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Inspection on 14/02/06 for Barons Lodge Psychiatric Nursing & Rehabilitation

Also see our care home review for Barons Lodge Psychiatric Nursing & Rehabilitation for more information

This inspection was carried out on 14th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 20 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The majority of residents spoken to at this visit gave positive comments on the staff group. Staff were described as "very nice", "reasonable" and that "they do their best", "treat me nicely". One resident said the best thing about living in the home was that "everyone gets on well". Residents benefit from a relatively stable staff group who know them well. Agency staff are not used in this home. Residents have the benefit of a separate rehabilitation unit.

What has improved since the last inspection?

Staff have made improvements in the care planning process which provides good information on the needs and wishes of individual residents. Individual risk assessments have improved. The records of medication have improved which assists in ensuring the health and welfare of residents. Opportunities for staff training have improved which will ensure that residents are supported by a well informed staff group. Systems are now in place for staff to receive regular one to one supervision with a more senior member of staff. This will assist in ensuring that staff are working effectively and that the training needs of any individual are assessed and addressed.

What the care home could do better:

As noted previously the home has a separate rehabilitation unit. However the inspectors are of the opinion that this facility is not being used to its full potential. Work needs to focus on providing activities and or rehabilitation programmes which address the individual needs and wishes of residents. A review of community activities should also be carried out.Residents must be supplied with clear information on the purpose of their stay in the home whether this is for rehabilitation or for long term care. Staff must be provided with clear guidance on action to be taken should any resident self harm or attempt suicide. Further work on the recoding of variable dosage medication needs to be done. The environment in the main building needs to be improved particularly the bathrooms. Work on the redecoration of bedrooms needs to be continued. Where repairs are required these must be dealt with promptly. Action must be taken to make sure that the health and safety checks are being carried out appropriately. Hot water must be supplied throughout the home and at a safe temperature. Regular maintenance checks must be carried out on the central heating system and repairs must be carried out promptly should any radiator in the home not be working. Prior to any increase in the number of residents the staffing levels and the laundry facilities must be reviewed. Staff must ensure that where any resident is moved to another room the room is cleared before the move.

CARE HOME ADULTS 18-65 Barons Lodge Psychiatric Nursing & Rehabilitation 24 Baron Grove Mitcham Surrey CR4 4EH Lead Inspector Liz O`Reilly Unannounced Inspection 14th February 2006 10:30 Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 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 Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.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 Adults 18-65. 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. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Barons Lodge Psychiatric Nursing & Rehabilitation 24 Baron Grove Mitcham Surrey CR4 4EH 020 8646 8280 020 8687 0355 Address 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) Genec Limited Mrs Florence Nwanganga Okehie Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can admit one named service user over 65 years of age. The home can admit one named service user with a diagnosis of dementia. 28th September 2005 Date of last inspection Brief Description of the Service: Barons Lodge is a registered care home with nursing for up to sixteen adults with mental health needs. The home is situated in a residential area of Mitcham close to shops and public transport facilities. Accommodation is provided in fourteen single bedroom and one shared bedroom. Residents also have access to communal lounge areas, a dining room and the rehabilitation unit. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two regulation inspectors on 14th February 2006 over five hours. At the time of this inspection twelve residents were living in the home. Work was in progress to join the present home with the property next door. This work had not been completed at this time. The inspectors had the opportunity to speak with six residents, two staff and the registered manager. A sample of records were examined. What the service does well: What has improved since the last inspection? What they could do better: As noted previously the home has a separate rehabilitation unit. However the inspectors are of the opinion that this facility is not being used to its full potential. Work needs to focus on providing activities and or rehabilitation programmes which address the individual needs and wishes of residents. A review of community activities should also be carried out. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 6 Residents must be supplied with clear information on the purpose of their stay in the home whether this is for rehabilitation or for long term care. Staff must be provided with clear guidance on action to be taken should any resident self harm or attempt suicide. Further work on the recoding of variable dosage medication needs to be done. The environment in the main building needs to be improved particularly the bathrooms. Work on the redecoration of bedrooms needs to be continued. Where repairs are required these must be dealt with promptly. Action must be taken to make sure that the health and safety checks are being carried out appropriately. Hot water must be supplied throughout the home and at a safe temperature. Regular maintenance checks must be carried out on the central heating system and repairs must be carried out promptly should any radiator in the home not be working. Prior to any increase in the number of residents the staffing levels and the laundry facilities must be reviewed. Staff must ensure that where any resident is moved to another room the room is cleared before the move. 