Inspection on 16/12/05 for Waverley Lodge

This inspection was carried out on 16th December 2005.

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

Waverley Lodge 21/11/07

Waverley Lodge 10/05/07

Waverley Lodge 21/06/06

Waverley Lodge 31/05/05

Waverley Lodge 16/09/04

Waverley Lodge 26/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Waverley Lodge Bewick Crescent Lemington Newcastle Upon Tyne Tyne & Wear NE15 8AY Lead Inspector Mrs Irene Bowater Unannounced Inspection 09:30 16 December 2005 th 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 DS0000000407.V258515.R01.S.doc Version 5.0 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. DS0000000407.V258515.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Waverley Lodge Address Bewick Crescent Lemington Newcastle Upon Tyne Tyne & Wear NE15 8AY 0191 264 7292 0191 264 7295 waverley.lodge@fshc.co.uk 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) Bewick Waverley Ltd Ms Ellen Raine Care Home 45 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (26) of places DS0000000407.V258515.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 19 service users on the ground floor will be category DE(E). 26 service users on the first floor can receive either nursing or personal care. 31st May 2005 Date of last inspection Brief Description of the Service: Wavererly Lodge is a purpose built care home that shares its site and is physically attached to another home belonging to the same company. The home is set in large landscaped gardens, in a residential area, close to all local amenities. The home provides social and personal care for older people who have dementia on the ground floor and general nursing care for older people on the first floor. The ground floor dining room has access to the main kitchen and the upstairs dining room has a small kitchenette attached. There are two lounge areas on each floor for residents to use. All of the bedrooms are for single occupancy and 28 of them have en-suite facilities. There are accessible toilets close to all lounges and dining rooms and each floor has adequate bathing facilities. DS0000000407.V258515.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over five and a half hours. The registered manager and other staff assisted throughout the day. The inspection focused on the outstanding requirements from the last inspection, assessment of the quality of live for the residents and examination of a range of records. Eight residents, ten staff and two relatives were spoken to throughout the day. The majority of the time was spent touring the home and spending time with the residents and staff. What the service does well: What has improved since the last inspection? The home have resolved several requirements from the last inspection in regard to the environment, staff training and some infection control practices. The Statement of Purpose and Service User Guide have been reviewed and are available for residents and their representatives. Residents who are self funding are now provided with a contract which sets out their rights. DS0000000407.V258515.R01.S.doc Version 5.0 Page 6 A refurbishment plan has been implemented. This shows when new furniture, carpets, bedding and redecoration are to take place. The provision of some items is beginning to improve the home. Some of the recommendations from the Infection Control Audit have been implemented resulting in a cleaner, fresher environment. There are now adequate domestic and laundry staff employed over a sevenday period and the use of agency staff has been reduced. The staff have received training in fire prevention and infection control. 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. DS0000000407.V258515.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000000407.V258515.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3. The Statement of Purpose and Service User Guide provides the residents and their representatives with the details needed to make an informed decision about admission to the home. The Statement of Terms and Conditions (or contract) ensures the rights and obligations are clear for residents and the provider. Without detailed admission assessments being carried out there is no assurance that residents needs will be met. EVIDENCE: The home has now developed a detailed service user guide. This is easy to understand and is given to residents and their representatives. Copies are also readily available in the home. DS0000000407.V258515.R01.S.doc Version 5.0 Page 9 Residents who are self funding are now provided with a statement of terms and conditions (or contract) when moving into the home. The admission policies are detailed, however residents who have been in hospital for some time do not always have an assessment before readmission. The care plans inspected also showed that the preadmission and admission records were not fully completed. DS0000000407.V258515.R01.S.doc Version 5.0 Page 10 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 The care plans are not consistent to adequately provide staff with the detailed information they need to meet residents’ needs. The lack of information regarding nutritional needs has the potential to place residents health at risk. The policies and procedures for the safe administration of medicines are not being followed, placing residents at risk of harm. Personal support is offered in a way, which protects and promotes residents right to privacy, dignity and independence. EVIDENCE: Each resident has a care plan which is based on the care management assessment and the homes own assessment. The home uses recognised nursing model and accredited risk assessments to implement the care plans. DS0000000407.V258515.R01.S.doc Version 5.0 Page 11 The plans inspected showed a lack of detail about how to deal with difficult behaviour and what action to take when a resident becomes distressed or is aggressive. The risk assessments were not updated monthly and the plans showed that they were not always updated to reflect residents changing needs. All residents have access to NHS facilities. Advice from the other professionals is sought regarding pressure sore