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Inspection on 01/06/05 for Silverdale House Care Home

Also see our care home review for Silverdale House Care Home for more information

This inspection was carried out on 1st June 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

Service users endorsed that they make choices regarding their daily lives and that staff are attentive and answer call alarms promptly. One service user stated that moving into the home had taken a big worry away and that she felt safe now. Meals are varied and clearly service users enjoy these in a relaxed atmosphere. Service users stated that they were assisted to use their vote and the day was well organised. Service users are well informed about how to make a complaint should they have reason to do so.

What has improved since the last inspection?

Training for both day and night staff has been provided in medicine management and care plans now contain information regarding the arrangements when service users are at the end of their life. Service users privacy and dignity is maintained. Service users have continued to express their satisfaction with the level of care and support given during this inspection.

What the care home could do better:

There are some staffing issues, which are outstanding from the previous inspection to resolve. Service users would benefit from a staffing review, which would clarify staff roles and responsibilities and ensure care staff, have appropriate allocation of hours to spend with them. Care plan documentation and record keeping require improvement to ensure that the needs of service users are fully met. Service users would benefit from improvement to the appearance of the home in relation to the quality of carpets and furniture as some of the carpets and chairs are worn and tired looking and require replacement. Service users would benefit from improved consultation and the implementation of quality monitoring and auditing systems, which are currently lacking in the home. The health and safety of service users may be compromised by the lack of systems in place for water storage and outlet temperature regulation, fire safety checks and workplace risk assessments. There are two outstanding requirements from the previous inspection, which must be addressed within the new timescale to avoid enforcement action.

