Inspection on 15/06/06 for Silverlea Residential Home

This inspection was carried out on 15th June 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.

Other inspections for this house

Silverlea Residential Home 21/01/08

Silverlea Residential Home 18/07/07

Silverlea Residential Home 20/02/07

Silverlea Residential Home 02/03/06

Silverlea Residential Home 09/06/05

Silverlea Residential Home 09/11/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Silverlea Residential Home 3 First Avenue Bradford Moor Bradford West Yorkshire BD3 7JG Lead Inspector Steve Marsh Key Unannounced Inspection 15th June 2006 09:30a 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 Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Silverlea Residential Home Address 3 First Avenue Bradford Moor Bradford West Yorkshire BD3 7JG 01274 661700 01274 660611 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) Mr Kevin Casey Care Home 35 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (35), of places Physical disability over 65 years of age (3) Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 2006 Brief Description of the Service: Silverlea Care Home is a large detached adapted property, located in the Bradford Moor area, overlooking the park and about one mile from the city centre. The home is registered to provide personal care for thirty-five residents in both single and double bedrooms, situated on all four floors of the building. There are steps to the front of the home. There is however level access to the rear of the property, and a passenger lift to all floors. Internally some areas of the home still require extensive refurbishment, although to meet present legislation the fire alarm system was replaced in 2004 and the home has recently been completely rewired. Externally there is a patio area to the front of the property, which the service users are able to use during the summer months. The home is on a main bus route from the city centre and there is street parking to the front of the property. The fees range from £318.14p to £354.75p per week (£365.00 for self funding clients). Additional charges are made for services such as hairdressing, newspapers, private chiropody, outings and the sweet trolley. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home, Health and Personal Care etc. An overall judgement is made for each outcome group based on the findings of the inspection. The Judgements reflect how well the service delivers outcomes to the people using the service. The judgement categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes are available on our website – www.csci.org.uk This unannounced inspection was carried out by two Inspectors between the hours of 9:30am and 5:30pm. The last inspection took place in March 2006 and a number of requirements were identified at that time, many of which were outstanding from previous inspections. The purpose of this inspection was to assess what progress the service was making in meeting statutory requirements and to assess the impact of any changes in the quality of life experienced by people living at Silverlea Care Home. The methods used included the examination of records, observation of care/work practices, discussion with residents, staff and management and a tour of the premises. As part of the inspection process the Inspectors also investigated one complaint recently received by the Commission alleging that residents were receiving inadequate diets resulting in weight loss. Although the complaint could not be substantiated requirements were made regarding the need to ensure nutritional assessments are carried out and the standard of record keeping. There are ongoing adult protection investigations, which have yet to reach a satisfactory conclusion. Survey questionnaires were provided to enable residents and/or their relatives to share their views of the service with the Commission. Of the twenty-five questionnaires left at the home (resident and relatives), none were returned. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 6 Detailed feedback was given to the registered provider and manager at the end of the visit. Requirements and recommendations made during this visit can be found at the end of the report. What the service does well: What has improved since the last inspection? What they could do better: Up to date information about the home must be made available to prospective residents, to help them decide whether to move in. The manager must ensure that care plans are specific to meet individual needs. Nutritional assessments must be undertaken for all residents on admission and updated as needed. The present care planning system should also be reviewed and care plans made easier for the staff to use as a working document. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 7 Senior staff must be more vigilant when completing the Medication Administration Record (MAR) sheets and implement a stock control system for PRN (as and when required) medication. The home continues to be in need of extensive refurbishment both to improve the resident’s quality of life and to ensure their health and safety. The manager must ensure that Criminal Record Bureau (CRB) checks are carried out for all staff and the employment files for all staff are available within the home. The registered provider and manager must establish clear areas of responsibility and demonstrate a genuine commitment to working with the Commission to improve the quality of care/services. The manager must continue to develop effective quality assurance monitoring systems, which must not only seek the views of the residents and/or their relatives but also all other interested parties. The manager must ensure that that the transaction sheets used for recording residents’ money held in safekeeping are kept up to date. Risk assessments for the building and to ensure safe working practices must be completed/updated to ensure the health and safety of the residents, staff and visitors. 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. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5 – Standard six does not apply to this service. Quality in this area is adequate. This judgement has been made using available evidence including a visit to the home. The statement of purpose and service user guide need updating to make sure that prospective residents are given correct information to make a decision about moving in. The admission procedure is thorough and the manager will not admit a resident unless she feels the staff team are able to meet their needs. EVIDENCE: The statement of purpose and service user guide have not been reviewed since 2004 and therefore do not reflect the change in manager and the number of care staff having achieved a National Vocational Qualification (NVQ). The care records showed that pre-admission assessment visits are carried out to see prospective residents in their own home or temporary place of residence. The local authority assessment of needs form was also available. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 10 In addition to the pre-admission assessment visit, residents and/or their relatives are invited to visit the home prior to admission to view the accommodation, meet the other residents and staff and stay for a meal. Admissions are usually planned although the manager confirmed that the home does respond to crisis situations and will take emergency admissions providing she is confident the staff team are able to meet their needs. To ensure that staff have the skills and experience to meet residents’ the manager has increased the level of staff training and ensures that they receive the support/supervision they require to effectively carry out their roles. Staff confirmed that they felt well supported by the manager and said that they were never asked to care for residents outside their area of expertise. The home does not provide intermediate care. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this area is poor. This judgement has been made using available evidence including a visit to the home. Although there is a comprehensive care planning system in place, the care plans are not user friendly and difficult to use as working documents. The residents’ healthcare continues to be compromised by poor care practices and record keeping. EVIDENCE: Care plans are in place for all residents and cover all aspects of their health and general welfare. Records show that the resident and/or relative are involved in the care planning process. The manager confirmed that care plans are reviewed on a monthly basis or sooner if the resident’s needs change significantly. Following a recent complaint received by the Commission alleging residents receive an inadequate diet and some were losing weight the care plans of six residents were looked at in depth. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 12 Three of the care plans showed that a nutritional assessment had not been carried out on admission and weight charts had not been completed. The manager confirmed that she was aware that one resident had lost a significant amount of weight and this was being monitored by the clinic she attended at the local hospital. However, the weight chart at the home had not been completed for six months and therefore the staff were unaware of the actual weight loss. There was evidence that one resident had been referred to a dietician because of her poor diet and weight loss and staff were now closely monitoring her dietary intake. The three other care plans reviewed had nutritional assessments in place and weight charts showed that residents were maintaining or gaining weight. Although the complaint was not substantiated the manager was reminded that a nutritional assessment must be undertaken on admission and all residents must be weighed on a regular basis as required in the last inspection report. Other inconsistencies in the care plans were noted. In some instances the care plan accurately reflected the level of care/assistance required by the resident and gave clear guidance to the staff. While other care plans were not specific enough and did not reflect the resident’s present circumstances, or had not been reviewed following changes in their healthcare needs. There was no risk assessment for a resident known to present challenging behaviour and the moving and handling plans for two residents did not appear to reflect their needs. Although comprehensive, some information within the care plans is now difficult to find and therefore it was recommended to the manager that the system be reviewed. Residents confirmed that medical examinations were carried out in their own rooms and said that staff always treated people with respect and provided assistance when needed. On reviewing the medication system two discrepancies were noted on the Medication Administration Record (MAR) sheets whereby staff had not signed for medication. In one instance tipex had also been used on the MAR sheet to blank out initials, which is poor practice and must not be allowed to happen again. No stock control system was in place for medication administered on a PRN (as and when required) basis and a lock still requires fitting to the fridge used for the storage of medication as required in the last inspection visit. The manager confirmed that all senior staff had recently received training from the local pharmacist on the safe storage and administration of medication and there is a medication policy and procedure document in place. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 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 quality in this area is adequate. This judgement has been made using available evidence including a visit to the home. Residents are encouraged by the staff to make informed decisions and choices about their daily lives for as long as it is practical for them to do so. However, the staff must ensure that the present level of leisure/social activities arranged for the residents is maintained and provide them with a stimulating environment. The quality of food is satisfactory. Catering staff are experienced and try hard to meet the residents’ preferences. EVIDENCE: The manager confirmed that the recently appointed activities co-ordinator is due to leave the home in the near future and until a new a person is appointed the care staff will be responsible for arranging activities and outings for the residents. Concerns have been raised in the past about the lack of appropriate leisure activities organised for the residents therefore it is important that a new activities co-ordinator is appointed as soon as possible. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 14 The daily routines of the home appear flexible and resident confirmed that they are encouraged to make as many decisions as possible about their daily lives. Residents also confirmed that they were able to receive relatives and friends in their own rooms if they wish to do so and that visitors were always made to feel welcome and offered refreshments. There were no visitors to the home during the visit therefore it was not possible to establish their opinion of the service. The residents confirmed that the meals provided were good and they were always offered an alternative if they did not like what was on the menu. The cook on duty had only been employed for a short period of time but appeared to have a good understanding of the resident’s dietary needs and tried hard to meet the personal preferences. There is a choice of meals at both lunch and teatime and although not large the portions seen at lunchtime were satisfactory and the food appeared to be enjoyed by all the residents. Aids such as plate guards were being used by some residents to help them maintain their independence whilst eating and staff were observed to offer support and assistance to residents as and when required. When reviewing the kitchen facilities three meals were found plated up in a unused hot cupboard one of which had gone mouldy. Action is therefore required to ensure that all cooked food is stored appropriately and in line with good practice guidelines. Hot and cold drinks are freely available to the residents throughout the day. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this area is adequate. This judgement has been made using available evidence including a visit to the home. There has been an improvement since the last inspection. The home is working towards creating a culture where residents and/or relatives can be confident that complaints and/or concerns will be taken seriously and their rights protected. EVIDENCE: There is a complaints procedure, which is on display within the home and in the service user guide. As previously mentioned in this report one anonymous complaint received by the Commission was discussed with the registered provider and manager as part of the inspection process and found to be unsubstantiated. Previous inspections have identified reluctance on the part of residents and relatives to raise complaints/concerns with the home because they felt that they would not be listened to or the matter addressed. However it is acknowledged that the manager is working towards creating a more open and inclusive culture at the home, which encourages residents, relatives and visitors to express their views and opinions of the service. Adult protection policies and procedures are in place and a number of staff including the manager have recently attended an adult protection-training Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 16 course. All other members of staff are registered to attend the same course and are just waiting for dates. At present there continues to be ongoing adult protection investigations at the home, which have yet to reach a satisfactory conclusion. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 17 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, 24, 25 and 26 Quality in this area is poor. This judgement has been made using available evidence including a visit to the home. The home continues to require extensive refurbishment, both to improve the residents’ quality of life and to ensure that their health and safety is not compromised. EVIDENCE: Internally the home continues to require extensive refurbishment and following the last inspection the registered provider was required to provide the Commission with a planned programme of refurbishment work by the 31st May 2006. This timescale was not met. However the week following this inspection the provider did supply the Commission with a schedule of work and although some clarification is still required, the timescales for completion have been accepted. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 18 The Commission still require confirmation that work highlighted by the Fire Safety Officer has been completed in line with his recommendations. All the communal areas are on the ground floor and consist of four lounges, one of which is a designated smoke lounge and a dining room. The dining room would benefit from decorating and although a temporary repair has been made to the floor covering it still requires replacing. The dining room tables and the coffee tables in the lounge area also require replacing as highlighted in previous inspection reports. Bedrooms are situated on all four floors of the home and consist of both double and single rooms. Many of the rooms require refurbishing and old furniture replacing. A number of seals have gone in double glazed units in the bedroom windows and therefore require replacing. The standard of bedding/pillows in some rooms was found to be poor with thin/worn sheets and lumpy pillows on beds. The carpet on the main staircase is threadbare in places and requires replacing as part of the refurbishment programme. No tube was in the fluorescent light at the top of the stairs, which must leave the staircase dark during the night and pose a possible risk of residents falling. This was mentioned to the manager at the time of the visit and she confirmed that the matter would be sorted out the same day. Call alarms are located in all bedrooms, however the alarm only sounds on the ground floor of the building and not on every floor, which means that if staff aren’t working on the ground floor they won’t be aware that a call bell is ringing. The present intercom system also allows staff to speak to residents in their rooms but could compromise their right to privacy. Changes must therefore be made to the system as part of the refurbishment programme. A strong smell of urine was noted in two bedrooms and in at least three rooms there was no soap or hand towels for the residents to use. In one bedroom on the top floor the water pressure to the hot water tap was very poor and the cold-water tap was not working. The home has in the past experienced problems relating to poor water pressure to the upper floors of the building and it would appear that these problems have not yet been fully rectified. A window restrictor requires fitting to a bedroom window on the first floor. Risk assessments should be carried on all other restrictors in place to ensure that they are fit for purpose and open to an appropriate width. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 19 The home was re-wired in 2005, however the provider has still not provided the Commission with a copy of the test certificate. All portable electrical appliances still need testing as required in the last inspection report. The kitchen is located on the ground floor of the home and following a recent visit from the Environment Health Department a number of requirements and recommendations were made and acted on. However, the kitchen area still requires a deep clean, decorating and more effective fly screens fitting to the windows. The laundry is located on the lower ground floor away from the areas used by residents. The laundry room still requires decorating and a new impermeable floor covering as part of the refurbishment programme. As the home still does not have a sluice and the washing machines do not have a sluice programme there continue to be high risk of cross infection occurring. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The quality in this area is adequate. This judgement has been made using available evidence including a visit to the home. Staffing levels are at a minimum with little cover available for staff sickness and/or annual leave without employing agency staff. There continued to be shortfalls in the recruitment process and the lack of robust procedures puts residents at risk. There now appears to be more emphasis placed on staff training and a commitment to having a staff team qualified to NVQ standard. EVIDENCE: The staff rota showed that on day duty the home continues to just meet the minimum staffing level. The requirement for three night staff to be on duty at all times is being maintained with the use of agency staff if necessary. There are presently sufficient cleaning staff employed, however the manager was reminded that should the number of residents increase significantly the cleaning hours must be reviewed in line with the needs of the service. No new members of staff had been employed since the last inspection visit. However, the employment file for the activities co-ordinator appointed by the registered provider is still not available in the home and the manager Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 21 confirmed that she had not had sight of it. Criminal Record Bureau checks have still not been carried out for three care assistants who have worked at the home for a considerable period of time. The manager confirmed that all new staff receive induction training and additional training, both to meet the needs of the residents and for selfdevelopment, is encouraged. There appears to have been an increase in the level of training made available to staff and the manager confirmed that she was in the process of planning a training programme for 2006/07, which will be made available to the Commission. Staff said that they were happy with the level and quality of training provided and felt well supported by the manager. In addition to the training course presently being arranged by the manager there is also an expectation that all members of care staff will achieve a National Vocational Qualification (NVQ) at level two (or equivalent), although at the present time only approximately 25 of the staff team have achieved the award. The manager is however in discussions with a local college and it is anticipated that further staff will commence NVQ training in the near future. The manager and staff confirmed that they receive a minimum of three paid days training per year. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, and 38 The quality in this area is poor. This judgement has been made using available evidence including a visit to the home. The manager is trying to create a more open and inclusive approach to the management of the home however there appears to be lack of accountability and/or clear channels of communication between the registered provider and manager. Until this matter is addressed and the management of the home demonstrate a genuine commitment to working with the Commission and other professional agencies it is difficult to see how the quality of the service will improve without external pressure being applied. There are no quality assurance systems in place although the manager is currently setting up processes to actively seek the views/opinions of residents, relatives etc Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 23 EVIDENCE: Mrs Linda Mumbley remains the manager although no application has yet been received by the Commission for her to become the registered manager. Mrs Mumbley has many years experience in the caring profession but has still to achieve a National Vocational Qualification at level four in management and care. The manager has an open and approachable management style and residents confirmed that she is kind and caring. The registered provider also works within the home on a daily basis and therefore one would expect that there would be clear lines of communication between the two. Unfortunately this does not always appear to be the case. It became apparent during the course of the inspection that although the last inspection report had been received by the home neither the registered provider or manager had actually read it. In addition, the pre-inspection questionnaire sent out by the Commission had not been returned and no response had been received to a recent letter requesting timescales for completion of outstanding fire safety work. A discussion was held with the registered provider and manager regarding the above and the need for them to work with the Commission to improve standards. The manager ensures clear channels of communication within the home by holding regular staff meetings and formal one-to-one staff supervision. There are currently no quality assurance monitoring systems in place although the manager is currently addressing this matter. A resident/relative meeting was arranged as part of the quality assurance process but unfortunately it was very poorly attended. Residents and/or relatives are encouraged to take control of their financial affairs if at all possible although the home still hold money in safekeeping for some residents. Only senior staff deal with the residents’ finances and transaction sheets are available showing income, expenditure and a balance. However, concerns were raised about the transaction sheets not being up to date and as this was highlighted in the last inspection report steps must now be taken to address this matter. Receipts are always obtained for purchases made by staff on behalf of residents and for some residents new Post Office instant saver accounts are currently being opened Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 24 Policies and procedures are in place to ensure the health and safety of the residents, however, it was noted that additional risk assessments require completing both for the environment and to ensure safe working practices. Information supplied by the home also indicates that the central heating system at the home has not been serviced and no test certificate was available. The manager must therefore forward a copy of the test certificate to the Commission or arrange for the system to be inspected as soon as possible. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 25 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 2 3 2 X 1 2 1 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 2 X 2 3 X 2 Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 4 -- 5 Requirement The manager must ensure that the home’s statement of purpose and service user guide are reviewed on a regular basis. The manager must ensure that the care plans in place are specific to the needs of the individual resident. Timescale for action 31/08/06 2 OP7 15 31/07/06 3 OP8 12 13 4 OP9 13(2) 31/07/06 The manager must ensure that nutritional screening is undertaken on admission and subsequently on a periodic basis. Residents must be weighed on a regular basis and the information recorded. Risk assessments and moving and handling plans must be completed and/or accurately reflect the individuals needs The manager must ensure that all medication is signed for appropriately on the MAR sheets. Tipex must not be used on MAR sheets under any circumstances. 31/07/06 A stock control system must be implemented for PRN medication. A lock is required to the fridge DS0000061674.V297905.R01.S.doc Version 5.2 Page 27 Silverlea Residential Home 5 OP15 16 6 OP19 23 7 OP19 23 8 OP20 23 9 10 OP20 OP22 23 23(2)© used for storing medication. The manager must ensure that all cooked food is stored appropriately and in line with good practice guidelines. The registered provider must refurbish the following areas of the home: 1) Second Floor – Corridors and staircase leading to first floor. 2) First Floor – Corridors and staircase leading to ground floor. 3) Ground Floor – Entrance and dining room. 4) Lower Ground Floor – Corridors and staircase leading to ground floor. 5) Bedrooms – As required throughout the building. 6) All work highlighted by the Fire Safety Officer must be included in the refurbishment programme. The kitchen requires a deep clean and decorating. More effective fly screens require fitting to the kitchen windows. The dining room tables and coffee tables must be replaced. Requirement outstanding from the last three inspection reports – timescales 31/03/05, 31/12/05 and 31/05/06 not met. The floor covering in the dining room requires replacing. The emergency call system requires servicing and a copy of the test certificate forwarded to the Commission. Sounders must be provided on all floors Requirement outstanding from the last two inspection reports – timescale 31/08/05 and 31/05/06 not met. Alterations to the present system DS0000061674.V297905.R01.S.doc 31/07/06 12/11/06 31/08/06 04/08/06 12/11/06 31/08/06 Silverlea Residential Home Version 5.2 Page 28 11 OP24 23 12 OP24 16(2) 13 14 OP24 OP25 13(4) 23 15 16 OP25 OP25 23 23 17 OP26 23(2)(k) 18 19 OP26 OP28 23 18 are also required to respect the residents right to privacy. Outstanding from last inspection report – timescale 31/05/06 not met. All double glazed window units must be replaced as required. Outstanding from last three inspection reports – timescales 31/03/05, 31/12/05 and 31/05/06 not met. New bedding and pillows must be purchased as required. Requirement outstanding from last inspection report – timescale 31/05/06 not met. The manager must ensure that appropriate window restrictors are fitted to all windows. A copy of the new electrical wiring certificate must be forwarded to the Commission. Requirements outstanding from the last two inspection reports – timescales 31/08/05 and 31/05/06 not met. All portable electrical appliances must be tested annually. Second Floor Bedroom (identified to manager) – The hot and cold water supply must be restored to this room. The laundry area requires refurbishing and a new impermeable floor covering. A sluicing facility must be provided at the home. Requirement outstanding from the last three inspection reports – timescale 31/08/05, 31/12/05 and 31/05/06 not met. All areas of the home must be kept free from offensive odours. The manager must ensure that at least 50 of the care staff DS0000061674.V297905.R01.S.doc 31/08/06 31/07/06 31/08/06 12/07/06 31/08/06 31/07/06 15/09/06 15/06/06 31/12/06 Page 29 Silverlea Residential Home Version 5.2 20 OP29 19 21 22 OP31 OP31 9 10 23 24 25 OP33 OP35 OP38 24 17(2) 13(4) 26 *RQN 24(a) team achieve a NVQ at level two or above. The manager must ensure that the employment files for all members of staff are available for inspection. Criminal record Bureau checks must be completed for all members of staff. The manager must achieve a NVQ at level four in management and care (or equivalent). The registered provider and manager must establish clear channels of communications and accountability. The manager must continue to develop effective quality assurance monitoring systems. The manager must ensure that all financial transaction sheets are up to date. The manager must ensure that risk assessments are completed/updated for the premises and to ensure safe working practices. A copy of the test certificate for the central heating system must be forwarded to the Commission. The registered person must produce a plan (the improvement plan) setting out methods by which, and the timetable to which, the registered person intends to improve the services provided in the care home. 31/07/06 31/12/06 31/07/06 30/09/06 31/07/06 31/08/06 14/08/06 Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 30 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 Refer to Standard OP7 OP23 Good Practice Recommendations It is recommended that the manager reviews the current care planning system and make it more user friendly. It is recommended that the manager carry out a risk assessment to ensure that the window restrictors in place are fit for purpose. Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Silverlea Residential Home DS0000061674.V297905.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!