care, continence and nutrition. Weight loss or gain and assessments for those at risk are not always up to date and care plans were not available for those who have lost weight. The home has policies and procedures available for the safe administration of medicines. There have been some improvements since the last inspection regarding the organisation and cleanliness of the drug trolley’s and the treatment room. The first aid boxes have been restocked and out of date fortified drinks returned to the pharmacy. The drug fridge was clean and daily temperatures are recorded. Medicine Administration Records and Controlled Drug audit showed no discrepancies. All handwritten directions are now written out in full and have two signatures. All medicines ordered and returned are now recorded in separate books to enable audit. There was some evidence that qualified nurses were “potting” medication well before it needed to be given and then signing the Medicine Administration Records much later. The risk of this poor practice was discussed with the nurse and the manager for remedial action. Throughout the day it was evident that the staff respected the residents rights to privacy and dignity especially in regard to personal care giving. The staff were observed to knock on doors before entering and using residents preferred names. DS0000000407.V258515.R01.S.doc Version 5.0 Page 12 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 Social activities are organised and provide stimulation and interest for the residents who live in the home. Support from the local community and families ensure that residents are given the opportunity to maintain previous lifestyle links. Residents are supported as far as they are able to take control over their lives. The dietary needs of residents are catered for with the provision of a varied and balanced selection of food. EVIDENCE: The home benefits from a designated activities organiser. She is enthusiastic and organises various events both within and outside of the home. Records of activities are displayed and there is photographic evidence of events, which the residents have enjoyed. She attends “leisure, pleasure and learning” meetings and proposes to start a “friends of the residents” group in the future. Events include, bingo, board games, cookery, pet therapy and crafts. Residents who are able visit local pubs and enjoy shopping. DS0000000407.V258515.R01.S.doc Version 5.0 Page 13 Visitors are welcome at any time and residents are given opportunities to keep in touch with their friends and local community including churches as they wish. Residents said they could get up and go to bed when they wanted to. Many spent time in the lounges, some stayed in their own rooms and said this was their choice. Residents’ have brought personal items with them on admission and their bedrooms are individualised and homely. There are large landscaped gardens surrounding the home. The residents who have mental health problems are not able to access the gardens unaccompanied, as there is no secure safe area. The home has a four week varied choice menu. The daily menu choices are displayed in both dining rooms. The meals were hot of ample portion size and appropriately served. The tables were nicely set with appropriate cutlery, condiments and crockery. Both units have small kitchen areas where drinks and snacks can be prepared. The staff offered drinks and biscuits throughout the day and fresh fruit is readily available. The residents spoken to said there was always plenty to eat and they confirmed that supper and early morning tea is provided. DS0000000407.V258515.R01.S.doc Version 5.0 Page 14 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 The complaints procedures are satisfactory with evidence that residents feel their views are listened to. Staff have knowledge and understanding of Adult Protection issues, which protects service uses from risk of abuse. EVIDENCE: The home has policies and procedures, which detail how to make a complaint. The records show that all complaints are taken seriously and are recorded with action taken. The policies and procedures for the Protection of Vulnerable Adults is in place and staff were able to discuss what to do should there be an allegation or suspicion of abuse. The training has been carried out in house and the “Care Alliance.” DS0000000407.V258515.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25,26 There has been some investment in the home, which is improving the environment for residents living there. There are a number of outstanding requirements, which have the potential to place residents at risk. There are infection control and health and safety issues, which place residents’ staff and visitors at risk of harm. EVIDENCE: The home is set in large well kept landscaped gardens. There is no easy access or safe garden area for residents who have dementia and those in wheelchairs would find it difficult to access the vast grassed areas. Since the last inspection the difficulty accessing the home has been resolved and staff no longer spend time running backwards and forwards answering the door when the main office is unmanned. A programme of redecoration and refurbishment has been implemented with progress and target dates. DS0000000407.V258515.R01.S.doc Version 5.0 Page 16 There are lounges and dining rooms on each floor, which are reasonably decorated. Some refurbishment has taken place since the last inspection including replacing lounge and dining room chairs. The downstairs lounge carpet was generally grimy and stained and the radiator guards have damage to the covering. The radiators were tea stained, dusty with food debris stuck to them or piled underneath. There are toilets and bathrooms close to the communal areas and twenty-eight bedrooms have an en-suite facility. There is no central heating within the communal bathing and en-suite areas. The home has provided wall mounted blow heaters to ensure the correct temperatures are maintained. Many of the requirements regarding the bathrooms and toilets have not yet been actioned from the last inspection in May 2005. The assisted bath upstairs is again out of use. The