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Inspection on 07/06/06 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 7th June 2006.

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

The inspector 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 13 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

Feedback from residents on the staff group was positive. Residents felt they were treated well by the staff and that staff were "very kind" and listened to them. Residents benefit from a stable staff group who they know well and who have a good understanding of their individual needs. Agency staff are not used in this home. Progress is being made to expand the opportunities for residents to obtain paid or unpaid employment in the community. The rehabilitation unit is a good resource for residents.

What has improved since the last inspection?

Since the last inspection of the home an extension has been added to the side of the home which has increased the number of places available to twenty one. At the time of this visit the extension had not been fully completed but the work seen was of a good quality and once completed will offer a good quality environment. Once completed the extension will provide large communal areas for all residents. A number of bedrooms in the main home area have been redecorated. Some progress has been made in moving towards individualised rehabilitation and activities programmes. The information available within individual care plans and the daily notes compled by the qualified staff have improved.

What the care home could do better:

The environment of the main home is in urgent need of attention. In particular the bathrooms are in a very poor condition. The inspectors are aware that work has been concentrated on the extension to the home. The inspectors were informed that work would commence on the bathrooms once the extension has been completed. This work must be carried out without delay.The inspectors found one resident sleeping on a damaged mattress. This mattress was replaced on the day of the visit. The inspectors also found one bedroom without a supply of hot water. Immediate requirements were made concerning the above issues and appropriate action was taken by the home. In addition the inspectors found children`s bedding on one residents bed, dried faeces on the pillow in one room, strip lighting in one bedroom, sinks in bedrooms without plugs, and one room with no curtains to the window. The management must ensure that staff carry out regular checks on bedrooms to make sure that they are clean, well maintained and appropriately furnished. Worn mattresses must be replaced by the home. Staff must take responsibility for reporting any maintenance issues and managers must follow these up. Staff need to make further progress in implementing individualised rehabilitation programmes. All staff need to be involved in the implementation of the programmes. It is recommended that the practice of care staff making checks on every resident throughout the day is reviewed to allow for less monitoring and more active support to residents. Staff need to ensure that risk assessments are backed up with care plans. Where any assessment including Waterlow indicates a risk to an individual information must be available as to what action is being taken by staff to lower the risk. Care staff should be provided with training on record keeping. In house training must be provided by an appropriately trained member of staff. A record of the trainers training must be available in the home. The management must ensure that they carry out their own Criminal Records Bureau checks, obtain two written references and a full employment and education record for all staff prior to them starting work in the home. Where any test on equipment including the fire alarm system shows a fault staff must make a record of the actions taken to rectify the fault.

