Inspection on 21/01/08 for Silverlea Residential Home

This inspection was carried out on 21st January 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 18/07/07

Silverlea Residential Home 20/02/07

Silverlea Residential Home 15/06/06

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 10:00 21st January 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.V358550.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.V358550.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 Vacant post 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.V358550.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 2007 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 to thirty-five people in both single and double bedrooms, situated on all four floors of the building. There are steps to the front of the home however level access is available to the rear of the property and there is a passenger lift to all floors. Externally there is a patio area to the front of the property, which people 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.V358550.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is One Star. This means the people that use the service experience adequate quality outcomes. This unannounced inspection was carried out over three days between 10am and 5pm on the first two days and between 10am and 12midday on the third day. The registered provider and manager were present on all three days. When we last did a full inspection in July 2007 we were concerned that the home was not meeting people’s needs in a number of areas. Following that visit we issued 2 statutory requirement notices telling the provider what he must do to improve the environment and the care plans. Since July 2007 we have had a number of meetings with the provider to discuss his improvement plans and we have visited the home twice to check on progress on specific areas. The purpose of this visit was to look at all areas of the service, to check if the improvements are continuing and to assess the impact of any changes on the quality of life experienced by people living at the home. To help us with this we were accompanied on the first day by an “expert by experience” from the organisation Help the Aged. An “expert by experience” is a person who, because of their shared experience of using services, is able to help us get a better picture of what it is actually like for people using services. During the visit the expert looked around the home and spoke to some of the people living there. The feedback she gave us has been incorporated into this report. During the visit we spent some time observing how people are cared for, we looked at records, talked to people living at the home and their relatives and looked around the building. Survey questionnaires were also sent out to relatives, staff, and other healthcare professionals so that they could share their views and opinions of the service with us. Eight relatives, two staff and two healthcare professionals returned the questionnaires and the information they provided has been used as evidence in the body of the report. What the service does well: Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 Page 6 The manager and staff create a warm and friendly atmosphere and treat everyone as individuals. Comments from questionnaires returned by relatives included the following “all the staff are efficient, warm, caring and kind” and “there is always a friendly feeling when you visit – staff are very helpful and caring, making it feel like home.” What has improved since the last inspection? The manager is due to due to start the Registered Manager’s Award in March 2008, which is the recognised management qualification for the post she holds. Sufficient staff are now employed on day and night duty to meet the needs of the people living at the home. The manager is now supernumerary to the staff rota and therefore is able to spend more time carrying out managerial responsibilities and supporting staff. There are clearer lines of communication and accountability between the registered provider and manager, although more work is still required before the home is managed effectively. The provider is also proving us with a monthly written report on the conduct of the home as required under Regulation 26 of the Care Homes Regulation 2001. There is now a system in place for staff supervision and as the manager is now supernumerary she should be able to make sure staff get regular supervision and arrange staff meetings. This will help to make sure staff get the support they need to meet people’s needs. The staff recruitment and selection procedure is now being followed. Staff are not employed until all relevant checks have been made to make sure they are safe to work with vulnerable people. A part time training officer has been appointed and a training programme has been put in place. More emphasis has been placed on making sure staff achieve a National Vocational Qualification (NVQ) at level two or above. This shows that the home is committed to ensuring that people who use the service are cared for and supported by a trained and skilled workforce. Work is continuing to make sure that the care plans address all areas of need including personal, health, and social care. The recording and storage of personal information relating to staff or people living at the home has improved and confidentiality is now maintained. A significant proportion of the refurbishment work as been completed making the environment more pleasant for people. Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Silverlea Residential Home DS0000061674.V358550.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.V358550.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 5 – Standard 6 is not applicable to this service. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People do not have up-to-date information to help them make a decision about moving in. People’s needs are assessed and they can visit or stay for a trial period to make sure that the home is right for them. EVIDENCE: Some improvements have been made to the service user guide. However, it still does not provide people with sufficient information on the care and facilities provided to enable them to decide if the home can meet their needs. Following our last visit the owner agreed to stop admitting new people to the home until improvements are made. We agreed that people who had already planned to come in for respite care could be exempted from this agreement. The records we looked at showed that people’s needs had been assessed before they moved in. Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 Page 10 The manager confirmed that people are always invited to visit before admission so they can look round, meet the staff and people already living there and stay for a meal, this helps them decide if they want to move in. One questionnaire returned by a relative made the following comment “the initial visit to the home was helpful and informative.” People are able to move into the home for a trial period so that they can experience at first hand the standard of care and facilities provided. Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, and 10 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Improvements have been made in the way people’s care needs are met. However, more needs to be done to make sure that all people’s health care needs are identified and dealt with. EVIDENCE: We looked at four people’s care records. Everyone living in the home has a care plan. Work is continuing to make sure that the care plans address all areas of need including personal, health, and social care. The care plans about personal care show that people are encouraged to maintain their abilities and do what they can for themselves. The plans dealing with health care show that the home is working with community based health care staff to address people’s needs in this area. This includes the community matron, community psychiatric nurses, and the district nurses. Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 Page 12 Questionnaires returned by two healthcare professionals showed that the home always seeks advice to manage and improve individual’s health care and people’s needs are usually met. Comments included “staff are very well informed of residents’ care and health needs and communicate this to all professionals” and “the care standards appear to have improved and liaising with the district nursing team has certainly improved.” We did not see much evidence that people, or those close to them, are involved in developing the care plans. However, people who were able said that they were generally pleased with the care and attention they received. Comments included “the staff are kind and caring” and “if I feel unwell the staff always contact the doctor and arrange a visit.” The nutritional assessment used by the home does not measure Body Mass Index (BMI). The BMI is a recognised tool used to determine if people’s weight is within the normal range or if they are at risk of being under or over nourished. The records show that 29 of the people living in the home weigh less than 7 stone (approx 44kgs) and this is a cause of concern. We have spoken to the manager about this during previous visits. One person’s records showed that he has lost a significant amount of weight in a relatively short time. The home is recording his weight more often and has started food charts to record everything he eats and drinks. However, when we looked at the food charts we saw that there were often long spells when he either had nothing or just a cup of tea. Typically this was between the evening meal, which is served at about 4.30pm, and breakfast, which he usually has around 9.00am. The food charts for another person showed a similar picture. Although the care plans say people should be given extra snacks between meals this is not happening in practice. When we checked the kitchen we saw that there is enough food and items such as teacakes are purchased so that people can have something more substantial than a biscuit at suppertime, (8.00pm). We were also concerned about the portion sizes; the home uses very small dinner plates. While some people may prefer smaller portions this may not be enough for everyone. The manager said she is dealing with this and has ordered standard size dinner plates. We looked at how medication is dealt with and found that people are getting their medicines as prescribed. Questionnaires returned by relatives showed that they are generally pleased with the standard of care provided and are kept informed of any significant changes in their relative’s condition. Silverlea Residential Home DS0000061674.V358550.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People who use this service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Little is being done to provide people with a range of appropriate social and leisure activities both within the home and the wider community. EVIDENCE: Most people’s care records have some information about their interests, preferences, and past lives. However, this is not being used to draw up individual social care plans with the result that people’s social needs are often overlooked. For example we saw in one person’s records that they enjoyed the company of other people but this person spent most of their time in a lounge where there was no one else they could speak to. The activities records show that there is very little going on in the home for people. There was an entertainer in November last year but since then there has been little other than occasional individual activities. The activities programme that we saw focused mainly on hairdressing, this was listed as an activity for four out of seven days. Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 Page 14 There was little evidence to suggest that people are encouraged to follow their religious beliefs although the manager confirmed that people would be assisted to attend places of worship if they wished to do so. No one has specific responsibility for organising social activities and therefore it is left to care staff to do what they can when they have time. The home has a number of different lounges and most people spend their days in one of these communal rooms. The main lounge tends to be the busiest, more people use this room, and if there are activities they are usually in the main lounge. During the visit we spent some time in one of the other lounges looking at how the people in that area are cared for. We found that the people there had little or no social stimulation. Staff only had contact with this group of people when there was a task to do, for example serving the afternoon tea. We saw that there were some missed opportunities for staff to talk to people. For example, staff came into the room on more than one occasion and walked out again without speaking to anyone there. The manager agreed that the people in this lounge do not get enough attention and said she would address this. We had a lunch at the home and the food was very well cooked and there was a choice of two main courses. The only negative comment was that there was a lack of appropriate crockery and there were no serviettes available, which meant that people having problems eating were unable to wipe their mouths. Silverlea Residential Home DS0000061674.V358550.