flooring in toilet 7 is badly stained The extractor fan toilet 14 is broken. The shelving in en-suites are worn and difficult to clean The flooring in several of the en-suites is stained and worn Unused bathrooms were being used as storage facilities All of the light and emergency call cords were dirty and knotted. Further problems were discussed with the manager: There is no suitable shower chair The water in the shower room is “pooling” making the staffs shoes and feet wet and causing a slipping hazard. The enamel is missing from the bath underneath the assisted chair in bathroom 1. There was little or no liquid soap or paper towels in any area to allow the staff to wash their hands effectively. There are grab rails and other appropriate aids in bathrooms, toilets and corridors. There are bathrooms that cannot be used as they have an ordinary domestic style bath installed that the residents are unable to use either independently or with assistance. There are hoists on each floor, one of which was broken. All resident areas have an emergency call system. Several of the emergency call cords were tied out of reach. The lighting in all areas was satisfactory. Water temperatures were checked and were within satisfactory limits. There are still some thermostatic mixing valves that need replacing. The bedrooms inspected were personalised according to residents’ preferences and lifestyles. There is an ongoing replacement of mattresses bedroom furniture, and bedside tables. Several of the bedrooms have benefited from new carpets. There has also been a replacement of bed linen, which is ongoing. DS0000000407.V258515.R01.S.doc Version 5.0 Page 17 There remains a problem with the general cleanliness of bedrooms and ensuite areas regarding the cleaning following spillages of body fluids, food and drinks. There are two sluices in the home. The sluice disinfector was fitted in the ground floor sluice. Following the last inspection when a requirement was made to have a disinfector on the nursing unit the disinfector was transferred leaving the ground floor without any safe means to wash and disinfect commodes or urinals. The sluice downstairs had commode chairs stacked on top of one another. Used commodes were being “slopped” out in a dirty hopper and left to soak in some liquid. The sluice upstairs was dirty, raised toilet seats were stained with faecal matter, used continence pads were not being “double bagged” causing an odour in the sluice and corridor. Neither sluice was locked. There was evidence of staff sharing residents’ toiletries, tights and “netty knickers”. There is no safe outside storage area for clinical waste and there is not a detailed cleaning schedule in place to ensure the home is cleaned to a satisfactory standard on a daily basis. The laundry was generally clean and organised. The clean linen room remains stacked high with linen with many items stored on the floor. DS0000000407.V258515.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The home is adequately staffed with qualified nurses and all other staff. The standard of recruitment and selection is satisfactory and protects resident from harm. After a period of considerable instability there is now a consistent staff team who offer consistent care to residents. EVIDENCE: The home has a core staff team who have worked at the home for some time. The staffing levels have been reduced from the previous regulatory requirements and the home is now staffed as follows: 1 6 5 3 1st Level Registered Nurse over 24 hours care staff until 4pm care staff from 4pm until 8pm care staff overnight. The previous problems with recruitment of domestic and laundry staff have been resolved and there are staff on duty over a 7-day period. The administrator post is job shared over 5 days and there is an activities organiser and maintenance person. The kitchen staff are shared with the adjoining home. The NVQ training programme within the home is currently on hold.50 of care staff do not hold NVQ level 2 or equivalent. DS0000000407.V258515.R01.S.doc Version 5.0 Page 19 A sample of the staff files showed that the recruitment and selection policy is being followed. Evidence showed that Criminal Record Bureau checks, two references, proof of identity and medical checks are sought before staff are employed. All staff receive contracts that set out their terms and conditions of employment. The home has a training and development programme. Training has included, mental health care, care planning, mandatory training, catheter care, and dealing with aggression. A course in Dementia care is to be provided by distance learning. DS0000000407.V258515.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,35,36,38 The general management of the home is satisfactory and the registered manager has a good understanding of the areas, which need to improve. The systems for consultation and quality monitoring are poor with little evidence to support the resident and representative views are sought or acted upon. Further improvements in the residents personal accounts are needed to ensure all their best interests are protected. There are health and safety practices, which pose potential risks to residents, staff and visitors. DS0000000407.V258515.R01.S.doc Version 5.0 Page 21 EVIDENCE: The registered manager has been in post since January 2004.She is a 1st Level General and Mental Health nurse. Other qualifications include Care of the Elderly, BA in Education and a Diploma. She has completed the Registered Managers Award. She is aware of her responsibilities and is making some progress in resolving outstanding requirements and other issues regarding the service. There are no effective quality assurance systems in the home. The manager completes regular audits regarding the service but the results are not published. Regular meetings are held, however are not well attended or recorded. Residents’ personal allowances are held in a central non-interest bearing account although some residents have savings in Barclays Bank. The Company is planning to change the systems to enable residents accrue interest on their own money, however this has not occurred to date. The