Inspection on 25/01/06 for Silverdale Nursing Home

This inspection was carried out on 25th 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 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

Silverdale Nursing Home 20/05/08

Silverdale Nursing Home 29/05/07

Silverdale Nursing Home 15/12/06

Silverdale Nursing Home 15/05/06

Silverdale Nursing Home 09/05/05

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

CARE HOMES FOR OLDER PEOPLE Silverdale Nursing Home Newcastle Street Silverdale Newcastle Staffordshire ST5 6PQ Lead Inspector Mrs Yvonne Allen and second inspector - Ms Rachel Unannounced Inspection 25 January 2006 11:00 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 Nursing Home DS0000060541.V282137.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 Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Silverdale Nursing Home Address Newcastle Street Silverdale Newcastle Staffordshire ST5 6PQ 01782 717204 01782 717204 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) Silverdale Care Homes Ltd Care Home 27 Category(ies) of Dementia - over 65 years of age (27), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (27) Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9/5/ 2005 Brief Description of the Service: Silverdale Mental Nursing Home provides nursing care for up to twenty-seven older people, both male and female, requiring long stay, short stay and respite care with severe mental health or dementia care needs.The home is situated in the residential area of Silverdale and is approximately two miles from Newcastle town centre.The home provides single storey accommodation and comprises of single and shared rooms. The majority of rooms are single rooms and some of them have en-suite facilities. Bedrooms can be personalised by the individual service user. The home has assisted bathing and toilet facilities, two communal rooms, a dining room and a quiet area. There are catering and laundry facilities on site.There are small car parking areas to the front and rear of the home. The grounds are not extensive and are easily accessible to the service user. There is a small patio area to the rear of the home equipped with garden furniture for service users to use during the summer months. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two inspectors and took approximately three hours. A tour of the home was carried out where the majority of bedrooms and all of the communal areas were inspected. Discussions were held with some of the residents who were able to converse with inspectors and a visiting relative. Discussions were also held with staff members, the provider and the prospective manager of the home. Examination of relevant records and documentation was carried out. Not all of the standards were assessed during this inspection, but those not fully met or not assessed at the last inspection were examined. Verbal and written feedback was given at the end of the inspection and requirements were left with the provider with timescales agreed. In between this inspection and the previous one there have been two monitoring visits made to the home and a meeting with the provider. An action plan for improvement has also been received from the provider. What the service does well: What has improved since the last inspection? Visits have been made in-between inspections in order to monitor progress and improvements at the home. These improvements have included a better system put in place for the recruitment of staff with more organised employee files. These files also now contain all the required information and checks on staff. Staff training had improved also with more staff having completed and been brought up to date with mandatory health and safety training. Some staff had Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 6 completed dementia awareness training. There were still some gaps in mandatory staff training. The presentation of meals had improved generally and not everyone was served soft diet. Although, when soft diet is served the presentation of this needs to be improved upon as highlighted in the report. The environment had started to improve having been painted internally and some of the rotten wood removed externally with UPVC cladding put on instead. The dining area had been moved into a separate room and this was a better arrangement. The overall cleanliness of the home had improved although there were still areas, which were in need of further improvement. The acting manager was now well underway with his application to become registered manager. And he was in the process of furthering his knowledge of general management and mental health awareness. What they could do better: The social, therapeutic and spiritual needs of residents are not fully met at the home and these are as important as meeting personal and nursing needs. The home would benefit from employment of a designated co-coordinator with knowledge of meeting the therapeutic requirements of residents with specific mental health needs. The provider stated that he would be purchasing a people carrier in order to take residents on trips out in the warmer weather. This would be an improvement and would widen the activity programme. All nursing and care staff must have some degree of training in dementia and mental health needs in order to be able to meet the specific needs of individuals accommodated in the home. The home must be able to evidence how it specifically meets the needs of the residents for which it is registered to accommodate. Although there had been some improvements made to the environment there were still areas in need of attention, adaptation and further improvement and attention is required in relation to infection control procedures. There were also some weaknesses in relation to the maintenance of a safe environment and these will need to be addressed. The provider will need to develop a system for quality assurance and auditing of the services provided. This will need to include the views of the residents or their representatives. