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Inspection on 05/10/05 for Sherwood View Care Home

Also see our care home review for Sherwood View Care Home for more information

This inspection was carried out on 5th October 2005.

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

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

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

What the care home does well

The home provides a relaxed and flexible routine, where residents were able to make choices about how and where they spent their day. Residents commented positively about the choice and variety of food on offer.

What has improved since the last inspection?

Improvements have been made in a number of areas. These include the general cleanliness of the home, upgrading of the bathing facilities to provide a better choice for residents, ongoing redecoration and refurbishment of the environment, arrangements in place to ensure the home is well run, training opportunities for staff have increased, and team work and staff morale have improved. Staff had also been issued with new uniforms. Residents and relatives commented that the manager was approachable and that they had confidence that issues raised with her would be addressed. Residents and relatives welcomed the improvements that had taken place.Efforts have been made to update residents assessments of needs and care plans, although further development and staff training was still required. The Pharmacist Inspector evidenced that all eye drops; liquid preparations, creams and ointments were now dated once opened. Medication was being stored securely and there was better stock rotation. Work was being undertaken to establish formal supervision for care and ancillary staff.

What the care home could do better:

More detailed information needs to be recorded about individual residents needs, preferences and abilities, on which to plan and deliver care. The home would need to ensure they maintain accurate records of all medication entering the home and when these were administered to each service user. A structured programme of activities needs to be put in place, as well as staff spending time with individual residents, so that residents social needs are met. Further progress needs to be made to ensure that all staff have appropriate training and skills to meet the needs of the resident group. The home needs to put in place an annual development plan, to ensure that there is continued progress towards further improving the care and facilities provided.

