Inspection on 29/08/06 for Benridge

This inspection was carried out on 29th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Benridge 16/10/08

Benridge 09/04/08

Benridge 03/05/07

Benridge 03/01/06

Benridge 11/07/05

Benridge 17/01/05

Benridge 07/06/04

Benridge 17/11/03

Benridge 25/04/03

Benridge 17/09/02

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

CARE HOMES FOR OLDER PEOPLE Benridge 53 Queens Road Southport Merseyside PR9 9HB Lead Inspector Mike Perry Unannounced Inspection 29th August 2006 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 Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Benridge Address 53 Queens Road Southport Merseyside PR9 9HB 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) 01704 530378 benridge@themacs.org Benridge Care Homes Ltd Mrs Carole Ann McLaughlin Mrs Valerie Flint Mrs Carole Ann McLaughlin Care Home 27 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (2) of places Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the CSCI. Twenty five places are to be registered in the category of DE(E) with 2 places registered in the category of OP for two named service users 3rd January 2006 Date of last inspection Brief Description of the Service: Benridge is a privately run residential care home registered for twenty-seven older people. Included within this registration are twenty-five places for those individuals with dementia and two in the category of old age. The home has been open for a number of years. Valerie Flint manages the home. The home is located in a residential area of Southport on one of the main roads leading from the town centre. As a result the home is close to local facilities and near to public transport routes. The home is operated from a detached building, which has amenities on three levels. A basement level provides bedroom and communal facilities. On the ground floor are further bedrooms as well as kitchen, dining room and two lounges. Further bedrooms are located on the upper floor. A number of bathrooms and toilets are also available. All areas are served by stair lifts. The current fees for the service are £410 per week. Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a ‘key’ inspection for the service and covered the core standards the home is expected to achieve. The inspection took place over a period of two days. The inspector met with residents and spoke with members of care staff on a one to one basis and the registered manager and the administrator. Three sets of relatives were also spoken to. Service user comment cards were also given out to try and gain more views as to how the home is run and what it is like to live there. Eight of these were returned and comments have been used to formulate this report. A tour of the premises was carried out and this covered all areas of the home including the resident’s rooms [not all bedrooms were seen]. Records were examined and these included three of the resident’s care plans, staff files, staff training records and health and safety records. What the service does well: Relatives interviewed were clear that they are kept up to date and informed of any changes in the care of residents in the home. There is evidence that residents’ health care needs are being met. Doctor’s visits are included in the care files. One resident has diverse needs in that she has a condition that requires a specialised diet and staff were knowledgeable on the way this affected the residents life and the need for monitoring. Medication administration recording [MAR] sheets were inspected and were clear and accurate. Residents seen were appropriately dressed and were clean and well presented. Relatives stated that the standard of personal hygiene for residents is consistent. Staff understood how to maintain privacy and dignity for residents and could give examples of how they did this. The social atmosphere in the home appears warm and relaxed. Staff where observed to be interacting and supporting residents. There is a notice board, which advertises some activities during the week. A therapist involves residents in physical activities [chair exercises etc] on a weekly basis. Staff reported that there is time to sit and socialise with residents and that some are escorted out locally on trips to the park for example. Sing-alongs are popular in the evening. Birthdays are celebrated. The dining room in the home is pleasantly furnished and tables well laid with tablecloths and cutlery laid. Residents were observed to interact well and clearly enjoyed their meals. Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 6 Relative’s spoken to were aware of how to complain and felt that management were very approachable and responsive and that ‘things are sorted out if needed’. The home is maintained well with all areas inspected being clean and tidy and well presented. Bedrooms were well personalised and homely. Externally the home is also maintained and there is disabled access at the front of the home with a well-designed ramp. There is training available in the home for staff with just over 50 of staff having NVQ qualifications. There is a standard induction programme and ongoing training is available. Relatives interviewed were very positive when talking about the staff and comments received were: ‘I can’t speak highly enough about the staff’ ‘They are very caring’ ‘Staff are suited to this work – lovely attitude – can diffuse situations well’ Val Flint is the manager of the home. During the inspection she was able to demonstrate an understanding and empathy for residents with dementia. The home are able to demonstrate systems whereby the quality of the service is under review and that they listen to the wishes of relatives who generally speak on behalf of the residents in the home. The general risk assessments form the basis of the health and safety management in the home. Records seen were up to date and the