CARE HOMES FOR OLDER PEOPLE Silverdale House Care Home 3 Nottingham Road Hucknall Nottingham NG15 7QN Lead Inspector Jayne Hilton unnnounced 01 June 2005 @ 14:00 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. Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Silverdale House Care Home Address 3 Nottingham Road Hucknall Nottingham, NG15 7QN 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) 0115 964 0400 0115 9634880 Mr Jamil Akhtar Mrs Fiona Elizabeth McShane CHR 36 Category(ies) of Old age, not falling within any other category registration, with number (OP) 36 of places Dementia - over 65 years of age (DE(E)) 5 Both Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 1 named person may be in the category PD. Date of last inspection 30/11/04 Brief Description of the Service: Silverdale Care Home for older people is situated on a main road close to Hucknall town centre. Although registered for a maximum of 36, there were 33 service users at the time of the inspection. Most have single bedrooms and there are some double rooms available for those who choose to share. The accommodation is on two floors with two lifts provided to give full access to the upper floor.There is a choice of sitting rooms and a spacious dining room. There are contained gardens to the rear, providing further seating areas. Social and personal care is provided within the home and health care needs are met by health professionals from the community. Recently, the registration for this home was amended to include a provision of care for up to 5 service users with dementia. Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on 1st June 2005, at 2pm by Jayne Hilton. The inspection process took four and a half hours. The Commission had received an anonymous complaint regarding night cover and this was investigated as part of the inspection. Three staff and the manager were interviewed. Two service users were spoken to in detail and others throughout the inspection. A sample of records was examined including three service users care plans. A tour of the premises was undertaken also. What the service does well: What has improved since the last inspection? Training for both day and night staff has been provided in medicine management and care plans now contain information regarding the arrangements when service users are at the end of their life. Service users privacy and dignity is maintained. Service users have continued to express their satisfaction with the level of care and support given during this inspection. Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 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 Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 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) 3,5 [6 is not applicable] Service users have a full assessment carried out prior to moving to the home however, further documentation is required to confirm that the home can meet those needs. Trial visits are arranged where appropriate. EVIDENCE: Three service user’s assessment documentation was examined and found to meet the standard, however there was no evidence that the manager had confirmed in writing to the service user that their individuals needs could be met by the home. Extended community care assessments were seen for those applicable. The manager stated she was clear that service users would not be admitted without a written copy of the assessment. Trial visits were reported to be offered, and the manager stated that any trial visits for any new/prospective service users will be, fully documented. [There have been no new admissions since the previous inspection] Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 9 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, 11 Although service users spoken with are happy that their needs are being met, the documentation of service users health, personal and social care needs is not satisfactory. This may compromise individual needs being fully met. On the whole service users are protected by the homes policies and procedures for medicines management, however these can be improved upon. Service users are treated with respect and their right to privacy upheld. The wishes of service users for the end of life are fully documented. EVIDENCE: A care plan system is in place, however the system appeared disorganised and difficult to follow. The manager accepted the inspector’s comments explaining that when staff completed the plans correctly they work well. None of the three care plans examined were up to date, as the dates of the last reviews was February 2005. However there were monthly summaries which, key workers complete for significant information and is a good idea, however these again were found to have some jumbling of information and would be better separated out. One service users daily diary indicated aggressive outbursts, however there was no record of this in the service users assessment or care plan. The Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 10 manager reported that the aggression had developed since moving into the home. A care plan for monitoring and evaluating behaviour should have been implemented when this need was identified. There was a note in the daily diaries that a fall had occurred, on checking the accident book, there was no entry found for this particular incident. Records of other accidents were recorded, however the detail on some was absent. Care plans were found, to be signed by, the service user or their representative. Healthcare checks are recorded in the GP and district nurse book and transferred into to the care plan, again there was some inconsistency of where information had been written, but overall cross referencing was evident. One service users care plan had not been dated correctly therefore follow up information from a health matter was confusing. There was no medication information included in the care plan information. It is recommended that medication profiles are included in the plan, which details medication reviews and changes of medication. Care plans did not state the service users preferred term of address. Service users spoken with knew about their care plans and stated that their healthcare needs were well met. They commented that the system for GP services was wonderful and that the GP arrive the same day. Service users confirmed that chiropody and dental services visit the home and district nurse services. It is recommended that chiropody and other health care checks are documented on a separate running record to the daily diaries to ensure current and useful information is not archived and can be easily accessed when needed. Appropriate risk assessments were in place for tissue viability and manual handling, there were none for dealing with aggressive behaviour. Within the accident book, twenty seven events had been recorded since 4/5/05 of which six were night time incidents of falls. Some did not accurately reflect the time of the accident, so these figures may vary slightly. There is no evaluation and monitoring system in place for falls and this is recommended. It is also recommended that night records are kept by night staff of what time they undertake checks, give attention to service users. All day care and night staff who administer medication have received training both in-house and from the local pharmacist (Hart Pharmacist). Training for staff in medicines management should be carried out by an accredited training body and regular competency assessments carried out by the manager. A medication round was observed and found to be satisfactory. Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 11 Service users confirmed their privacy and dignity was always respected and that a telephone was always available even if the pay phone is not working, which it was reported not to be on the day of the inspection. Telephone calls are taken in privacy and mail is given unopened. The service users wishes for the end of life are recorded in their care plans. Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14,15 Service users social cultural, religious and recreational interests are generally met and service users are helped to make choices and decisions about their life and daily routines. Service users enjoy their meals in a relaxed atmosphere. EVIDENCE: Service users spoken with reported that activities are organised and include bingo, quizzes, keep fit and a trip down the river in the summer is usually organised. One service user stated that she would like to go out shopping more but staff shortages prevent this. The service user commented that one staff member was good at bringing items in for her when she needed them. It was also conformed by service users that they take, holy communion, together with the visiting priest. Two particular service users make craft items to sell at the fetes organised by the home, one sews the other knits and they told the inspector they work as team to fundraise. A mobile library visits the home too. It was clear from speaking with service users and observing staff that service users are offered choices and can make decisions about their daily lives. It is recommended that increased activities provision be provided whereby service users can be provided with 1:1time for personal shopping. Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 13 It was reported by service users that the food is pretty good and that they get a choice. The cook is helpful regarding special diets. A party had been held the day before to celebrate a 100th birthday of a service user at the home. A copy of the menu was examined which was varied and offered choices. A likes and dislikes list was also seen in the kitchen. A mealtime was observed and service users were relaxed and allowed to eat their meal in their own time. Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Service users are aware of the how to make complaints and feel safe living in the home. Service users use their right to vote. Policies for protecting service users from abuse are in place but training is not; and the policies require some amendment. EVIDENCE: A complaints policy was observed to be in place, which meets the standard. There were no complaints recorded since the last inspection. This visit was carried out in order to investigate a complaint about staffing levels at night and the tasks that they are expected to perform. The outcome of the investigation was not upheld. The issues raised are reported on in Standard 27, several recommendations have been made regarding the issues raised. Previous complaints the last being recorded on 26/7/04, are documented in a complaints book, it is recommended that a ring binder file be used with a formal template and which copies of any letters and investigation records, can be kept with the complaint The manager reported that all service users were on the electoral list and those that had wanted to use their vote had been to. Service users spoken with confirmed they had been to the local polling station and the trip was well organised by the staff escorting them. There was a Protection of Vulnerable Adults guidance policy file observed in the home and a whistle blowing policy. The whistle blowing policy does not Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 15 however address, where malicious allegations are made and how the management will deal with this. Staff, have not yet undertaken training in adult protection. Service users stated they felt safe in the home. Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 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 standard(s) 19. 20, 21, 22,23, 24,25, 26 Service users live in a clean, comfortable and homely environment, however some of the furniture and carpets are worn and need replacing. Some malodour is present. EVIDENCE: Although the home is registered for a maximum of 36, there were 34 service users at the time of the inspection. Most have single bedrooms and there are some double rooms available for those who choose to share. The accommodation is on two floors with two lifts provided to give full access to the upper floor. There is a choice of sitting rooms and a spacious dining room. There are contained gardens to the rear, providing further seating areas. The furniture in the main lounge is in need of replacement as looks worn, also the carpet in the lounge is worn and in need of replacing. The manager reported that new carpets and chairs were on order. Four service users bedrooms were examined, all were clean and well personalised. Service users confirmed that they had brought their own items Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 17 with them from home. Lockable facilities were provided and all had window restrictors in situ. There was some mal odour noted in one room and on a hallway and the manager reported that new carpets were on order. Water temperatures were sampled and found to be satisfactory and low surface radiators are provided. Service users were observed using keys to open their bedroom doors, however the issue of keys needs to be included within the care plan. Service users reported that staff answer call alarms promptly. Bathrooms, with assisted bathing and toilets were adequate in number and all have handrails. Liquid soaps and paper towels were seen in all but one toilet. Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 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 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) 27, 28, 29, 30 The staffing structure requires review to ensure service users needs are being fully met. Staff are trained and competent to do their jobs, however recruitment practices are not robust and there is a need to implement protocols for night record keeping and staff breaks. EVIDENCE: The staff rotas were examined these demonstrate four care staff on duty for daytime shifts and two at night with one on call. The staffing levels meet the previous guiding standards and therefore meet current standards. There was no written information to indicate that staffing levels were not sufficient. Service users did say that staff were busy and that they could do with more staff. Service users reported that they did not see night staff very much, but they would pop their head round their bedroom door to say goodnight. As part of a complaint, made to CSCI, it was reported that night staff have to undertake laundry duties. On examination of night staff job descriptions, laundry duties are documented as part of their duties. The manager reported that she has recently met with night staff and has agreed to put a proposal to the provider for a laundry assistant to be employed. It was also reported that when night staff take breaks, this leaves the other staff member working alone. It is the professional judgement of the inspector that it is acceptable for staff to be disturbed on breaks should service users Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 19 require attention, however protocols should be in place to address this and which allows staff to take time back for disturbances on breaks. The manager would need to monitor the amount and type of disturbances and review staffing levels if the records indicate so. There were no night work records and therefore no evidence to substantiate the claims. It is recommended that night records are implemented for documenting checks on service users, when service users are up in the night and any attention given to service users for turning, bed changes, making drinks etc. Include in the night records of occasions the member of staff on their break are disturbed and the reason and agree a protocol for re-numeration of time [time off in lieu] The issue of night staff and day care staff undertaking laundry duties is an issue which must be addressed as the guiding standards staffing levels require 2hrs per person to be spent on domestic and laundry tasks therefore for 36 service users 72 hours must be provided for these tasks for the current number of service users. There are currently 66 domestic hours provided for 34 service users. It is therefore necessary that a staffing review take place to ensure that care staff, are not undertaking laundry duties in their allocated care hours. Staff interviewed agreed that, although they accept that laundry duties have to be undertaken that this does take valuable time away from service users. Staff commented that, they no longer have time