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 7 A policy in relation to death and care of the dying must be developed in order to ensure that individuals are assured dignity and respect at this time and that personal wishes and spiritual needs are upheld. A system must be developed in relation to efficient record keeping. 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 Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 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 Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 4, and 5 Representatives and placing officers are able to make an informed decision before residents come into the home. The home falls short of meeting individual and specific needs in relation to dementia and mental health care. EVIDENCE: Information contained within the Statement of Purpose and Service User Guide documents will need to be updated in relation to the manager details and new staffing structure. Residents coming into the home do not usually visit prior to admission due to their limitations but families are welcome to come and view the home and meet other residents and staff. The inspector was informed that contracts for self-funding residents contain a trail period as do social services contracts. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 10 The staff in the home are meeting basic individual personal and nursing care needs. However the psychosocial, therapeutic and spiritual needs of the residents accommodated in this home are not fully met. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 The general standard of care planning was good but staff will need to ensure that plans are more carefully followed. Residents are protected by the medication policies and procedures. Individual dignity and respect was sometimes compromised and residents could not always be assured of this. EVIDENCE: A random selection of care plans was examined during the inspection. The overall standard of these care plans was good. Plans had been regularly updated and evaluations were comprehensive and detailed. The assessment of general healthcare needs was good and care plans had been developed as required for each identified problem. There was evidence of the assessment of nutritional needs and a plan in place for this. There was evidence of nutritional supplements available on prescription and evidence of the monitoring of individual weight. It was noted that specific instructions for regular observation of a resident who was in bed and unable to use the call buzzer had not been followed as per the care plan. The plan called for half hourly observation of this lady whilst she was in her room. There was no written evidence that this had been carried out. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 12 The GP was visiting the home at the time of the inspection but did not have time to speak to the inspector. However, she invited the inspector to write to her following the inspection. A letter was duly sent and the inspector is awaiting her comments. The medication procedure was observed and MAR charts were examined. These were found to be in order at the time of the inspection but when “o” is documented the reason for omission had not always been given. Individual dignity was observed to be compromised at the time of the inspection. At lunchtime, all residents were given a spoon to eat their meal with instead of a knife and fork, irrespective of whether this was applicable for them or not. This was discussed at the time of the inspection and this practice must stop and residents must be properly assessed and specialised adapted cutlery provided at mealtimes where required. There was no written policy available in relation to “Death and Dying”. This is a home for life and, as such, provision must be made for residents who are in the final stages of their life. The policy must include the maintenance of dignity and respect for individuals. There must also be a written procedure in relation to sudden or unexpected death and this must be made available to the nurse in charge on each shift. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The lifestyle in the home does not fully satisfy individual social, cultural, religious and recreational interests and needs. The provision and presentation of meals had improved somewhat but does not fully meet the standard required. EVIDENCE: There was evidence both written records, and observation at the time of the inspection, that some degree of activities and entertainment takes place in the home on a regular basis. However, specialist knowledge of this client group is required in order to fulfil their individual specific needs in this area. Therapeutic stimulation of individuals was poor. There was no evidence of involvement with the local community, nor was there any evidence of visits by the local clergy in relation to upholding spiritual needs. No church services were held in the home. This must be taken into consideration. The provider commented that he is intending to provide a people carrier vehicle in order to take the residents on trips out during the summer months. This will be a most welcome addition and will enhance the social activity programme. