CARE HOMES FOR OLDER PEOPLE
Balliol Lodge Balliol Lodge 57-60 Balliol Road Bootle Liverpool Merseyside L20 7EJ Lead Inspector
Diane Sharrock Key Unannounced Inspection 7th 9th and 13th March 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Balliol Lodge DS0000065370.V326409.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. Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Balliol Lodge Address Balliol Lodge 57-60 Balliol Road Bootle Liverpool Merseyside L20 7EJ 0151 9336202 0151 9336303 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 Bharat Modhvadia Mrs Jaya Bharat Modhvadia ** Post Vacant *** Care Home 32 Category(ies) of Dementia (32) registration, with number of places Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The service should employ a suitably qualified and experienced Manager who is registered with the CSCI Service users to include up to 32 DE (E) The service is registered to provide nursing or personal care up to a maximum of 32 service users in the category of DE (E) 8/8/06 Date of last inspection Brief Description of the Service: Balliol Lodge is a care home that provides nursing and personal care for up to 32 Residents. The care provided is for Residents with a diagnosed condition of dementia. Balliol Lodge is situated on a busy main road near a college. The local train station is accessible at the bottom of the road and there are a number of shops within walking distance and a main shopping centre a little further. The main shopping areas of Liverpool can be accessed via public transport. The home is a privately owned by Mr and Mrs Bharat Modhvadia who became the new Providers in April 2006. The Manager has since resigned from the home and the Provider is in the process of recruiting a new Manager. Balliol Lodge is 2 converted buildings on 3 floors, there is a passenger lift to some of the bedrooms. There are various single rooms, and a number of double bedrooms none with en-suite facilities. Bedrooms are situated on all 3 floors with 3 lounge areas and 2 dining rooms on the ground floor. There is also a smoking area available for the Residents. The Home has gardens to the rear. Parking is available to the front and the rear of the building. Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a period of 3 days. During the inspection discussions took place with 8 Staff, and 6 Residents. A total of 2 comments cards were forwarded to the CSCI with regard to the home. The Inspector completed the inspection by looking at the homes records and undertaking a tour of the building. Feedback was given to the Provider at the end of the inspection. Information about fees has not been supplied in the homes pre inspection questionnaire. This must be supplied to CSCI and published in the homes Statement of Purpose and in contracts and terms and conditions. This will help make sure that prospective Residents and their Representatives are fully informed prior to making any decisions before moving into the home. What the service does well: What has improved since the last inspection?
Residents stated that they were happy with the food provided and commented that it was “ok”, “very nice food here” Staff were enthusiastic and committed to make improvements to the home and to develop standards and activities. The training matrix for staff was detailed and showed a varied amount of training and development of staff that had taken place.
Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 6 Some improvements have been made following the previous inspection especially in training and development of Staff. The homes statement of purpose and inspection reports are openly displayed and offered to people by the main reception area. There has been some maintenance work and decoration to some areas of the environment and all areas seen were clean and tidy. Quality assurance questionnaires carried out in September 2006 were positive in their comments about the home. The results need to be summarised and published so that everyone is aware of the comments made including any actions that the home may have decided to take. What they could do better:
During the inspection concerns were raised regarding breaches in the Regulations. Repeated breaches of Regulations must not continue and the Provider must demonstrate his commitment and responsibilities in achieving compliance with the Care Home Regulations 2001. These concerns were discussed with the Provider and the Nurse in Charge. An improvement plan must be submitted to CSCI giving details of how the Provider will be meeting the regulations and how they intend to improve the home. The Staffing policy must be updated giving Staff clear instructions on the procedures for replacing Staff to ensure safe numbers of Staff are in place each day to meet the needs of all Residents at the home. The previous Manager has resigned, and therefore the Provider should ensure that the home is appropriately managed until such time a Registered Manager is appointed. Staffing should be provided to supply and organise activities at the home for residents. Although some changes to the management of resident finances have been made, a complete review of how Residents finances are managed must take place, any procedures for managing finances must meet the requirements of the Care Home Regulations 2001. New Staff need to be supported and given full induction, training, and supervision. Training for Staff in Dementia, abuse awareness, challenging behaviour, national vocational training, and activities, basic care needs and rights. must be supplied to all outstanding Staff who have not yet received their mandatory training. Training records must be updated and evidence of 3 days paid training given for all Staff. Pre-admission assessments must be done by a person qualified to assess the resident’s needs, which includes their nursing needs, prior to residents being admitted to the home. These assessments should be completed in every case
Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 7 to make sure that the home can provide care for which they are registered to provide. An application for variation must be submitted to CSCI as a matter of priority for the one resident identified as out of category. All Residents must be assessed to ensure they are currently placed in a safe environment, this includes their bedrooms. Care plans did not reflect all of the residents needs. Care plans should be completely reviewed and developed to show evidence that they can eventually meet all parts of the standards including the provision of social care. The current activities organiser was on sick leave and no additional time was given to Staff to provide activities. Staff tried their best to implement some form of activities when they could. Activities must be developed and Residents consulted about what they would like at their home. Care plans did not give any details about how Residents social needs would be met. Many Residents were noted to have good abilities to be involved, however some said they were “bored” and didn’t have much to do. The Provider must evidence how communication and participation will be improved including their thoughts and needs around activities, and their home. The environment had been improved to an adequate standard, however there were many areas still in need of repair maintenance and decoration. Maintenance and decorating programme must be developed and shared with Residents/ Representatives and Staff to show how the home will be developed. On the ground floor there are malodorous smells and a review of current cleaning products and cleaning schedules must take place so that these smells can be eliminated. Risk assessments must be updated and in place for all noted hazards, including, doors wedged open, windows without restrictors, and incidences of challenging behaviour, this is necessary to ensure the safety of residents. 