CARE HOMES FOR OLDER PEOPLE Sherwood View Care Home 29 Village Street Derby DE23 8DF Lead Inspector Jo Wright Pharmacy Inspector - Naveeda Knopp Announced 5 October 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sherwood View Care Home Address 29 Village Street Derby DE23 8DF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01332 271941 01332 271941 European Care (SW) Ltd Vacant Care Home with nursing 39 Category(ies) of Old Age, not falling into any other category registration, with number of places Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12 January 2005 Brief Description of the Service: Sherwood View is a purpose built home providing nursing and personal care for up to 39 people aged 65 years and over. The home is located next door to another home owned by the same company. The home has 31 single and 4 double bedrooms located on the ground and first floor. All rooms except one have ensuite facilities. Access to the first floor is by stairs and a passenger lift. Sherwood View is approximately three miles from the Derby City Centre, and is close to local shops and facilities. Communal areas consist of a large lounge and dining area and a quiet room on the ground floor. The home has a smoking area, and a garden area. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Previous inspections have highlighted significant numbers of outstanding requirements, which has resulted in the Commission carrying out five monitoring visits. Discussions relating to non-compliance have also taken place with the Registered Provider. This announced inspection was carried out by two inspectors, and took place over 8 hours. Records were examined, including care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual service users). The pharmacy inspector visited the home on 26/09/05 to carry out an inspection of the medication standards. An assessment was made with respect to the requirements made at the last inspection and following the monitoring visits. The manager was present at this inspection. She was appointed recently and intends to apply to CSCI for registration as the Registered Manager. This inspection showed that the home has made significant progress towards meeting the requirements and recommendations from the previous inspection reports and monitoring visits. What the service does well: What has improved since the last inspection? Improvements have been made in a number of areas. These include the general cleanliness of the home, upgrading of the bathing facilities to provide a better choice for residents, ongoing redecoration and refurbishment of the environment, arrangements in place to ensure the home is well run, training opportunities for staff have increased, and team work and staff morale have improved. Staff had also been issued with new uniforms. Residents and relatives commented that the manager was approachable and that they had confidence that issues raised with her would be addressed. Residents and relatives welcomed the improvements that had taken place. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 6 Efforts have been made to update residents assessments of needs and care plans, although further development and staff training was still required. The Pharmacist Inspector evidenced that all eye drops; liquid preparations, creams and ointments were now dated once opened. Medication was being stored securely and there was better stock rotation. Work was being undertaken to establish formal supervision for care and ancillary staff. 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. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 4 The information recorded within the assessments was insufficient to ensure that individuals needs were fully identified and planned for. Although efforts have been made to provide staff training, the staff team as a whole did not have the necessary skills and knowledge to fully need residents needs. EVIDENCE: The Statement of Purpose and Service User Guide seen did not contain all of the required information. Not all information in these documents was up to date or accurate. Copies of the Service User Guide were available in the bedrooms. Contracts/terms and conditions were in place. The care plans of four residents were examined in detail as part of the case tracking process, which is used to help determine how the home meets the needs of individuals. Efforts have been made to ensure that pre-admission and on admission assessments were completed for all residents. Assessments did not include all essential information about individuals needs, preferences and abilities. This did not ensure that staff had identified the necessary information to fully identify individual needs, and plan care. The files did not Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 9 clearly show that all residents or relatives, where able, were involved in completing their assessment. Residents spoken with considered that some staff had a good understanding and knowledge of their needs, although this did not apply to all staff. A number of new staff have been recruited and staff confirmed that they were working through an induction training programme, to develop their skills and knowledge. Evidence obtained during a recent monitoring visit, supported that a range of training opportunities were being offered. Efforts had been made to identify the training needs of the staff team as a whole and appropriate courses booked. The following courses have been booked – 2 places - on hearing loss; 3 places - low vision awareness; 11 places - manual handling training; 6 places - food fortification; 2 places - PEG feeding; 2 places (qualified staff) and 2 places (care staff) – palliative care. One of the qualified members of staff has recently qualified as a manual handling trainer. The manager acknowledged that not all staff have the skills and knowledge to fully meet the needs of residents, and priority was being given to staff training. Therefore the requirement made in the previous two inspection reports had been partially met. