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Inspection on 28/09/05 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 28th September 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 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 gave very positive comments on the home. Residents spoken to at this visit felt the home was comfortable and that the staff group were supportive. One resident said it was "the best home I`ve been in". Another resident said "it`s nice here everyone gets on well and the staff are good". One resident stated "the staff are kind and treat me well". All residents were complimentary on the food provided. All said they were happy with the meals and the amount of food available. One resident said "the food is really good and there`s plenty to eat". Another resident said staff were "good cooks, I like the food".

What has improved since the last inspection?

The cleanliness in the home has improved since the last inspection. Residents now benefit from having an activities officer who has been in post since the end of last year. The manager reported that new flooring has been installed in the entrance hall and in the lounge areas which improves the environment for residents. The home now has a stable staff group which offers continuity of care to residents.

What the care home could do better:

To ensure that protection of residents policies and procedures relating to the protection of vulnerable adults must be reviewed. All staff must be provided with training on this issue. Policies and procedures relating to self harm and suicide must be available to staff. Further work needs to be done on care planning to make sure each care plan covers the full needs and aspirations of each individual. Care plans must clearly show how the home will meet these needs and wishes.Clear individualised information must be available to staff on interventions or strategies for dealing with challenging behaviour. Work needs to continue to improve the environment for residents. Quality assurance and monitoring needs to lead to an annual appraisal of the home. Rehabilitation programmes need to address the individual needs of residents and residents need to be provided with information on and agree with their individual programme.

CARE HOME ADULTS 18-65 Barons Lodge Psychiatric Nursing & Rehabilitation 24 Baron Grove Mitcham Surrey CR4 4EH Lead Inspector Liz O`Reilly Unannounced Inspection 28th September 2005 10:00 Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 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.V254267.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 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.V254267.R01.S.doc Version 5.0 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.V254267.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age Range To admit one named service user over seventy years for a period of rehabilitation. When the resident leaves, the age range is to revert back to 18 to 70 years. 31st August 2004 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.V254267.R01.S.doc Version 5.0 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 and one pharmacy inspector over five hours. The inspectors had the opportunity to speak with seven residents and three members of staff. A sample of records were examined. What the service does well: What has improved since the last inspection? What they could do better: To ensure that protection of residents policies and procedures relating to the protection of vulnerable adults must be reviewed. All staff must be provided with training on this issue. Policies and procedures relating to self harm and suicide must be available to staff. Further work needs to be done on care planning to make sure each care plan covers the full needs and aspirations of each individual. Care plans must clearly show how the home will meet these needs and wishes. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 Page 6 Clear individualised information must be available to staff on interventions or strategies for dealing with challenging behaviour. Work needs to continue to improve the environment for residents. Quality assurance and monitoring needs to lead to an annual appraisal of the home. Rehabilitation programmes need to address the individual needs of residents and residents need to be provided with information on and agree with their individual programme. 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.V254267.R01.S.doc Version 5.0 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.V254267.R01.S.doc Version 5.0 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): 1, 2 & 3 Documents have been produced which provide prospective residents with information on the service. The assessment process ensures the individual needs and aspirations of residents are known prior to admission. Further work needs to be carried out on the care plans in place. Further work needs to be undertaken to ensure that all residents have a clear understanding of the purpose and duration of any rehabilitation. EVIDENCE: The home has produced a Statement of Purpose and a Service User Guide which provide information on the service as well as the aims and philosophy of the home. Residents confirmed they were provided with a copy of the Service User Guide and a copy of the Statement of Purpose is available in the home. Prior to admission to the home assessments are carried out by staff from social services. A copy of the assessment is provided to the home which ensures that staff have information on the needs and aspirations of individual residents. The manager must ensure that all the information supplied is used to compile the individual care plan. Certain residents spoken to who stated they were staying in the home for rehabilitation did not have a clear understanding of how long they would be staying at the home. Each resident must be provided with clear information on Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 Page 9 their individual rehabilitation programme including the expected duration of the programme. The home provides a good variety of meals to meet the needs and wishes of residents taking into account social, cultural or religious needs. Efforts are made to improve communication with residents who’s first language is not English. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 Page 10 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): 6&9 Further work needs to be carried out on care plans to ensure these cover all the needs and aspirations of individuals. Rehabilitation plans need to be tailored to individual needs. Risk assessments are in place. EVIDENCE: Basic care plans were seen to be in place. However the care plans examined did not reflect the full needs and aspirations of residents. It was noted that risk assessments had been carried out covering activities for individuals but these were not included in the care plans in place. In one instance information on supporting one resident to manage their budget was found in the financial records but was not set out in the care plan. No information was seen to be available on how staff were to support and develop budgeting skills for this resident. The rehabilitation plans seen were not individualised. Rehabilitation activities were the same for each resident. It was noted that the wishes of one resident in relation to social activities were not included in the care or rehabilitation Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 Page 11 plan. The information supplied by the social worker for this particular person stated that the rehabilitation plan needs to be focused. However the inspectors found no evidence that this had been addressed. Information that one resident required a more varied social life was not reflected in the care plan. None of the files examined contained an individualised rehabilitation plan. It was not clear to the inspectors how the activities on offer relate to individual needs. Weekly rehabilitation programmes seen followed the set plan of activities on display. Plans had not been reviewed. One programme had not been updated since 2003 another plan had not been updated since 2004. Risk assessments were seen to be in place covering certain areas for individual residents. As noted previously the risk assessments seen were not always reflected in the care plans. Staff must ensure that where risk assessments indicate a risk to the residents or others clear intervention strategies are made available to all staff and are discussed with the resident. A review of the care plans, risk assessments and rehabilitation programmes for residents must be carried out. The six monthly review of the care provided must include all areas, care planning, rehabilitation and risk assessments. The daily recording seen was of a good standard. In one instance notes stated residents had shown “bizarre behaviour”. It would be more useful for staff to describe the actual behaviour. Where qualified staff have completed documentation or entries in the daily record they must sign with their full signature and their qualification. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 Page 12 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): 12, 14, 15 & 17 Residents enjoy a weekly party in the home. As noted previously the programme of activities and rehabilitation needs to be individualised. Residents confirmed they can have visitors within the home. Residents were happy with the food provided. The menus for the home showed a good variety of meals on offer. EVIDENCE: One of the residents in the home at the time of this visit stated they attended college four days each week. The resident said they enjoyed the courses and felt supported by staff to continue with their education. The manager informed the inspectors that the majority of residents are encouraged to attend the rehabilitation unit five days a week “as if they were going to work”. The unit is furnished with a kitchen, art and crafts room, IT room and laundry. Residents return to the main home for lunch. One resident felt that the time spent in the rehabilitation unit could be reduced but made more focused on their individual needs. It was noted that on the Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 Page 13 day of this visit one resident was cooking while five other residents watched and wandered in and out of the various rooms in the unit. One resident spent time watching a member of staff surfing the internet. Residents said they enjoyed the weekly party at the home on a Friday when they choose and cook what they want to eat with wine. Residents also said they enjoyed watching videos and the arts and crafts sessions in the home. Residents confirmed that they could have visitors at the home when they wished. Certain residents said they had visits from their family. Residents are involved in some of the domestic tasks around the home such as looking after their own rooms, setting tables and clearing away after meals. Residents gave very positive comments on the food provided. One resident stated the “food is very good and there is plenty to eat”, another resident informed the inspector that “the cook is very good, we get nice food”. The menu seen offers clear choices at each meal time and takes into account the cultural needs of individuals. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 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): 18, 19 & 20 Residents confirmed that they make their own choices regarding their personal appearance. Arrangements are in place for residents to be offered regular health care checks. The home has arrangements for the ordering, storage, recording, administration and auditing of medication and has access to a pharmacist for advice. On the day of the visit errors and omissions in recording were found that might have an effect on the health and welfare of residents. EVIDENCE: Residents confirmed that they made their own choices about getting up and going to bed. Residents said they chose their own clothing and hairstyles. Two residents stated they enjoyed going out shopping for clothes. Each resident is allocated a keyworker from the staff group. Information on advocacy services was seen to be on display in the home. Since the last inspection visit there has been a death at the home. This has been referred to the Coroner and investigations were still in progress at the time of this inspection. