Inspection on 20/10/05 for Beaufort Lodge

This inspection was carried out on 20th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

Other inspections for this house

Beaufort Lodge 15/06/07

Beaufort Lodge 14/08/06

Beaufort Lodge 25/04/06

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Beaufort Lodge 38 Beaufort Road Kingston Upon Thames Surrey KT1 2TQ Lead Inspector Diane Thackrah Unannounced Inspection 20th October 2005 09:35 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beaufort Lodge DS0000065236.V260076.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beaufort Lodge Address 38 Beaufort Road Kingston Upon Thames Surrey KT1 2TQ 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) 020 8546 2073 020 8390 9253 CHD (Care Homes) Ltd Care Home 20 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (7) of places Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: Beaufort Lodge provides care for twenty older people. The home is owned and managed by Care Homes of Distinction LTD, who have recently taken over the home. This organisation also own and manage ten other care homes. Beaufort Lodge is situated in a residential street close to the centre of Surbiton. Accomodation is provided over three floors. There is a lounge/dining area on the ground floor and a conservotory, which is the homes smoking area. There is a well maintained garden to the rear of the property. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 20th October 2005 between 09.35 and 16.00. Care records were examined and a partial tour of the premises took place. A number of service users were spoken with, as were staff members and the Deputy Manager and Registered Individual. The home has recently been taken over by a new company, Care Homes of Distinction. There has been no Registered Manager in place at the home since 29th June 2005. No person(s) have been proposed as Registered Manager since that date. The service provided at the home - both to staff and service users, has been significantly compromised by the absence of such a person taking day-to-day control of the running of the home. A number of concerns are raised following this inspection of the home regarding issues which compromise the health, safety and well being service users living in the home. What the service does well: What has improved since the last inspection? Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 6 The Responsible Individual said that there are plans to make improvements to the all areas of practice in the home. Training and development has been highlighted as an area in most need of improvement. There has been the development of a new staff training room at the home, and a number of staff members have commenced training. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4. Care practices in the home do not fully take into account the wishes and views of service users. This results in some service user’s needs not being fully met. EVIDENCE: A number of service users were spending time chatting together in the communal lounge at the time of this inspection. These service users appeared content with life in the home. There was a television on in the lounge, which was loud, and showing a children’s television programme. Some service user’s said that they did not want to watch a children’s programme, and that the volume of the television was too loud. One service user said that they were happy with the volume, and choice of programme. Also, there was feedback that some of the entertainment provided by visiting musicians, is not enjoyed by all service users. There must be consultation with service users about activities held in the communal lounge in order to ensure that needs and preferences are understood and met. Written records must be maintained of this consultation. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 10 A Recommendation was made at the last inspection of the home, in line with the intentions of the then Registered Providers, that a different security system be introduced, that did not cause the current, loud and unpleasant noise and possible disturbance to service users. However, no action has been taken to address this issue. The Responsible Individual said that this bell would be removed on the day of this inspection. This recommendation is repeated. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. There are major shortfalls in planning for care. This has potential for service user’s health, personal and social care needs not being meet. Practices in handling medication, do not fully ensure the safety of service users. Staff members receive training about how to treat service users with respect and preserve their dignity. However, there was one instance were a service user’s privacy and dignity was not respected. EVIDENCE: There have been no improvements in the care planning process since the last inspection of the home. The new Registered Providers are in the process of implementing a new ‘Standex’ format of care plans, however, there has been no training for staff members in using this new format, and the current arrangements for recording care are poor. Care plans currently in use are confusing. One service user has three different care plans, each in a different format. Daily observation records in relation to this service user detail that they have a pressure sore, but there was no record of this in their care plan. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 12 Records held in the home by the Community Nurse detail that this service users’ pressure sore is healed. There was a risk assessment in relation moving and handling, but this had not been completed until one month after the service user was admitted to the home. No other risk assessments were recorded and there were no records detailing that the service user, or their representative had been involved in the drawing up of the care plan. A further two care plans were examined, these contained some instructions about how personal and health needs should be met, however, neither care plan had been reviewed since May 2005, or had been signed by the service user. There were records detailing that service user’s weight is monitored on a sporadic basis. There was no record of service user’s weight on their arrival to the home. Daily observation records are maintained, however, records examined lacked detail, had not been recorded in chronological order, and some were not understandable. The Responsible Individual explained one instance were a General Practitioner hand visited a service user in the home, and a Care Manager had visited another service user, however, there were no records of this. Additionally one service user had a Medication Administration Record, which detailed that they had recently been prescribed a cream. There were no details about what this cream was for, or were it should be applied, in the service user’s care plan. A record of accidents and incidents is maintained, however, there were daily records for two service users, which detailed that they had fallen in the home. One service user had been taken to hospital as a result of a fall but the home’s accident log contained no record of these falls. The Deputy Manager who was in charge of the home at the time of these accidents said that she was unaware of the need to complete accident forms. This is of concern. Policies and procedures are in place regarding the use of medication and staff members report that they have received training in the safe handling of medication. However, there were a number of issues regarding medication that are of concern. Medication is stored in a locked cupboard and appropriate facilities are available for medication that requires refrigeration. There was one cream for one service user that was not stored in a locked facility, nor were there any records detailing how the cream should be applied. Four Medication Administration Records examined had unexplained gaps. There were no details about any allergies suffered by service users. Additionally, there was one service user who had eye drops stored in their bedroom. There was no record of these being used, and a staff member said that they were unaware until the time of this inspection, that the drops were being used. Action taken on discovering these eye drops is concerning. A staff member entered the service user’s bedroom without knocking first. The eye drops were taken from the service user with little discussion about why this was happening, or without their views being sought. This is poor practice that compromised the dignity, and right to privacy of the service user. Staff members were noted to knock before entering bedrooms, and consult with Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 13 service users appropriately at all other times during this inspection. One service user reported that they found staff members to be “kind and helpful” A number of Requirements have been made regarding these issues, including two repeat Requirements. It is acknowledged that the Responsible Individual said that extensive training is planned, that a training room has been created in the home, and an external training organisation were providing training in Protection of vulnerable adults, and Health and Fire Safety with some staff members at the time of this inspection. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. There are limited opportunities for service users to engage in recreational activities. It is therefore unclear whether service users experience a lifestyle that matches their preferences. There are opportunities for service users to maintain contact with friends and family. This allows them to maintain some control over their lives. Wholesome and enjoyable meals are provided. Service users are consulted about meals and therefore differing expectations and lifestyles are well catered for. EVIDENCE: A children’s television programme was being shown in the communal lounge at the time of this inspection, some service users were unhappy with this, and said that the television was too loud. One service user was content with the programme, and volume. Some service users appeared to be enjoying a ‘sings-long’ with a staff member later in the inspection. Some service users have television in their bedroom, and there is a selection of books available. There are currently no structured activities provided and no formal arrangements for consulting with service users about activities, through meetings or monthly reviewing of their care plan. This issue is discussed in further detail in Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 15 Standard four of this report, and Requirements have been made regarding the need for the home to consult with service users about organised activities, and to provide further facilities and opportunities for recreation. It is recommended that service users meetings be held, with minutes kept, in order to gain to views and preferences of the service user group. The Responsible Individual said that she is planning to recruit an activities organiser, who will address these issues. Daily observation records detail that service users are assisted to maintain contact with their family and friends, and to access and maintain links with the local community. The home has an open door policy, and visitors can be seen in bedrooms, or in the communal lounge/dining room. A hot lunch of sausage, gravy and fresh vegetables was being served in the communal dining room during this inspection. This meal was well presented and appeared wholesome and nutritious. All service users spoken with said that they were enjoying the meal. The cook said that she consults with service users about their preferences, and always provides an alternative if the service user does not like the main meal. The kitchen was found to be clean, and regular temperature checks are carried out on fridge and freezers and there was a good supply of fresh fruit and vegetables available. There was a notice board detailing what was for lunch on the previous day. The Registered Provider should ensure that there is a menu displayed, that is up to date, and details a choice. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The arrangements for handling complaints, and for recognising and responding to suspected abuse are not robust, and do not fully serve to protect service users. EVIDENCE: Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 17 There are policies and procedures in place for dealing with complaints. Information is made available in the Service User Guide about how a compliant, concern or suggestion should be made, and how this will be handled. This information also includes details about how a complaint may be made to the Commission for Social Care Inspection. The home has adopted the Protection of Vulnerable Adults policy developed by the Royal Borough of Kingston Upon Thames. However, there are concerns regarding the home’s response to a recent complaint made by a service user. A service user in the home has recently reported that money has gone missing from their purse. There were records detailing that the police have been informed about this incident, including a police crime reference number. There were also records detailing that discussions about this incident have been had with the service user’s Care Manager. However, the reporting of, and recording of this incident have been poor, as has practice following the incident. When a service user reports money going missing, the Care Manager involved in their care, and the Commission for Social Care Inspection must be informed of the incident without delay. This did not happen. Daily observation records regarding this incident were not completed until three days after the event. No inventory was available regarding the service users possessions at the time of moving into the home. There must be an investigation into this incident, with written records being made available to the Commission for Social Care Inspection. All staff members working in the home must receive refresher training in the adult protection, including identifying suspected, or actual abuse and reporting this. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24, 25 and 26. Some areas of the home are safe and well maintained, however, there are a number of shortfalls, which put people at risk of harm and do not provide safe and comfortable surroundings in which to live. EVIDENCE: The Responsible Individual said that there are plans to redecorate most areas in the home. Communal areas in the home were generally well maintained, homely and comfortable. The garden and surrounding grounds are safe and well maintained. However, there are a large number of maintenance and environmental issues that require action in bedrooms and bathrooms. Problems identified are as follows: * Bedroom 6 has a hole in the wall. * The call bells in bedrooms 8, 10, 12, and both ground floor toilets are broken. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 19 * * * * * * * There were no paper towels in the ground floor toilet. There was no hot water in bedrooms 15 and 12. There was an offensive odour in bedrooms 3 and 8. There was no handle on the hot water tap in bedroom 3. There were no handles on the draws in bedroom 12. Overhead light bulbs were not working in bedrooms 8 and 15. There was faeces on the radiator in bedroom 8. Bedrooms viewed all contained a sink, covered radiator, and window restrictor. Heating cannot be controlled in individual bedrooms. The Responsible Individual said that service users had not requested adjustable heating in their bedrooms, but should this happen; the Registered Providers must provide this. Lighting, ventilation and heating were appropriate. All sinks are fitted with thermostatic valves. Some bedrooms contained personal possessions belonging to service users, and appeared homely. There were other bedrooms that had few personal possessions or other homely touches. It is recommended that action be taken to provide service users with a more homely environment in which to live. The majority of bedrooms seen had clocks that did not work as the batteries had gone. It is recommended that systems are put in place were by staff members are aware when clocks run out of batteries, and replace them. There was documentation detailing that the local Fire Officer carried out an inspection of the home on 19th September 2005. The home was found to be safe, other than a Requirement being made regarding the need for emergency lighting to be fitted to the emergency staircase. This issue must be addressed. There are a number of environmental adaptations throughout the home, including a passenger lift, raised toilet seats and assisted baths. There is a laundry, which is situated well away from the kitchen. The home’s washing machine has broken down, and currently the washing machine in the companies neighbouring home is being used. The Responsible Individual said that a new washing machine has been ordered. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 30. There have been shortfalls in the arrangements in staff training. Staff members currently do not have sufficient skills to ensure that the needs of service users are fully met. EVIDENCE: There are two staff members working in the home who have achieved a qualification at NVQ Level 2 in Care. There has been no progress in providing NVQ Level 2 in Care training for staff members, since the last inspection of the home. However, the Responsible Individual said that there are plans to introduce NVQ Level 2 in Care training, for all staff members working in the home. This training must commence without delay for at least 50 of the current staff team in order for the home to meet the National Minimum Standard. There was a lack of documentation in the home detailing staff training. One staff member confirmed that they had recently attended training in the Safe Handling of Medication and in Dementia Awareness. Previous inspections have highlighted that new staff members have undertaken induction training that is in line with ‘Skills for Care’. Due to the lack of documentation detailing staff training; it is unclear whether staff members have undertaken training and development necessary for doing their jobs. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 21 A number of concerns have been raised as a result of this inspection in relation to major shortfalls in care practices. There is a need for all staff members to undertakes training in: * Recording Keeping in Care Homes. * How to use the ‘Standex Format of Care Planning. * Protection of Vulnerable Adults (including identifying and reporting suspected abuse. * The recording and reporting of incidents and accidents in the home. * The safe handling of medication. (For all staff members responsible for handling medication) * Dignity and Respect. There must be a, written, Tranining and Development Programme in place, which is in line with ‘Skills for Care’ specifications, and ensures that staff members have the skills for fulfilling the aims and objectives of the home. There must be individual staff training profiles detailing training undertaken by each staff member. The Responsible Individual has a positive approach to training and said that there are plans for training and development for the current staff team. A training room has been developed at the home, and at the time of this inspection training was occuring in Protection of vulnerable adults, Health and Safety and Fire Safety. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38. The home is not managed well and there is no leadership, guidance and direction to staff members to ensure that staff members receive consistent and quality care. This results in some practices that do not promote and safeguard the health, safety and welfare of service users. EVIDENCE: There is no Registered Manager in place, and this has been the case since June 2005. From examination of documentation in the home, and discussions with staff members, it is evident that there is poor communication between staff members, and they are unclear about what is expected of them. A manager must be appointed, and an application must be made to the Commission for Social Care Inspection regarding this post. Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 23 There has been little progress in the development of a quality assurance programme. A Requirement made at the last inspection of the home regarding the need to provide the results of an effective quality assurance, to service users and their representatives is reiterated. The Responsible Individual said that there are plans to implement a system of quality assurance, however, there was no business, or development plan detailing when this will occur. This must also be implemented. Policies and procedures are currently in the process of being reviewed. There have been no formal supervision sessions for staff members since the Registered Manager left post in June 2005. Prior to this, supervision had not been provided on a regular basis. All staff members should receive formal supervision at least six times each year. Supervision must cover all aspects of practice, philosophy of care in the home and career development. Records of supervision sessions must be made available for inspection. There are facilities for the safe storage of hazardous substances and a contract is in place for the collection of clinical waste. All hot water outlets have a thermostatic safety valve, however, monitoring must occur to ensure the safety and well being of service users. An accident and incident book detailed that only four accidents have occurred since the last inspection, while other records available in the home indicate that the accident book is not well maintained. Windows have restrictors, and there are covers on radiators. Fire fighting equipment is available throughout the home, however there are a number of issues in relation to fire safety that are of concern. The Responsible Individual said that regular testing of fire alarm occurs, and there are fire drills, and emergency lighting is tested. There were no records indicating that this occurs. Records must be available detailing the weekly testing of the fire alarm and emergency lighting, and quarterly fire drills. Doors in corridors have magnetic closing devises to promote fire safety. There was one bedroom however that had a wedge to keep the door open. Only devises, approved by the local fire officer may be used to keep doors open. At the time of this inspection, the lock on the boiler room door was broken, allowing service users access to this room. This is potentially dangerous. The Responsible Individual stressed that this room would be secured on the day of this inspection. Beaufort Lodge DS0000065236.V260076.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 2 X 2 2 2 STAFFING Standard No Score 27 X 28 2 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X 1 X 1 Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 25 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 OP4 Regulation 12.1a 16.2m(n) 24.1a Requirement Timescale for action 01/01/06 2 OP7 15 (2)(b) 3 OP7 12.1a 13.4c 15.1&2 The Registered Providers must ensure that: 1. There is consultation with service users about activities held in the communal lounge. 2. There is a structured plan of activities, which is based on the likes and preferences of service users. Written records must be maintained of this consultation and any activities provided. The Registered Providers must 01/12/05 ensure that care plans are reviewed at least once monthly, and updated to reflect changing needs. Records must be maintained of each review. (Repeat Requirement. Timescale of 01/09/05 not met) The Registered Providers must 01/12/05 ensure that each service user has only one care plan in place that: 1. Details their individual needs in relation to health, personal and social care, DS0000065236.V260076.R01.S.doc Version 5.0 Beaufort Lodge Page 26 4 OP7 12(1)(a) 13(1)(b) 5 OP7 12.1a Sch3 17.3a b 6 OP8 12.1a 13.1b Sch3m and how staff members will address these needs. 2. Details a moving and handling risk assessment, which has been completed prior to them moving into the home. 3. Details any other identified risks. 4. Includes a record of their weight on arrival at the home, and on a periodic basis. 5. Includes an inventory of the service user’s possessions. 6. Includes a record of the service user, or their representive’s involvement in the care planning process, including their signiture. The Registered Provider must 01/12/05 ensure that clear records are maintained of any consultation with, or visit from a health or social care professional, regarding a service user. The Registered Provider must 01/11/05 ensure that daily observation records are: 1. Recorded in one place. 2. In chronological order. 3. Are clear and understadable. 4. Are in sufficent detail. 