Inspection on 22/04/08 for Silver Lodge

This inspection was carried out on 22nd April 2008.

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

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

CARE HOMES FOR OLDER PEOPLE Silver Lodge 12 Housley Lane Sheffield South Yorkshire S35 2UD Lead Inspector Shirley Samuels Key Unannounced Inspection 22nd April 2008 07:05 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 Silver Lodge DS0000071080.V362655.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. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Silver Lodge Address 12 Housley Lane Sheffield South Yorkshire S35 2UD 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) 0114 246 8177 0114 257 8383 silverlodge@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross BC OpCo Ltd Position Vacant Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Mental registration, with number disorder, excluding learning disability or of places dementia (32) Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Dementia - Code DE, maximum number of places 32 Mental Disorder, excluding learning disability or dementia, Code MD maximum number of places 32 The maximum number of service users who can be accommodated is: 32 New service First inspection 2. Date of last inspection Brief Description of the Service: Silver Lodge is a Care Home providing personal care for elderly people with dementia. The home is a large detached house set in its own grounds; it is built on two levels, consisting of the original building and extensions including a conservatory. The home is situated on a quiet road in Chapeltown near to the shops, library and local amenities. The home is spacious and allows service users to wander around communal areas of the home freely, with a selection of quiet or popular seating areas for the service users to visit alone or with family and friends. The home does not provide nursing care. The manager confirmed that the range of monthly fees from 1st May 2007 were £359 - £401 per week. Additional charges included hairdressing and private chiropody. Copies of the inspection reports are displayed in the entrance to the home. Further details about this service can be obtained by contacting the manager. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means people who use the service experience adequate quality outcomes. This was a key inspection carried out by Shirley Samuels on Tuesday 22/04/08, from 7:05am-4:30pm. Since the last inspection the home has been taken over by new owners who are taking positive steps to improve the overall standard for people using the service. In the report we make reference to “us” and “we”, when we do this we are referring to the inspector and the Commission for Social Care Inspection. The inspector sought the views of five people using the service, four staff, three visiting relatives and the manager Jayne Vickers who assisted with the inspection. This visit was a key inspection and the inspector checked all the key standards. During this visit we looked at the environment, and made observations on the staffs’ manner and attitude towards people. We checked samples of documents that related to peoples support, care and safety. These included three assessments and care plans, three medication records, and three staff recruitment files. The inspector looked at other information before visiting the home. This included the Annual quality assurance assessment (AQAA). The inspector would like to thank everyone for their welcome and help in this inspection. What the service does well: Before moving into the home people were given information to help them make a decision about whether the home was right for them or not. Each person had a contract so they knew the terms and conditions of their stay. Assessments were carried out before people moved into the home. This helped staff to make a judgement about whether they could meet people’s needs. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 6 People were treated with respect and their right to privacy was upheld. People were involved in activities of their own choice according to their own individual needs and interest. They were encouraged and supported to maintain important personal and family relationships. People were encouraged to make choices and to have as much control over their live as possible. People said the food they received was varied, tasty and satisfying to them and relatives supported this view Complaints were taken seriously and acted upon. The home is well run and the manager makes sure that the home is run in the best interest of the people using the service. People are able to make comments about the service. There are examples of changes being made because of comments received. The staff work in a way that upholds the health safety and welfare of themselves and of the people using the service. What has improved since the last inspection? What they could do better: Care plans needs further development to make sure they detail peoples needs in full. Where risks are identified regarding challenging behaviour this needs to be risk assesses and action taken to make sure people are not placed at unnecessary risk of harm. The medication procedures particularly for medication stored and administered during the night needs to be more secure. There were shortfalls in the reporting and action taken following incidents of abuse. There were some gaps in the reporting of events to the Commission for social care inspection. Some parts of the home were in a poor state of repair. Issues raised by the environmental health regarding the cleanliness of the kitchen showed there were shortfalls in the standard required. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 7 Staffing levels were not always being maintained, to make sure people’s needs were met. The financial procedures in place did not fully promote peoples financial interest. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Silver Lodge DS0000071080.V362655.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 Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. People receive information about the home and their needs are assessed before they move into the home. The home does not provide intermediate care. EVIDENCE: In the AQAA the manager told us the home provides easy to read information about the home. Pre admission assessments are carried out and people are able to visit the home with their relatives before they move in. Contracts were seen which contained the information required by the care homes regulations. This made sure that people moving into the home and their next of kin knew the terms and conditions of their stay at the home. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 10 Relatives said they were provided with written information about the home. This made sure that people had the information they needed to make a decision about whether the home was appropriate or not. Bright, colourful and eye-catching notices were displayed in the immediate entrance to the home. This was welcoming and informative for relatives. The larger open area at the bottom of the stairs where people can lounge and wonder had very little to stimulate and orientate them. Each person had an assessment that was completed before they moved into the home. The staff said in the main the assessments reflected the person and were there were gaps in the information they were able to obtain this soon after admission. This made sure that staff had the information they needed, to make a judgement about whether they could meet people’s needs. The home does not provide intermediate care. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience adequate outcomes in this area. We made this judgement using a range of evidence including a visit to the service. People’s needs are not fully set out in a plan of care, and changing needs are not adequately reviewed. People’s rights are upheld. EVIDENCE: In the AQAA the manager told us. “At Silver Lodge there is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet residents needs. Systems for providing medications are followed ensuring medication needs are met. Personal support is provided in a way, which promotes and protects residents privacy, dignity and independence”. Staff were transferring care plans onto the new organisations care plan format. We saw three care plans which in the main detailed the health, personal and social care needs of people using the service. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 12 Staff said the senior care staff wrote care plans and contributions were sought from people using the service and their relatives. Relatives spoken to confirmed they had been consulted. The care plan format required each area of need to be identified on a separate sheet of paper. This sheet included the person’s need, what action staff had to take and what the outcome should be for the person. There were examples of care needs identified in 2006 showing no change at all. Records made stated “care plan remains the same” or “care plan still valid” when it was clear that there had been changes. For example a care plan saying a persons walks with a frame when in fact they were no longer able to use a frame and was in need of a wheelchair. This meant that peoples care plans were not accurately updated. One person’s care plan did not include a risk assessment regarding challenging behaviour and the potential risk to that person and to other people. This placed people at risk of harm. There were some good examples of records made about the care given. And the outcomes of professional visits from the GP district nurse etc. The use of codes in other parts of the daily recordings, for example “abcd care needs provided”. This prevented the reader from fully understanding what was being said without having to gross reference with other parts of the care plan. Relatives said, Staff kept then informed about any changes in peoples health. They added that staff did not hesitate to get a Doctor or call an ambulance if it was needed. We saw records made following professional visitors including dentist, chiropodist, district nurse and opticians etc. This showed that people’s health care needs were met. The home had a written medication procedure. All except one member of staff responsible for administering medication had received safe handling of medication training. Appropriate records were kept of medication administration, medication, was administered in line with instructions, storage facilities were clean and secure A medication fridge was provided and there was an appropriate procedure in place for administering controlled drugs. The procedure for administering and recording “homely remedies” given during the night was unsafe. The staff member responsible for administering during the night had not completed medication training, there were medications that were not in the original container/boxes and the recording system was not robust enough. This could place people at risk. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 13 The manager took immediate action to ensure safe medication procedures at all times. Observations were made of they way staff approached people. They were respectful and patient. People said the staff are “nice” and “very good”. Relatives told us the staff were always respectful and spoke to people in an appropriate manner. Blue plastic aprons were used at mealtimes to protect peoples clothing. This did not promote peoples dignity. The manager said a more appropriate and discrete covering had been ordered. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. People are encouraged to make choices and exercise control over their lives. EVIDENCE: In the AQAA the manager stated, “We provide a varied menu with a selection of choices. Visitors are welcome at any time. People are able to choose to live the lifestyle they choose. Activities are good and inclusive. We have a new activities organiser and we are looking at new activities by consulting with service users, relatives and staff”. Staff told us they had fundraising events coffee mornings and raffles. Activities included, gardening, baking, crafts and writing life stories. Details of activities were displayed people said they were able to take part in activities if they wished. Staff were seen sitting with people chatting, joking and singing, there was plenty of laughter. People clearly enjoyed this. This makes sure that people have the opportunity to be involved in activities of their own choice according to their own individual needs and interest. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 15 Some people went on regular outings with family. Staff said that a group of people regularly went to the local church on Sundays. One relative said. More outings for people who did not have any relatives would be nice. Relatives told us they were encouraged to visit and keep in touch. They said they were made welcomed when they visited and were offered refreshments. Staff told us they encouraged people to make choices by showing them what was available always asked questions. They added getting to know people, their likes and dislikes was important. This meant that when necessary they could make choices for them based on what they knew about them. People’s care plans included details of their food likes and dislikes. Observations were made of staff encouraging people to eat and offering assistance in a dignified manner. People told us they liked the food provided. Relatives agreed that the food was good; there was choice and variety. This makes sure that people receive a varied, tasty and nutritious meal that is satisfying to them. Since the last inspection dining chairs and tables had been replaced. Tables were nicely set with tablecloths mats and centrepiece. This created a pleasing surrounding in the large dining room. There was an offensive odour in the small dining/lounge area, which could make the dining experience less enjoyable. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience adequate outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Complaints are taken seriously. There are some shortfalls in the procedures for protecting people from harm. EVIDENCE: In the AQAA the manager told us “We have a complaints procedure, which is made available to all residents and visitors. All complaints are dealt with promptly and niggles or grumbles are recorded. All complaints are addressed within 28 days”. The Manager told us there had been no complaints in the last 12 months. Relatives told us they had been given information about how to make a complaint. They added they had not made any complaints but felt they could talk to staff or the manager if they had any concerns. One relative said, “Just a little reminder to the staff often sorts things out”. Staff told us they had received training on safeguarding adults. They were able to tell us what they would do and who they would talk to if they had any concerns about people being harmed. Records were seen which recorded the assault of one person living at the home on another person living at the home. Medical attention was sort. However this Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 17 assault was not reported to the local authority safeguarding adult’s team. A risk assessment detailing what action was going to be taken to protect people from harm had not been completed. The manager was instructed to report it to the local authority and to complete a risk assessment. Nether had the incident been reported to us as required by the Care Homes Regulations 2001. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience adequate outcomes in this area. We made this judgement using a range of evidence including a visit to the service. There were shortfalls in the environment and standards of hygiene. EVIDENCE: In the AQAA the manager told us Since Southern Cross Healthcare has taken over the management of the home, extensive monies have been made available to improve the environment. The home is clean and generally odour free. The home has a pleasant atmosphere and homely feel. A number of bedrooms have been decorated and this is ongoing. Furnishings have been purchased and this also is ongoing. New fencing has been erected to create an enclosed safe garden for service users. “There plans to resite the laundry room, decorate 2 bedrooms each month and one communal area. Plans to upgrade the kitchen and we will continue to Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 19 refurbish the home and make sure it is safe as part of our 12 month environmental plan”. There was an offensive odour noted in the small dining/lounge area. The carpet and vinyl flooring was discoloured and stained. While people did not make any negative comments about this area we judge that this is an unpleasant area for people to sit and to eat in. One of the staff said there had been some flooding in this area, the carpet had been cleaned but not replaced. It was possible the smell was coming from this. The kitchen was dirty; there was food debris around fridges sinks etc, work surfaces were discoloured the floor covering was ingrained there were areas on the tiled walls that were brown and covered in grease. The Sheffield City Council Environmental Health inspected the kitchen on the 22nd Feb 2008. The home was given requirements and recommendations by the Environmental health to improve the standards in the kitchen. We saw an action plan completed by the manager and operations manager with time scales for all the requirements made by the environmental health to be completed. The majority of the bedrooms were pleasant and odour free. Staff told us due to levels of incontinence there were a couple of rooms were they found it difficult to maintain an odour free environment. There were toilets with carpets on the floor. This is not good practice for hygiene reasons, where there are problems with incontinence. There were no sluicing facilities at the home the staff told us they had to empty the commodes down the toilets. This is not good practice and could lead to cross infection. The manager said there were plans to have a sluice fitted. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Staff are competent to meet the needs of the people using the service. There are some shortfalls in staffing and recruitment. EVIDENCE: Staff told us, there are care and domestic staff vacancies. Part time staff have worked extra hours and efforts are made by the manager to ensure that there are enough staff on duty. This means that there have been shifts where the required staffing level to met the needs of the people have not been maintained. Relatives said, “The staff do a wonderful job, “The staff do seem to be under a lot of pressure”, “We cannot praise the staff enough”, “the staff are very caring and nice”. ”. One said, “Mum could not feed herself when she came but she can do a lot for herself now”. Long-term vacancies within the domestic team have meant that the cleanliness of the home has not been maintained to the standard required. The manager told us that some recruitment had taken place and new staff would be starting shortly. Staff said they work well as a team and that communication between them was good. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 21 More than 50 0f the staff team are trained to National Vocational Qualification NVQ 2 in care. This means that staff have a good understanding of the needs of the people they are caring for. The home had a written recruitment policy. References, medical and criminal records checks were carried out before people started work at the home. This made sure people were protected by the homes recruitment procedures. There was one example were gaps in employment history had not been checked. This could place people at risk. There were two people who did not have a contract of employment stating the hours they worked and the position they held. Staff told us they receive regular training. The records showed they had received all essential training including fire, health and safety, moving and handling. This showed that staff were given the training and skills needed to support and care for the people using the service. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. The home is well managed, the procedures, ensure the health safety and welfare of people using the service and the staff. EVIDENCE: In the AQAA the manager told us “The manager has a good understanding of the areas in which the home needs to improve and arrangements are being progressed for them to be sourced and implemented. People are protected by the systems in place for maintaining health, safety and welfare. The manager has worked at the home since 1990 and has been the manager for three and a half years and has retained her position with the new owners. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 23 Staff told us the manager is approachable and knows the people well. People told us they liked the manager and were able to point her out when she came into the room. Some were able to tell us her name. This showed the manager had contact with people and showed an interest in their every day experience of the home. Relatives said they were asked to comment on the quality of the service, relatives meetings were held where they were able to receive information and discuss what ever they wanted to. The manager said the results of people’s comments would be displayed. This made sure the home was run in the best interest of the people using the service. Records were kept of peoples monies managed by the home. Receipts were kept of all transactions. The manager told us that cash was checked against the records of balance. The records show that this had been done in the past but not over the past couple of months. For some people there was a substantial amount of cash kept at the home. This is not good practise and does not promote the financial interest of the people. Staff told us they had received health and safety training. They were able to give examples of how they promoted the health and safety of people and themselves. They said hazards were reported and dealt with quickly. Observations were made of staff using the hoist to move people staff did this confidently while providing reassurance to the person. We saw appropriate moving and handling techniques, wheelchairs were used with footplates. Where footplates were not used this was recorded in the care plan. This made sure the health safety and welfare of people and staff is promoted and protected. Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 24 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 3 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 1 2 x x x x x x 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 x x 2 Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement People’s care plans must include details of all their needs and what action staff need to take to meet those needs. Were challenging behaviour has been identified, A risk assessment must be developed This must detail what the risk is, who is at risk and what action needs to be taken to reduce the risk. Risk assessments must be kept under review. Care plans must be reviewed and updated regularly to make sure they reflect any changes in peoples needs. All staff responsible for administering medication must receive appropriate training and be competent. Medication must be retained in and administered from its original packaging. There must be a safe recording system for recording the administration of “homey remedies”. To promote peoples dignity, blue plastic aprons must not be used DS0000071080.V362655.R01.S.doc Timescale for action 20/05/08 2 OP7 15 20/05/08 3 OP7 15 20/05/08 4 OP9 18 20/05/08 5 6 OP9 OP9 13 13 20/05/08 20/05/08 7 OP10 12 20/05/08 Silver Lodge Version 5.2 Page 26 8 9 OP18 OP18 37 37 10 11 OP19 OP19 23 16 12 13 OP19 OP26 16 16 to protect clothing. Where protection of clothing is necessary this should be appropriate and discrete. All incidents of abuse must be reported to the Local authority safeguarding adult’s team. Any event, which adversely affects the wellbeing or safety of any service user, must be reported to the commission for social care inspection. All parts of the care home must be kept clean and reasonably decorated. There must be adequate furniture, bedding, furnishings including curtains and floor covering suitable for the needs of people using the service. The carpet and vinyl flooring in the small dining lounge area must replaced. The home must after consultation with the environmental health authority make arrangements for maintaining satisfactory standards of hygiene. Therefore all the recommendations made by the environmental health on the 22nd of Feb 2008 must be complied with. The home must be kept free of offensive odours. There must be slicing facilities provided. There must be at all times enough staff on duty to meet the needs of the people using the service. The recruitment procedures must include checking gaps in people’s employment history. Staff must be supplied with a 20/05/08 20/05/08 10/10/08 10/06/08 10/06/08 10/10/08 14 15 16 OP26 OP26 OP27 16 16 18 10/06/08 10/10/08 10/06/08 17 OP29 19 10/06/08 Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 27 18 OP35 16 contract of employment that includes details of the hours they are employed to work and the position they hold. The amount of cash kept in the home must be covered by the homes insurance. Cash must be checked at regular intervals and records kept of this. 10/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations Consideration should be given to making the area at the bottom of the stairs more interesting for people. For example details of activities, menus, weatherboards, details of date month and year etc. these should be displayed in an appropriate format. Staff should have access to a summary of the care plan that is easy to read and quick to reference. The records should detail who has contributed to the care plan. To promote peoples financial interest there money should be banked 2 3 4 OP7 OP7 OP35 Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Silver Lodge DS0000071080.V362655.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!