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 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 standard(s) 7, 8, 9, 10, and 11 Efforts were being made to ensure that personal support was offered in such a way as to promote residents’ privacy and dignity. The assessments and care plans reviewed did not provide a clear picture of individual residents needs and how they were being met. The home had a comprehensive general medication handling policy but this was not always adhered and this puts some residents at risk of treatment failure. EVIDENCE: Residents and relatives spoken with considered that the majority of staff met their privacy and dignity. However, residents were able to describe incidents where dignity was not maintained, ie when being hoisted, occasional poor quality of ironing. Residents and relatives spoken with felt that the majority of staff were respectful and friendly, and that staff attitudes had improved over recent months, although certain members of staff did not always speak to them in a respectful manner. The manager was aware of this issue and was taking appropriate action to address this. The care plans of four residents were examined in detail as part of the case tracking process, which is used to help determine how the home meets the needs of individuals. Care plans examined did not provide sufficient detail for Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 11 staff to provide appropriate care to fully meet resident’s needs, and had not all been updated to reflect any changes. This applied to care plans developed by staff and core care plans. This is an outstanding requirement from reports dating back to January 2004. Not all files supported that residents and/or relatives had been involved in planning and reviewing their care. The monthly statements did not review the effectiveness or appropriateness of the care and treatment being delivered. The manager was aware of these issues and committed to improving the standard of care planning. Care staff were recording information about residents day to day lives, and this provided a clearer picture of how the resident had been. Residents and relatives spoken with felt that qualified staff took appropriate action to contact GPs as required. Information recorded in the files did not fully support that residents’ health needs were being fully met, ie incomplete records of visits by health care professionals. Care plans had not been updated following changes to health care needs. This was discussed at length with the manager. Files examined did not contain details the personal wishes of the residents at the time of severe illness or post death. This was particularly relevant for one resident whose care was case tracked. This has been a requirement in the previous three inspection reports. The majority of staff had not received training in care of the dying, to enable them to discuss this issue with residents. The Pharmacist Inspector reviewed the medication administration record (mar) sheets for all residents. Areas of concerns were highlighted and feedback was given to the nurse in charge and the manager on the day of the inspection. Compliance to requirements relating to medication that were issued by the lead Inspector at a previous additional visit was also confirmed on this inspection. A number of shortfalls in administration and recording of medication were noted. The details of these issues are covered in a separate letter to the owner and manager. Medication was noted to be stored in secure cabinets and Controlled Drugs were been stored in an appropriate cabinet that would conform to current legislation. Medication that required cold storage (2-8’C) was being stored in a clinical fridge that required defrosting. The maximum and minimum temperatures of this unit not monitored, only the current temperature. It was confirmed to the inspector that a new clinical fridge was on order as there had been anomalies in the temperature readings. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 12 Short dated in use medicines did have the opening dates marked on the packaging and that stock rotation was now occurring at the home. The home had recently arranged for medication no longer in use to be removed from the premises via an approved waste transfer agency. The manger verbally confirmed that all nursing staff had been re-issued with NMC code of ethics, refresher medication handling training and the Royal Pharmaceutical Society Guidelines on medication handling practises in care homes. The Pharmacist Inspector concluded that the medication-handling standard had not been met on this inspection but further improvements had been made since the last unannounced inspection. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 The home has made limited progress towards providing activities, and the social needs of residents were not fully met. A varied range of meals and alternatives were provided, offering residents a choice and a balanced diet. EVIDENCE: Although the home employs an activities coordinator, this member of staff was on maternity leave. Arrangements had not been put in place to maintain regular social and leisure activities for residents. Residents spoken with said that they were bored and did not have enough to do to occupy their day. Files did not clearly demonstrate how individual social needs would be met. Several residents spoken with commented that certain staff made time to talk to them on a one to one basis, although not all staff saw this as a priority. Relatives were encouraged to visit at any time, and several residents regularly when out of the home accompanied by relatives. Where able, residents went out independently. Visits by family and friends were well recorded in the files. The majority of residents and staff spoken with considered that the meals provided were satisfactory, and provided good choice and variety. Residents commented that staff went out of the way to provide a cooked breakfast each day of their choice. A few residents spoken with indicated that the presentation and taste of main meals could be improved. It was noted that the home did not have sufficient dining tables and chairs to seat 39 residents. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 14 A number of residents commented that they preferred to sit in the lounge area to eat their meals. A number of residents remained in wheelchairs at the dining table. Staff stated that this was in response to the residents needs. Residents seated in wheelchairs were not well supported or near to the table when served their meals. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Further work needs to be done to ensure that residents and relatives feel confident that all staff will listen to and act on their complaints. Procedures were being strengthened to protect residents from abuse. EVIDENCE: The complaints procedure on display was inaccurate, in that it did not provide the current address for the company. The service user guide made reference to but did not include a summary of the complaints procedure, and stated that residents were given a copy of the procedure. The Commission has received three complaints in the last six months, about the care and services provided at the home. These complaints have been referred to the company to investigate. A number of these complaints were upheld following investigation. However, records relating to these complaints were not available in the home. The manager was investigating an internal complaint at the time of this inspection. Residents and relatives commented that the new manager was approachable, and felt more confident in being able to raise concerns. They commented that previously they had not felt confident that their concerns were listened to and acted upon. This is supported by the complaints received by the Commission. The policies and procedures relating to the Protection of Vulnerable Adults have been updated since the monitoring visit in September 2005. A copy of the local authority Protection of Vulnerable Adults procedure had been Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 16 obtained. Staff receive a copy of the shortened version of the local authority procedure. Information about the referral procedure to place staff on the POVA register had been obtained. Staff were attending Protection of Vulnerable Adult training provided by the local authority. Out of the 36 staff employed at the home, 19 have not attended this training. Training request forms have been forwarded to the local authority training department for these staff. Internal training on ‘understanding abuse’ has been arranged for December 2005. Information relating to ‘No Secrets’, and consent was available to staff. No referrals through the Adult Protection Procedures have been received since the last inspection. Discussion with staff demonstrated that they had a basic knowledge of the procedures and who to report any incidents to. Staff felt confident to raise any concerns relating to residents welfare. Staff confirmed that they were due to attend training in the future. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21,22, 23, 24 and 26 Improvements have been made to the standards of hygiene and cleanliness throughout the home, and to ensure that residents have a safe, comfortable environment to live in. EVIDENCE: Considerable improvements have been made to the environment over recent months, to provide a clean and better maintained home. This included new items of bedroom furniture, replacement of carpets in a number of bedrooms, new flooring covering in several toilet areas, new lounge carpet, new conservatory and upgrading of several bathrooms. Sluicing disinfectors have been installed in both sluice areas, to support good hygiene standards. Residents and relatives spoken with welcomed the improvements to the facilities and felt that the standard of cleanliness had improved over recent months. All areas of the home were clean and free from odours at the time of this inspection. The deployment of domestic staff hours and clear cleaning schedules has bought about the above improvement. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 18 Heating has yet to be provided in the conservatory area. The manager stated that priority would be given to addressing this issue. The manager acknowledged that some rooms were in need of redecoration and personalising. Although a written plan had not been developed, the manager was aware of the areas that required attention. A number of areas of the home have been altered to storage areas and fire detection had been installed. The manager was advised to contact the Fire Officer to check whether any additional fire precautions were required. A new electronic bath and hoist had been fitted, which reduced the amount of moving and handling for residents and staff. Staff commented the need for the third mobile hoist, which was currently out of use due to a fault. The manager reported that she was in discussions with the manufacturer about repair or replacement of this hoist. Staff confirmed that a high percentage of residents required hoisting. Observation would support a review of the range of moving and handling aids, as all three hoists were similar in nature, and no alterative moving and handling aids were seen being used. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, 29 and 30 The recruitment procedures in place need to be followed at all times and appropriate checks carried out prior to new staff taking up post to ensure residents are protected. Continued efforts need to be made to ensure that all staff have received appropriate training so that they are competent and skilled for the work they carry out. EVIDENCE: Evidence gathered during the monitoring visit in September 2005 showed that not all required information has been obtained for staff to work in the home. All staff files have since been audited, and any missing information (references and Criminal Record Bureau checks) identified and sent for. The manager had identified the reasons for shortfalls in information and had taken appropriate action. The manager was aware of the need to follow procedures in order to provide the safe guards to offer protection to residents living in the home. The written recruitment and selection policy and procedure had been amended to include carrying out POVAfirst checks on staff, in addition to Criminal Record Bureau checks. Information gathered during the monitoring visit in September 2005 supported that training towards National Vocational Qualifications was available for staff. New staff were being supported to commence NVQ training shortly after taking up post. The home has made good progress towards meeting the 50 target of care staff having achieved NVQ Level 2 or equivalent, although this target has not yet been achieved. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 20 Newly recruited staff stated that they were completing the homes induction training. The manager confirmed that this meets the required specifications. Since the last monitoring visit in September 2005 a training matrix had been developed to show what training staff had previously attended, and assist to the manager to identify future training needs. The manager acknowledged that not all staff had attended all mandatory and appropriate training to meet peoples needs. Efforts had been made to provide a range of training for staff over the coming months. Staff welcomed the increased opportunities for training. The manager had identified key areas of training, but this had not been developed in an annual training plan. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, 37 and 38 Improvements have been made in the running of home, which has benefited residents, relatives and staff. Continued efforts need to be made to ensure that all staff have received all mandatory training. EVIDENCE: The new manager took up post in April 2005, and has yet to submit an application to the Commission for registration as manager. This has been delayed due to proposed changes in registration of the home. Since taking up post the manager has identified and bought about significant changes to improve the running of the home and residents care. The manager had clearly identified further areas for improvement and development. Staff spoken with supported the changes within the home, and reported that staff morale had improved. Staff felt that the manager was approachable and listened to their ideas and suggestions, and allowed them to develop these Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 22 further. Staff commented that communication and team work between all grades of staff had improved, although they acknowledged that this could be developed further. Qualified staff were working more closely with care staff, to supervise their practice and the standards of care delivered. Although not all care staff have received formal supervision, some progress has been made to establish this. The supervision records for four members of staff were seen during this inspection. Clear procedures were in place to safe