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 Page 15 A qualified nurse is on duty at all times in the home. The manager reported that the home has good links with the local psychiatric services and can call on professionals to offer advice and support. Arrangements were seen to be made for residents to receive regular health care checks. All medications administered by staff along with the policies and records relating to receipt, storage, administration and disposal of medication were examined. The manager was interviewed, three residents’ care plans for reviewed and the amount of medication counted and compared to the amount that should be in stock for all medication not supplied in a monitored dosage system to ensure residents receive their medication as prescribed. From these observations and discussions policies and procedures were seen covering all aspects of medication management and have been updated since the last inspection to reflect current safe practice. The dosage of medication was written in figures rather than words on the administration record for medication to be taken when needed for four residents. The administration of one medication was not recorded accurately. The administration record indicated the total dose of medication given in milligrams rather than reflecting the number of different strength tablets given. These findings had no effect on the health and welfare of these residents. In four instances the receipt of medication had not been record or the quantity of medication carried over from one month to the next was not indicated on the administration record. For three residents where two different types of sedative medication had been prescribed for varying degrees of agitation, no care plans or written directions were seen detailing the when these medications are to be used or when one medication should be used instead of the other. This made it difficult to calculate how much medication should be in stock and whether the medication for these residents had been given as prescribed to ensure the health and welfare of residents. From the records and examination of the container all other medication had been given as prescribed unless otherwise recorded, changes to medication clearly identified, all other medication was stored and administered safely by appropriately trained staff. All these arrangements ensure that the health and welfare of service users are protected Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 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 A suitable complaints procedure is in place. The homes’ procedure on protection from abuse needs to be reviewed and policies and procedures on self harm and suicide must be made available. All staff must be provided with training on protection of vulnerable adults. EVIDENCE: The complaints procedure was seen to be on display in the home. Should any resident make a complaint a record is made which includes what the complaint is, any actions taken and the outcome of the complaint. The home will respond to any complaint within clear timescales. Information on contacting the Commission is also available. The record of complaints showed no complaints had been received since 2004. Residents spoken to said they felt if they had any problems or concerns the manager would help them with this. None of the residents spoken to reported any complaints about the home. The home has available a copy of the local authority policies and procedures for dealing with any allegation or suspicion of abuse. It was noted that the homes’ procedure seen at this visit did not comply with the local authority procedure. In order to ensure that protection of residents the homes’ procedure must be reviewed to make sure that all allegations or suspicions of abuse are reported to the local authority and the Commission without delay. No policies or procedures were available in the home in relation to self harm or suicide. Due to the nature of this service staff must be provided with clear guidance on working with residents at risk of self harm or suicide. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 Page 17 Residents can deposit cash in the home for safekeeping. Accurate records were seen to be kept to ensure that residents’ money is safeguarded. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 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, 26, 27, 28 & 30 Progress is being made to ensure that the home is well maintained. This work needs to be continued to bring all of the home up to a satisfactory standard. Communal areas are well maintained and comfortably furnished. Bathrooms need to be updated to ensure that residents are provided with a well maintained environment. EVIDENCE: The manager reported that since the last inspection new carpets have been fitted to the lounges and new flooring to the entrance hall. One empty bedroom was about to be redecorated and refurbished. The manager informed the inspector that another bedroom would be redecorated at the same time. The redecorating and refurbishment of bedrooms needs to be continued. A number of rooms are showing signs of wear and tear some quite marked. The shower holder in the first floor bathroom is broken. The shower curtain and bath mat need replacing in the ground floor bathroom. All bathrooms need updating and redecorating. It was noted that the lock on the ground floor toilet and shower room cannot be opened from the outside. To ensure the health and safety of residents this Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 Page 19 lock must be replaced with a lock that can be opened by staff from the outside in the event of an emergency. In a number of bedrooms handles were missing from drawers and wardrobes. To ensure that residents are provided with a comfortable, well maintained environment regular checks must be carried out on the furnishings around the home with prompt action taken to repair any damage. The majority of the home was found to be clean and tidy. One bedroom was found to have an offensive odour which the manager was addressing. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 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): 32, 34,35 & 36 Adequate staffing levels are in place. The recruitment checks carried out assist in protecting residents. The training provided helps in ensuring residents are supported by a well informed staff group. Further training courses need to be provided covering certain areas. Staff supervision needs to be carried out on a regular basis to ensure that residents are cared for by a well supported staff group. EVIDENCE: During the day residents are supported by one qualified nurse and two carers. At night one qualified nurse and one carer are awake in the home. Since the last inspection a rehabilitation officer has been employed who is on duty during the week. A full time cook is available Monday to Friday along with one part time domestic and a part time administrator. A review of staffing levels should be included in any review of the rehabilitation programme. The staff rota showed that the qualified staff in the home worked twelve hour shifts. The manager informed the inspectors that staff do have breaks during their shift. As there is only one qualified nurse on duty at any one time this person cannot leave the home. The home owner must keep Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 Page 21 A sample of staff files were looked at which showed that checks were carried out, including Criminal