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. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Information on the individual needs and aspirations of residents is provided to residents prior to their admission to the home. Further work needs to be done to make sure that all residents have a clear understanding of the reason for their stay at the home. EVIDENCE: Before admission to the home an assessment of individual needs is carried out by staff from the local authority. A copy of this assessment is provided to the home. In addition staff from the home carry out their own assessment. This information is used to set up an initial care plan. As noted at previous inspections a number of residents who said they were staying at the home for rehabilitation did not have a clear understanding of how long the rehabilitation would take. Residents must be provided with clear information on the purpose of any rehabilitation, the duration and any requirements of the programme. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 67&9 Each resident is provided with an individual care plan. Risk assessments are in place and reviewed on a regular basis. Further work needs to be done to make sure staff have guidance on what to do should any resident self harm or attempt suicide. EVIDENCE: Improvements have been made in the care planning since the last inspection of the home. Care plans include information on individual needs, aims and objectives and actions to be taken. Care plans were seen to be reviewed on a regular basis. The care plans seen included more details for staff on the needs and wishes of individuals. Care plans are signed by staff and residents. Work needs to continue on improving the care planning and consideration should be given to providing staff with training on person centred care planning. Consideration should be given to requesting residents to provide more information, which they are willing to share with staff, on their individual history. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 10 Identified risks have now been included in the care plan for individual residents. Risk assessments were seen to be reviewed. Where any resident has been identified as at risk of self harm or suicide the registered persons must ensure that clear guidance is available for staff on actions to be taken in the event of any self harm or attempted suicide. Good information was seen to be available on actions to be taken should a resident be missing from the home. Any restrictions on movement or decision making is included in the care plan. Residents are encouraged to manage their own finances with staff support and guidance where needed. Information on advocacy services is available in the home. At present none of the residents in the home are using advocacy services. Further work needs to be done to make sure that residents are supported by staff to make decisions about their day to day lives particularly in relation to daily activities and the food provided. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14, 16 & 17 Further work needs to be done to offer more varied activity within the home and in the local community. Residents rights were seen to be respected and any responsibilities recorded. Work needs to be carried out on the menu in the home to offer choices. EVIDENCE: One resident is attending a college course, another is supported in voluntary work and the inspectors were informed that arrangements were being made for one resident to attend literacy skills classes. As noted in the last inspection report the rehabilitation programmes are not individualised. One resident was observed sitting with a staff member who was looking at the internet, one resident was seen playing cards on a computer, three residents were doing arts and crafts and one resident was reading a book. Residents were observed doing much the same activities in the afternoon. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 12 A number of residents expressed boredom with the activities taking place. Comments from residents included, “I used to enjoy the rehab but seen and done it now”. “I enjoy the drawing and a little bit of cooking”, “there needs to be different things going on”, “should not be so much, once or twice a week not every day”. “I would like to play pool”, “I would like to watch videos”. Work needs to be done to individualise the rehabilitation programmes. The activities provided need to be tailored to the needs and wishes of the residents and take into account whether individuals are in the home for rehabilitation or on a long term basis. The recording of activities was not up to date the majority of entries were last done in November 2005. The activities participated in were “rubber stamped” on each weekly sheet with home economics, art and craft, exercise group etc. Notes included ‘has participated well in activities this week’. This statement was seen to be repeated for other weeks. These records are not useful and underline the lack of any individualised plan. The inspectors are of the opinion that the rehabilitation centre is not being used to its full potential and needs to be organised and staffed around the needs and wishes of residents. Consideration should be given to reviewing the mix of structured and recreational activities. Comments received indicated that community activities and trips were not happening as frequently as in the past. When reviewing the activities in the home consideration should be given to increasing community activities. The inspectors are aware that as part of the rehabilitation programme for some residents the use of public transport