to sit and chat with service users. It has become apparent that similar issues were raised at the last inspection and a requirement was set to review staffing structures by December 2004. Therefore as the issues have still not been resolved the requirement will be carried forward in this inspection report. A sample of two newly employed staff files were examined, one was fully completed and one was missing a reference and copy of identification such as a birth certificate. A signed medical questionnaire is included but it is recommended that this be revised to ensure that staff sign a declaration that they are physically and mentally fit to undertake the tasks identified in their job description. Staff confirmed they had been issued with a copy of the General Social care Councils Code of Conduct Booklet The manager reported that staff, are paid for at least three training days. The training records were not easy to decipher and it would be a good idea for the manager to create an easy reference training programme grid which clearly Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 20 indicates when training is due or has been carried out. A colour coded system or smilar is recommended. Evidence gathered from the training records indicated that most staff have received training in First Aid, Fire training, Dementia Care, Food Hygiene, Manual Handling and a good level of NVQ work Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 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) 33,36,37,38 Quality monitoring and audit systems are not yet in place, neither is a formal system for staff supervision. The health, safety and welfare of service users is somewhat compromised by lack of fire safety records, water outlet temperatures, legionella prevention and lack of workplace risk assessments. EVIDENCE: The manager showed the inspector the prepared questionnaires, which are due to be given out to service users and their representatives. The manager reported that information collected, will be fed back in resident/relatives meetings. This system must be implemented promptly. The Registered Provider is reported to make weekly visits, however there was no evidence of Provider Regulation 26 reports for these visits. Formal supervision is not in place, however the manager reported that she had carried out some appraisals in the last twelve months. Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 22 Insurance cover is appropriate as evidenced from the insurance certificate The electrical circuit five yearly check, is due and the manager reported this has been arranged. The registered manager must send a copy of the certificate to CSCI. The gas safety check is booked for 7th June 2005 and the certificate must be sent to CSCI. Fire safety check records were not up to date, the last one being September 2004. There were no records of water outlet testing to maintain water temperatures to 43 degrees, neither were there any evidence for the prevention of legionella. A fire safety risk assessment was seen, however there were no generic risk assessments in place for safe working practices. The health and safety poster was up to date. The inspector reminded staff, to wear aprons when serving food. Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 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 x x 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 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 Standard No 16 17 18 Score 3 3 3 x x 1 x x 1 2 2 Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 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 OP3 Regulation 14 Requirement Timescale for action 1/9/05 2. OP7 3. OP7 4. 5. 6. OP7 OP8 OP8 7. 8. 9. OP19 OP19 OP26 The manager must confirm to service users in writing that the home can meet their respective needs 15 The Registered Manager must ensure that all service users’ care plans are thorough,complete, up to date, signed and dated THIS IS AN OUTSTANDING REQUIREMENT 15 Ensure that care plans are structured in a way that they instruct staff how the needs of service users are to be met 14,15 Ensure that care plans and risk assessments are appropriatly evaluated and reviewed 17 Ensure all accident records are fully completed. 14, 15, 17 Ensure care plans contain information regarding how their health care needs will be met and carry records of attendance at routine and other healthcare checks and include a running record of incidents of falls. 16, 23 Replace the carpet in the lounge 16,23 12, 13 Replace the chairs in the lounge Ensure the malodour identified is eradicated 1/9/05 1/9/05 1/9/05 1/9/05 1/9/05 1/9/05 1/9/05 1/9/05 Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 25 10. OP27 18 11. OP19 7, 9, 19 Schedule 2 26 12. OP33 13. OP33 24 14. 15. OP33 OP37 18 17 16. 17. OP38 OP38 23 12, 13 The Registered Manager must ensure additional laundry/domestic staff as identified during the inspection are available at peak times of activity.THIS IS AN OUTSTANDING REQUIREMENT Ensure staff personal files contain all the specified information as required by schedule 2 of the regulations The Registered provider must undertake his responsibilities regarding regulation 26 visit reports. Service users must be consulted regarding whether their needs are being met[Quality Monitoring systems must be implemented] Formal supervsion arrangments must be put into place Ensure all records required by regulation are in place and completed[water safety systems,fire test records,accident records] Provide copies of electrical and gas safety certificates to CSCI Ensure staff follow food safety requirements at all times 1/9/05 1/9/05 1/9/05 1/9/05 1/9/05 1/9/05 1/9/05 1/9/05 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. Refer to Standard OP7 OP8 OP8 Good Practice Recommendations Review the current format of the care plans to provide an improved and easier system for staff and service users to follow Provide a record sheet for each healthcare need within the care plans to ensure appointments, treatments and follow ups are not overlooked Include a medication profile in each service users plan and which documents medication reviews and changes. C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 26 Silverdale House Care Home 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. OP8 OP9 OP12 OP16 OP18 OP18 OP24 OP26 OP27 OP27 OP30 OP33 16. OP38 Use behaviour monitoring tools alonside detailed care plans for dealing with and evaluating incidents of aggression or challenging behaviour Medicines training for staff should be undertaken with an acredited training body and competency assessments should be routinely carried out Increase the number of hours of the activities person to service users wishes for 1:1 shopping trips A formal system format for recording complaints should be devised and which can be filed in ring binder file with any letters/corresspondence and investigation notes. Amend the whistleblowing policy to ensure that it clearly states what action will be taken if staff are found to have made an allegation maliciously All staff should undertake training in adult protection The allocation of door keys and keys for lockable facilities should be documented [or risk assessed] in service users care plans Ensure liquid soap is provided in all toilets and bathrooms Implement protocols regrading staff breaks Implement night records to include night checks, attendance of service users during the night and any work tasks delegated etc. Improve the system for recording and monitoring staff training needs.Produce an annual training programme for all staff Be innovative when devising service user surveys and use one topic every three months, to keep interest of service users in its completion and to adress each topic in detail, rather than eg Are you satisfied with the food? A range of questions about food and mealtimes should be included and the responses actioned upon Risk assessemnts should be in place for all safe working practice topics Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Silverdale House Care Home C53 C03 S9790 Silverdale V230735 010605 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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