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 14 The maintenance of personal autonomy and choice is very limited, mostly due to the reduced capacity of most of the residents to make a choice. However, this had not been explored in detail and it is recommended that a life history of each individual be developed outlining previous hobbies, interests, family and employment history and other interesting features of the life of the residents. This might then provide a base for conversation and mutual communication between staff members and individual residents. It was identified that the cook had recently left and the provider was preparing meals, with the help of a carer. The provider stated that he possessed a current basic food hygiene certificate. It was not identified whether the carer working alongside him was in possession of this qualification. It is a requirement that all employees working in the kitchen and handling food possess a current basic food hygiene certificate. The main meal appeared appetising and the presentation of food had improved since the last inspection. It was identified that a liquidised meal had been prepared and this was not presented well. The food had been liquidised all together and not separated into individual portions, relating to meat/fish, vegetables and potatoes. This was discussed with the provider at the time and a requirement left for this to be improved upon. The nutritional quality of the meals provided needs to be reviewed in order to ensure that individuals are receiving adequate amounts of protein, vitamins, minerals and carbohydrates each day. It is recommended that an assessment of the menus be carried out by a dietician/nutritionalist. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 A procedure for logging concerns and complaints will need to be put into place at the home. Legal rights of residents are upheld wherever possible. Staff are in need of further training in POVA in order to ensure that residents are protected from abuse. EVIDENCE: The complaints procedure is displayed in the home and includes the details of the CSCI. Two complaints had been received by the CSCI since the last inspection with some of the concerns having been upheld. There was no evidence of the maintenance of concerns/complaints by the home and it is required that any complaints received are recorded together with the investigations and action taken, if any, as a result. This could be in the form of a complaints book and must be available for inspection. There were no residents using advocates at the time of the inspection and the inspector was told that families and social services usually acted as representatives. The electoral role was completed each year but there were currently no individuals who had the capacity to vote at election times. Some staff members were questioned on the Vulnerable Adults procedure and were unfamiliar with this. It is important for all staff to be aware of this and to have the knowledge and training in the recognition and reporting of suspected abuse as well as Whistle blowing. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Although there had been some improvements made to the home there were still areas in need of attention, adaptation and further improvement. Attention is required in relation to infection control procedures. EVIDENCE: A tour of the environment was conducted. It was noted that the entrance to the home appeared cleaner and brighter than previously. Inspectors were concerned that the front door to the home is still locked with a lock and key and the key is hung up. The lounge and dining areas were now more defined and this was more practicable. Some painting and redecoration had been carried out to the environment since the last inspection, although, in some areas this appears to be unfinished and in need of a topcoat of paint. Part of the exterior of the home had been improved with the addition of UPVC cladding. This did not extend all around, however, and the remainder of the home externally appears worn and in poor condition especially around the rear of the home. There is a recommendation to complete the work of restoration on the remainder of the property. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 17 The rear of the home was also cluttered with extraneous items. The inspectors were informed that the provider was still in the process of discarding unwanted items and that these would be removed shortly. It was noted that products falling under COSHH regulations were left out around the home. The residents accommodated in this home are very vulnerable and must be protected from hazards to their safety at all times. Therefore these products must be kept locked away when not in use. There were no COSHH data sheets or relevant risk assessments. The domestic/maintenance person, when questioned, was unaware of COSHH requirements and will need training in this area, as will any other staff who handle COSHH products. There was no lock on the toilet located next to room 16. A lock must be applied which is of the type, which can be accessed from the outside in case of emergencies. In one of the shared bedrooms two sets of dentures were found stored in one denture pot. This must cease and separate denture pots provided. In bedroom number 15 there was a strong mal odour. This must be eliminated. There were extraneous items stored in the toilet located next to room 5 and the bathroom by room 19. These must be removed and stored in a more appropriate area and