Inspection on 02/11/05 for Sidegate Lane Nursing Home

This inspection was carried out on 2nd November 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 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

Sidegate Lane Nursing Home 13/08/07

Sidegate Lane Nursing Home 17/08/06

Sidegate Lane Nursing Home 07/02/05

Sidegate Lane Nursing Home 10/11/04

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

CARE HOMES FOR OLDER PEOPLE Sidegate Lane Nursing Home 248 Sidegate Lane Ipswich Suffolk IP4 3DH Lead Inspector Jane Higham Announced Inspection 2nd November 2005 10:05 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 Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 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. Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sidegate Lane Nursing Home Address 248 Sidegate Lane Ipswich Suffolk IP4 3DH 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) 01473 274141 01473 715245 Orbit Housing Association Mrs Michelle Webster Care Home 24 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24), Mental disorder, excluding learning of places disability or dementia (4), Mental Disorder, excluding learning disability or dementia - over 65 years of age (4) Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20 July 2005 Brief Description of the Service: 248 Sidegate Lane is a purpose built, 24 bedded care home with nursing which offers accommodation to people over the age of 55 who suffer from severe mental infirmity. The home also offers four beds for the care of people over the age of 55 with enduring functional mental health needs. The home is owned by the Orbit Housing Association and is situated in a residential area of Ipswich, close to local amenities and a short bus or car journey from Ipswich town centre. The home was first registered in 1993 and in 1998 was registered to accommodate somewhat younger adults, over the age of 55, thus recognising the incidence of dementia in the younger age group and looking to meet their needs. In October 2005, the registration of the home was again amended to include four beds for people with functional mental health needs. Orbit Housing Association is a non profit making organisation run by voluntary committees and providing a cross section of housing throughout the country. The home is operated in conjunction with both health and social care services and as such admission can only be accessed via these agencies. Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Announced Inspection of 248 Sidegate Lane, a twenty-four bedded care home with nursing, situated in a residential area of Ipswich, which provides care and accommodation to people over the age of 55 suffering from severe mental infirmity. Additionally four beds are allocated to residents who have long term functional mental health needs. The home is owned by Orbit Housing Association and operated in conjunction with Suffolk health and social services. This was the second inspection in the inspection year 2005/2006. The inspection took place on 02 November 2005 over a period of 7 hours. This report should be read in conjunction with the report of the Unannounced Inspection of 20 July 2005. The home was inspected against the National Minimum Standards: Care Homes for Older People and the Care Standards Act 2000. The National Minimum Standards and the Care Homes Regulations 2001 are referred to throughout this report and any non compliance identified. All core standards have been assessed over the two inspections. Information contained within this report was taken from the pre-inspection questionnaire which was submitted to the Commission by the home prior to the inspection taking place. The home was provided with resident and relative comment cards which were made available within the service. Three relative comment cards were returned to the Commission and comments made have been referred to within this report. The Inspection process was assisted by the Registered Manager of the home and discussions were held with some residents, relatives and staff. The inspection was focused on the services and accommodation provided to four service users who had recently been discharged to the home from long term hospital care. What the service does well: In order to ensure that they are able to meet the needs of prospective residents, the home ensures that a detailed pre-admission assessment is carried out and in the case of the four recently admitted residents that invaluable liaison work is undertaken with other involved statutory agencies. The home provides a very high standard of accommodation which is both spacious and homely. It was evident to the onlooker that staff encourage Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 6 residents to personalise their own room in order to express their own preferences and styles. The home has placed an emphasis on the importance of providing residents with a programme of activities which are appropriate to their needs and abilities and also ensures that residents psychiatric and emotional needs are monitored and met by either community mental health services or qualified staff working within the home. What has improved since the last inspection? What they could do better: The inspection identified that there are several issues where furniture and bathroom equipment need either repair or replacement. Two of these constitute a health and safety risk to residents. One issue in relation to service users using ensuite bathrooms belonging to other residents poses a serious breach to the dignity and privacy of service users and this practice needs to be discontinued without delay. In doing so the service must ensure that all residents have a choice of whether they wish to use shower or bath facilities on each unit. Whilst it was acknowledged at the time of the inspection that certain care staff have undertaken training in the care of older people with dementia, there does not appear to be an organised approach to this area of training. The service needs to ensure that all care staff receive training in this area of service provision and that the content of this training is made available for inspection. Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 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. Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 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 Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 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): 1, 2, 3 and 5 Advocates of prospective residents could not necessarily be assured that they would receive adequate information to enable them to support family members to make a decision about whether they would wish to live at the home. The home is able to provide all residents with written information on their terms and conditions of placement. Prospective residents can expect to be part of a detailed pre-admission assessment process to ensure that the home is able to meet their assessed needs and to be provided with opportunities to visit the home before making a decision to live there. EVIDENCE: The home has a Statement of Purpose and Service User Guide which is produced as one document and sets out in detail the services which the home intends to provide. Whilst this document has recently been amended in support of the home’s application to vary its registration to provide care for four services users under the category of mental disorder, certain required amendments were identified during this inspection. These amendments are required to confirm that the home can offer care to people who suffer from mental disorder and that all residents must be aged 55 and over. This is a Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 10 well-presented document which also provides information on the terms and conditions of placement. It was identified during the inspection, that the family of one recently admitted resident had not received this information. Family members should be issued with the Statement of Purpose and Service User Guide where they act as an advocate for the resident. The pre-admission information was examined in relation to two recently admitted residents both of whom had previously been living in long-term hospital care. The home should be commended on the level of valuable preadmission work which took place prior to admission. The majority of staff working in the home visited the prospective residents in hospital and formal meetings were held between the management and senior staff of the home and ward staff and a pre-discharge folder was completed for each person with information about daily routines and care needs. In addition the home is able to evidence that a detailed Community Care Assessment was completed by the care co-ordinator and provided to the home before any plans for admission were made. The home was able to evidence that some families visited the home prior to admission as did one prospective resident. On admission the two residents in question were accompanied by hospital staff who worked alongside the home’s care staff for a period of two days in order to ease the transition process. Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, 9, and 10 Residents living at the home can expect to be provided with a plan of care and to have both their physical and mental health needs met. At the time of the inspection, minor omissions meant that residents were not necessarily protected by the homes policies and procedures surrounding the administration of medication. Issues around inappropriate practice meant that residents could not necessarily expect that their right to privacy would be upheld. EVIDENCE: As part of the inspection process, the care plans for two residents who had been discharged from long-stay hospital care and had been living at the home for approximately one week were examined. Both care plans had been based on those completed by hospital staff before discharge, were detailed in their content and gave a clear picture of the level of support and interventions required. The care plan was further supplemented by a description of preferred daily routines which had been produced by hospital staff. Individual risk assessments were completed as part of the care planning process although lacked some significant information. These omissions are highlighted under Standard 38 of the report. Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 12 Systems for the administration and safe keeping of medication were examined. In the case of the newly admitted residents, medication was not as yet dispensed into blister packs in line with other service user medication. Service User medication was stored securely in fit for purpose trolleys. Systems used for the storage of controlled drugs was found to include additional security measures and balances of prescribed medication were recorded. It was noted that the Medication Administration Record for two of the newly admitted residents contained gaps where medication had been administered but not signed for. The home was able to evidence through resident care plans that both the physical and mental well-being of service users is monitored. In addition to the presence of qualified nurses, both general and RMN, the Manager of the home has had meetings with the Practice Manager of the local surgery with a view to securing community health services for the newly admitted service users. Residents are all provided with their own room with ensuite facilities which enables all assistance with personal care to be provided in private. Staff have ensured that the residents recently admitted to the home from long-term hospital care are provided with their own clothing. On the day of the inspection, all residents seen looked well groomed. During the inspection, it was highlighted that due to the lack of shower facilities in the communal bathroom of one unit, staff were taking service users into ensuite facilities belonging to other residents. This practice must be discontinued as it does not protect and promote the dignity of individual service users. Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 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 the following standard(s): 12, 14 and 15 Residents living at the home can expect to be provided with leisure activities which suit their assessed needs, preferences and abilities. Additionally residents can expect to be supported to make choices and have their preferences taken into consideration. Feedback gained did not totally confirm that service users could expect to receive a varied and nutritious diet. EVIDENCE: As part of the inspection, the provision of meals for service users was examined. Staff and management reported that “ fruit smoothies” had recently been introduced to the home in an attempt to ensure that residents were receiving the recommended five portions of fruit and vegetables per day. It was reported that one staff nurse was undertaking research into the provision of the recommended “five portions” has part of a degree in health promotion. Residents consulted over the quality of meals provided were positive in their feedback, although some staff raised concerns as to what they perceived as a lack of choice for residents, including a lack of fresh ingredients. The home’s chef was consulted at the time of the inspection and advised that the meal menu was currently being amended to include more choice. Evidence in the form of records suggested that in general the mid-day meal included fresh vegetables. In order to promote the choice of residents in relation to Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 14 meal provision it was suggested that the home’s chef investigated the use of digital photographs of plated meals. As in the previous inspection, the home was able to evidence that it ensures that residents are offered a programme of activities which is suited to their needs and abilities. On the day of the inspection, the provision of activities was discussed with the Activities Co-ordinator employed by the home. During the week of the inspection, activities had included a Halloween Party, a “pampering” session, walking to the shops and a video afternoon. The Activities Co-ordinator also reported that residents are often accompanied to the local pub for lunch. Relatives of one of the newly admitted residents reported how the self esteem and confidence of their family member had improved in the one week they had been resident at the home. They advised that they had been very impressed with the accommodation provided and were starting to introduce some personal belongings into the resident’s room. Information on the preferred daily routines of the recently admitted residents had been provided by hospital staff and these were incorporated into the resident’s daily life at the home. Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 Residents living at the home can expect to be provided with sufficient information to enable them to raise any concerns or complaints they may have about the service. Residents can also expect that the home’s procedures protect them from the risk of abuse. EVIDENCE: As detailed in the previous inspection report, the home has a detailed complaints procedure produced by Orbit Housing Association. It was reported that the home had recently received a complaint in relation to the quality of the meals provided and this had been addressed by the Manager. The home was unable to evidence that it kept a log of complaints which could provide an audit trail of action taken. One relative’s Comment Card indicated that the respondent was unaware of the home’s complaints procedure. Since the previous inspection, the management of the home has ensured that the existing staff members who had not been subject to an Enhanced Disclosure via the Criminal Records Bureau have now been through this process. Since the previous inspection the Commission has received no complaints in relation to this service and all staff have received training in the recognition of and reporting of suspected abuse. Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 -26 Residents living at the home can expect to be provided with a good standard of both private and communal accommodation, which is comfortably furnished and homely. At the time of the inspection certain issues in relation to the repair of equipment and furniture prevented residents from living in a completely safe and well maintained environment. EVIDENCE: On the day of the inspection, an environmental tour of Unit 4 was undertaken. This was the unit where four service users had recently been discharged to from long-term hospital care. 248 Sidegate Lane comprises of a purpose built building which stands well back from the roadway in well-kept grounds. In total there are twenty four bedrooms, all for single occupancy and all of which have ensuite shower and toilet facilities. Accommodation is arranged in three living units, two situated on the ground floor of the building and one on the upper floor. A passenger lift services both floors. Each living unit comprises of eight bedrooms, a Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 17 communal lounge, with dining area and a small integral kitchen, where drinks and light snacks can be prepared. In addition to the ensuite facilities provided, each living unit has a communal assisted bathroom and communal toilet facilities. In addition to the lounge areas on each unit there is also a spacious reception area, with comfortable seating and a communal lounge with a conservatory leading off. During the inspection, the bedrooms provided to the newly admitted residents were examined as was the communal accommodation within the unit. Each bedroom had been attractively decorated in preparation for the new residents and staff had been involved in the selection of soft furnishings. Rooms provided maximum space and had the benefit of ensuite facilities ensuring privacy. Whilst rooms were found to quite devoid of personal belongings, staff had advised that they were going to encourage residents to make their rooms more homely. The lounge area provided a very homely and comfortable environment in which residents can spend their leisure time. The family members of one newly admitted resident reported that they were very impressed with the quality of the accommodation provided. Whilst all areas of the home were maintained to a good standard of hygiene and cleanliness, issues in relation to equipment and furniture which needed repair or replacement were identified as listed below. * The leg to the dining room table was loose and unstable and constituted a health and safety risk to both service users and staff. * There is no workable shower in the Zone 4 communal bathroom. * Staff reported that the assisted bath seat in the communal bathroom on Zone 4 becomes stuck and has necessitated residents having to be lifted from it by care staff. Residents spoken to at the time of the inspection appeared to be very pleased with their accommodation, although feedback on this subject was limited. Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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, 29 and 30 Residents can expect to be cared for by an appropriate number of staff who have a varied skills base and who have sufficient training to enable them to fulfil their roles. Residents can also expect to be protected by the home’s recruitment procedures. EVIDENCE: As in the previous inspection, the home was staffed to an appropriate level to meet the specialist needs of service users. On the day of the inspection, two registered nurses were on duty, supported by five care staff, one of whom was allocated to escort a resident to an outpatient hospital appointment. The staffing rota seen also evidenced that during the night period, residents are supported by one registered nurse and three care staff. This staffing level is in addition to ancillary staff, domestic staff and the presence of the registered manager. Two of the three relative Comment Cards submitted indicated that in the opinion of the respondents, there were not always an adequate number of staff on duty. No evidence was found to suggest that the staffing levels currently provided were inadequate. As part of the inspection, three staff personnel files were examined. These showed that two written references had been obtained before the commencement of duties as had an Enhanced Disclosure via the Criminal Records Bureau. Staff training records evidenced that Orbit Housing Association provide all newly employed staff with a structured induction Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 19 training package, which complied with TOPPS standards and included all mandatory areas. Training records evidenced that some staff had also undertaken additional areas of training which ranged from Optical Awareness to Chiropody. Whilst many of the staff had accessed some form of training on the care of older people with dementia, there was no conformity in relation to the level of knowledge expected. Taking into consideration that the home provides a service to residents with severe mental frailty a formal approach to the provision of training in this field is needed. On the day of the inspection, two care staff and one student nurse were spoken to on Zone 4. It was clear that they had made the new residents very welcome and due to the valuable preparatory work carried had already gained a good knowledge in relation to their individual needs. The relatives of one of the newly admitted residents reported that they had noticed how much more individual time staff spent with service users and had been very impressed at how helpful, kind and pro-active staff had been. Another relative visiting the home commented on how well their family member had settled and had attributed this to the staff providing such a warm and welcoming atmosphere. Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 20 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): 37 and 38 In general the home is well managed and administered effectively in the best interests of service users. Residents can expect to be provided with a generally safe environment with the exception of the maintenance of certain items of equipment. EVIDENCE: During the inspection records required by regulation were referred to and in some areas examined. It was highlighted that the home did not maintain a log of complaints which provides details on the nature of the complaint, action taken and outcome reached. This document is required in order to comply with Regulation 17(2) Schedule 4 of the Care Homes Regulations 2001. In general the home was able to evidence that it provided a safe environment for both service users and staff. However, some items of equipment and Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 21 furniture were highlighted as requiring repair or replacement. It was noted that whilst the home did carry out individual risk assessments as part of the care planning process, in the case of two of the residents recently admitted from long term hospital care, significant risks identified as part of the discharge and admission care planning had not been risk assessed in relation to their placement at the home. These included risk assessments in relation to individual residents smoking and to the management of aggressive incidents. Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 22 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 2 3 4 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 2 2 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X 2 2 Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 23 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(1) Requirement The Registered Persons must ensure that the required amendments are carried out on the Statement of Purpose so that it correctly reflects the service offered at the home. The Registered Persons must ensure that the Statement of Purpose is made available to families of service users where they act as an advocate for the resident. The Registered Persons must ensure that the medication administration records are completed whenever prescribed medication is administered to a resident. The Registered Persons must ensure that residents do not use the ensuite facilities provided in other residents’ rooms. The Registered Persons must ensure that the home maintains a log of all complaints received. The Registered Persons must ensure that the dining room table located in Zone 3 is either repaired safely or replaced. DS0000024487.V253412.R01.S.doc Timescale for action 30/12/05 2 OP1 4(1) 02/11/05 3 OP9 13(2) 02/11/05 4 OP10 12(4)(a) 02/11/05 5 6 OP16 OP19 Schedule 4.11 23(2)(c) 02/11/05 02/11/05 Sidegate Lane Nursing Home Version 5.0 Page 24 7 OP21 23(2)(j) 8 OP22 23(2)(c) 9 OP30 18(1)(c)(i ) 10 OP38 13(4)(b)& (c) The Registered Persons must ensure that there is a workable shower facility in the communal bathroom sited on Zone 4. The Registered Persons must ensure that the assisted bath seat sited in the communal bathrooms on Zone 4 functions safely. The Registered Persons must ensure that all care staff are provided with a planned training programme on the care of older people with dementia. The home must be able to evidence the content of this programme. The Registered Persons must ensure that risk assessments are completed in relation to residents who smoke or are identified as exhibiting challenging behaviour. 31/01/06 02/11/05 31/03/06 02/11/05 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 Refer to Standard OP15 Good Practice Recommendations The Registered Persons should consider the use of digital photographs to assist residents with limited communication skills to select meal options. Sidegate Lane Nursing Home DS0000024487.V253412.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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. 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