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Inspection on 17/01/06 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 17th January 2006.

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

Residents are not admitted to the home until their needs have been assessed. Residents and a relative spoken with during the inspection praised the quality of care provided at the home. One resident said it was "the best move they`d ever made" and that support was there whenever needed. The relative confirmed that she had been involved in the development of her mother`s care plan. Residents reported that staff treat them with dignity and respect and that they are able to make choices about their lives. Residents made positive comments about the meals and the menu book showed that meals provided are varied healthy and nutritious. On a tour of the premises the home appeared clean throughout.

What has improved since the last inspection?

Throughout the inspection it was apparent that the manager has made a number of changes to the running of the home in order to address the requirements set at the last inspection. The care planning system at the home has improved, which makes the information more accessible to staff and allows for amendments to be made to care plans more easily. Healthcare appointments attended are now being monitored and recorded using a clear format and medication profiles are now held on each resident`s file, which promotes safer practice. The manager reported that senior staff have now attended Medication Administration training by a training body and staff spoken with confirmed this. The chairs in the lounge and carpets through the ground floor of the home have been replaced, which has made the environment more homely and comfortable for residents. As part of the quality assurance process satisfaction surveys have been sent out to residents and their relatives and returned. This information will now inform any further developments or necessary changes to the service. Problems with staffing levels particularly around laundry / domestic duties have now been addressed appropriately and the complaint investigation that was carried out by the Commission in November 2005 relating to this issue was not upheld.

What the care home could do better:

Although the care planning system has improved staff need to start using this system more effectively. Evidencing that care plans are being reviewed every month and stating exactly what are the changes / amendments is still required. Better systems for monitoring and recording training and training needs of staff are still required. It was very difficult to evidence what training has been provided especially if certificates are not obtained. The registered manager must ensure that staff are following correct procedures with medicine administration and recording. The health and safety of residents continues to be compromised while all necessary fire safety tests and risk assessments are not being undertaken. Recruitment practices need to improve at the home to ensure the safety and protection of all residents. New staff must not commence employment until at least the return of a POVA First Check. When a resident discloses an incident that is verbal abuse then this must be followed up using the Protection of Vulnerable Adults Policy and Procedures.

CARE HOMES FOR OLDER PEOPLE Silverdale House Care Home 3 Nottingham Road Hucknall Nottingham NG15 7QN Lead Inspector Joanna Carrington Unannounced Inspection 17th January 2006 10:00 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 Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 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. Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 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 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) 0115 9640400 0115 9634880 Rodenvine Limited Jamil Akhter Mrs Fiona Elizabeth McShane Care Home 36 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (36) of places Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 named person may be in the category PD. Date of last inspection 01/06/05 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 thirty six, there were thirty two service users living at the home 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. Recently, the registration for this home was amended to include a provision of care for up to five service users with dementia. Fiona Mcshane has now stepped down as Registered Manager and is taking the lead role in administration. Julie Shotton has been appointed as care manager and is in the process of applying to be registered as manager with the Commission. Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over eight hours on the 17th January 2006. This was the home’s second of two statutory unannounced inspection. In addition to this there was also a visit to investigate a complaint in November 2005, which was subsequently not upheld. The main purpose of this inspection was to follow up the sixteen requirements set at the last inspection. The main method of inspection was called ‘case tracking’ which meant selecting three residents and tracking the care they receive by checking their records, discussion with them and staff and observation of care practices. Altogether two residents, two members of staff and one relative were spoken with. The inspector was informed of a recent incident at the home, which had to be dealt with at the time of the inspection. This, therefore, unavoidably impacted on the inspection, which meant that a couple of requirements could not be followed up. Those requirements are repeated in this report but are not identified as outstanding. What the service does well: What has improved since the last inspection? Throughout the inspection it was apparent that the manager has made a number of changes to the running of the home in order to address the requirements set at the last inspection. The care planning system at the home has improved, which makes the information more accessible to staff and allows for amendments to be made to care plans more easily. Healthcare appointments attended are now being monitored and recorded using a clear format and medication profiles are now held on each resident’s file, which promotes safer practice. The manager reported that senior staff have now attended Medication Administration training by a training body and staff spoken with confirmed this. Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 6 The chairs in the lounge and carpets through the ground floor of the home have been replaced, which has made the environment more homely and comfortable for residents. As part of the quality assurance process satisfaction surveys have been sent out to residents and their relatives and returned. This information will now inform any further developments or necessary changes to the service. Problems with staffing levels particularly around laundry / domestic duties have now been addressed appropriately and the complaint investigation that was carried out by the Commission in November 2005 relating to this issue was not upheld. 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 DS0000008790.V274308.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 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 the following standard(s): 3 and 4 (6 not applicable) Prospective residents do not move to the home until their needs have been assessed. No evidence was seen to confirm that prospective residents are informed in writing that the home will be able to meet their needs. EVIDENCE: For all three residents that were case tracked there was evidence of either the placing authority’s community care assessment of the home’s own preadmission assessment. These assessments obtain information on the personal, health and social needs of prospective residents to ensure that the home is suitable in meeting all of these needs. One resident case tracked was admitted to the home in November. No evidence was sought during the inspection to confirm that the manager had confirmed in writing to the resident that their individual needs could be met by the home. A timescale is set to provide the manager with an opportunity to supply the Commission with this evidence in order to confirm whether this requirement has been met. Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 and 10 There have been some obvious improvements to the care planning system, for ensuring that the personal, social and healthcare needs of residents are identified and how these are to be met. However, staff need to use this documentation more effectively. Some changes implemented since the last inspection will help to assure that the medication system is safe, however, some further improvements to recording is required. Residents continue to be treated with dignity and respect and their right to privacy is upheld. EVIDENCE: Since the last inspection, as recommended, the manager has implemented a new system for recording how the needs of residents are to be met. Care plans for different needs are documented separately, which means that care plans can be updated and amended more efficiently. Preferences of residents for example, with washing and dressing are included on care plans, which is good practice. There was also evidence seen of residents and / or their relatives signing to say they agree with the care plans. The manager must ensure that this practice continues. There is now a better system for evidencing that care plans are reviewed monthly. However, staff are not utilising this properly and subsequently care plans are either not being Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 10 reviewed or where it states that needs have changed there is no detail as to what has changed or a cross reference to any amendments. As recommended at the last inspection there are now forms to record all healthcare appointments and District Nurse visits, which is helpful for ensuring that regular healthcare checks are undertaken and monitoring the health of residents. Risk assessment tools are used to assess healthcare needs such as pressure area, moving and handling, falls and self- harm. Fall and accidents are correctly cross referenced to entries in the Accident Book, however, as identified at the last inspection there is still not enough detail being recorded. If the accident is not witnessed then it must state the circumstances of the accident according to the resident. Although it has been documented in detail what advice District Nurses have given to staff regarding the management of a resident’s pressure sore, this information is held only on daily records which has the potential of getting lost. There are care plans in place for all residents for the prevention of pressure sores but there also needs to be care plans specifying the support required to manage and treat a pressure sore. As well as stating that someone has Diabetes and on a risk assessment identifying that this person needs their “diet to be made safe” a care plan is required that outlines what are their dietary needs and guidance to staff as to what constitutes an appropriate healthy diet for a resident with Diabetes. As recommended at the last inspection, there are now medication profiles held on each resident’s care file and medication training has been provided by an accredited training body. The manager gave the date of this training and staff spoken with confirmed their attendance, however, the manager must ensure that certificates are obtained as satisfactory evidence. In general the medication system appeared to be reasonably safe. The medication trolley was well organised and instructions on Medication Administration Records were