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Thorough complaint and adult protection policies and procedures make sure that individuals are listened to and protected from any form of abuse. EVIDENCE: There is a clear complaints procedure in place and feedback from people living at the home and their relatives shows that they would have no problem approaching the manager if they had any concerns about the standard of care provided. Questionnaires returned by relatives also showed that they are aware of the complaints procedure and with one exception confirmed that the home had responded appropriately to any concerns they had raised. This means that the home is listening to people and taking their concerns seriously. The complaints records showed that the home has not had any complaints since July 2007. Adult protection policies and procedures are in place and all staff receive training on the recognition and reporting of abuse. Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical environment has improved but the refurbishment programme must be completed to make sure that people live in a safe, comfortable and well maintained home. EVIDENCE: In September 2007 a Statutory Requirement Notice was served on the provider relating to the fitness of the premises. The timescale set for the completion of the refurbishment programme was the 30 November 2007. On the 26 November 2007 we received a request from the provider to extend the date until the 31 January 2008 to which we agreed. Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 Page 17 On the third day of this inspection we looked around all areas of the building to assess compliance with the statutory requirement notice. We found that a significant proportion of the works specified in the notice had been completed. Double glazed window units have been replaced, the main stair carpet has been replaced and new laminate flooring has been fitted in the dining room. The staircase, lower ground floor corridor, ground floor corridors and entrance hall have been redecorated and appropriate locks have been fitted to all the bedroom doors. New bedroom furniture has been ordered. The front lounge has had new patio doors fitted and the office equipment and furniture that was previously stored in this room has been removed making the environment more pleasant for people. The main area of work outstanding is the redecoration of bedrooms and the communal areas. However, three decorators have now been employed to complete these works and we saw the progress they were making with bedrooms on the first floor. The provider also informed us that when these works are completed all the bathrooms and toilets will be redecorated. Locks still require fitting to at least two toilet/bathroom doors to ensure privacy. The provider informed us that all these works will be completed by May 2008. We will be undertaking further visits to ensure that progress is being maintained. The laundry still requires decorating and a new impermeable floor covering needs to be fitted. However staff can now access the sluice room without going through the laundry, which reduces the chance of cross contamination. Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are protected by the recruitment and selection procedures. There is a commitment to staff training and to ensuring that people receive the standard of care and support they require. EVIDENCE: The staff rota showed that sufficient staff are now employed on day and night duty to meet people’s needs. However, both questionnaires returned by staff indicated that they felt more auxiliary staff needed to be employed so that they could spend more time with people and less time undertaking laundry and domestic duties. The manager is now supernumerary to the staff rota and therefore is able to spend more time carrying out managerial responsibilities and supporting staff. At the last inspection we were concerned that although staff recruitment and selection procedures were in place they were not being followed and therefore staff unsuitable to be work with vulnerable adults might be employed. Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 Page 19 However, on reviewing the employment files of three recently appointed staff it is apparent that the manager has now addressed this matter. Staff are now only employed after all the relevant checks have been made and two satisfactory written references received. The home has recently employed an external agency to review the recruitment documentation and provide staff with new contracts of employment and a staff handbook. The home continues to employ a part time clerical assistant to assist the manager and has also recently recruited a part time trainer so that more inhouse training can be provided. The manager confirmed that the appointment of the clerical assistant and trainer has had a positive impact on the service and enabled her to delegate some of her workload. New staff receive induction and foundation training following the Skills for Care Common Induction standards and there is then an expectation that they will study for a National Vocational Qualification (NVQ). Currently about 33 of care staff have achieved a NVQ at either level two or three depending on the post they hold. The training plan provided shows that the remaining staff will either have achieved the award or be registered on the course within the next six months. This shows that the home is committed to ensuring that people who use the service are cared for and supported by a trained and skilled workforce. Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Management of the home has improved which benefits people living in the home. However these improvements must be maintained and developed to make sure the home is run in the best interests of the people who live there. EVIDENCE: Mrs Jean Marlow was appointed manager of the home in February 2007 although she is not yet registered with us. The home has been without a registered manager since October 2005. Mrs Marlow has many years experience in the caring profession and this is the second time she has managed Silverlea Care Home. Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 Page 21 Mrs Marlow has not yet achieved a NVQ level four in management and care (or equivalent), however she is due to start the course in March 2008. At previous inspections concerns have been raised about the lack of communication and accountability between the registered provider and manager, which was affecting the overall management of the service. This appears to have been resolved to some extent and formal monthly meetings are now held. The provider is also proving us with a monthly written report on the conduct of the home as required under Regulation 26 of the Care Homes Regulation 2001. We do still have concerns that the provider is not pro-active and continues to only make improvements to the service when directed to do so by us or other statutory authorities. This lack of commitment has a detrimental effect on the day-to-day management of the home and is not in the best interest of people using the service. Some quality assurance systems have been put in place although the manager needs to develop the systems further before they are effective. The home sent surveys to health care professionals and relatives in August 2007. Seven were returned. Overall the responses were positive and several people commented on how friendly the staff are. One person said, “Very friendly and always appear to make residents and visitors feel at ease”. The systems for monitoring the quality of the service need more work so that the home is able to identify areas of good practice and areas for improvement. This was discussed with the manager and the owner. There is now a system in place for staff supervision. Six out of seven staff files looked at had evidence of supervision; most people have had two supervisions in the past six months. The manager is now supernumerary therefore she should be able to make sure staff get regular supervision. This will help to make sure staff get the support they need to meet people’s needs. People living at the home continue to be encouraged to take control of their financial affairs if at all possible although the home still holds money in safe keeping for some people. On reviewing the records we found that the transaction sheets were up to date and people now get their personal allowances on the date it is due. There has been a general improvement in record keeping and information about staff and people living at the home is now up to date and held securely on the premises. Policies and procedures are in place to safeguard the health and safety of the residents, visitors, and staff. However, additional risk assessments still need to be carried out for the building and to make sure staff follow safe-working practices. Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 3 3 2 Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 Page 23 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 service user guide must be updated so that people are provided with sufficient information to decide if the home is right for them. Outstanding from last inspection - timescale 30/04/07 and 30/09/07 not met. People experiencing weight loss must be offered and encouraged to eat additional nutritious food at regular intervals. So that their weight is maintained within the normal range. People must be offered a range of appropriate social and leisure activities so they have the opportunity to lead a full and active life. Outstanding from last inspection – timescale 30/09/07 not met. The following areas of the home must be refurbished: Bedrooms - Redecorating, Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 Page 24 Timescale for action 31/03/08 2. OP8 13 31/03/08 3. OP12 16(m) 31/03/08 4. OP19 23 31/05/08 refurbishment including replacing old and/or worn furniture. Communal areas - Refurbish as required including replacing all old furniture. All work highlighted by the Fire Safety Officer must be included in the refurbishment programme. 5. OP21 23 All bathrooms and toilets must be decorated as part of the refurbishment programme and locks fitted as required. Outstanding from the last inspection – timescale 30/11/07 not met. 31/05/08 6. OP25 13 7. OP31 9(2)(i) 8. OP31 9 To safeguard people radiator 31/03/08 guards must be fitted to all radiators throughout the building unless they have guaranteed low temperature surfaces. Outstanding from the last inspection – timescale 30/11/07 not met. The manager must obtain a 31/08/08 recognised management qualification equivalent to NVQ level 4, to evidence she has the qualification and skills to manage the home effectively. Outstanding from the last inspection – timescale 31/12/08 not met. The manager must apply to the 29/02/08 Commission for registration. Outstanding from the last inspection – timescale 31/08/07 not met. Effective quality assurance monitoring systems must be established and maintained. Risk assessments must be DS0000061674.V358550.R01.S.doc 9. OP33 24 12/02/08 10. OP38 13(4) 31/03/08 Version 5.2 Page 25 Silverlea Residential Home completed/updated for the premises and to ensure safe working practices. Outstanding from the last inspection – timescales 30/04/07 and 31/08/07 not met. 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 Nutritional assessments should include a Body Mass Index (BMI) to make sure that people’s weight is within the normal range, or if they are at risk of being under or over nourished. It is recommended that the laundry area is refurbished and a new impermeable floor covering fitted. 1. OP26 Silverlea Residential Home DS0000061674.V358550.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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