Inspection on 29/05/06 for Silverwood Care Centre

This inspection was carried out on 29th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Silverwood Care Centre 10/04/07

Silverwood Care Centre 01/10/05

Silverwood Care Centre 06/06/05

Silverwood Care Centre 07/02/05

Silverwood Care Centre 30/09/04

Silverwood Care Centre 25/03/04

Silverwood Care Centre 01/07/03

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

CARE HOMES FOR OLDER PEOPLE Silverwood Care Centre Flanderwell Lane Sunnyside Rotherham South Yorkshire S66 0QT Lead Inspector Ms Rosemary Reid Key Unannounced Inspection 29th May 2006 11:30 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 Silverwood Care Centre DS0000003088.V290470.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. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Silverwood Care Centre Address Flanderwell Lane Sunnyside Rotherham South Yorkshire S66 0QT 01709 532022 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) Modelfuture Limited, Post Vacant Care Home 64 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (33) of places Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Both Units must have separate staff groups One specific service user under the age of 65, named on variation dated 07 July 2004, may reside at the Home. 1st October 2005 Date of last inspection Brief Description of the Service: Silverwood Care Centre was part of the Ashbourne group, which has been taken over by Southern Cross earlier this year. Silverwood Care Centre is a purpose built home providing personal care for up to 64 older people. It has accommodation over 2 floors connected by staircases and 2 lifts. All the rooms are single and have en-suite toilets. The home is internally compartmentalised into 2 units Minewood and Shaftsbury. An application has been received by the CSCI to change registration to increase bed numbers to the care of people with dementia and reduce number of places of the residential provision, which will have the effect of having three units. The first floor accommodates up to 33 older people, the ground floor up to 31 older people with Dementia. Each unit has dedicated staff, accommodation and activities. Both levels have access to secure gardens. A central kitchen and laundry serves the home. Silverwood Care Centre is located in the residential area of Sunnyside, a suburb of Rotherham. The home is on a bus route bus numbers 3, 4 and 10 and within a short walking distance of bus stops. The home has a car park to the front of the building. Fees for Dementia Care are £370 - £435 and Residential £329 - £375 and Respite care £340 – 375 dependent on needs assessment as at 1st April 2005 and additional charges are made for hairdressing from £5:50, Chiropody from £10:00, Optical, Dental services, specialised toiletries and magazines etc. The registered person makes information about the service available to residents and their families via the home’s Statement of Purpose and the Service User Guide. A copy of the inspection report is made available at the home. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on the 29th May from 11:10am to 3:40pm to assess National Minimum Standards for Older People and speak with visitors to the home and on the 30th May from 8:00am – to 2:00pm for further assessment and to speak with the manager. A further visit was arrangement to visit on the 27th June at 7pm to meet with relatives at their support group. This was the first visit to the home by this inspector. The inspection focused on the requirements from the previous inspection of 1st October 2005, six residents’ files were case tracked along with the key standards of the National Minimum Standards for Older People and four staff records were also assessed. The appointed manager is Mrs Shelagh Bell who is working towards completing the Registered Managers Award. Action had been taken on all of the requirements from the previous inspection. The home had been previously owned by Ashbourne Care, which has been taken over in recent times by Southern Cross. The home is in a transitional stage with both administration systems and care plan formats. Six residents files (three from the dementia unit and three from the residential unit) were cased tracked. Each file examined had assessments, pressure care, and care plan, daily recording with the exception of monthly recording since February 2006. Supporting documents were also seen for example home’s desk diaries, medication records, staff files and Health & Safety records. Four staff files were also assessed. The home has two activities organisers and a lively activities programme with a monthly magazine published. All residents in both levels of the home were observed and many were spoken with. However, the residents in the dementia unit, due to their diagnosis of dementia they could not always give their personal views of the delivery of service. One visitor to the home was interviewed who spoke about the home in positive terms. The inspector spoke with five staff members, two senior care and the manager over the two visits. A tour of the premises/environment/front and rear gardens showed that on going maintenance work has been undertaken. Feedback of the inspection was given to the Miss Bell, the appointed manager. Fourteen survey satisfaction feedback cards and pre-paid envelopes were left at the home for the residents or relatives to make their comments were left at the home (seven for the dementia unit and seven for the residential unit). Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 6 Nine feedback cards had been returned to the Doncaster office, which confirmed that these people were overall satisfied with the delivery of service. What the service does well: What has improved since the last inspection? What they could do better: The domestic team was observed working extremely hard and the home was seen to be clean and tidy. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 7 However, although the domestics were cleaning the carpets there were problems with odour control throughout the home on the first visit and no offensive odours on the second visit to the home. All staff must ensure that all spillages or accidents are cleaned as soon as possible. The manager started to undertake to do staff supervision sessions and appraisals however, did not continue the supervision sessions. Staff must have formal supervision sessions and annual appraisal with records kept. Care plans had been routinely reviewed on a monthly basis until February 06 and then had not been reviewed since that date. Annual reviews are planned to be undertaken. Improvements have taken place with the storage of medications along with training of senior staff for the administration of medication, which is in the final stages of completion. However, records of administration were assessed and some senior staff did not always sign the record after administrating the medication. The home has thirty-three care staff with only three staff members that have NVQ level 2 above. Seventeen staff members have been enrolled on the NVQ level 2 course but have not started the course at this time. In the past staff have been enrolled and worked towards achieving the NVQ awards however, then the training company went into bankruptcy. 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. Silverwood Care Centre DS0000003088.V290470.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 Silverwood Care Centre DS0000003088.V290470.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): 3, 6 Quality in this outcome area is good, and this judgement has been made using the evidence available. Service users and prospective service users have up to date information regarding the registered provider. An assessment of need is undertaken and all service users have a contract/statement of terms and conditions of residency, which safeguards their legal rights. Intermediate care is not provided in Silverwood however, the service offers short stays and respite care. EVIDENCE: The service has developed a Statement of Purpose and the Service User Guide; both have gone to head office for updating due to the recent take-over. In discussions with service users, family and staff confirm that previously the Service User Guide had been given to prospective service users and/or relatives. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 10 The six service users’ files that were case tracked had copies of contract/statement of terms and conditions of their residency and delivery of care. Records show that Pre-admission assessment is undertaken and this was recorded within the individual service user’s care file to ensure that the home can meet their needs. Records show and in discussions with service users and families confirmed that the home welcome visits before admission to assess the quality, facilities and suitability of the home. The home does not offer intermediate care. There was evidence that respite care provision is used. Silverwood Care Centre DS0000003088.V290470.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): 7,8,9,10,11 Quality in this outcome area is adequate, and this judgement has been made using the evidence available. Arrangements for dealing with resident’s health issues are adequately met by staff at the home, with support from health professionals, and care planning systems are sufficiently detailed to enable staff to deliver the care to residents who have specific identified needs and promoting good health. A number of senior staff are not working to the organisations policies and procedures for administration of medication. EVIDENCE: Care plans were case tracked and six care plans were examined. Care plans are currently being changed to the new Southern Cross format. Care plans were reviewed monthly until February 2006 and have not been reviewed since. There is evidence within individual residents’ care plans that consideration is given by staff to the areas of race, ethnicity, sexuality, gender, disability and belief. There have been improvements to the storage of medications. temperature of the fridge for medications is taken and recorded. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 The Page 12 Senior care staff administer medicines to the residents and have undertaken training on the Administration of Medications. Records for the administration of medications were assessed, not all senior staff are working to the company’s policies and procedures or good practice in that senior staff are not always signing the records at the point of administrating the medications. Records were examined and discussion with the staff confirmed resident’s healthcare needs are met. District nurses also attend the home to carry out injections, take bloods and attend to dressings for residents. The unit diaries were assessed which showed that appointments to hospital, reviews are recorded and there is a good system in place to remind residents and staff to ensure appointments are not missed. There were many examples of good practise observed on the day, good interactions between staff, residents and a visitor. Most residents were referred to by their first name and this was with the approval of residents and recorded in their care plan. Staff were observed to actively promote independence but residents were given respect and dignity when staff were giving any aspect of care. On each bedroom door has a picture of the resident, their name and the name of their key worker. The home will contact the spiritual advisor of the individual resident’s choice and the wishes of the individual resident with regard to their arrangements they want after death are discussed and recorded. It is also recorded if the resident does not want to discuss this matter. Silverwood Care Centre DS0000003088.V290470.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): 12,13,14,15 Quality in this outcome area is excellent, and this judgement has been made using the evidence available. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets resident’s tastes and choices. Social interaction and the activities programme provided stimulation and interest for residents. EVIDENCE: Ten residents were spoken with and everyone who commented on the food said they enjoyed their meals times and they liked the choices offered. A four weekly menu is offered, which provides a balanced and varied diet. Records show that all residents have nutritional assessment completed and dietician is used when needed. Improvements have taken place at meal times to streamline the way that meals are served. The home had appointed two activities co-ordinators e activities available. There is a range of activities had been undertaken for example Easter Bonnet Parade, allotment, gardening, and in house entertainment. Tea for three, sherry/coffee mornings, drop-in centre, trips to country parks and day trips etc. The home has a minibus available to take residents to events. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 14 A summer fayre is planned. Activities that take place meet the needs of the residents and photographs of events for example the 10th anniversary party of the home opening. A magazine is printed with the months activities programme. Visitors are welcomed at all reasonable times and residents can choose to entertain their visitors in the lounges or their bedrooms. There were residents who used their bedrooms as bed-sitting rooms and did not really want to be involved in the social activities in the home but enjoyed watching other people doing the activities. Records show that there is the availability of having communion in the individual resident’s bedroom and the care plan records that time must be given to the resident for their prayers. The mini bus will take residents who wish to go to the drop in centre. Service users and or relatives are asked with regard to the resident’s religious/spiritual needs as part of the admission process so that the staff can contact the local religious representative to visit. Through observation the inspector spoke with one visitor to the home. They confirmed they could visit at any time, and could see their friend in either the lounge areas or the resident’s own bedroom. They said that they were highly satisfied with the delivery of service. Where possible families are involved in care planning and have been asked about the residents interests and likes and dislikes. Records show that residents/relatives meetings have taken place with minutes taken. There is also a support group for relatives who need this service. Staff were openly and indirectly observed throughout the inspection, good interactions between staff and residents the staff members encouraged residents to make choices whenever possible, for example options at meal times. Tour of bedrooms found that most had been made very homely and residents had some personal possessions in their rooms. The manager stated that they were waiting for residents name plates and knockers for each bedroom door to affirm their identity, to also give a sense of ownership and belonging. Silverwood Care Centre DS0000003088.V290470.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): Quality in this outcome area is good, and this judgement has been made using the evidence available. Residents and relatives are provided with information to enable them to raise concerns or complaints about the home and their care. Staff had knowledge and understanding of adult protection issues, which promotes protection of residents from abuse and training, has taken place on this matter. EVIDENCE: The home’s complaints policy and procedure is clear and accessible to all residents and visitors. Records show one complaint had been made in November 2005 and no complaints have been since that time. Action had been taken to resolve the matter by the manager. The questionnaires that were returned showed that service users and relatives (who completed the questionnaire on behalf of the resident) were satisfied with the service and new how to use the complaints procedure. One relative wrote, “Overall this care home meets the complex needs of my elderly mother and any issues are raised by me and dealt with as they occur in partnership with staff”. Another relative said about staff members and the manager, ”they’re stars” The home has policies and procedures for adult protection staff spoken with confirm they are aware of these polices and procedures and training sessions have taken place. Staff induction records show that residents’ welfare/rights are discussed, which includes Adult Protection matters. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 16 It is the company’s policy for staff to have annual mandatory training, which includes Adult Protection matters. The company have adult protection procedures and the home had a copy of Rotherham Metropolitan Borough Council Social Service Adult Protection Procedures all of which promotes the residents rights to complain and uphold their protection while at Silverwood Care Centre. No Adult Protection investigations have taken place at this service. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 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, 26 Quality in this outcome area is good, and this judgement has been made using the evidence available. Service users live in a safe well-maintained environment, which was clean and tidy. The manager and her staff are working to ensure an environment free from offensive odours. EVIDENCE: Silverwood residential home is a purpose built care home home. The home meets the requirements of the Disability Act and the layout is suitable to meet the needs of the all the residents of Silverwood Care Centre. An application has been received by CSCI to increase the numbers of places for people who have dementia and decrease places for residential beds. All bedrooms are single occupancy and there was evidence that many of the residents had personalised their bedrooms. There is a selection of communal areas throughout the home. There is a redecorating programme in place for all areas of the home. There are some bedrooms that have new carpets and new mattresses have been obtained nearly on a monthly basis, for example two mattresses have been ordered in the month of May. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 18 The domestics were observed working extremely hard to ensure a clean and hygienic environment on both visits to the home. However, on the first visit there were areas throughout the home and used by service users that had offensive odours. On the second visit there were no mal odours within the home. The manager explained that the cleaning rota had been changed twice to control odours and that four bedrooms were deep cleaned each day along with other domestic tasks. There is a choice of bathing facilities for example, assisted baths and showers with a number of toilets placed around the home. Gardens are at the rear of the home and staff are working with residents on a small allotment and growing plants for the garden for those residents who enjoy gardening. There are also plans to have a pond in the garden, which will be used for service users who receive care on the residential unit. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 19 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 Quality in this outcome area is good, and this judgement has been made using the evidence available. Staff seen on the visits were enthusiastic and are working positively to meet residents care needs and improve their quality of life. There is a training and development plan that shows the staff receive regular training on different aspects of care to meet the changing needs of residents. EVIDENCE: Rotas were examined which showed that there was sufficient staff on duty. Records show that staff had induction and training courses had been booked for Health and Safety, Food Hygiene, First Aid, Moving and Handling training had taken place ensuring that service users are in safe hands at all times. The manager is working to formulate a training plan to show that the staff had received 3 days paid training per year so that they can keep up to date with care practices. Three care staff members have NVQ level 2 with one of having NVQ level 3 and one working toward the award. Seventeen care staff have registered on National Vocational Qualification level 2 but have not started the course at the time of inspection. It is unfortunate that in the past staff have enrolled and worked to achieve the NVQ award and the previous training company went into receivership. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 20 Medication training for staff that administer drugs has taken place by an accredited body. The manager said that the next focus for training for staff is infection control. The organisation has recruitment policies and procedures, which include equality and diversity for residents who live and for staff who work at Silverwood Care Centre. Staff files show that these policies and procedures were completed in a correct manner for example two references are obtained and CRB/POVA checks are undertaken. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 33, 35, 36, 38 Quality in this outcome area is good, and this judgement has been made using the evidence available. The company and the appointed manager are working to ensure leadership; guidance and direction to staff to ensure residents receive consistent quality care. This results in the health, safety and welfare of residents and staff being promoted and protected. Staff members have had informal supervision. However, staff supervision session and annual appraisal started but had continued, which does not support or develop staff and that does not benefit the care given to residents or the development of the staff group. EVIDENCE: The appointed manager has been in post for a year. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 22 She is experienced in working in a residential social care setting and was working to complete the Registered Managers Award. She is aware of her responsibilities and aims to run the home in the best interest of service users. Miss Bell is not the registered manager but said that she will be sending an application in the near future to become the registered manager. Residents/Relatives and staff meetings have taken place with minutes taken. A new development is to have a support group for relatives. Supervision sessions and appraisal of staff were discussed with the manager and staff that were interviewed these have not taken place. The organisation has sound policies on all areas of care and employment matters and is aware of current legislation. The manager and her team undertake audits to ensure adherence to policies and procedures in their dayto-day practice. All staff sign when given their copy of the company’s handbook and sign when they have read the new policies and procedures. The appointed manager has taken action to ensure health & safety measures are undertaken and are up to date. The service has a Health & Safety Committee and the home has a good record of meeting relevant health and safety requirements. The home has a handyman who is responsible for fire prevention testing measures and testing of water temperature. For example, the home has a fire risk assessment and fire prevention procedures have taken place. Hoists have been serviced and water temperatures are recorded. Accident records were examined and records show that staff complete appropriate documentation. In the entrance of the home there was a display of what action the staff take to reduce falls and accidents within the home. It is the intention of the manager to change the display on a regular basis for example Miss Bell is preparing a display on nutrition for the elderly. Records show that some residents take responsibility for their own financial matter while for other residents their families deal with all monetary issues. The service provides receipts and receipts are obtained for any financial transactions. All necessary insurance cover is in place to enable it to fulfil any loss or legal liability. Monitoring visits are undertaken on a monthly basis from a representative of the parent company. Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 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 X X 3 X 3 2 X 4 Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12 Requirement The Registered Person must ensure that care plans are reviewed on a monthly basis. The Registered Person must ensure that all staff that administer medication complete records in accordance with legislation i.e. that all medications records are signed at the time of administration. The Registered Person must ensure that the home has good odour control for all areas of the home. The Registered Person must ensure that 50 of care staff be qualified to National Vocational Qualification level 2. The registered Person must ensure that staff have formal supervision sessions and annual appraisals with records kept. Timescale for action 01/08/06 2. OP9 13(2), Sch3(3)(i) 01/07/06 3. OP26 16 01/08/06 4. OP28 18 31/12/06 5 OP36 18, 19 31/12/06 Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Silverwood Care Centre DS0000003088.V290470.R01.S.doc Version 5.1 Page 27 - 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!