clear. There were some gaps seen on the MAR where the administration of medication has not been signed for and where boxed medication is used the MAR must record stock balance to ensure that remaining tablets correlate with what tablets have been taken. A member of staff was asked to talk through the administration process and explained that the MAR is signed when the medication has been dispensed into the medication pot. Staff must be fully aware that administration records must only be signed after the resident has taken their medication. It stated on one resident’s care plan that they selfadminister one of their ‘as required’ medications. The manager showed the inspector the current risk assessment for this that is being developed, which is to be signed by the GP. Staff spoken with were able to identify the necessary values in working with older people such as maintaining dignity, promoting choice and respecting the right to privacy. Residents spoken with confirmed that staff do treat them with respect and that staff always knock on their bedroom doors and await permission before entering. Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Residents are helped to exercise choice and control in their lives and contact with their family, friends and the community in general is maintained and promoted. Residents are provided with wholesome nutritious meals, but more written documentation of alternative meal options is required. EVIDENCE: Both residents spoken with said that their family and friends are always made to feel welcome and they can have visitors whenever they want. A relative also confirmed that staff are always welcoming and helpful. The bedrooms seen show that residents can bring their own possessions when they move into the home and a resident spoken with said that she can access her care plan whenever she requests and in general is able to exercise choice and control of her own life. Residents can choose to participate in their own committee meetings. Minutes of the last meeting documented what activities residents like to do such as bingo, quiz night, sing-along, an entertainer, a chocolate demonstration and barbeque. There are also occasions when staff take residents out for example, a racing night at British Legion, trips out on a boat and on the trams. The manager reports that during the summer months a rota will be in place to allow for staff to take residents for walks and shopping trips. Residents’ also regularly run a fundraising event that is open to the local community. A relative spoken with commented how staff have said to her that they are often Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 12 too busy to lead activities in the home. There were times during the day of the inspection that staff were observed standing by the Nursing Station chatting to each other when they could have been spending that time interacting with residents. The menu book was looked at as part of the inspection. It was evident that meals continue to be wholesome, nutritious and varied. Residents spoken with said that the meals on offer are always very nice. The cook reported that on the day of the inspection four alternative meals were prepared for those that did not want the planned meal. This is good practice and therefore should be evidenced. It is recommended for this reason and also in case of a food poisoning outbreak that it is recorded who has had which alternative meals provided. Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 13 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’ complaints are taken seriously and acted on, but increased use of the Adult Protection Policy and Procedures is required. EVIDENCE: Since the last inspection an additional Complaints Visit was carried out by an inspector following an anonymous complaint regarding lack of staffing, staff being taken off care duties to perform laundry and kitchen duties, residents losing weight and that they are not given food at proper intervals. All elements of this complaint were not upheld. The Commission have received several complaints of this nature, including one that was investigated as part of the last inspection, all of which have been unfounded. Both residents spoken with are aware of the home’s complaints procedure and said that they felt comfortable raising any concerns or complaints they have with the manager. The Complaints Procedure is appropriate and refers to complaints being responded to within one month and also that the Commission can be contacted if they are not happy with any outcomes. As recommended at the last inspection the manager has now implemented a Complaints File and forms for recording complaints. As opposed to a Complaints Book, this system is in line with data protection. There were four different complaints held on this file, all of which were relating to staff conduct. There was a lot of confidential information held on this file. Only a brief account of the nature of the complaint and any necessary action should be included with a cross reference to detailed information which is then held securely. Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 14 One of the complaints was investigated appropriately following the Nottinghamshire Protection of Vulnerable Adults Policy and Procedures. One of the other complaints should have also been regarded as an issue of Adult Protection and subsequently investigated using this procedure. Therefore, the Adult Protection Unit and the Commission should have been notified as well as Social Services in order to determine how to proceed with an investigation. Staff spoken with demonstrated an understanding of their responsibilities under the Adult Protection Policy and Procedures in terms of disclosing alleged abuse. As recommended at the last inspection staff have now received training in Adult Protection. Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The replacement of carpets and chairs has assured that residents live in a comfortable and homely environment, which is clean and hygienic. EVIDENCE: On a tour of the premises it was evident that the chairs and carpets in the lounge and throughout the ground floor have all been replaced. There was a malodour present in the hallway around the entrance to a resident’s bedroom. Further investigation is necessary to ascertain what the malodour is and how it can be eliminated. The home was clean throughout. The laundry and sluice facilities are appropriate to meeting the needs of residents. Liquid soap and paper towels were available in all of the toilets and bathrooms inspected. Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 16 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 Staffing levels are appropriate to the needs of residents. More improvement to recruitment practices is still necessary to ensure that residents are protected. Staff are trained to enable them to be competent in their jobs, however, a better system for monitoring training needs and evidencing courses already attended, is required. EVIDENCE: As already mentioned in this report, an additional visit was made in November last year as a result of an anonymous complaint regarding staffing. Since the last inspection, an assigned member of staff carries out laundry tasks for two hours per day, in addition to four care staff on shift during the day. Staff spoken with reported that there are currently no problems with staffing levels and that most staff are usually happy to work some extra hours to cover leave and sickness. The staff rota was inspected and indicated no issues at present. Two staff files were looked at. Both contained two references and evidence of POVA First Checks being carried out prior to the return of their full Criminal Record Bureau (CRB) check. One of the staff, however, commenced their employment before the return of the POVA First Check. Where a registered person permits a new worker to start work before the CRB check has been received he must appoint a qualified and experienced “staff member” to supervise them and as far as is possible ensure the “staff member” is on the same time as new worker. There was no record of a supervision programme available on either staff member’s file, which is also required. Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 17 One of the references seen was not a good one but there was no evidence to indicate that this had been followed up, to ensure that the member of staff is fit to work at the care home. The application form currently used for recruitment does not request information about any previous training or qualifications, which is essential information that is helpful in again establishing an individual’s fitness to work at the care home. The date that staff commence employment at the care home must be included on their staff file. The manager was eventually able to provide some evidence that staff have received training in First Aid, Fire training, Dementia Care, Food Hygiene, Manual Handling, Adult Protection and Medication Administration but finding this evidence was not easy. Better documentary evidence is required such as certificates, which can then be kept on individual staff files. The recommendation to improve the system for recording and monitoring staff training needs still applies. Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 18 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): The manager’s fitness to run the home will be assessed fully during the process of her application to register as manager. Residents’ finances are safeguarded. Improvements to quality monitoring and health and safety practices are still required and implementing a system for staff supervision is now outstanding. EVIDENCE: The Registered Manager as specified in this report has in fact stepped down as manager. A senior member of staff has been appointed as care manager and has applied to be registered as manager with the Commission. Money held on residents’ behalf is stored securely and records of transactions were seen for residents’ case tracked and appeared to be in order. The manager does not hold lots of cash within the home and therefore will transfer money received by families into one bank account but keeps very detailed records of what amounts have gone into the account for each individual resident, which is then checked regularly to make sure the total amount in the bank account tallies with sums held in the home etc. This appears as a very Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 19 complex system and would have taken too long for the inspector to examine thoroughly, but the manager does feel that this is the safest. It is recommended therefore, that this system be also independently audited. Since the last inspection Quality Assurance Questionnaires have gone out to residents and their relatives and have been returned. This information now needs to inform the Annual Service Development plan for the home. Since the last inspection in June the Commission have received three Regulation 26 reports by the service provider. The Registered Provider is still required to undertake unannounced visits at least monthly to the home and produce a written report on the conduct of the care home, which in accordance with Regulation 26 of the Care Home Regulations 2001, is to be provided to the Commission. Staff files seen show that staff are still not receiving regular supervision sessions. These are required and it is recommended in the National Minimum Standards that six supervision sessions be held for each member of staff per year. Since the last inspection the manager has implemented adequate measures for the prevention of Legionella. Certificates of Bacterial Analysis issued from a Contractor were seen. The last monthly