Records Bureau checks, prior to starting work in the home. These checks assist in protecting residents. Staff are offered a variety of in house training sessions. The record of training included Schizophrenia, personal care, communication, confrontational skills and dealing with violence and aggression in the workplace. The training provided was seen to be tailored to meet the needs of residents and staff. The training on violence and aggression was provided in response to an incident in the home. One member of staff has completed NVQ training and the manager reported that three members of staff were in the process of completing this training. Not all staff have completed food hygiene training or, as noted previously, protection of vulnerable adults training. The home owner must ensure that all staff involved in the preparation of food are supplied with basic food hygiene training and all staff in the home protection of vulnerable adults training. The manager informed the inspectors that all staff are provided with one to one supervision from a more senior member of staff. However this was not occurring six times a year in line with National Minimum Standards. The owner and manager must ensure that staff are provided with supervision at least six times each year which will ensure that residents are supported by appropriately supervised staff. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 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 In order to ensure that residents’ views are taken into account an assessment of the service must be carried out along with an annual development plan. The owner must ensure that a monthly report is made following a visit to the home. Staff carry out regular checks to ensure the health and safety of residents. EVIDENCE: Quality monitoring and assessment systems must be developed to ensure that the home is meeting its stated aims and objectives. The views of residents and others connected to the home should be taken into account when carrying out an annual review of the service. The results of consultation with residents about the home must be published and an annual development plan must be produced. A copy of the report following the annual review must be provided to the Commission. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 Page 23 The home owners must ensure that once a month they provide to the Commission a report on their visit to the home. A copy of the report must also be available in the home. Records showed staff make regular checks on the building and equipment in the home. A sample of the records were seen at this visit. Maintenance checks were seen to have been carried out on the fire alarm system, call bells, emergency lighting, fire extinguishers and water system. The maintenance and in house checks carried out help to ensure the health and safety of residents, staff and any visitors to the home. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 2 x x Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 2 3 x 3 LIFESTYLES Standard No Score 11 x 12 3 13 x 14 2 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Barons Lodge Psychiatric Nursing & Rehabilitation Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x DS0000019074.V254267.R01.S.doc Version 5.0 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 YA6 Regulation 15 Requirement The Registered Persons must ensure that care plans include the full needs and aspirations of individual residents along with information on how these will be met. Where risks have been identified these must be reflected in the care plan. 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. The registered person must ensure that the receipt of all medication into the home is recorded appropriately. The registered person must ensure that care plans are in place for all sedative medication used to control behaviour detailing when and how the medications are to be used. 7th November 2005. Timescale for action 10/01/06 2 YA6 15 10/01/06 3 YA20 13 01/12/05 4 YA20 13 01/12/05 Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 Page 26 5 YA23 13 6 YA23 13 & 12 7 YA23 13 8 YA24 23 The Registered Persons must review the homes’ policy and procedure in relation to the protection of vulnerable adults to ensure that any allegation or suspicion of abuse is reported to the local authority and the CSCI The Registered Persons must ensure that policies and procedures are in place in relation to residents who may be at risk of self harm or suicide. The Registered Persons must ensure that all staff are provided with training on the protection of vulnerable adults. The Registered Persons must ensure that the following issues relating to the building are addressed:1) the lock to the toilet on the ground floor must be replaced to allow for access by staff in the event of an emergency. 2) The shower curtain and mat must be replaced on the ground floor. 3) Furniture in the home must be checked and repaired as required. 01/12/05 01/12/05 10/01/06 10/12/05 9 YA35 18 10 YA36 18 11 YA39 24 The Registered Persons must 10/01/06 ensure that all staff involved in the preparation of or handling of food are provided with basic food hygiene training. The Registered Persons must 10/01/06 ensure that all staff are provided with supervision from a more senior member of staff at least six times a year. The Registered Persons must 10/01/06 ensure that quality monitoring and assurance systems are in place. An annual development plan must be produced. A copy of the DS0000019074.V254267.R01.S.doc Version 5.0 Page 27 Barons Lodge Psychiatric Nursing & Rehabilitation plan must be provided to the CSCI The results of residents surveys must be published. 12 YA43 26 The Responsible Individual must produce a monthly report on the home. A copy of each report must be supplied to the CSCI with a copy available in the home. 10/12/05 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 YA20 Good Practice Recommendations It is recommended that the dose of medication for all medication entries on the administration record be written in words rather than figures and that where two separate strengths of medication are used each strength is written separately on the administration record. It is recommended that the quantity of any medication carried over from one month to the next be recorded on the administration record. 2 YA20 Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V254267.R01.S.doc Version 5.0 Page 28 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.V254267.R01.S.doc Version 5.0 Page 29 - 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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