home maintains detailed records of all transactions cross references receipts and regularly audits the accounts. The manager has implemented supervision for staff with records kept. She is still endeavouring to complete all supervisions and appraisals herself which is not practicable and may result in the targets not being met. The staff have received training in safe working practices. The fire training and fire risk assessment are up to date. Several of the bedroom doors were held open with wooden chocks, footstools and bespoke metal doorstoppers. Accident recording was and monthly analysis was satisfactory and could be cross-referenced to the care plans. The home uses bed rails and protective covers on the nursing unit. The risk assessments were not up to date or clear regarding their use. Many of the residents use “Steredent”to clean their dentures. The storage of the effervescent tablets in bedrooms and en-suites has not been risk assessed. The contact maintenance records were available and up to date and the in house maintenance records were well organised, dated and signed. DS0000000407.V258515.R01.S.doc Version 5.0 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 3 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 1 X 2 2 1 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 3 X 2 DS0000000407.V258515.R01.S.doc Version 5.0 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 OP3 Regulation 14,15 Requirement The home must complete a comprehensive assessment for all residents who are admitted or readmitted to the home. The care plans must set out the detail the action to be taken to ensure all aspects of health, social and personal care needs of residents are met. All risk assessments must be regularly reviewed and up dated to meet residents changing needs. Timescale of 1/09/05 not met Nutritional screening must be undertaken for those assessed at risk. Nutritional care plans must be in place, advice from dieticians implemented, weights recorded and weight loss or gain reviewed and actions recorded. Timescale of 1/09/05 not met The home must ensure that all medication is dispensed and signed for at the time of administration. The home must continue to DS0000000407.V258515.R01.S.doc Timescale for action 31/03/06 2. OP7 15 31/03/06 3. OP8 13,14,17 31/03/06 4. OP9 13,17 16/12/05 5. OP20 16,23 31/03/06 Page 24 Version 5.0 6. OP21 23 7. OP21 23 8. OP22 14,16,23 replace the worn, stained and damaged chairs. The damaged occasional furniture requires replacing. All the radiators and guards require cleaning and the plastic on the guards repaired. Timescale of 01/09/05 not met. The home must replace the assisted bath. Bathrooms must not be used to store soiled and clean linen. Items must not be stored on bathroom floors. The home must audit all flooring in bathrooms, toilets and ensuites and replace stained worn vinyl. The wooden shelving must be repainted or re-varnished to enable easy cleaning. The bath in room 1 must be re enamelled or replaced. All bins must have suitable lids. All bathrooms, bedrooms and toilets must have liquid soap and paper towels. All emergency call cords must reach floor level. Both light cords and emergency cords must be sheathed to enable daily cleaning. Timescale of 01/10/05 not met. The home must provide an appropriate shower chair. The drainage in the shower room must be investigated and repaired. The home must ensure there are sufficient aids, hoists and bathing facilities installed to meet the assessed needs of the residents. The hoist must be repaired. All emergency call cords must reach skirting level. DS0000000407.V258515.R01.S.doc 31/03/06 31/03/06 31/03/06 Version 5.0 Page 25 9. OP24 16,23 10. 11. OP25 OP26 23 13,26 12. OP26 13,16 13. 14. OP28 OP33 18 12,24 The ongoing replacement of bedside tables and bedrooms carpets must continue. Timescale of 01/10/05 not met. The home must ensure all thermostatic mixing valves are fitted to prevent risk of scalding. All staff must follow the Infection Control policies and procedures. The sluices must be regularly cleaned and commodes cleaned following the homes procedures. Commodes and urinals that cannot be cleaned must be replaced. The commode chairs, which are stained, and the legs corroded must be replaced. The clinical waste must be appropriately bagged and a secure outside area provided. Clean linen must not be stored on the floor. Timescale of 01/10/05 not met. The home must ensure that there is liquid soap and paper towels available in all resident areas to enable effective hand washing. The home must ensure that there is no sharing of residents’ toiletries or clothing. The home must review the practices regarding the cleaning of commode pots to ensure there is no cross contamination. All light cords that are knotted and grimy must be replaced and be easily cleanable. All of the bins must be foot operated and have suitable lids. The home must continue with NVQ level 2 or equivalent training. The home must establish and maintain a system for reviewing DS0000000407.V258515.R01.S.doc 31/03/06 31/03/06 31/03/06 31/03/06 30/06/06 30/06/06 Page 26 Version 5.0 15. 16. OP35 OP38 12,17,20 13,23 and improving the quality of care including the quality nursing care with records kept. The home must ensure that any 31/03/06 interest accrued is paid into individual accounts. The home must not hold fire 31/03/06 doors open with wooden chocks or other artificial means. The home must liaise with the Fire Officer regarding appropriate door closures. Risk assessments and records for the safe use of bed rails must follow MDA guidance. Risk assessment for the use of Steredent cleaners must be implemented. Timescale of 01/09/05 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. 2. Refer to Standard OP22 OP26 Good Practice Recommendations The home should provide a safe secure garden area for residents with dementia care needs. The home should implement the recommendations of the Infection Control Nurses report. DS0000000407.V258515.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 DS0000000407.V258515.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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