Inspection on 03/10/06 for Bathurst Lodge

This inspection was carried out on 3rd October 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 no outstanding requirements from the previous inspection report, but made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bathurst Lodge 30/05/07

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Bathurst Lodge 74 Bathurst Road Gloucester Glos GL1 4RJ Lead Inspector Mr Paul Chapman Key Unannounced Inspection 3rd October 2006 09:00 Bathurst Lodge DS0000067438.V308054.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 Bathurst Lodge DS0000067438.V308054.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. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bathurst Lodge Address 74 Bathurst Road Gloucester Glos GL1 4RJ 01452 552683 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) www.holmleigh-care.co.uk Holmleigh Care Homes Ltd Acting manager - Gill Cormack Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager must complete approved training in Health & Safety, and protection from abuse. Date of last inspection 19/10/05 Brief Description of the Service: Bathurst Lodge is a detached two storey, Victorian brick built property situated in a cul-de-sac. There is off-road parking to the front of the house and a good sized garden to the rear. The home provides living accommodation on the ground and first floors. On the ground floor there is a lounge, kitchen, dining room, bathroom and one bedroom. On the first floor there are five single bedrooms and a bathroom. Bathurst Lodge provides accommodation for up to eight people with learning disabilities. The home is staff 24 hours a day, seven days a week. The property is one of a group of seven registered care homes in Gloucestershire that are owned by Holmleigh Care. The home has a Statement of Purpose that is available from the manager and a copy of the Service User’s Guide was available on the home’s notice board. The fees for the home range from £748.89 to £1293.98 per week. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Holmleigh Care Ltd became the owner of this property on April 1st 2006. The organisation’s management team recognised that a number of areas of the home were not maintained to a satisfactory standard, in line with their policies and procedures. Since April the organisation have had regular dialogue with the CSCI regarding these issues. The CSCI recognise the organisation’s commitment to address these issues. The report accurately reflects the findings at the time of the inspection but significant improvements have continued to be implemented within the home since the inspection. This site visit was completed over two days, Tuesday 3rd October and Friday 20th October and in total took twelve hours. On entering the property through the double gates there is parking for a number of vehicles including the home’s transport. The bay window of the front room overlooks this area. The main entrance to the home is to the left hand side of the property. On entering the building there is a good-sized hallway with stairs leading to the first floor and the majority of peoples bedrooms. On the right hand side of the hallway are doors leading to the front room, before entering the front room there is a door that leads to and a ground floor bathroom. There is also a door to the ground floor bedroom. To the left hand side of the hallway is a door leading to the dining room and kitchen. This part of the home has been undergoing some major building work where French windows have been installed, and wall has been knocked down making the dining room bigger. Leaving the dining room through the door on the right you enter the kitchen. From the kitchen you can access the back garden. The principle method used to gather evidence was case tracking. This involves examining the care notes and other related documents for a select number of people living at the home. This is followed up by talking to them or their relatives/representatives, or observing them. This provides a useful, in depth insight as to how people’s needs are being met from more than one source of evidence. At this inspection all of the people living at the home were case tracked. As no relatives or representatives were at the home the manager was asked for the names and addresses of family members and other professionals involved in the care of people in the home. These had not been supplied by the time this report was published. The CSCI will send surveys to these people and their comments will be taken into account at the next inspection. On the first day of the site visit the senior support worker worked with the inspector providing the necessary information. In addition to this a group of 4 staff were spoken with. On the second day the acting manager was present throughout. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Care plans developed from the needs assessments must be specific, measurable, achievable, realistic and time-constrained. Care plans must also provide the staff team with enough information to enable them to support people in a consistent manner. People’s assessments and care plans should provide evidence of the people being involved in developing them. People living at the home must be given the opportunity to be involved in the day-to-day running of the home. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 7 Risk assessments should enable people to complete day-to-day activities whilst minimising the risks to their safety. The manager must ensure that all people are enabled to choose what is on the menu. The use of photos was suggested. People’s personal care needs must be identified and met by the staff team. No health assessments have been completed and this should be addressed to minimise potential risks to people. Where the staff manage people’s money the records must be accurate and provide an audit trail. It is planned that the communal accommodation will be redecorated and improved in the near future. This should provide people with a more homely better quality environment. The manager must ensure that any future recruitment of staff adheres to the relevant procedures and that people are not put at risk due to the required checks not being completed. The manager must ensure that staff complete training in protection of vulnerable adults. Quality Assurance systems must be put in place. These systems should involve people living in the home. The manager must ensure that the appropriate fire safety checks are completed regularly. 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. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 8 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 Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 9 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, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed and have been reviewed within the previous 12 months. It is impossible to confirm whether people’s needs are being met due to poor guidelines for staff. Residency agreements are not signed by people, or their representatives and therefore it is unable to confirm whether people agree with these terms. EVIDENCE: There have been no new admissions to the home since the previous inspection. The senior support worker on duty for the first day of this site visit was asked whether there was an admissions policy. Unfortunately they were unable to find it. As part of the second day spent at the home with the acting manager evidence was available of each person being assessed by the previous manager. These documents provided a substantial amount of information about peoples needs although some shortfalls were identified and discussed with the acting manager. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 10 Residency agreements were examined. None of the agreements had been signed by the people living at the home or their representatives. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 11 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, 8, 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans/assessments have been written for each person which detail people’s needs, but the guidelines to meet those needs are poor and do not enable a consistent approach by staff. People have not been involved in the care planning process to this date limiting empowerment and choice. Potential risks to people are being assessed with the intention of enabling people to complete activities. EVIDENCE: Information about the people living at the home is stored appropriately in the home’s office/and or a storage cupboard that is locked at all times. The files for all of the people were examined. Care plans/assessments were present in all of the files. The previous manager had reviewed all of these Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 12 documents within the past 12 months. The detail provided in these documents about peoples needs was substantial. Care plans examined provided some guidelines about meeting people’s needs but it would have been difficult for staff to support people consistently. The manager stated that care plans will be re-written in a newer simpler format. Care plans written by the acting manager were examined. These provided a format that would make it easier for staff to follow. The manager is aware of the need to keep these plans simple and the ones examined were discussed. Future care plans must provide staff with detailed guidelines that enable them to provide people with consistent care that meets their needs. These care plans should also be specific, measurable, achievable, realistic and time-constrained. None of the care plans examined provided any evidence that the person for whom the plan was written was involved in at any point. Again this was discussed with the acting manager and methods how this will be achieved in the future. The organisation are in the process of implementing the use of Essential Lifestyle Plans (ELP’s) for all people. The manager should ensure that all people in the home have these completed. Some risk assessments were present. This is another area that is being readdressed by the acting manager with the format being changed and the plan to assess a significant number of activities that have not been assessed previously. The manager explained that they intend for the staff to write risk assessments and that they will spend time with each of them discussing the assessments, and providing training. Assessments already completed by staff were examined and discussed with the manager. All documents are stored securely. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 13 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): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are leading more active and varied lifestyles that promote their independence and personal development. Meals are varied and nutritious but choice can be limited for those who have limited communication. EVIDENCE: People living at the home access day services locally and the inspector took the opportunity to visit a day service in Cheltenham on the day of the site visit. Speaking to staff on duty they all agreed that the number of activities people were involved in had increased significantly since the new provider had taken over. It was agreed though that a shortfall at the current time is that only two staff are able to drive the home’s vehicle. This can restrict the amount of activities that people are involved. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 14 Some of the activities that people are involved in regularly include swimming, going to the pub, cinema, meals out, day services and social clubs. Staff stated that they were due to take four of the five people to a Butlin’s holiday camp two weeks after this site visit. There is a notice board in the dining room. It contained details of various activities being organised for the future including a disco and a Halloween party. In addition to this it also provided information about a support group for service users. The menus were examined and showed that people have access to a good range of meals and snacks. A number of people have communication difficulties and staff were asked how they ensured that these people had the opportunity to choose what they would like to eat. There was no formal method being used to achieve this. It is recommended that this system be formalised and in discussion with the manager a number of methods to achieve this were highlighted. This included the use of photos and symbols. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 15 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, 21 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Potential risks to people are minimised through the medication administration being managed correctly. Personal care needs have not been assessed and this may put people at risk of their needs not being met consistently by the staff team. Health care assessments have not been completed and this may present unnecessary risks to people. EVIDENCE: Notes are present for appointments with other professionals. Personal care needs have not been assessed for all people and therefore some needed guidelines for staff are either poor or not in place. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 16 It is recommended that the manager and staff complete “OK health assessments” for each person as there was no evidence of any assessments being completed previously. Examination of the home’s medication administration showed it to managed effectively. No errors were identified at this site visit. There have been issues about medication administration previously and staff were spoken with at length about the training they receive and who administers medication. No evidence was found of information to meet the criteria of standard 21. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 17 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 poor. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, but this only enables some people to voice their concerns. Staff have not completed training in the protection of vulnerable adults which may place people at unnecessary risk. People’s financial records that are maintained by staff are poor and this puts people at risk of financial abuse. EVIDENCE: Observations of the relationships between the staff and people living at the home confirmed this. Staff were respectful and made time to listen to people. The home has a complaints procedure. This is not appropriate for all of the people at the home as some may be unable to voice their concerns. When speaking with staff this was discussed. They were asked if someone was unable to voice a concern how they might show they were unhappy. Responses were detailed and showed that staff were aware of specialist needs. Speaking to staff on duty only one staff member had completed any training in the protection of vulnerable adults. This must be addressed by the management team. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 18 People’s financial records were examined and found to be incorrect. This must be addressed by the manager. Where it is assessed that people are unable to manage their own finances this must be recorded as part of a care plan. Also the manager must review the amount of money kept in the home to ensure that it is covered by the home’s insurance. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 19 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, 25, 26, 27, 28, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The quality of the communal accommodation is poor making it difficult to provide a homely atmosphere. Each bedroom is decorated differently to a high standard that reflects the interests of the people living in them. The home is clean and hygienic which minimises potential risks to people. EVIDENCE: As part of the site visit a tour of the premises was completed. The senior support worker stated that they understood that blinds had been ordered for the windows in the front room, office and on the landing. All of the bedrooms of the people living at the home were seen. They were all well decorated and personalised with peoples possessions. Whilst looking around the bedrooms a number of shortfalls were identified: Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 20 1. Power cables for electrical appliances were stretched across gaps where people may walk. 2. A basin in one bedroom was missing the hot tap completely and the cold tap had been turned off. A similar issue was also identified in another bedroom. 3. A significant amount of plaster was missing from under one window. 4. A chest of drawers in one bedroom was missing a number of the handles. 5. A person’s door handle had been repaired very poorly. Shortfalls identified with the landing on the first floor: 1. Radiator guard unsafe (actually fell of when touched). 2. The carpet was threadbare where different parts of it joined together. In addition to this carpet was not flat and “bumpy”. This may cause an unnecessary risk to people with poor mobility. Shortfalls identified with the bathrooms and toilets: Upstairs bathroom 1. 2. 3. 4. 5. 6. 7. 8. No curtain or blind. No sink plug. Floor covering around the toilet not sealed. Tiling poor from where bathroom suite has been replaced previously. No lampshade. No toilet roll. No hand towels. Light switch pull cord had no toggle and was black with dirt. Downstairs bathroom 1. Hole in the ceiling above the shower, the senior support worker believed this was due to water damage. 2. Extractor fan needs cleaning. Inspection of the kitchen showed it was a little “tired” and needs decorating. One cupboard had a door missing and there looked to be paint bubbling/flaking on the exterior wall. This room must be addressed. As highlighted elsewhere in this report major building work is being completed in the dining area. A wall has been knocked down and French windows fitted. At the time of the site visit this was still being completed. The staff explained that they understood this was going to be finished whilst people were on holiday at Butlins. At the same time the front room was also going to be decorated. At the second visit the manager explained that the builders were working elsewhere but this work will be completed. It was discussed that when Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 21 this work is due to be completed the manager should consider people moving to temporary accommodation. The reasons for this being the nature of the work to be completed, the size of the home and the needs of the people living in the home. Staff were asked whether people living at the home had been asked about the colours these rooms were going to be painted. Staff replied “no” and it was recommended that the people living there were given the opportunity to choose. At the time of this site visit the home appeared to be clean. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 22 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 poor. This judgement has been made using available evidence including a visit to this service. People have been put at unnecessary risk due to a new staff member working in the home without a Criminal Records Disclosure. The amount of staff training has increased since the new organisation have taken over. EVIDENCE: A sample of staff files were examined. All of the files were well organised containing the information required by these regulations. On arrival for the first day of the site visit staff were extremely busy supporting people with personal care before they went out. This was discussed with the manager and it was questioned whether enough staff were available during this period. The manager explained that this was the busiest morning due to the number of people going out. It was suggested that perhaps the staffing for this morning is reviewed to ensure that people’s personal care is not rushed. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 23 The only shortfall related to a new staff member employed in August this year. Examining their personal file the Criminal Records Bureau disclosure was missing. The Protection of Vulnerable Adults list check had been completed. This staff member had been completing personal care and had not been working under supervision. This was brought to the attention of the manager. They were open and honest about this shortfall. The manager must ensure that no one living at the home is put at this risk in future. Staff training certificates were stored in their personal files. When speaking with staff during the first day of the site visit they confirmed the training they had received and made comment about the increase in training. The acting manager must ensure that all staff receive regular supervision sessions. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 24 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 poor. This judgement has been made using available evidence including a visit to this service. The manager is committed to a person centred approach to care which will be of benefit to the people living at the home and hopefully empower them in the future. People’s involvement in day-to-day decision-making is limited but has improved over recent months. Fire safety equipment has not been checked regularly as required by regulations and this has put people at unnecessary risk. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 25 EVIDENCE: The acting manager has been at the home for the previous 4 months. They have worked with people with learning disabilities for the previous 4 years in a supported living environment. They have completed their National Vocational Qualification (NVQ) level four in Management and are just about to start an NVQ level four in care. During the conversations with the manager they showed they were committed to providing a needs led service where the people living at the home will have input in what happens from day to day. Currently quality assurance processes are limited but they are improving. A number of ideas were discussed to develop this process. This included the use of questionnaires to other professionals, relatives. Records were available confirming that the fridge and freezer temperatures are recorded daily. The manager must ensure that the food probe is used regularly. Cleaning chemicals are stored securely in a locked cupboard. Examination of the available fire safety records showed that: 1. Staff had not completed any checks of the fire alarm system between September 2005 and 2006. 2. The staff last completed a fire drill in September 2005. 3. Staff last checked the emergency lighting in January 2005. A qualified engineer has serviced the emergency lighting and fire alarms during this time. However it is unacceptable that staff have not complied with the regulations. It becomes a requirement of this report that all staff complete fire safety training and that regular checks are completed as prescribed by the regulations. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 26 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 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 1 25 3 26 3 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 1 1 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 3 2 3 X 1 X X 1 X Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 27 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 YA5 Regulation 5 (1) b Requirement The registered person must ensure that each person has a statement of terms and conditions signed by either the person, or their representative. The registered person must ensure that needs assessments are completed for each of the people living at the home. The registered person must ensure that people’s identified needs are addressed in their individual care plans. The registered person must ensure that all people are empowered to make decisions about their lives and records are kept evidencing this. The registered person must ensure that all people are given the opportunity to participate in the day-to-day running of the home. The registered person must ensure that risks to people are assessed, minimised and managed appropriately to enable people to live fulfilling lifestyles. The registered person must ensure that all people are given DS0000067438.V308054.R01.S.doc Timescale for action 01/12/06 2. YA6 14 22/12/06 3. YA6 15 02/03/07 4. YA7 15(2) c 01/12/06 5. YA8 16(2) m 01/12/06 6. YA9 13 (4) b, c 22/12/06 7. YA17 17(b) 22/12/06 Bathurst Lodge Version 5.2 Page 28 choices about the food they eat. 8. YA18 16(2) i The registered person must ensure that people’s personal care needs are assessed and that care plans are developed to meet those needs. The registered person must ensure that all people’s health needs are assessed. The registered person must ensure that people’s wishes are identified to meet the detail of this standard. The registered person must ensure that all people are aware of the home’s complaints procedure. Each person must be given a copy of the procedure. The registered person must ensure that comprehensive records are kept for the monies of each person whose finances are managed by the home. A care plan should also be developed that supports this. The registered person must ensure that all staff complete training in the protection of vulnerable adults. The registered person must ensure that the areas highlighted in the body of this report are addressed. The registered person must ensure that the areas highlighted in the body of this report are addressed. The registered person must ensure that the areas highlighted in the body of this report are addressed. The registered person must ensure that any staff employed in the future have Criminal Records Bureau checks completed before they start working alone. DS0000067438.V308054.R01.S.doc 22/12/06 9. 10. YA19 YA21 12, 14 14, 15 22/12/06 02/03/07 11. YA22 22 01/12/06 12. YA23 17(2) schedule 4 (9) 01/12/06 13. YA23 13(6) 02/03/07 14. YA24 23 (2) b, d 23 (2) b, c, d, j 23 (2) b, d 19 31/03/07 15. YA25 31/03/07 16. YA27 31/03/07 17. YA34 01/12/06 Bathurst Lodge Version 5.2 Page 29 18. 19. YA36 YA37 18(2) 8(2) 20. YA39 24 21. YA42 23(4) The registered person must ensure that all staff receive regular supervision sessions. The registered person must ensure that the manager’s application to be registered with the CSCI is submitted. The registered person must develop quality assurance systems that involve the people living at the home. The registered person must ensure that all fire safety checks are completed as prescribed by the regulations. 01/12/06 01/12/06 02/03/07 01/12/06 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. 3. Refer to Standard YA19 YA24 YA32 Good Practice Recommendations The registered person should use the “OK health check” to assess peoples needs The registered person should consider people moving to temporary accommodation when the major renovation work is being completed on the home. The registered person should review the staffing for the busy early shifts that happen regularly. Bathurst Lodge DS0000067438.V308054.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. 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