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. Balliol Lodge DS0000065370.V326409.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 Balliol Lodge DS0000065370.V326409.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): 3 standard 6 is not applicable Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home did not gather nor provide sufficient information to a prospective Resident, therefore they cannot ensure they are able to meet Residents needs and choices prior to them moving in. EVIDENCE: One care plan case tracked gave basic details of a residents needs, but these had not been incorporated into a plan of care. There were no details that indicated the person had dementia. Staff had admitted a new Resident that was out of category of registration of the home. No application for a variation had been submitted to CSCI. This was a repeated concern noted at the last inspection. This demonstrates that staff in the home may not have the skills and experience to fully meet this persons needs. Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 10 To admit residents that are out of the homes registered category would be considered an offence under Section 24 of the Care Standards Act 2000. Failure to comply with the conditions of registration Pre-admission assessments viewed were inadequate, these must be completed by a person qualified to assess the persons needs including their nursing needs, so that Staff can determine if the home can meet their needs regarding the homes current registration status of older people over 65 with dementia. Further work, development and management must take place to ensure all Residents needs and requests are taken into account as one Resident so that the Resident receives the care and support they need, including medical and nursing care. The nurse in charge liaised with the local authority following this inspection so that the identified Resident Out of category could have an appropriate care review. A resident was admitted into a bedroom, which had a ripped carpet, which has now been replaced and no restrictor to their window, doors wedged open. All Residents must be assessed to ensure they are currently placed in a safe environment this includes their bedrooms. Balliol Lodge DS0000065370.V326409.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): 7/8/9/10 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home did not adequately manage Residents health and personal care needs. EVIDENCE: Three care plans were reviewed for case tracking. One plan identified a person admitted to the home out of category, thus raising the fact that their needs were not wholly being met by Staff. The Resident did not have a care plan and no details of how their physical, nursing needs or social needs would be met. One person had a problem with their legs but staff had not given any details in the care plan to say what care would be given to help this problem. Care plans showed no evidence of social care needs being met so Residents have little input to their social care from Staff. Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 12 The Nurse in Charge acknowledged the need for all care plans to have a complete review and the work to be carried out to ensure the residents care needs are fully met and documented. The Staff observed during the inspection were attentive and polite to the Residents. Residents spoken with said, “Staff are lovely here”, A sample of records for the storing and recording of medications showed good management in this area. Balliol Lodge DS0000065370.V326409.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): 12/13/14/15 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home does not provide adequate support to residents to meet their social needs. EVIDENCE: Although the home has an Activities Organiser it was noted she is currently on sick leave. There had been no management of this area or supply of Staff to organise events in her absence. Some Residents said “there’s nothing much to do” and one Relatives comment cards indicated that, activities in the home were limited and would benefit from more input of activities. During the inspection, the staff were observed sitting around a table with residents trying to encourage people to paint and engage in talking, some residents were having a foot spa. Staff in discussion explained that they were trying their best to provide some activities when they had a chance during their shift. Staff felt they would benefit from training in activities especially for people with dementia and were eager to learn. Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 14 There is limited ground floor space, stairs have locked gates and the grounds are difficult to access, this decreases the amount of space residents have to walk around in. Staff stated there are no residents meetings, which indicates no formal way for residents to be consulted and give their opinions on how the home operates. Some areas around the home needed further improvement to enhance resident’s privacy and choice. One toilet window had no covering to promote privacy during personal care. A risk assessment was seen for one resident stated they did not want a key for their bedroom, however in discussion with this person, they indicated they would like the key to help keep their room private. These areas should be developed and possibly reviewed with training to help Staff support residents with such things especially where they have potential to maintain their independence. Staff felt that menus and the ordering of food stuffs had improved and that planned menus could be provided. Residents stated that they were happy with the food provided and commented that it was “ok”, “very nice food here” Balliol Lodge DS0000065370.V326409.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Training and polices help protect the Residents from abuse.The home have some Staff with updated training however some Staff still needed training. EVIDENCE: A sample of 4 Staff personnel files showed good recruitment checks are in place, however the support and supervision of Staff had not always been carried out especially for new Staff. Supervision, induction and training for Staff must be developed to provide safe and competent Staff to meet the needs of Residents. Most Staff had received training in abuse awareness and Staff felt they had benefited from this training. Some Staff had still not received this mandatory training although it is acknowledged that this training had been implemented following the previous inspection. All Staff must receive this mandatory training to make sure they are able to protect and support residents appropriately at all times. The homes complaints policy is clearly displayed in the homes guide and is easily assessable to everyone. Balliol Lodge DS0000065370.V326409.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): 19/26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home did provide an adequate environment for Residents to live in. EVIDENCE: It was established that the Manager had resigned from the home after a period of absence. However some areas of improvement had been noted and all areas seen were clean and tidy. Some areas of the home observed still needed attention. The home did not have a maintenance and development plan that could be shared with residents and staff to gain their opinions about their home. On the ground floor at various times in the day there were malodorous smells. A review of the current cleaning products and schedules must be reviewed to take any action to get rid of these smells.
Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 17 A tour of the premises revealed that one bathroom had a hole in the ceiling, the flooring was ruffled in some areas, and this could present a Risk to residents of tripping or falling. Staff explained that they are unable to use the bathrooms. The bathrooms need repair, and the hot water fixing so that Residents have the choice of using a range of bathing facilities. One ground floor shower room had malodorous smells and no blinds/ covers to its frosted glass window. This affects the dignity of residents. There were scrapes to most woodwork, doors frames and doors, and skirting boards. One lounge had a broken TV cabinet, faulty coffee table, and curtains hanging off their tracks. Some rooms had doors wedged open and no risk assessments seen to take action to eliminate any identified risks. Some rooms felt hot and unable to gage the temperatures of rooms. It would be recommended to install room thermometers so that staff can help to maintain a comfortable temperature for Residents. One bedroom carpet observed to be in a poor condition was replaced during this inspection once its condition was pointed out to the Provider. Regular audits of the home by the Provider should identify areas for repair and development prior to any further inspections. The Provider agreed to carry out all necessary actions to ensure the safety of the home and its residents. Risk assessments are in place at the home but they need updating and all areas seen should be included in these assessments. Balliol Lodge DS0000065370.V326409.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): 27/28/29/30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home does not always provide sufficient, experienced and trained Staff to meet the resident’s needs. EVIDENCE: There is a long-standing Staff team who were observed to have a genuinely caring attitude towards Residents. The Staffing rota’s indicated there were low Staffing levels within the home on some occasions. Discussions with Staff confirmed this. Previous concerns have been raised about the levels of staff in the home and the provider needs to ensure the levels of staff are adequate to meet the needs of the residents. There is no registered manager. The appointed manager who had been off on sick leave has now resigned, whilst they were off no additional management hours had `been put in place to cover this absence. No activities hours had been arranged whilst the current organiser was on sick leave. In discussion with staff they were unsure if they had domestic Staff for the weekend and they felt that sometimes staff shortages were not covered.
Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 19 The management of Staffing levels must be reviewed to ensure the home is Staffed appropriately according to the ongoing dependencies of Residents. The providers commitment to the basic number of Staff on each shift must be displayed in the homes statement of purpose and any changes to the basic levels must show evidence of a clear rationale to link the levels with the Residents needs and this should be done in consultation with all Residents, Relatives and Staff. One new member of Staff had not had any assessment or support to show whether they were competent to provide care work and there was no evidence of induction or whether their training needs were being fully met. There was no evidence of supervision for this member of Staff. The rota showed they had been included in the Staff rota and had not been provided with extra hours for supervision and induction while they had been learning to do their job. In assessing the procedures for the recruitment and selection of Staff , four Staff files were sampled, including one new member of Staff. These files showed appropriate checks are in place prior to recruitment, however supervision was not evident and training records were not up to date. Records showed that Staff had received some mandatory training, however some were out of date and some were blank. The Provider must audit the records to show what training individuals need and must be able to evidence how the trained nurses are receiving continual professional development. There was no structured plan to evidence what actions the Provider was taking to ensure NVQ training would eventually meet the National Minimum Standards target, however the pre inspection questionnaire stated that at least 26 of Staff have a care qualification. It was noted that some Staff would benefit from updated training in Dementia, abuse awareness, challenging behaviour, activities and basic rights and care needs. Staff meetings should be carried out at least monthly, as currently they are adhoc. Balliol Lodge DS0000065370.V326409.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): 31/33/35/38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not always well managed and run in the best interests of Residents. EVIDENCE: Issues identified throughout this report evidence that the home was not being managed well during the appointed Managers absence. These issues were discussed with the Provider during this inspection. The Provider must make arrangements for the management of the home while they are in the process of recruiting a new Manager. Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 21 Samples of finances managed by the Provider were reviewed during this inspection. Areas of concern such as poor recording and storage were discussed with the Provider. The inspector visited the home over 3 days to give the Provider the opportunity to provide all records relating to finances. Previous invoicing was noted to have charged Residents monthly for toiletries and entertainment however there were no receipts available for these regular outgoing sums of money. The Provider acknowledged that he had continued the invoicing similar to the previous owner but has now stopped this invoicing system. The personal allowance monies of residents were also previously being stored in the company account. The Provider acknowledged he would stop this practice and take the necessary steps to provide individual and clear transparent accounts for residents. The management of all Residents finances must be completely reviewed and accessible to the future Manager and the Residents. All Residents must receive their full personal allowance payable into their own personal account or advice taken from them as to were they would like their money stored. If during this review any financial discrepancies are noted then they must be reported to the placing authority to allow them to carry out an updated review. Staff are not being provided with one to one supervision. This is evident in records and through discussions with Staff. An action plan must be developed to ensure appropriate action is taken to meet the national minimum standards and to ensure all Staff have regular 1 to 1 time to discuss their needs and developments. Quality assurance questionnaires carried out in September 2006 appeared positive in their comments about the home. The results need to be summarised and published. Various maintenance certificates were produced showing some evidence of appropriate checks to facilities at the home. The accident book had recorded a serious incident where a Resident and Relative had been hurt. There was no record of what actions the manager had taken to prevent further incidents occurring although the Nurse in Charge was able to verbally explain that they had reviewed the situation and organised a professional assessment for one Resident. Internal audits must take place to ensure that any identified actions are taken to minimise any reoccurrence of accidents. Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 22 All aspects of health and safety and management of the home must be acted upon appropriately to ensure the health and safety of everyone at the home and to evidence that the Provider has fulfilled his legal obligations. The Provider must carry out their own regular health and safety audits at the home. Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 1 X X 2 Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 24 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 1(a) 2(a)(b) Requirement All new Residents admitted to the home must be appropriately assessed to ensure that the care home can meet the Residents needs. A variation application form and supporting evidence for one Resident out of category must be sent to the Commission, so that it can be ascertained whether the persons needs and choices can be met by the home. Timescale for action 18/05/07 2. OP7 15 1 2 All Residents must have clear and accurate care plans showing how their needs will be met, to include their physical nursing and social needs. Regular audits must be carried out to show that Staff are giving Residents updated care plans reflecting their needs. The home must have competent and trained Staff to meet the Residents needs at all times. Staff must have training in dementia, abuse awareness 18/05/07 4. OP18 18 (1) a c 18/05/07 Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 25 5 OP31 CSA 2000 section 11 8 1) 2) 20 a b 6 OP35 7 OP38 Reg 23(1)(2)b )(c)Reg 13 4 a)c) challenging behaviour, activities and induction. Arrangements must be made for 18/05/07 the suitable day-to-day management of the home and an application for manager’s registration made to the Central Registration Team. The management of finances 18/05/07 must be reviewed so that clear and accurate records are kept for all Residents finances. Resident monies must not be stored in a company account Regular health and safety 18/05/07 inspections of the home must be made to show how the home is safe for Residents. Regular repairs must be undertaken to ensure the environment is suitable for residents. 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 OP12 Good Practice Recommendations Residents need to be consulted about what activities they would like and arrangements in place to support Residents with their social needs. Activities should be further planned and developed to meet Residents social needs. The homes environment should be developed further to meet the needs of Residents with Dementia including safe access to the garden. The use of space within the home should be reviewed to ensure that is sufficient room available to Residents, including those who like to walk around. To develop regular minuted Resident/Relative meetings. The Staffing levels should be kept under review in order to make sure that Staffing levels are appropriate to the
DS0000065370.V326409.R01.S.doc Version 5.2 Page 26 2 OP27 Balliol Lodge needs of the Residents .To publish the homes Staffing commitment for each day in the statement of purpose. 3 OP32 4 OP30 To continue with ongoing Staff meetings and develop the implementation of supervision and appraisals. To ensure all parties are aware of the Companies “whistle blowing” policy. To continue developing and updating training records and provide evidence of 3 days paid training for all Staff each year. To develop an overall training and development plan for the home based on both the identified Staff training needs and Service Users needs including the trained Staffs clinical needs. The Provider should continue with development of NVQ training so as to meet the target of 50 by 2005 Balliol Lodge DS0000065370.V326409.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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
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