Inspection on 21/12/05 for Bennett House

This inspection was carried out on 21st December 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bennett House 18/12/06

Bennett House 28/06/06

Bennett House 22/06/05

Bennett House 23/01/05

Bennett House 10/09/04

Bennett House 16/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Bennett House Park Lane Woodside Telford Shropshire TF7 5HR Lead Inspector Janet Adams Unannounced Inspection 21st December 2005 12:20 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 Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 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. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bennett House Address Park Lane Woodside Telford Shropshire TF7 5HR 01952 582588 01952 582080 lynf@accordha.org.uk 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) Accord Housing Association Limited Mrs Stephanie Matthews Care Home 45 Category(ies) of Dementia (26), Old age, not falling within any registration, with number other category (19) of places Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate a maximum of 45 service users. The home may accommodate a maximum of 45 Elderly Persons of whom 26 may be suffering from Dementia and 1 may have physically disabilities under 65 years of age. The home may from time to time admit persons between the ages of 60 and 65 years of age, upon consultation with the Commission for Social Care Inspection. 22nd June 2005 3. Date of last inspection Brief Description of the Service: Bennett House is registered as a care home for up to 45 older people requiring personal care, which may include up to 26 older people designated as having dementia Some people come to live at the facility on a short term respite basis. Many people move into the home after attending the day care centre which is also on the site of Bennett House. The Accord Housing Association owns the home, and the Registered Manager, Stephanie Matthews, transferred within the Accord Group to be in charge of Bennett House in July 2005.The home, situated in the Woodside area of Telford, is a purpose-built bungalow style building, which during the past year has been subject to a lot of financial investment, refurbishment and team effort to improve the living accommodation provided there. It is divided into four separate units, each unit comprises of single bedrooms, bathroom, separate toilets, a lounge area and a kitchen/dining area. As the home is in the centre of the extensive regeneration project which is ongoing within the locality, it is anticipated it will benefit from the local community facilities which are being upgraded in the very near future. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and commenced at 12.20pm lasting six hours. The main aim of the inspection was to follow up recent investigations into complaints about care provided for people who stay at the home on a short term basis, and to follow up a two hour site inspection carried out at the home on December 6 2005.The report for this visit is available on request from CSCI (Commission for Social Care Inspection). The inspection included observing activity within the home, inspecting the premises, an ‘in depth look’ at records, for residents and staff, talking and listening to over half of the 44 people living there, staff on duty at the time of the inspection. There was one visitor available to speak to on this occasion. These discussions were carried out in private on a one to one basis, or together in groups. Everyone was happy to share comments, which were explored and reflected in the main body of the report. At the time of the inspection several members of care staff including the management team were on sick leave, The Registered Manager for the home was off sick at the time of the inspection, as were the Deputy Manager and two other senior carers. It was confirmed that two management team members from another Accord home in Telford had been seconded to Bennett House to manage, develop and improve the service delivery for the residents at Bennett House, focussing specifically on the needs of people living there with dementia related conditions. Four of the 44 people living at the home at the time of the inspection were staying at the home for short stay respite care. On this occasion a total of 22 out of 38 National Minimum Standards were assessed. What the service does well: It was impressive to see that the home continued to more than meet National Minimum Standards for some parts of the service and support it provides for its residents. The home meets the individual personal and health care needs of the elderly people living at Bennett house on a long term basis in a most desirable manner. Many residents spoken to stated they were happy to be living at Bennett House felt safe, and were well cared for. Keeping all residents busy in a variety of daily life and social activities is considered to be vital at Bennett House. The whole care team embrace the issue of activities to make sure people have the support they need to live as full a life as possible. Despite the staffing challenges, a variety of activities Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 6 seen being held ensured all people living there had the opportunity to be involved in many of festive activities arranged as part of the build up to Christmas and the New Year. Although the decorators were seen to be at work on site, this did not seem to be a concern. The internal areas of the home were seen to be spotlessly clean and safe. Recruitment procedures for staff were seen to be very thorough. The home has a commendable system to make sure when people are interviewed at least two people perform an interview assessment with scores which show how suited the person is to the job. What has improved since the last inspection? What they could do better: CSCI is currently concerned about the staffing at the home due to several care staff members, including the manager being on long term sick leave. Until this situation improves, the home will have inspection visits at least monthly to make sure the remaining staff team are getting the right support to provide the care and services the residents need and expect. Outcomes of two recent complaints show that admission procedures, especially for residents moving into Bennett House for a short period of time need to be further improved. There needs to be an effective system in the home to make sure staff are made aware of all the needs of new residents, especially those who are unable to communicate their wishes and feelings due to their medical condition. Although recordkeeping and training for staff was seen to have taken place to improve residents records and the care delivery when a person first moves into Bennett House, this part of the service still needs to be improved further. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 7 Other recordkeeping issues in need of further improvement include accident and complaint records, as well as staff training, qualification and supervision records, A total of 9 more statutory requirements were made as a result of the findings of this inspection. However, it was seen that many issues of the issues are in hand, including finding replacement commodes. 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. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 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 Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 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): 3, 4 & 5. Bennett House’s admission procedures needs to be further improved to show there is sufficient information to clearly demonstrate they can meet the long term and short term needs of people thinking about moving in there. EVIDENCE: It is noteworthy to report that a suitably experienced staff member from Bennett House now goes out to meet and assess any people who are thinking about moving into the home. At this stage, every resident and relative is encouraged and invited to come to visit or perhaps spend some time at the home. Many people become permanent residents as a result of getting to know the ‘Bennett Lifestyle’ by coming to stay on a short term basis. A sample of the type of ‘welcome pack’ left with potential residents and seen in records of people who had moved in showed that enough information is gathered by the home at this stage of the admission process. Likewise, all necessary easy to read and understand information is left with the potential resident to help the person decide whether the home will be suitable. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 10 When the records of four residents who had moved in for short term care were looked at in depth, none of the records were seen to have all of the information written in as expected. Although it was good practice to see that all resident records had copies of professional assessments from people such as social workers, when the Bennett House care information was checked, There were a lot of gaps and some sections of the forms were blank. Discussion about this issue at the inspection confirmed that some training for the care team had been carried out to improve this, but from the records seen it was apparent that this has not resolved it. The home needs to implement an effective system so that when a person is admitted, staff get any additional information needed to care for that person, which is shared with the team involved in the person’s care so they are fully aware of the new residents needs in as short a period of time as possible. On balance, it was positive to see in all four sets of records that the night -time care plans gave a good pen picture of what the peoples needs and preferences were. These were laid out in detail on two sides of A4 paper, which were easy to read and understand. Although the views of all the people spoken to confirm they were happy to be living at Bennett House, felt safe and well cared for, the home did not have adequate record keeping to prove this, or to demonstrate residents and family involvement in all aspects of the admissions process. Accord Housing is fully aware of the above matters and in an effort to improve this has conducted a thorough audit into the care practices on Bluebell Unit. A report of this audit has identified several actions to be carried out, however there are no timescales in the report to assure CSCI when they are to be carried out. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 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, & 10. Although staff are sensitive to meeting the needs of residents in a respectful manner, this is not shown in care planning paperwork for ‘short term stay’ residents, which means there is no confirmation residents get the care they need and expect. EVIDENCE: When four care plans of people staying at the home for a short period of time were looked at in depth, (including those of a resident CSCI were involved in a complaint investigation about), it was seen that records had not been personalised with enough information about the people or their medical conditions to describe how those people needed to be looked after. This is a particular cause for concern, especially for the type of residents who move into Bluebell Unit, as these individuals have some type of dementia related condition which affects their needs and behaviours, and the behaviours of other people already living there. Many of these individuals are not able to express their needs and wishes and therefore it is vital that all relevant information is gathered from the people who can provide it, wherever possible. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 12 The above shortfalls have already resulted in two complaints currently being looked into as part of an ‘All Agency’ investigation. Although efforts to improve this are already being addressed by the registered provider and the home team, these matters must be prioritised as a matter of urgency to assure CSCI of the home’s ability to continue to provide this type of service. From observing care delivery and residents interaction with the staff team it was noteworthy to see that a sincere, caring, respectful rapport exists at Bennett House. This confirms what the inspector was told by residents (who were able to do so) that people were happy living at Bennett House, felt well cared for and the staff respected their privacy. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 13 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 The Bennett House team work in close liaison with residents and their relatives to promote choice and control over individual lifestyles and preferences in order that these can be continued or further enhanced when they live there. EVIDENCE: It was impressive to see that this excellent part of the service Bennett House provides continues to be carried out at a consistently high standard despite staffing challenges. Established systems seen in place confirm there are daily written details about the activities people are involved in. The content of the minutes of the regular monthly resident meetings also confirmed that residents were fully involved in making decisions and choices about a variety of issues in the home including activities for Xmas, meals, and care plans, and raising awareness about comments and complaints. As the inspection was carried out the week before Xmas, a lot of the activities going on in the home were seen to have a festive theme. Christmas reminiscence word games were seen being held on Bluebell Unit upon arrival at the home. One resident who has spoken to the inspector at other visits was proud to share the news that he was a ‘television star’ as a result of the homes efforts to make links with the children of the local community. The person said he really enjoyed the opportunity of being able to tell wartime stories to local Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 14 youngsters, and was most surprised to be filmed by the local television company whilst doing this. Recycling has continued to become very topical in the home, and residents are involved in a variety of activities in promoting this. On the day of the inspection, the senior activity organiser was saying her farewells to the residents, as she was leaving her employment at the home that day. Although many staff members and residents agreed she would be sorely missed, the individual herself is confident that being as the activity lifestyle is so well established, the team would make sure this part of the service would continue to excel at Bennett House. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 15 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, & 18. Complaints records need to show they are dealt with promptly. Systems for protecting service users require improvement to protect the people living there at possible risk of harm or abuse. EVIDENCE: At the June2005 inspection, it was seen required that the complaints notice in the hallway was updated to ensure that it clearly outlined the contact details for CSCI. This has been carried out. Although the home has received four complaints in the past six months that CSCI are aware of, the home complaints logbook has not been kept up to date to show this information. Three of the complaints were not recorded in it. Two of the complaints involved an ‘All Agency investigation’ into some of the care practices at the home. These investigations have not yet been completed. Accord Housing have been most cooperative about this issues and have conducted an audit at the home in order to further improve standards at the home. This has taken some time to carry out, and although the audit is complete, CSCI have not received a full report of this, and remain concerned that enough is not being done soon enough to resolve this matter. As a result of such concerns, CSCI will be carrying out visits to the home at least monthly to measure the progress they are making. Furthermore, the visits are also deemed necessary due to the high levels of absence by staff members due to sickness. A lot of information was seen available in various parts of the home for residents and their visitors to raise their awareness of outside support groups Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 16 such as Age Concern they can approach for professional advice about care home matters. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 17 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 &26. The ongoing commitment of Accord Housing ensures the standard of the environment continues to be improved and adjusted to provide residents with a clean comfortable and well maintained home to live in. EVIDENCE: All areas of the home were seen to be spotlessly clean. During the past year Bennett House has had considerable refurbishment, and at the time of the inspection, workmen were there redecorating the communal corridors. This has made a huge difference and compliments the recent extensive facelift carried out in the lounges and bathrooms. Residents commented they were looking forward to seeing the finished result when the carpets they had helped choose were fitted. Random checks of hot water outlets confirmed the newly installed thermostats were doing their job and keeping temperatures within safe limits. The new specialist baths have continued to enhance the lifestyle of people living there. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 18 Since the last inspection, the outcome of a small fire on the premises has resulted in thorough auditing of fire safety procedures and practices in the home, which has involved the local fire safety officer. Although the staff were praised for managing the incident extremely well, Accord Housing carried fully explored all areas of fire safety in order to further enhance already good practices. Replacement of some worn furniture in the residents smoking area was identified to be in hand to be dealt with. This was discussed with the person in charge at the end of the inspection. It was seen that the home had not yet managed to find a suitable model of commode to replace the wooden ones, which were noticed to be showing signs of wear and tear at the inspection at the start of 2005, it was felt that this matter would be sorted within the next month. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 19 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): 27,28,29, &30 The procedures for the recruitment of staff need to be improved to offer protection to people living in the home, and show that residents are actually supported by a committed staff group that meet the needs of each individual in a sensitive and professional manner. EVIDENCE: It was pleasing to see that the home had improved the recordkeeping for the team duty rotas since the Inspection visit on December 6 2005. As recorded earlier, at the time of the inspection staff reported that there were 19 care team members, including the majority of the management team absent due to sickness. Much of the absence within the management team has been longer than 28 days. This has posed to be an enormous challenge to keep satisfactory standards of care maintained. It is obvious that staff morale has been affected by these events, therefore it was commendable to observe the professionalism of the team to ensure this has not been made apparent to the residents. In order to make sure all the jobs are getting done during such times, a system to monitor care delivery has been introduced- senior care team members now complete a quality checklist twice daily to ensure residents needs have been met. This system has only recently been implemented; therefore it is too soon for staff to comment on how effective it is. The person in charge of the home knowledgably confirmed the temporary management arrangements in place. This was seen reflected in the duty rotas and staff signing in book. CSCI are still awaiting written confirmation of the Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 20 management arrangements from the Registered Provider, which is necessary due to the Registered Manager’s absence. Although the home is heavily reliant on agency staff at the moment, a good working relationship between the home and the agencies have meant that a lot of staff provided have worked at the home quite regularly. In addition, Accord Housing has seconded staff from other schemes to support the core of permanent staff that remains at Bennett House. Towards the end of the inspection a manger from another Accord Housing scheme was seen assisting the Team Leader administer tea - time medications. Although the home has been short of staff