01/11/05 The Registered Provider must: 1. Ensure that a request is made to the Pressure Sore Nurse for a visit to be made to the service user who has a pressure sore. 2. A written record must be made detailing the arrangements for, and outcome of this visit. 3. The service user has a care DS0000065236.V260076.R01.S.doc Version 5.0 Page 27 Beaufort Lodge 7 OP8 Sch4 12a 37c(f) 8 OP9 13 (2) 9 OP10 12.1a & (4)(a) 10 OP18 37.1f Sch4 12f plan that details all action to be taken by the home in relation to the service user having, or being at risk of having a pressure sore. The Registered Provider must ensure that: 1. A record is maintained of any falls in the home. 2. Notice is given to the Commission for Social Care Inspection, without delay, of any incident or accident in the home. The Registered Provider must ensure that; 1. There are no unexplained gaps in Medication Administration Records (Repeat Requirement. Timescales of 01/03/05 & 01/09/05 not met) 2. All medication kept in the home is stored securely. 3. The allergy section on Medication Administration Records is completed for all service users. 4. There is a record of all medication (both prescribed, and home remedies) that is being taken by a service user. The Registered Provider must ensure that: 1. Staff members knock before entering a service users bedroom, unless there is a care plan that suggests otherwise. 2. Consult appropriatley with service users before making a decision about anything that impacts on the service users life. The Registered Provider must ensure that there are written records detailing the recent DS0000065236.V260076.R01.S.doc 01/11/05 01/12/05 01/12/05 01/12/05 Beaufort Lodge Version 5.0 Page 28 11 OP19 23 (2)(b) incident of money going missing in the home. These must include: 1. The times and dates that the money was reported missing. 2. The people who have been informed, and when. 3. The action taken by the home to investigate this incident. The Registered Provider must ensure that corrective action is taken in relation to: 1. The hole in the wall in bedroom 6. (Repeat Requirement. Timescale of 01/09/05 not met) 2. The call bells in bedrooms 8, 10, 12, and both ground floor toilets being broken. 3. No paper towels being available in the ground floor toilet. 4. No hot water being available in bedrooms 15 and 12. 5. The offensive odour in bedrooms 3 and 8. 6. No handle on the hot water tap in bedroom 3. 7. No handles on the draws in bedroom 12. 8. Overhead light bulbs not working in bedrooms 8 and 15. 9. Faeces on the radiator in bedroom 8. 01/11/05 12 OP28 18 .1a(c) The Registered Provider must ensure a commitment to supporting at least 50 of the staff team to achieve an qualification at NVQ Level 2 in Care by the end of 2005. DS0000065236.V260076.R01.S.doc 01/02/06 Beaufort Lodge Version 5.0 Page 29 Records must be available detailing the staff members undertaking this training, and the predidcted date of completing the training. (Repeat Requirement. Timescales of 01/03/05 & 01/09/05 not met) 13 OP30 12.1a,18. 1(a)(c)(i) The Registered Providers must ensure that all staff members, including senior staff members, who currently work in the home, and any new staff members undergo training in: 1. Recording Keeping in Care Homes. 2. How to use the ‘Standex Format of Care Planning. 3. Protection of Vulnerable Adults (including identifying and reporting suspected abuse. 4. The recording and reporting of incidents and accidents in the home. 5. The safe handling of medication. (For all staff members responsible for handling medication) 6. Dignity and Respect. 14 OP30 12(1)(a) 18.1(a)(c) The Registered Provider must ensure that: 1. There is a, written, Tranining and Development Programme in place. 2. There is individual staff training profiles detailing when each staff member has undertaken training. The Registered Provider must appoint a suitably qualified person to the post of Registered Manager. This person must DS0000065236.V260076.R01.S.doc 01/02/06 01/02/06 15 OP31 8(1)(a) (2)(a)(b) 01/12/05 Beaufort Lodge Version 5.0 Page 30 16 OP33 24.1(a)(b) (2)(3) make an application to become registered with the Commission for Social Care Inspection. The Registered Provider must ensure that: 1. The results of satisfaction surveys are published and made available to service users. (Repeat Requirement. Timescales of 01/03/05 & 01/09/05 not met) 2. There is an annual development plan in place, which is available for inspection. 01/02/06 17 OP36 18 (2) 18 OP38 12(1)(a) 13(4)(a) The Registered Provider must ensure that all staff members receive formal supervision. Records of supervision sessions must be maintained. The Registered Provider must ensure that: 1. There is regular monitoring of hot water in the home, with records kept. 2. Weekly testing of the fire alarm and emergency lighting, and quarterly fire drills occur, with records kept. 3. Service user’s bedroom doors are not wedged open. 4. The lock on the boiler room door must be made good. Service users must not have access to this room. 01/01/06 01/12/05 Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 31 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 4 Refer to Standard OP4 OP12 OP15 OP24 Good Practice Recommendations The Registered Provider should change the door alarm so as to ensure that service users are not disturbed each time the front door is open. The Registered Provider should ensure that service users meetings are held, with minutes kept, in order to gain to views and preferences of the service user group. The Registered Provider should ensure that there is a menu displayed, that is up to date, and details a choice. The Registered Provider should ensure that systems are put in place were by staff members are aware when service user’s bedroom clocks run out of batteries, and replace them. The Registered Provider should ensure that action is taken to provide service users with a more homely environment in which to live. 5 OP24 Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 32 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Beaufort Lodge DS0000065236.V260076.R01.S.doc Version 5.0 Page 33 - 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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