guard residents’ money. Residents, relatives or an independent person managed residents finances and personal allowance whenever possible. Six residents had small amounts of money in safe keeping at the time of this inspection. Receipt books should be available in both homes, and all entries and withdrawals should be witnessed and countersigned, as stated in the home’s policy. The training matrix identified that not all staff had attended mandatory training. Efforts had been made to address this. Moving and handling training was being provided through the local authority or internally. The following training had been arranged – fire safety (2 sessions) November 2005, food hygiene (12 places) October 2005, Health and safety October 2005, first aid (12 places) November 2005. Infection control training had not been arranged as yet. Some health and safety issues were noted, eg trip hazards - dividing curtains in one shared room was too long, the vacuum cable was across the corridor, and the fire extinguisher was not mounted to the wall in the lounge area. Some staff were also observed wearing latex disposable gloves inappropriately between caring for residents. These issues were bought to the attention of the manager. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 x 3 STAFFING Standard No Score 27 x 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 3 3 3 x 3 2 x 2 Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4&5 Requirement The Statement of Purpose and Service User Guide must be reviewed and amended to include up to date and essential information. Assessments must include all essential information about individual residents needs, preferences and abilities, and demonstrate resident/relative involvement. All staff must individually and collectively have the skills and experience to deliver the services and care that the home offers to provide. Care plans must set out in detail the action that needs to be taken by staff to ensure that all aspects of needs of the resident are met, and demonstrate resident/relative involvement. (Previous timescale of 30 September 2004 not met) Residents wishes concerning terminal care and arrangements after death must be discussed and recorded (Previous timescale of 30 September 2004 not met). A structured programme of activities must be put in place Timescale for action 31/12/05 2. OP3 14 31/12/05 3. OP4 12(1)(a)( b)18(1)(a ) 15(1) 30/04/06 4. OP7 31/12/05 5. OP11 12(3) 31/12/05 6. OP12 16(2)(m)( n) 31/12/05 Page 25 Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 7. OP16 22(5) 8. OP20 23(2)(p) 9. 10. OP28 OP29 18(1)(a) (b)(c) 17(2)19(1 )(b) 11. 12. 13. 14. 15. OP30 18(1)(a) (b)(c) and up to date information circulated to residents (Previous timescale of 31 March 2005 not met). The current and up to date complaints procedure must be avialable to residents, relatives and visitors. Adequate heating must be provided in the conservatory area (Previous timescale of 28 February 2005 not met) 50 of care staff must be trained to NVQ Level 2 or equivalent. All information required in Schedule 2 and 4 of the Care Homes Regulations 2001 is recorded for all members of staff. All staff must receive training apporpriate to the work they are to perform. 30/11/05 31/10/05 31/12/05 31/12/05 30/04/06 OP36 OP37 OP38 16. OP9 17. OP9 18. OP9 All staff must receive informal and formal supervision 17(1) All required records must be (4) maintained. 18(1)(a)(c All staff must have received )(i) training in mandatory safe working practices (Previous timescale of 30 November 2004 not met) 13(2)17(1 When a variable dose is )(a) prescribed a record must be made of the actual dose quantity given to the resident. 13(2)17(1 All medication administration )(a) sheets(printed or handwritten) must clearly indicate the date of administration of a medicine to the resident. 13(2) There must be a record of all medication received in to the home. Previous stock holding must be carried forward on to current mar sheets. 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc 18(2) 30/04/06 31/12/05 30/04/06 07/11/05 07/11/05 07/11/05 Sherwood View Care Home Version 1.40 Page 26 19. OP9 13(2) 20. OP9 13(2) This is outstanding from the additional visit dated 19/07/05. All Medication should be administered according to the Prescribers instructions as stated on the dispensing label or prescription. A suitable clinical fridge must be used for medicines that require cold storage. Current guidelines on monitoring the suitability and efficiency ie maximum/minimum and defrosting must be followed. 07/11/05 14/11/05. 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. 3. 4. 5. 6. 7. 8. 9. 10. Refer to Standard OP7 OP11 OP15 OP15 OP16 OP16 OP19 OP19 OP22 OP30 Good Practice Recommendations Monthly reviews of residents care plans should report on the effectiveness or appropriateness of the care and treatment being delivered. All staff should receive training in care of the dying. The provision of dining tables and chairs should be reviewed to meet the needs of current and future residents. Residents should be further consulted about the presentation and quality of meals provided. A copy of all complaint investigations, including those referred to the company for investigation, should be avaiable in the home. The manager should take appropriate action to ensure that residents and relatives feel confident that all staff will listen to and act on their complaints. A written plan for redecoration and refurbishment of the building should be put in place. The manager should contact the Fire Officer to check whether any additional fire precautions were required in the nearly created storage areas. A review of the range of moving and handling aids avialable to staff should be undertaken. An annual training and development plan and indiviudal training records for all staff should be developed. 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 27 Sherwood View Care Home 11. OP35 12. 13. 14. 15. 16. OP9 OP9 OP9 OP9 OP9 Receipt books for money and valuables should be available in both homes, and all entries and withdrawals should be witnessed and countersigned, as stated in the home’s policy. A copy should be obtained of nurses signatures who have read and agreed to abide by the homes medication handling policies. Discontinued prescribed items need to removed from the current mar sheets by the supplying Pharmacist. Medication profiles of current medication with dosages are to be maintained in the service users care plans. The management of the home frequently documents and carries out medication audits at the home. All handwritten mar sheets are verified by a second nurse to ensure accuracy of information transcribed. Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 Page 28 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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 Sherwood View Care Home 20051005 SherwoodView AN Stage 4 S48929 V241039 C52.doc Version 1.40 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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