the bathroom made accessible and fit for the purpose for which it is registered. The fire door located in the corridor next to room 3 did not close properly. This must be rectified. In the laundry it was noted that a resident’s underwear was left soaking in a bucket. This procedure is not in keeping with infection control guidelines and must cease. In bedroom 22 the commode was rusty and worn and in need of replacement. Throughout the home the lighting was poor and there were no bedside lamps provided for residents. This must be rectified and bedside lamps provided. The bath hoist was found to be unhygienic with traces of faeces underneath the seat. This must be thoroughly cleaned in order to prevent cross infection and the staff responsible must be trained in the prevention of cross infection. There was only one adapted/assisted bath provided in the home and there were 22 residents. At a ratio of one bathing facility to every 8 residents, this was insufficient. The other two baths will need to be made into assisted baths or one of them as an assisted bath and a separate shower room. This was discussed with the provider during feedback. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 Staff were provided in sufficient numbers at the home. Individual staff skills will need to be assessed and further developed in order to ensure that all the assessed needs of the residents are fully met. EVIDENCE: There were a total of 22 residents accommodated in the home at the time of the inspection all in need of nursing care. The numbers of trained and care staff provided was in keeping with the existing staffing notice. It was identified that a member of staff who was working in the kitchen at the time of the inspection also worked as a care assistant but had not been identified on the staffing rota. The staffing rota must be accurate with all staff accounted for. Laundry staff and a domestic/maintenance person were provided. There was a current vacancy for a cook at the home as the cook had recently left. The home employed Registered Mental Nurses and the prospective manager was a Registered General Nurse. Staff NVQ training will need to be addressed. Some of the care staff are trained nurses overseas and the provider will need to evidence that their qualifications match the NVQ level 2 requirements in direct care as discussed at the time of the inspection. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 19 Some staff training had taken place since the last inspection. This had included training in dementia awareness. The provider will need to ensure that all care and nursing staff working at the home receive training in dementia awareness, challenging behaviour and other related training. Mandatory staff training was on going and most of the staff had received updates in moving and handling and fire safety training, including fire drills. Some staff, however, had missed out on this training. The health protection nurse had recently given some training and advice in infection control at the home. There was no evidence of trained nurses having had clinical update training or help toward maintaining PREP requirements. It is recommended that the prospective manager commence supervision sessions with the nurses where individual training needs can be identified and supported. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34 37 and 38 The prospective manager had been well received by the staff and families of the residents in the home. Further attention is required in the development of quality auditing, better record keeping and the maintenance of a safe environment. EVIDENCE: The prospective manager was in the process of applying for registration with the CSCI at the time of the inspection. He is a Registered Nurse with clinical experience in various settings within the NHS and private sector. The inspector was informed that the prospective manager was undergoing training in Dementia and Mental Health at the local University and had also commenced NVQ level 4 in Management training. Staff comments received at the time of the inspection were complimentary about the prospective manager stating that he was approachable and supportive. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 21 The inspector was shown evidence of staff meetings, which had taken place. When asked about residents/relatives’ meetings the inspector was informed that one meeting had taken place since the last inspection. The provider and manager will now need to introduce quality assurance within the home. The auditing of services provided will need to be developed and these must include the views of the residents and/or their representatives. The provider was asked about the financial viability of the home and the inspector was assured of this at the time. There was an up to date certificate of insurance in place at the home. Care plans and care records were kept securely. Other records relating to the maintenance and administration of the home were very disorganised and this will need to be improved upon to ensure the smooth running and management of the home and ensure that the home is keeping within Data Protection requirements. Records and documentation were examined in relation to maintenance and Health and Safety within the home. There was no record available at the time of the inspection, of the testing of hot water temperatures at bath outlets and no record of the testing of emergency lighting. These will need to be implemented without delay and tested and recorded on a monthly basis. PAT testing had been carried out as required. Fire alarms had been tested but records were somewhat haphazard and will need to be more organised. There was no test certificate in place to evidence that the home complied with Legionella legislation. This will need to be addressed without delay. There were foods in the freezer, which were not labelled with the type of food and the date. This will need to be addressed without delay and foodstuffs kept in accordance with environmental health requirements. Not all employees had received the required update training in moving and handling and fire safety training and this will need to be addressed and records maintained. Seven staff members had attended Basic Food Hygiene training on 15/11/05. Generic risk assessments will need to be developed for the working environment and this was discussed with the provider and manager at the time. Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x x 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 2 2 2 2 2 2 2 2 STAFFING Standard No Score 27 2 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 3 x x 2 2 Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No 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 2 Standard 12 7 and 8 Regulation 16(2)(m) 12(1)(b) Requirement Social and therapeutic activities for individuals must be improved The provider must make proper provision for the care and treatment of residents. This is in relation to ensuring follow through of care plans. A policy must be developed to promote dignity and uphold wishes in the event of death, following death and in relation to sudden or unexpected death of residents. Soft diets served must be properly prepared and presented Suitable cutlery must be provided at mealtimes to include adapted cutlery and crockery where needed. The provider must ensure that all staff have the knowledge and understanding of the recognition of abuse and the procedures to follow in the reporting of abuse or whistle blowing. All parts of the care home must be free from hazards. This was in relation to the safe storage of COSHH materials. DS0000060541.V282137.R01.S.doc Timescale for action 20/03/06 20/03/06 3 11 12(2,3,4) 20/03/06 4 5 15 15 and 22 16(2)(i) 16(2)(g) 20/03/06 20/03/06 6 18 18(c)(i) 20/03/06 7 38 13(4)(a) 20/03/06 Silverdale Nursing Home Version 5.1 Page 24 8 10 12(4)(a) 9 10 11 10 26 19 12(4)(a) 16(2)(k) 23(2)(l) 12 13 14 15 16 19 38 26 26 and 22 25 23(2)(o) 23(4)(c)(i v) 13(3) 13(3) 23(2)(p) 17 38 18(1)(c)(i ) 18 19 20 21 22 38 38 38 27 26 23(4)(b)( d) 23(4)(b)( d) 23(4)(b)( d) 17(2) schedule 4(7) 13(3) A suitable lock must be provided to the toilet by room 16 of the type which can be accessed in an emergency Individual dentures must be stored in separate containers The strong mal odour in room 15 must be eliminated Extraneous items must be stored away in suitable storage areas. This was in relation to the toilet by room 5 and the bathroom by room 19 All external areas must be left clean and tidy The fire door in the corridor outside room 3 must be made to close properly Individual underwear must not be left to soak in buckets The commode in room 22 is in need of replacement The poor lighting throughout the home must be addressed and bedside lamps provided unless a risk assessment suggest otherwise COSHH data sheets must be in place together with risk assessments for all COSHH products used and staff must have training in this area There must be monthly testing of emergency lighting and records kept All staff must receive at least 2 fire drills per year and these must be recorded Generic risk assessments must be developed in relation to the building The staffing rota must be accurate and all staff accounted for The bath hoist must be thoroughly cleaned and maintained in a hygienic DS0000060541.V282137.R01.S.doc 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 Silverdale Nursing Home Version 5.1 Page 25 23 21 23(2)(j) 24 25 30 16 18(i)(c)(i) 22(1) and (8) 26 33 24(1)(2)( 3) 27 37 17(1,2,3, 4) 28 38 18(1)(c)(i ) condition to prevent the spread of infection Sufficient adapted baths must be provided for the number of residents accommodated in the home at a ratio of 1:8. Another two of the baths must be adapted for use. Trained nurses must receive help to maintain PREP requirements and clinical updating A log of concerns/complaints must be commenced and maintained together with records of investigations and actions taken A system for quality assurance must be developed and any surveys must include the views of the residents or their representatives Records, including policies and procedures, must be up to date, accurate and kept in accordance with Data Protection requirements All staff must receive the required update training sessions in moving and handling and this must be recorded 20/04/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 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 2 3 Refer to Standard 9 15 19 Good Practice Recommendations When“o” is documented on the MAR charts, the reason for this must be clearly identified. It is recommended that an assessment of the menus be carried out by a dietician/nutritionalist. There is a recommendation to complete the work of restoration on the remainder of the property both DS0000060541.V282137.R01.S.doc Version 5.1 Page 26 Silverdale Nursing Home 4 28 internally and externally. The provider should ensure that the qualifications of the care staff employed from overseas are equivalent to NVQ level 2 or above Silverdale Nursing Home DS0000060541.V282137.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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