CARE HOME ADULTS 18-65 Barons Lodge Psychiatric Nursing & Rehabilitation 24 Baron Grove Mitcham Surrey CR4 4EH Lead Inspector Liz O`Reilly Unannounced Inspection 7th June 2006 10:30 Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 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.V298793.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 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.V298793.R01.S.doc Version 5.2 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 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. As agreed on the 03/05/2006, one named service user (male)over the age of 65 with a Mental Disorder can be accommodated within the home 14th February 2006 Date of last inspection Brief Description of the Service: Barons Lodge is a registered care home with nursing for up to twenty one 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 on the ground and first floors of the home. Residents also have access to communal lounge areas, a dining room, a large garden and the rehabilitation unit. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.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 by two regulation inspectors. Questionnaires were provided to residents in the home and were sent to a sample of relatives and other professionals who visit the home. Four questionnaires were returned by the requested date of 10th July 2006. What the service does well: What has improved since the last inspection? What they could do better: The environment of the main home is in urgent need of attention. In particular the bathrooms are in a very poor condition. The inspectors are aware that work has been concentrated on the extension to the home. The inspectors were informed that work would commence on the bathrooms once the extension has been completed. This work must be carried out without delay. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 6 The inspectors found one resident sleeping on a damaged mattress. This mattress was replaced on the day of the visit. The inspectors also found one bedroom without a supply of hot water. Immediate requirements were made concerning the above issues and appropriate action was taken by the home. In addition the inspectors found children’s bedding on one residents bed, dried faeces on the pillow in one room, strip lighting in one bedroom, sinks in bedrooms without plugs, and one room with no curtains to the window. The management must ensure that staff carry out regular checks on bedrooms to make sure that they are clean, well maintained and appropriately furnished. Worn mattresses must be replaced by the home. Staff must take responsibility for reporting any maintenance issues and managers must follow these up. Staff need to make further progress in implementing individualised rehabilitation programmes. All staff need to be involved in the implementation of the programmes. It is recommended that the practice of care staff making checks on every resident throughout the day is reviewed to allow for less monitoring and more active support to residents. Staff need to ensure that risk assessments are backed up with care plans. Where any assessment including Waterlow indicates a risk to an individual information must be available as to what action is being taken by staff to lower the risk. Care staff should be provided with training on record keeping. In house training must be provided by an appropriately trained member of staff. A record of the trainers training must be available in the home. The management must ensure that they carry out their own Criminal Records Bureau checks, obtain two written references and a full employment and education record for all staff prior to them starting work in the home. Where any test on equipment including the fire alarm system shows a fault staff must make a record of the actions taken to rectify the fault. 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.V298793.R01.S.doc Version 5.2 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.V298793.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. Evidence suggests that before anyone is admitted to the home assessments of their needs are carried out. As noted in previous inspection reports further work is needed to make sure that all residents have a clear understanding of the reason for their admission to the home whether that be for long term care or rehabilitation. EVIDENCE: The inspectors examined a sample of residents files and found that prior to their admission to the home the needs of each individual had been assessed by a Care Manager. Copies of the assessments were on file. In addition staff from the home will visit prospective residents and carry out their own assessment of needs. Staff use the pre admission assessments to set up an initial care plan for residents. As noted in previous inspection reports residents must be provided with clear information on the reason for their admission to the home. If residents are admitted for rehabilitation then they need to be provided with information on the rehabilitation to be provided and an estimated timescale. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 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): 6, 7 & 9 Quality in this outcome area is adequate. Improvements have been made in care planning. These improvement need to be continued to produce more person centred care plans. Further work needs to focus on involving residents in decisions about their life and activities in the home. Risk assessments are in place for individuals. EVIDENCE: Each resident is provided with a care plan setting out individual needs. Improvements have been made in making care plans more individualised and including the wishes, likes and dislikes of each person. However further work should be carried out on the care planning process and it is recommended that staff are provided with training on person centred planning. Staff must ensure that care plans provide information on the full needs and aspirations of each individual. It was noted in one instance that references were made to inappropriate behaviour for one resident but this was not noted in the care plan. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 10 As noted in the last inspection report 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. Daily recording by the qualified staff is of a good standard. Staff must ensure that the records include all care provided. It was noted in one care plan that a resident should be receiving daily one to one sessions from staff. Records did not evidence that this work was being carried out. The notes provided by the keyworkers were poor and in certain instances contained inappropriate comments. It is recommended that care staff are provided with training on record keeping. Individual risk assessments are in place which can help in supporting residents to lead a more independent lifestyle. Staff must ensure that where any risk has been identified this is supported by information on actions to be taken on the care plan. Further work should be focused on supporting residents to make their own choices on day to day issues. Supplying clear information to residents on the reason for and estimated length of their stay in the home will help in supporting individuals to make decisions about their future. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 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): 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. Progress is being made in supporting residents to take part in or gain employment outside the home. Further work needs to focus on meeting the individual needs of residents for rehabilitation or activities. Residents said that they were encouraged to keep in contact with friends and relatives and that they are supported to attend religious centres of their own choosing. The published menu for the home is not accurate. EVIDENCE: The home has the benefit of a rehabilitation unit which is in a separate building in the back garden. This provides good space for rehabilitation activities. Improvements have been made in the range of activities and rehabilitation available. The rehabilitation officer is supporting residents in seeking employment outside the home. However these improvements need to be continued to create individualised activity or rehabilitation. A review of the activities on offer should be carried out. A number of residents felt that the activities available were repetitive and did not cater for their needs Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 12 or wishes. Consideration should be given to mixing social activities with the rehabilitation particularly for those residents who are living in the home on a long term basis. The library room appears to be little used by residents and consideration should be given to expanding the use of the resource. All staff need to be involved in the rehabilitation or activities. It was noted that care staff spend time checking where each resident is and recording this throughout the day. The inspectors are of the opinion that this practice should be reviewed and tailored to the risk of individuals self harming or absconding from the home. This may provide more time for staff to be engaged in activity in the home rather than monitoring. Progress is being made in relation to activities and seeking employment outside the home. However the programme for the rehabilitation unit has not been individualised. Residents confirmed that they can attend religious centres of their own choice as often as they wish. Residents informed the inspectors that they “sometimes go out shopping and sometimes go to the pub for a meal”. The registered persons should consider the provision of a vehicle for the home to assist where appropriate with community activities. Residents also confirmed that they can have visitors to the home if they want and can meet with their friends or relatives in the communal areas of the home or in the privacy of their own room. Menus have been reviewed since the last inspection however the food provided did not match with the published menu. Staff informed the inspectors that they used left overs from the day before on a regular basis instead of the published menu. Residents must be supplied with a healthy, varied diet. Menus must be compiled in consultation with residents. Individuals must be offered clear choices at each meal time and the senior person on duty must be consulted on any changes in the menu. Any changes to the published menu must be clearly recorded. Issues regarding the food provided in the home were highlighted at the last inspection. The menu must be reviewed in consultation with residents and a copy of the new menu must be provided to the CSCI. Feedback from residents indicated that meals were often delayed in being served which resulted in the food being “cold” by the time they received it. The serving of meals should be monitored by the person in charge of each shift to ensure that food is served as soon as possible. Separate menus were seen to be produced to meet the cultural or religious needs of individuals. Consideration should be given to involving residents with the planning, shopping and preparation of food. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. Staff monitor the health of residents and support individuals to attend health care check ups. Medication is well managed. Further information needs to be available on medication given “as required”. EVIDENCE: All residents are registered with local GP practices. Arrangements are made for residents to attend the GP surgery with staff support if needed. The home has good links with local psychiatric services and can call on the consultant psychiatrist for advice if needed. A qualified nurse is on duty at all times. Staff ensure that residents have the opportunity to obtain regular health care checks including optical, dental, chiropody and breast screening. Staff monitor the weight of residents. Staff need to be reminded to record any actions they take should an individual show any significant weight gain or loss. Medication is appropriately stored and records of medication given are well maintained. Staff keep clear records of all medication coming into and going out of the home. Staff need to make sure that any medication prescribed to be given “as required” is accompanied by instructions on the maximum dosage. The 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. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. Residents confirmed they were aware of the complaints procedure and who to go to if they have a problem. To assist in ensuring the protection of residents all staff have been provided with training on the protection of vulnerable adults. EVIDENCE: The complaints procedure is on display at various places throughout the home. Residents are aware of their right to make a complaint if they are unhappy with any aspect of the home or the care provided. Systems are in place for the recording of any complaint received along with any actions take to investigate the complaint. Policies and procedures are in place to protect residents from self harm or suicide. Staff are provided with guidance on actions to be taken should any resident identified as at risk attempt suicide or self harm. All staff have received training on the protection of vulnerable adults. Facilities are available for residents to deposit small amounts of money with the home for safekeeping. A sample of individual financial records were examined and found to be well maintained, up to date and accurate. Where staff are supporting residents to manage their budget this is included in the care plan. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 15 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, 27, 28 & 30 Quality in this outcome area is poor. Staff are not taking sufficient care to ensure that residents are provided with a homely, comfortable and clean environment. The inspectors are aware of the improvements being made with the addition of the extension to the home. However the condition of the bathrooms and some of the bedrooms in the rest of the home is very poor. EVIDENCE: At the time of this visit to the home the extension which includes additional bedrooms with en suite bathrooms and additional communal space had not been completed. Once completed these facilities will improve the environment in the home. However the condition of certain areas in the main building is of concern. The bathrooms are in urgent need of refurbishment. Hot water must be available in all bathrooms. The condition of the décor in bathrooms was very poor. The management must supply to the CSCI information on the refurbishment of all bathrooms in the main building along with timescales for the completion of this work. Feedback from residents indicated that toilets were often “not very clean”. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 16 A number of bedrooms in the main house have been redecorated and this work must be continued to ensure that all bedrooms are decorated to an adequate standard. A programme with timescales for the redecoration of the remaining bedrooms must be supplied to the CSCI. All staff must be made aware of their responsibility for ensuring residents are provided with a comfortable, homely and clean environment. The inspectors viewed a sample of bedrooms. In one bedroom dried faeces was found on the top pillow. One resident had been supplied with bedding more suitable for a child. One resident was sleeping on a damaged mattress which made sleeping uncomfortable. No curtains were available in one bedroom. One bedroom was supplied with strip lighting. No hot water was available in one bedroom and plugs were not supplied for all hand basins. Requirements have been made for the home to address these issues. Senior staff must make regular checks on bedrooms to ensure that they are in good condition. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. Residents are generally satisfied that the care they receive meets their needs. Staff are offered good opportunities for in house training. The record of the trainers training must be maintained. Staff are clear about their role and what is expected of them. As noted previously work should focus on staff taking a more active rather than monitoring role. Further work needs to be done to make sure appropriate checks are carried out on staff. EVIDENCE: Residents made positive comments on the approach of the staff group. New staff have in induction training and there are good opportunities for in house training. The home’s training and development plan shows regular monthly training sessions. Training includes health and safety issues, personal care, cultural, social and emotional needs, health care, activity participation, communication and mental health. A record of the trainers training needs to be maintained to provide evidence that the training provided is up to date and based on current good practice. The inspectors examined a sample of staff files. Up to date Criminal Records Bureau checks were not available on each file. In one instance one written reference had been obtained and one verbal reference but they had both been Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 18 supplied by the same person. The employment and education history for one member of staff did not include any information prior to 2001. To ensure the safety of residents the registered persons must make sure that Criminal Records Bureau checks are carried out by the home before staff commence work in the home. Two written references must also be sought and a full employment and education history must be provided by staff. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 19 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): 37, 39 & 42 Quality in this outcome area is good. The manager is appropriately qualified and experienced to run the home. A quality monitoring system has been developed which includes consultation with residents. Staff carry out regular checks on the home to ensure the health and safety of residents, visitors and staff. EVIDENCE: Residents are able to feedback to the organisation their views on the home and the care provided. This information is part of the quality monitoring system and can be used by the organisation to influence the development plan for the home. Health and Safety checks are carried out on the building and equipment. It was noted there were some gaps in the weekly fire alarm testing but this was now being carried out weekly. A record of fridge and freezer temperatures is maintained to ensure the safe storage of food. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 20 Staff must ensure that where faults are noted a record of the actions taken is kept. First aid can be provided as a qualified nurse is on the premises at all times. Staff are provided with training on moving and handling. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 21 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 1 28 3 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000019074.V298793.R01.S.doc 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 2 15 3 16 2 17 1 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Barons Lodge Psychiatric Nursing & Rehabilitation Score 3 3 2 x 3 x 2 x x 3 x Version 5.2 Page 22 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 YA6 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. YA13 YA14 YA16 12(1)(2)(3) The Registered Persons must ensure that rehabilitation programmes are designed to meet the needs of individual residents. 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. DS0000019074.V298793.R01.S.doc Timescale for action 01/11/06 01/11/06 3. YA17 16(2)(i) 01/11/06 Barons Lodge Psychiatric Nursing & Rehabilitation Version 5.2 Page 23 The serving of meals should be monitored by the person in charge of each shift to ensure that food is served as soon as possible. 4. YA20 13(2) 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. 5. YA24 YA25 23 The Registered Persons must 01/11/06 ensure that the following issues relating to the building are addressed:All hand basins must be supplied with plugs. Fully operational curtains must be provided in all bedrooms. All mattresses in the home must be checked. Damaged mattresses must be replaced. Checks must be carried out on all bedding to ensure that it is in good condition and is suitable for adults. Strip lighting in bedrooms must be replaced by more domestic style lighting. Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 24 01/10/06 Plans must be made for the redecoration of the laundry room. The Registered Persons must ensure that staff record any actions taken to arrange the repair faulty equipment. 6. YA24 23(2) The Registered Persons must replace the mattress in room 10. (this issue was the subject of an immediate requirement) The Registered Persons must ensure a supply of hot water is available in room 7. (this issue was the subject of an immediate requirement) The Registered Persons must supply to the CSCI a revised programme for the refurbishment of bathrooms and the completion of the redecoration of bedrooms. This programme must be commenced without delay. The Registered Persons must ensure that prior to commencing work in the home the following checks are carried out for all staff:Criminal Record Bureau checks/POVA First Two separate written references. All staff must provide a full employment and education history. The Registered Persons must ensure that a record of the DS0000019074.V298793.R01.S.doc 07/06/06 7. YA24 23(2) 08/06/06 8. YA24 23(2)(b)(d) 01/11/06 9. YA34 19 01/10/06 10. YA35 18(1) 01/10/06 Page 25 Barons Lodge Psychiatric Nursing & Rehabilitation Version 5.2 training provided for staff who are providing training to others is maintained at the home. 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 YA6 Good Practice Recommendations It is recommended that staff are provided with training on person centred care planning. Care staff should be provided with training on record keeping. 2. YA6 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 review the working practices within the home with a view to involving more staff in the rehabilitation and or activities. The Registered Persons should consider how residents can be more involved with the planning, shopping and preparation of food. 3. YA14 4. YA13 5. YA13 . YA16 Barons Lodge Psychiatric Nursing & Rehabilitation DS0000019074.V298793.R01.S.doc Version 5.2 Page 26 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.V298793.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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