Inspection on 06/10/05 for Bendigo Nursing Home

This inspection was carried out on 6th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bendigo Nursing Home 19/06/07

Bendigo Nursing Home 19/05/06

Similar services:

Springfield House

The Shelley

Thorndene

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Bendigo Nursing Home 22 Arundel Road Eastbourne East Sussex BN21 2EL Lead Inspector Kathy Flynn Announced Inspection 6th October 2005 10:00 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 Bendigo Nursing Home DS0000065151.V249515.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. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bendigo Nursing Home Address 22 Arundel Road Eastbourne East Sussex BN21 2EL 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) 01323 727274 Kindcare (UK) Ltd Vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability (25) of places Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the maximum number of service users to be accommodated will be twenty-five (25). Service users must be aged sixty-five (65) years and over on admission. Service users may also have a physical disability. Date of last inspection 9th May 2005 Brief Description of the Service: Bendigo Nursing Home is registered to provide nursing care for up to 25 older people, over 65 years, or individuals with physical disabilities. Situated in a residential area of Eastbourne it is approximately 20 minutes walk from the town centre with its variety of shops and public transport facilities, with a library, GP surgeries and dental practices accessible. The home is a converted detached property, the kitchen, the staff room and storage facilities are in the basement with a further three floors containing a lounge, resident’s individual bedrooms, 19 single rooms and three double rooms, assisted bathrooms and toilets. There are uneven floors in some area of the home, narrow corridors and steps that can restrict movements throughout the home, with some rooms only accessible by negotiating steps. There is a small passenger lift, which has been recently improved and can now be used by wheelchair users and staff. There is a large garden to the rear with an access slope at the side of the home for wheelchairs and is used when weather permits. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The requirements recorded in the previous inspection report were used to develop the plan for this unannounced inspection. The aims were to assess if the home had met these requirements, identify aspects of the service that have improved and how the service could be developed for the benefit of the residents. The inspection was carried out over 7 hours from 10.00, it included a tour of the home, an examination of care plans, staff records and training, policies and procedures and the menu. The inspection was arranged so that all the residents were spoken with. The chef, three members of staff and the acting manager were happy to discuss the services provided. There were no social activities at the home during the inspection but staff did spend time talking to residents in the lounge. The home has been without a registered manager for several years, and the acting manager is currently responsible for some of the management decisions at the home. There were 17 residents at Bendigo at the time of the inspection, one resident had been admitted to the hospital and there were 7 vacant places. What the service does well: What has improved since the last inspection? The acting manager advised that a system of involving residents and their relatives when care plans are reviewed has been introduced and will be extended to include all residents in the home. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 6 The manager explained that some activities are provided by outside entertainers, a music session had been arranged for the day before the inspection and a show for the day after the inspection. What they could do better: 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. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 7 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 Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 8 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): 1, 2, 3, 4 and 5. Standard 6 is not assessable. The statement of purpose and service users guide is inadequate and does not provide correct up to date information, for prospective residents and their representatives, to be clear about the services provided and how the home will meet their needs. A pre-admission assessment for new residents is not available, therefore their needs are not identified and staff are unable to provide appropriate care and support on admission. EVIDENCE: The statement of purpose and service users guide is provided in a loose leaf brochure format. Although there is a considerable amount of information in this it is not easy to read and there is insufficient detail provided for the day to day management of the home, additional fees, physical standards and the organisational structure of the home. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 9 There is no evidence to confirm that residents are given a copy of the home’s terms and conditions or contract on admission. The acting manager advised that these are kept at head office. The pre-admission assessment form for a recent admission was not available. The acting manager advised that one had been completed but it could not be found during the inspection. The transfer sheet from the hospital provided incorrect information concerning the resident’s needs and the acting manager explained that the needs of the residents would be assessed on a daily basis and would be discussed with the family who visit regularly. The resident’s son explained that they were given the name of homes that had spaces and that he is happy for his mother to be at Bendigo, where he thinks she will receive the care that she needs. He advised that she likes fruit and this was provided at the time by the staff. The acting manager agreed that with a completed pre-admission form and supporting information from the family the staff would be able to understand a resident’s preferences and provide appropriate support from the day of admission. The acting manager stated that beds are offered on a trial basis and prospective residents and their relatives can visit the home to look at the rooms and ask the staff about the services provided. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 10 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, 10 and 11. There is no clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet residents’ needs. Personal support in this home is not offered in such a way as to promote and protect residents’ privacy, dignity and independence. EVIDENCE: The care planning system was discussed in detail at the last inspection and although it has improved considerably there is more work to be done to ensure that it provides a complete picture of the needs of residents and how they can be met. Although the staff throughout the inspection, and the registered nurses during handover, showed a good understanding of residents’ basic needs the expectation is that this information is recorded in the care plan. The acting manager advised that they have started involving relatives in reviewing the care plans and that the difficulty with the information available in the care plans may be due to poor recording by staff. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 11 A nutritional screening tool is not used effectively and the acting manager was unable to show evidence that action is taken to address weight loss or gain. The acting manager advised that this will be used when care plans are reviewed. The staff were able to discuss the importance of treating residents with respect and providing appropriate support. However its was noted that staff failed to respect the dignity of residents, one resident was wearing clothing that did not cover her body, another was advised that they could not provide personal care because they were giving out lunches and inappropriate language was used when a resident made comments about the care provided. These issues were discussed with the staff and the manager during feedback, the staff understood why there were concerns and the expectation is that appropriate training will be provided for staff to ensure that residents are treated with respect at all times. The needs of some residents have changed and the acting manager advised that additional support and aids, pressure relieving mattresses, are used to ensure that the residents continue to make decisions about their lives. Relatives are able to visit at any time and can stay at the home if they wish. If a resident’s health deteriorates and the acting manager feels that the home cannot meet them then suitable alternative placements may be arranged. The staff discussed the care of residents if their needs change and the support that they provide for residents relatives and friends at this time. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 12 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, 14 and 15. Residents would benefit from a varied programme of social activities. A menu is in place and special dietary needs can be catered for, however the residents are not able to exercise choice over their diet and what they eat. EVIDENCE: Activities at the home are not provided on a daily basis although staff were noted to talk to residents in the lounge. Some residents prefer to spend their time in their rooms, one likes to watch TV while others said that although the TV is on they are not interested. Residents spoken with during the inspection were happy to discuss their days, one would like to go out but has little opportunity, one likes to talk but realises that the staff are good but busy and do not have the time. One resident likes to watch sport but does not know when it is on, is not mobile therefore is not able to switch the TV on when he needs to, he also likes to listen to the radio, sport and plays, but he does not have one. The staff and manager were unable to show that they have a good understanding of the residents’ social interests and although they reacted to the information provided during feedback, they should be able to do this on a daily basis without the involvement of the Commission for Social Care. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 13 Residents who expressed an opinion said that they feel comfortable at the home, they feel staff provide the support they can in the time they have. Staff said that they are able to provide care for the residents but are not able to spend as much time with each resident as they would like to. This was clearly evident in the limited choices that residents have and the limited control they have over their lives. The chef explained that residents can choose what they want at mealtimes and choices are included in the menus, although he also stated that he provides the meals that are requested by the staff. The residents who expressed an opinion stated that they did not know what is for lunch, as they are not asked what they would like, and the staff were unable to show any evidence of consultation with the residents. The concerns noted during the inspection were that meals are not provided on the basis of the residents’ likes and dislikes, although some staff showed that they know what some residents prefer. One resident does not like parsley sauce although she was given this at lunch and staff had to be asked to replace it. Residents who have a pureed diet are not given a choice of pudding, jelly and cream was given to them while others had chocolate sponge and custard. It is not clear why these particular residents have limited choices, the chef agreed that puddings can also be pureed and the acting manager said that they should be given choice. Some residents in the lounge need assistance with food while others are independent. It was noted that one resident has to wait, after having soup, until the residents who require assistance have finished before he can have the main part of the meal. It was not clear why this practice is thought to be appropriate and staff agreed that residents should be given their meals at the same time. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 14 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, 17 and 18. The staff have some knowledge and understanding of Adult Protection issues and this protects the residents from some forms of abuse. EVIDENCE: There have been no complaints since the last inspection and the acting manager advised that appropriate policies and procedures are in place. Residents who expressed an opinion said that they did not have any complaints about the home, they feel staff ‘do their best’ and they have the opportunity to vote in elections if they wish. Staff have received training in adult protection and were able to show that they understand some forms of abuse and how they should deal with any concerns they may have. However there was no evidence that staff were aware that restricting residents’ choices and not allowing them to make decisions about their day to day life can be regarded as a form of abuse. The training provided should be reviewed to ensure that staff have the opportunity to discuss every day aspects of care at the home. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 15 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, 20, 21, 22, 25 and 26. Improvements to the appearance of the home have created a more comfortable environment for residents, staff and visitors, although there is no evidence of plans to provide a well maintained and safe environment for residents and staff. A programme of deep cleaning and a system to control infection is not in place therefore residents are not protected. EVIDENCE: An assessment of the home by an Occupational Therapist has been completed and a number of recommendations were recorded, including the environmental risk assessment with regard to the garden that was identified at the last inspection. The manager advised that the changes identified in the report have not yet been addressed. A shaft lift and stair lift enable residents to have access to most parts of the home, some residents are placed in rooms that are only accessible by steps or removable ramps, the acting manager advised that risk assessments are Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 16 completed for these residents. Residents are encouraged to use zimmers and other mobility aids to encourage them to be as independent as possible within their own capabilities. A review of bathing and toilet facilities was identified at the last inspection, the acting manager advised that this is ongoing and will be addressed. An on-going maintenance programme for the home is not in place, this should include the issues raised in the Occupational Therapists report and the basic repairs identified in the last inspection. Communal space at the home is limited and there is no evidence that there are any plans to improve this. Some parts of the home were found to be reasonably clean but there is no deep cleaning programme in place, the individual employed to do cleaning is also expected to do the laundry, she has insufficient time to provide the level of cleaning expected. She is quite clear about what is required of her and this does not include cleaning of beds, the manager advised that the care staff should do this but the staff were unaware that this is their responsibility. A system of deep cleaning throughout the home is required and should be developed as part of an infection control system. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 17 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): 27 and 29 Staffing shortages are reflected in the lack of choices available for residents and the limited opportunities that residents have to make decisions about day to day living. A thorough recruitment programme is not in place and does not provide the safeguards to offer protection to residents living in the home. EVIDENCE: This inspection identified that staff were not aware of individual residents preferences, residents were not encouraged to make choices about their day to day lives and staff did not have the time to spend with all the residents. The staffing numbers were discussed with the acting manager. The expectation is that a sufficient a number of staff are working at the home to ensure that residents receive appropriate care and support. The staffing numbers should be reviewed in line with the assessed needs of residents. During the inspection it was noted that references and CRB/POVA checks were not available for new members of staff. The acting manager advised that staff are still recruited through head office with the registered provider responsible for references and appropriate checks, and he has to date had no say in who is appointed. This was discussed in detail at the last inspection and the acting manager was advised that it is his responsibility as manager to ensure that checks are Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 18 completed prior to an offer of employment. The expectation is that the manager plays an active role in recruitment, from advertising to interviews and the appointment of staff for the home. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 19 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, 32, 33, 34, 35, 36, 37 and 38. The appointment of a registered manager is required to ensure that the care and support continues to meet the assessed needs of residents. The systems for resident’s consultation are poor with little evidence that residents’ views are sought or acted upon. Training has not been provided by an appropriately qualified individual, therefore staff and residents are at risk. EVIDENCE: A registered manager is not in place at the home, the acting manager is currently responsible for managing the home on a daily basis and he has not applied to register with the CSCI. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 20 This inspection, like the previous one, identified the concern that without a manager the home may not be run in the best interests of the residents. The feedback obtained from residents, who expressed an opinion, and staff was positive, they felt the home is comfortable. There were 17 residents at the home during the inspection, some have lived there for some time and the staff have a good understanding of their needs. However there was no evidence that the staff understood the needs of recent admissions to the home. As recorded in the last report if the number of residents increases significantly, with current staffing numbers and if the manager is not appointed, the provision of care may be affected. The statement of purpose is not adequate, a quality assurance and monitoring system is not in place and there was no evidence of residents’ views or opinions being sought. Therefore there is no system in place to measure if the home can meet aims and objectives or the needs of residents. The home has liability insurance, however there is no indication that financial and business plans show that an effective and efficient administrative management of the business are in place. The acting manager explained that the home does not accept responsibility for residents’ money, head office is responsible for invoicing and collecting fees. Supervision is not in place, therefore there is no system of assessing the training needs of staff or discussing their personal development. One of the issues highlighted in the last report was the inappropriate use of manual handling aids. Additional training was to be provided for all staff with the expectation that individuals who are qualified to provide this training will do so. The acting manager advised that the training had not been provided by an appropriately qualified person. Therefore the manual handling training should be reviewed, updated and arranged so that it can be linked directly with the needs of the residents in the home. The policies and procedures have been in place for some time and have not been reviewed by the present acting manager. They should be reviewed and updated to ensure that they reflect the services available and inform staff of the care practices that they are expected to provide. Residents’ doors continue to be propped open with wedges, chairs and walking frames, despite a fire officer advising the acting manager that this is not safe before the last inspection, and a requirement was recorded in the last report. Alternative system should be used to ensure the safety of residents. Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 21 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 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 Score 1 1 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 1 1 X 2 X X 2 2 STAFFING Standard No Score 27 2 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 1 2 3 2 2 1 Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 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 OP1 Regulation 4&5 Requirement That the statement of purpose and service users guide is reviewed and updated to reflect accurately the services and support provided at the home, in line with NMS. Previous timescale of 01.08.05 not met. That each resident is provided with contract/terms and conditions. Previous timescale of 04.07.05 not met. Pre-admission assessments to be completed to ensure that the home can meet the prospective residents needs. That residents care plans should reflect the assessed needs of residents. They are drawn up whenever possible with the involvement of residents and their representatives. Previous timescale of 04/07/05 not met. That a nutritional assessment tool is provided and used to screen residents and action is taken to address weight gain and loss. Previous timescale of DS0000065151.V249515.R01.S.doc Timescale for action 09/01/06 2 OP2 5 09/01/06 3 OP4OP3 14 06/11/05 4 OP7 15 09/01/06 5 OP8 13 06/11/05 Bendigo Nursing Home Version 5.0 Page 23 5 OP10 18 (1)(c)(i) 16 (m)(n) 6 OP12 7 OP14 12 (2) 8 OP15 16 (i) 9 OP18 18 (1)(c)(i) 5 (b) 23 10 OP19 11 OP21 23 12 13 OP26 OP27 13 (4)(c) 18 (1)(a) 14 OP29 19 Schedule 04/07/05 not met. Training to be provided to ensure that staff provide care based on the privacy and dignity of residents. That the current provision of activities and entertainment is built on further and that social care planning and assessment is documented. Previous timescale of 04/07/05 not met. Care practices at the home to be developed and provided on the basis that residents’ choices and preferences are met. A wholesome and appealing diet to be provided for residents based on their preferences and dietary needs. Relevant training in Adult Abuse to be provided for all staff to ensure that residents are protected. That a written programme to demonstrate the routine maintenance and renewal of fabric and decoration of the premises is provided to the CSCI and implemented. Previous timescale of 01/08/05 not met. That a full review of the bathing and toilet facilities is completed to ensure an appropriate provision for the residents accommodated. Previous timescale of 01/08/05 not met. An appropriate deep cleaning system to be developed and introduced. Staffing numbers to be reviewed and appropriate numbers allocated to meet the assessed needs of residents. A thorough recruitment procedure to be followed to DS0000065151.V249515.R01.S.doc 06/11/05 09/01/06 09/01/06 06/11/05 06/11/05 09/01/06 09/01/06 09/01/06 09/01/06 06/01/05 Page 24 Bendigo Nursing Home Version 5.0 2 15 OP31 9 16 OP33 24 17 18 19 20 OP34 OP36 OP37 OP38 25 (2) 18 (2) 17 23 21 OP38 13 22 OP38 13(3)(5) ensure the protection of residents. Previous timescale of 04/07/05 not met. That the home is always managed by a person fit to be in charge and that the manager is registered with the CSCI. Previous timescale of 01/08/05 not met. That a system of reviewing and improving the quality of care in the home is established. Previous timescale of 04/07/05 not met. That a business and financial plan be made available to the Commission on request. A programme of formal supervision be developed and introduced. Policies and procedures to be reviewed and updated in line with the NMS. That a fire risk assessment for the home is completed and that advice from the Fire Service is sought in relation to the fire safety in the home, including keeping residents doors open. Previous timescale of 04/07/05 not met. That environmental risk assessments are completed on al areas including the garden. These needs to reflect the measures taken to reduce the risks to residents. Previous timescale of 01/08/06 not met. Training in manual handling and infection control to be reviewed updated and repeated for staff as required. Previous timescale of 04/07/05 not met. 09/01/06 09/01/06 09/01/06 09/01/06 06/03/06 09/01/06 09/01/06 09/01/06 Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Bendigo Nursing Home DS0000065151.V249515.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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