment of this individual with vulnerable people. Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sheldon Lodge DS0000028697.V301217.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!