it was reported that they have never worked a shift below the minimum staffing levels. During the inspection, additional ‘floating staff’ were seen on duty to assist the team members during this challenging time. Furthermore, the home currently has several staff vacancies it is in the process of filling. This situation is being closely monitored by CSCI and at least monthly visits will be carried out. When five sets of records for staff were looked at, it was commendable to see effective systems to show that people are thoroughly checked out to be suitable to work at the home. The recruitment part of these records showed interview assessments with scores were completed in depth by at least two staff members. All information was organised and easy to access. However, not all information was available to prove staff members had appropriate qualifications or had received the training that was listed on the staff training record. This meant there was no written proof to show the person had been trained for the job she was appointed for. When the records of people who have been delegated to assume more senior management roles were looked at, this was also the case - there was not enough evidence to show they had the necessary skills to carry out the additional responsibilities expected of them. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 21 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, 36, 37 & 38. Shortfalls in staffing have compromised consistency in the day to day management of the home, which have also affected the usually good systems of communication to seek the views of the service users and families/representatives. EVIDENCE: The impact the new manager has had on the home could not be fully appreciated on this occasion, due to her prolonged absence. Although the home team are currently challenged it was noteworthy to be informed that efforts to improve relationships between relatives and residents and staff on Bluebell Unit have started. The person in charge of the home was seen to be thanked for the enjoyable ‘get together’ that had taken place earlier in the week, to launch this project. A developing rapport with the community mental health team has resulted in the launch of a ‘monthly clinic’ when nurses and psychiatrists will be available to meet and speak to family members and Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 22 staff. Minutes of staff and residents meeting show they continue to be held monthly, allowing a forum for people to express opinions and make suggestions. The content of a staff meeting held by the manager in November shows the home is dealing with a lot of important issues to improve the service it provides. Progress has been slow due to a lack of consistency within the management team that has meant that the home team have not had the supervision they have had in the past. Examination of management team records also confirms that the registered provider has not carried out supervision sessions as expected. In an effort to remedy this issue a special ‘tracker’ form has been introduced by the home. When the accident monitoring system was assessed on this occasion, it was seen that not all accident forms had been completed by the line manager as seen at the Announced inspection earlier in the year. This demonstrates the impact the current staffing situation has had on the recordkeeping in the home during this challenging time. Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 23 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 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 3 4 3 X X X X 2 STAFFING Standard No Score 27 2 28 2 29 4 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 2 2 2 Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? No 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 14(2) Requirement The registered provider must implement an effective system to ensure that when a person is admitted, any staff member involved in the care for a new resident gets any additional information needed to care for that person, which is then shared with the team involved in the person’s care. Residents care plans including those at the home on a short term basis must have all the detailed information required to make sure staff can fully look after the person as soon as possible from the point of admission. The registered provider must provide CSCI with realistic timescales when the actions identified in their audit report of Bluebell Unit dated 14/12/05 will be carried out. The home complaints log must clearly reflect details including outcomes of all complaints about the service. DS0000020538.V274963.R01.S.doc Timescale for action 23/01/05 2 OP7 15, Sch 3 23/01/05 3 OP4 14(2), 18(1,3) 14/01/05 4 OP16 22(7)(a) (b) 31/01/06 Bennett House Version 5.1 Page 25 5 OP26 13(3) 6 OP27 18(1)(a) 7 8 9 10 OP28 OP30 OP36 OP37 18(1)(a) 18(1)(c) 18(2) 17(1,2&3) Sch 3,4 11 12 OP37 OP38 17, Schs 3&4 13 (6) Sch 3. (j) All wooden commodes must be discarded and taken out of use because of the risk of infection as they cannot be adequately cleaned and disinfected. They must be replaced with a nonpermeable material. (Timescales of 30/04/05 not met) Accord Housing must submit written confirmation of the strategy to effectively manage and staff the home until absence has reduced and vacancies have been filled. Staff records must provide evidence of the their qualifications. All staff records including those for new starters must detail the training they have undertaken. All care staff including management staff must receive bi monthly supervision. The homes record systems must be streamlined and developed to contain all of the required elements of the National Minimum Standards, including information held in service user records. (Timescales of 30/04/05 not met) All records must be available for inspection at all times. The home accident monitoring system must evidence that the person in charge has been made aware of any accident or incident which occurs in the home, and show appropriate follow up action has been taken. 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 06/01/06 31/01/06 Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP21 Good Practice Recommendations It was noted that commodes are in the majority of bedrooms. The use of commodes for nighttime use should not be a routine occurrence. If someone finds it difficult at night to get to the toilet because of the distance from their room then consideration must be given to increasing the number of toilets within the vicinity. It is strongly recommended that each unit have an automatic sluicing disinfector available to ensure the safe disposal of bodily waste, to reduce the risk from contamination and to control the spread of infection. 2. OP26 Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Bennett House DS0000020538.V274963.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!