check of water outlet temperatures carried out by the home was in October 2005. The required gas and electrical testing has been carried out along with the regular servicing by a contractor of the Fire System. The fire safety tests that are required to be carried out and recorded by the home are still not satisfactory. Although the contractor can substantiate that some fire tests were conducted between 3rd October 2005 and 4th January 2006 no weekly fire alarm tests have been recorded on the appropriate documentation. Automatic Door Release Tests also need to be undertaken weekly. One resident living at the home uses bed rails, which were assessed as being needed by the District Nurses. A written risk assessment must be carried out in accordance with Health and Safety Legislation to ensure that the use of bed rails is appropriate and safe. Environmental / workplace risk assessments are still required in accordance with Health and Safety at Work Legislation. Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 1 X 2 Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? yes 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 The manager must confirm to service users in writing that the home can meet their respective needs. The manager must supply evidence of this by 14th February to confirm that this requirement is now met. Ensure that care plans and risk assessments are appropriately evaluated and reviewed. An immediate requirement was issued as this is an outstanding requirement, initial timescale of 01/09/05 not met. For the named resident develop a care plan providing guidance and instructions to staff on how to treat and manage this person’s pressure sore. For the named resident provide further information on the appropriate care plan on how to manage this person’s diabetes. Ensure all accident records are fully completed. An immediate requirement was issued as this is an outstanding DS0000008790.V274308.R01.S.doc Timescale for action 14/02/06 2 OP7 14,15 17/01/06 3 OP7 15 07/02/06 4 OP7 15 07/02/06 5 OP8 17 17/01/06 Silverdale House Care Home Version 5.1 Page 22 requirement, initial timescale 01/09/06 not met. 6 OP9 13(2) Ensure there are adequate arrangements in place for the recording and administration of medicines. This includes… 1. Only signing on MAR charts after medicines have been administered. 2. Do a written risk assessment for selfadministration of medication before the named resident starts selfadministering. 3. Recording the quantity of boxed medication on MAR charts. 13 Ensure that following the disclosure of any form of abuse that the Adult Protection Policy and Procedures are followed. 12, 13, 23 Take appropriate action to eliminate the malodour identified. 19 To ensure that an employee is fit to work at the care home provide evidence that bad references are appropriately followed up. 19 Ensure that if staff commence employment before the return of a CRB then this is only after return of a POVA First check, and that the new member of staff is supervised by an appropriately skilled and experienced staff member, which is evidenced. An immediate requirement was issued in respect of this. 26 The Registered provider must undertake his responsibilities regarding regulation 26 visit reports. An immediate requirement was issued as this is an outstanding requirement, initial timescale DS0000008790.V274308.R01.S.doc 31/01/06 7 OP18 28/02/06 8 9 OP26 OP29 28/02/06 01/03/06 10 OP29 17/01/06 11 OP33 01/03/06 Silverdale House Care Home Version 5.1 Page 23 12 OP36 18 of 01/09/05 not met. Formal supervision arrangements must be put into place. An immediate requirement was issued as this is an outstanding requirement, initial timescale of 01/09/05 not met. Undertake all fire safety tests as required in accordance with Fire Precautions Legislation. An Immediate Requirement Notice was issued for this. Ensure individual risk assessments are carried out for the appropriate and safe use of bedrails. 17/01/06 13 OP38 23 17/01/06 14 OP38 13 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations Use behaviour monitoring tools alongside detailed care plans for dealing with and evaluating incidents of aggression or challenging behaviour. This recommendation was identified in the last inspection report. Record in detail what alternative meals have been provided and which residents have had this alternative. For protecting confidentiality do not provide detail about complaints and action taken in the complaints file but cross-reference to a detailed record that is held securely. The allocation of door keys and keys for lockable facilities should be documented [or risk assessed] in service users care plans. This recommendation was identified in the last inspection report. Improve the system for monitoring and recording staff training needs. Produce an annual training programme for DS0000008790.V274308.R01.S.doc Version 5.1 Page 24 2 3 4 OP15 OP16 OP24 5 OP30 Silverdale House Care Home 6 OP33 all staff. This recommendation was identified in the last inspection report. 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 address each topic in detail, rather than e.g. Are you satisfied with the food? A range of questions about food and mealtimes should be included and the responses acted on. This recommendation was identified in the last inspection report. Independently audit the system for holding residents finances. Undertake written environmental / workplace risk assessments. This recommendation is repeated from the previous inspection report. 7 8 OP35 OP38 Silverdale House Care Home DS0000008790.V274308.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Nottingham Area Office 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 DS0000008790.V274308.R01.S.doc Version 5.1 Page 26 - 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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