may be important. However consideration should also be given to providing the home with its own transport to allow for more frequent ad hoc community activity. Residents are offered a key to their bedroom. Residents confirmed that they can make their own decisions about when to be alone or in company. Residents have unrestricted access to the home and grounds. Any responsibilities for housekeeping tasks are included in the care planning. Residents are involved in cooking in the rehabilitation unit and the inspectors were informed that certain residents are also involved in cooking meals for the group at weekends. However residents are not regularly involved in the shopping for food. Consideration should be given to including residents in the planning, shopping and preparing of food. One resident has been provided with their own menu. For other residents the home has a four week rolling menu. Comments from residents on the food included “I like the food very much”, “the food is good”, “the cook chooses what we eat” and “its getting better, sometimes I get what I want”. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 13 The meals being served at the time of this visit were not those indicated on the menu. The menu seen at this inspection did not offer residents a real choice on certain days. The meal offered on one Sunday offered roast chicken and vegetables or roast chicken and rice. A new menu, with clear alternatives, needs to be provided following consultation with residents. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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 The health care needs of residents are met. Medication was seen to be well managed in relation to storage, disposal and administration. Further work needs to be done on the information available for “as required” medication. EVIDENCE: Arrangements are in place for residents to have regular health checks. Staff monitor the condition of residents and refer to the appropriate health care professionals if they have any concerns. The GP for the home visits on a monthly basis or more frequently if required. The home has good links with local psychiatric services and can call on the consultant psychiatrists for advice. A qualified nurse is available in the home at all times. The records held on medication have improved since the last inspection. All medication administration sheets were up to date and accurate. A record of medication received into the home is in place. The strength of dosage given where variable is recorded and the quantity of medication carried over is noted. The manager must ensure that clear written instructions are available and included in the care plan for all “as required” medication. Information must Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 15 include the dosage to be given, the circumstances, the frequency and where more than one medication is used the order in which they should be given. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 An up to date complaints procedure is in place. The policies and procedures in place to protect residents from abuse have been reviewed. EVIDENCE: The complaints procedure for the home was seen to be on display in the dining room. The procedure is also available in each residents room. It was noted that the procedure in the dining room contained the contact details of the Commission. One procedure included contact details of the NCSC and two included the details of the local health authority. The manager needs to check that all procedures are up to date. To assist in the protection of residents all staff have been provided with training on the protection of vulnerable adults. The policies and procedures for the reporting of any concerns or allegations of abuse have been reviewed since the last inspection. Staff are aware that they must report any allegation of abuse to the local authority and the Commission. Policies and procedures are now in place in relation to residents who are at risk of suicide or self harm. As noted previously further work needs to be carried out to make sure all staff are aware of any actions to be taken should any resident self harm or attempt suicide. Policies and procedures are in place to protect residents finances. Facilities are available for residents to deposit small amounts of money in the home. The records kept on individual finance were seen to be well maintained, up to date and accurate. Where staff are supporting residents to manage their finances this is now included in the care planning documentation. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 17 Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Work needs to be carried out on the main building to provide residents with a comfortable and safe environment. The standard of cleanliness particularly in bathrooms is not adequate. EVIDENCE: At the time of this inspection work was being carried out to add extensions to the home to eventually join with the house next door. In addition certain bedrooms in the main home were being redecorated. A number of areas in the main building were seen to be in urgent need of attention. The bathrooms on the first and ground floor are in poor condition. Both bathrooms are in urgent need of refurbishment. The shower head in the ground floor shower room is partially blocked by lime scale and needs descaling. At the time of this visit no hot water was available from the shower. These issues were the subject of immediate requirements. The shower curtain is spotted with mould. The sink in the ground floor toilet was leaking and the earth wire under the sink was loose. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 19 In the first floor bathroom the bath side is loose, the shower curtain is dirty, the bin is broken and the paintwork is in poor condition. The locks on bathroom and toilet door must be of a type that can be opened by staff in the event of an emergency. This issue was the subject of an immediate requirement. Subsequent discussion with one of the directors of the home indicated that work to refurbish the bathrooms was planned. This work needs to be carried out without delay. Four bedrooms seen during the course of this inspection require redecoration. In one bedroom the lighting supplied is a strip light. This is not in line with a domestic style bedroom and needs to be replaced. One resident who’s bedroom was in the process of being redecorated was being accommodated in another bedroom. The bedroom where this resident was staying had not been cleared and contained various items including a number of mattresses and a Christmas tree. The registered person must clear this room of all items which do not belong to the resident. The television in one residents bedroom was buzzing constantly. This television needs to be repaired or replaced. The radiator in one residents bedroom had not been working since before Christmas. An immediate requirement was made at the time of this visit for the radiator to be repaired. The registered persons have reported that this has been attended to. The registered persons must supply to the Commission a plan for the refurbishment of bedrooms and bathrooms with timescales for completion. The home is furnished with one washing machine and a dryer. The laundry area is in the rehabilitation unit. Consideration should be given to increasing the amount or size of washing machines and dryers when the number of people in the home increases. The paintwork in the laundry area is in need of attention. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 & 36 Staff are provided with opportunities to take part in training. All staff are provided with regular one to one supervision. EVIDENCE: One qualified member of staff and two carers are on duty throughout the day. At night one qualified member of staff and one carer are awake in the home. The qualified member of staff is also the registered manager who works during the week and is the deputy manager who works at the weekend. A rehabilitation officer, cook, administrator and domestic staff work in the home Monday to Friday during the day. When the home is accommodating more residents then a review of the staffing levels and hours of work must be carried out. At least two qualified staff and three care staff should be on duty during the day. The review of the staffing levels should also include catering and domestic hours. At present staff work from 8am to 8pm every day. These long hours worked on such a regular basis are of some concern. When reviewing the staffing levels the registered persons must review the hours worked during the day. Staff meetings are held on a regular basis which makes sure that staff are kept up to date on any issues or changes. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 21 Three care staff are in the process of completing NVQ training. All members of staff involved in food preparation have received training in food hygiene and the protection of vulnerable adults. One member of staff spoken to has also taken part in first aid and food hygiene training. Since the last inspection of the home a programme for staff supervision has been implemented. The manager confirmed that all staff are provided with one to one supervision every two months. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 & 42 An annual review of the service, taking into account the views of residents and other stakeholders needs to be carried out. Staff must keep accurate records of all health and safety checks carried out in the home. EVIDENCE: Quality assurance and monitoring systems need to be further developed. The manager informed the inspectors that questionnaires had been sent out. An annual review of the care provided needs to be carried out taking into account the views of residents and other stakeholders in the service. A copy of the report produced from the review of the service must be sent to the commission. The results of residents surveys needs to be made available to residents and any prospective residents. Staff carry out regular checks on the building and equipment to ensure the safety of residents, staff and visitors to the home. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 23 It was noted that the checks carried out on the hot water supplied was not accurate. The hot water supplied to the first floor bathroom was over the highest mark of 50 degrees centigrade on the thermometer. The record of temperatures for this bathroom were 40 degrees on each day. An immediate requirement was made at the time of this inspection for the hot water to be supplied at a safe temperature and for checks to be made on the recording of the hot water in the home. No hot water was available in the ground floor bathroom at the time of inspection. An immediate requirement was made for hot water to be supplied to all bathrooms. Staff make regular checks on the fire alarm system to ensure it is in good working order. Professional maintenance checks on the fire alarm system, emergency lighting and call bell system were seen to be carried out on a regular basis. Staff carry out fire drills to ensure that residents and staff are aware of actions to be taken should the system be activated. The last fire drill was carried out on 10th February 2006. It was noted that the fire extinguishers in the home had not been checked since 1st February 2005. The registered persons must ensure that maintenance checks are carried out on the fire extinguishers. The first aid boxes need to be checked on a monthly basis to ensure they are adequately and appropriately stocked. One first aid box was found to have very little content and the second first aid box contained TCP and bicarbonate of soda. It was noted that Steradent was not being stored appropriately in the home. The manager must ensure that any harmful substances are stored safely. A record of the last professional maintenance checks on the central heating system was not available in the home. An up to date gas safety certificate was not available. The registered persons must provide the commission with copies of these records. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 3 3 2 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 x 33 2 34 x 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000019074.V285816.R01.S.doc 3 2 x 2 x LIFESTYLES Standard No Score 11 x 12 x 13 2 14 2 15 x 16 2 17 2 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Barons Lodge Psychiatric Nursing & Rehabilitation Score x 3 2 x x x 2 x x 2 x Version 5.1 Page 25 yes 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 YA3YA6 Regulation 15 Requirement The Registered Persons must ensure that care plan include information for residents on their individual rehabilitation programme along with the estimated duration of the programme. (timescale of 10/01/06 not met) 2. YA9 13(4)(c) &12(1) The Registered Persons must ensure that where any resident has been identified as at risk of self harm or suicide clear guidance is available to staff on what actions to be taken in the event of any self ham or attempted suicide. 25/04/06 Timescale for action 10/01/06 3. YA13YA14 YA16 12(1)(2)(3) The Registered Persons must ensure that rehabilitation programmes are designed to meet the needs of individual residents. Staff must provide useful accurate records of activities for individual residents. 01/05/06 Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 26 4. YA17 16(2)(i) The Registered Persons must provide a menu which is compiled in consultation with residents, which offer clear alternatives and address the cultural and or religious needs and wishes of residents. A copy of the menu must be provided to the CSCI. The Registered Persons must ensure that clear written instructions are available and included in the care plan for all “as required” medication. Information must include the dosage to be given, the circumstances, the frequency and where more than one medication is used the order in which they should be given. 01/05/06 5 YA20 13(2) 01/05/06 6 YA24 23 The Registered Persons must ensure that the following issues relating to the building are addressed:All shower curtains must be cleaned effectively or replaced. The leak to the sink in the ground floor toilet must be repaired. The bin in the first floor bathroom must be replaced. Checks must be carried out on all electrical items including televisions to ensure they are in good working order. Strip lighting in bedrooms must be replaced by more domestic style lighting. The items stored in bedrooms 01/05/06 Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 27 which do not belong to residents must be moved to another storage area or disposed of. Plans must be made for the redecoration of the laundry room. 7. YA24 23(2)(b)(d) The Registered Persons must supply to the CSCI a programme for the redecoration or refurbishment of bathrooms and the completion of the redecoration of bedrooms. This programme must be commenced without delay. 23(2)(p) The radiator in bedroom 7 must be repaired. This issue was the subject of an immediate requirement. 7. YA24 23(2) 13(4) The locks to all bathrooms and toilets must be of a type which can be opened by staff from the outside in the event of an emergency. (timescale of 10/12/05 not met) This issue was the subject of an immediate requirement. 8. YA24 23(2)(j) 13(4) The Registered Persons must ensure that hot water is supplied to the ground floor shower room. The shower head must be descaled. These issues were the subject of immediate requirements. 9. YA33 18(1)(a) 12(1) Prior to any increase in the number of residents DS0000019074.V285816.R01.S.doc 01/05/06 8. YA24 20/02/06 20/02/06 20/02/06 01/05/06 Version 5.1 Page 28 Barons Lodge Psychiatric Nursing & Rehabilitation accommodated in the home a review of the staffing levels must be carried out. This review must include all staffing and the hours worked by staff. 10. YA39 24 The Registered Persons must ensure that quality monitoring and assurance systems are in place. An annual development plan must be produced. A copy of the plan must be provided to the CSCI. The results of residents surveys must be published. 11. YA42 13(4) The Registered Persons must ensure that hot water supplied to bathrooms is of a safe temperature. This issue was the subject of an immediate requirement. 12. YA42 13(4) The Registered Persons must ensure that staff keep an accurate record of hot water accessible to residents on a daily basis and whenever assisting a resident with bathing. This issue was the subject of an immediate requirement. 13 YA42 23(4c)(iv) 13(4) The Registered Persons must 01/05/06 ensure that maintenance checks are carried out on fire extinguishers. The Registered Persons must ensure that monthly checks are carried out on first aid boxes DS0000019074.V285816.R01.S.doc 01/08/06 20/02/06 15/02/06 14 YA42 13(4) 12(1) 01/05/06 Barons Lodge Psychiatric Nursing & Rehabilitation Version 5.1 Page 29 and that they are stocked correctly. 15 YA42 23(2)(p) The Registered Persons must supply to the CSCI copies of the last professional maintenance check on the central heating system. A copy of the gas safety certificate must be sent to the CSCI. 01/05/06 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 YA6 YA6 Good Practice Recommendations It is recommended that staff are provided with training on person centred care planning. It is recommended that residents are more involved in the care planning process and are requested to share with staff some of their life history and their views on their previous experiences. The Registered Persons should carry out a review of the mix of structured and recreational activities taking into account the needs and wishes of residents and the purpose of their placement. The Registered Persons should consider the provision of a vehicle for the home to assist where appropriate with community activities. The Registered Persons should consider how residents can be more involved with the planning, shopping and preparation of food. 3. YA13YA14 4. 5. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V285816.R01.S.doc Version 5.1 Page 31 - 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. 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