ongoing management ensures residents safety What has improved since the last inspection? What they could do better: Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 7 The homes own assessments carried out prior to residents being admitted need to be more thorough so that the home can be assured that they can meet the needs of a prospective admission. All of the residents have a care plan recorded in their file. The care plan is a single sheet, which contains a very good pen portrait and social history followed by a list of care interventions. These are similar for each resident and are not personalised so that some care needs are not addressed. For example one resident who has challenging needs around safety when becoming disturbed and agitated has no care interventions recorded so that staff had no guidelines to care for the resident on these occasions. Care is evaluated on a regular basis although entries should be in more detail and set against the main aims and objectives of the care plan so that they can be measured. Relatives interviewed did not have any real idea of the existence of a care plan and had not been asked to review this with staff on an ongoing basis. It is recommended that care staff do include relatives in the care planning process and record any reviews as part of the evaluation process. The records inspected indicated that no medicines had been returned since May 2006 and the inspector would recommend that medicines be returned on a more frequent basis. The supplying pharmacist does audit the medicines on visits to the home but there was no report available and advice was given to ask for a written report on future visits. Staff administrating medicines must all be appropriately trained. Some staff, have received no training apart from in-house briefing by the manager. All staff currently administering medicines must receive this training as a matter of urgency. Some residents share bedrooms and portable screens were noted to be in situ. The screens can be awkward to move and rather cumbersome and they also cannot be used by residents independently. It is recommended that fixed curtain type screens be installed in these bedrooms. The management were aware of the local procedures for reporting of any allegations of mistreatment although staff had only limited understanding in this area. Some more specific training, standardised from social services, is needed so that staff have a deeper understanding of the issues relating to the Protection of Vulnerable Adults [POVA]. Given the resident group the management should give some thought as to promoting the environment with respect to assisting resident’s orientation. For example residents names on bedrooms doors and orientation signs for bathrooms and toilets. The laundry is in need of some minor attention. The walls and floor need painting to ensure easy cleaning. It was observed that staff do not always wear Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 8 protective clothing when carrying dirty laundry. Plastic aprons should be available in the laundry. Currently the home does not return reports from the registered provider under regulation 26 of the care home regulations and this should now be considered as it forms part of the homes quality assurance processes. Legionella risk and the current arrangements for the management of risk of scalds from hot water outlets in baths were discussed. There is a need to ensure that circulating hot water is 50c plus and that thermostatic controls ensure hot water is delivered at no more that 43c. 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. Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 9 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 Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 10 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 [standard 6 not applicable] The quality of this outcome group is adequate. This judgement has been made using available evidence. Assessments are carried out prior to admission but one did not include social worker assessments and the homes own assessment was incomplete so that a full picture is not available at the time of admission. EVIDENCE: Three care files were inspected in some detail and contained evidence of pre admission assessments as part of the admission procedure. Two files had full assessments from referring social workers and also contained information from health care professionals as well as the homes own assessment completed by the home manager. Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 11 One file did not contain any assessments by professionals and the homes assessment was incomplete in that some of it was not filled out [a dependency assessment was the only document completed] and therefore did not meet standards around adequate assessment. There was some discussion around this particular resident and the inspector is satisfied that the homes management did try to obtain necessary assessments but were unable to get these. The homes own assessment needs to be much more thorough however so that the home can be assured that they can meet the needs of a prospective admission. The manager was referred to standard 3 and the criteria needed for assessments. Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10 The quality in this outcome area is adequate; this judgement has been made on available evidence. Personal care needs are met consistently overall so that residents are treated with respect and their dignity maintained. There is a need to develop some aspects of care planning so that all needs are addressed and staff can have consistent guidance on care interventions. EVIDENCE: All of the residents have a care plan recorded in their file. Three were seen in depth and discussed with care staff. The care plan is a single sheet, which contains a very good pen portrait and social history followed by a list of care interventions. The care interventions are standardised on the records seen and are virtually the same of each resident. This means that care interventions are not personalised for residents and also some care needs are not addressed. For example one resident who has challenging needs around safety when Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 13 becoming disturbed and agitated has no care interventions recorded so that staff had no guidelines to care for the resident on these occasions. Care is evaluated on a regular basis although entries under this heading should be in more detail and set against the main aims and objectives of the care plan so that they can be measured. Relatives interviewed were clear that they are kept up to date and informed of any changes in the care of residents in the home. The entry on all care plans seen is that ‘the relative declines to read the care plan – keep informed’. Those interviewed did not have any real idea of the existence of a care plan however and had not been asked to review this with staff on an ongoing basis. It is recommended that care staff do include relatives in the care planning process and record any reviews as part of the evaluation process. There is evidence that residents’ health care needs are being met. Doctor’s visits are included in the care files. Residents spoken to discussed trips to the doctor and the chiropodist was visiting the home at the time of the inspection. One resident has diverse needs in that she has a condition that requires a specialised diet and staff were knowledgeable on the way this affected the residents life and the need for monitoring. Another resident had transient ischemic attacks [small disabling events], which the staff understood and were monitoring with input from the GP. There are no residents self-medicating as this is judged as high risk due to the level of cognitive impairment. Medication administration recording [MAR] sheets were clear and accurate. Medicines are received into the home on the MAR sheets and there is a return to pharmacy record. The records indicated that no medicines had been returned since May 2006 and the inspector would recommend that medicines be returned on a more frequent basis. The supplying pharmacist does audit the medicines on visits to the home but there was no report available. Advised to ask for a written report on future visits. Staff administrating medicines must all be appropriately trained and this was discussed with management as some staff, night staff particularly, have received no training apart from in-house briefing by the manager. The home has bought in some training covering induction, administration of medicines and specialised techniques. All staff currently administering medicines must receive this training as a matter of urgency. Residents seen were appropriately dressed and were clean and well presented. Relatives stated that the standard of personal hygiene for residents is consistent. Staff understood the concepts of privacy and dignity for residents and could give examples of how to maintain this. Some residents share bedrooms and portable screens were noted to be in situ. The screens can be awkward to move and rather cumbersome and they also cannot be used by Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 14 residents independently. It is recommended that fixed curtain type screens be installed in these bedrooms. Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 15 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): 12,13,14,15 The quality in this outcome area is good; this judgement was made on the available evidence. Residents are supported to be involved in activities although there is a realisation that more can always be developed in this area to ensure a better quality of life for residents. A choice of good quality home cooked food is provided to the residents who enyoy their food in pleasant surroundings. EVIDENCE: The social atmosphere in the home appears warm and relaxed. Staff where observed to be interacting and supporting residents. The chiropodist was visiting during the inspection and this was the focus of some good interaction with residents and staff enabled residents to focus on the activity. There is a notice board, which advertises some activities during the week. A therapist involves residents in physical activities [chair exercises etc] on a weekly basis. Staff reported that there is time to sit and socialise with Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 16 residents and that some are escorted out locally on trips to the park for example. Sing-alongs are popular in the evening. Birthdays are celebrated. Relatives awareness of activities in the home is limited indicating that perhaps more could be done with relatives in involving them in the daily social life. Relatives comments where positive however regarding the staffs ability to interact and support residents, some of whom can present with challenging behaviours; ‘staff can’t do enough’, ‘staff are very helpful and handle some difficult situations well’. Dinnertime was observed. The opportunity for socialisation is again emphasised with the dining room being very pleasantly furnished and tables well laid with tablecloths and cutlery laid. Residents were observed to interact well and clearly enjoy the experience. All residents are encouraged to join in at meal times. Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 17 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): The quality in this outcome area is adequate; this judgement was made on available evidence. There is a complaints procedure so that residents rights are upheld and people feel that concerns are addressed. Management are aware of local proccedures but staff need to have a deeper understanding of issues around protection of vulnerable people. EVIDENCE: There is a complaints procedure and this is made available through the service user information available. Relative’s spoken to were aware of how to complain and felt that management were very approachable and responsive and that ‘things are sorted out if needed’. The information available includes the contact details of The Commission for Social Care Inspection [CSCI]. There have been no complaints about the service since the last inspection. The management were aware of the local procedures for reporting of any allegations of mistreatment although staff had only limited understanding in this area. Staff reported that they had undergone some general training in abuse awareness via a DVD that he home have purchased. Some more specific training, standardised from social services, is needed so that staff have a deeper understanding of the issues relating to the Protection of Vulnerable Adults [POVA]. Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 18 Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 19 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): 19,26 The quality in this outcome area is good, this judgement was made on available evidence. Residents are provided with a safe, comfortable and homely environment in which to live. EVIDENCE: The home is maintained well with all areas inspected being clean and tidy and well presented. Bedrooms were well personalised and homely. There are 2 main day areas but there is also a third day room which can be accessed by residents and relatives who require more privacy as well as being used as a general meeting room. Given the resident group the management should give some thought as to promoting the environment with respect to assisting residents orientation. Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 20 Currently bedroom doors are not marked with residents name or [possibly photo] and there are no orientation aids for bathrooms and toilets. Externally the home is also maintained and there is disabled access at the front of the home with a well-designed ramp. The laundry is small but well equipped. There was some discussion around the use of the sluice in the laundry and since the inspection the management have accessed advice from environment health officials. It is recommended that any commode contents be emptied in a toilet rather than this area. The walls to the laundry are flaking and in need of painting. The floor likewise needs some attention to ensure easy cleaning. There is no designated laundry staff and care staff share duties in this respect. It was observed that staff do not always wear protective clothing when carrying dirty laundry. Plastic aprons should be available in the laundry. Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 21 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 quality in this outcome area is good; this judgement was made on available evidence. Staff numbers are appropriate and service user’s needs are being met effectively. Staff training is co ordinated enabling them to understand and meet the needs of the residents effectively although more diverse learning could be insigated. Staff are recruited appropriately so that residents are protected. EVIDENCE: For 21 residents at the time of the inspection there was the manager, one senior carer and 2 other carers, domestic staff and a chef. There is also an administrator who supports this team. Staffing in the home is fairly stable with minimal turnover. This was supported by both relative and staff interviews [records indicate 6 staff left since last inspection]. There is training available in the home. Just over 50 of staff have NVQ qualifications. There is a standard induction programme and ongoing training is available. This is heavily reliant on DVD training and work sheets. Comments from staff were that this could be balanced it some external trainers having Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 22 input. For example first aid training, which was seen as more practical and needed, hands on approach. Relatives interviewed were very positive when talking about the staff and comments received were: ‘I can’t speak highly enough about the staff’ ‘They are very caring’ ‘Staff are suited to this work – lovely attitude – can diffuse situations well’ Staff files were seen and the recruitment standards concerning necessary checks to ensure staffs fitness were carried out satisfactorily. Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 23 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): 31,33,35,38 The quality in this outcome area is good; this judgement was made on available evidence. The manager of the home displays the skills and knowledge to manage the home so residents and staff needs are supported There are systems in place so that the quality of the service can continue to be improved with reference to service users needs and comments. Health and saftey is generally amanaged well so that rsidents are kept safe in the home. One requirment is made . EVIDENCE: Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 24 Val Flint is the manager of the home. Val was registered with CSCI in 2005. She worked previously in the home and has completed her Registered Managers Award at level 4 NVQ. During the inspection she was able to demonstrate an understanding and empathy for residents with dementia. An administration officer who has also worked in the home a number of years supports Val. The home are able to demonstrate systems whereby the quality of the service is under review and that they listen to the wishes of relatives who generally speak on behalf of the residents in the home. The annual quality assurance audit includes attention to relatives feedback and the home also collect comments in the ‘appreciation file’. There are some internal audits carried out such as regular risk assessments of the environment. [The home has responded well here to previous requirements by the inspection team]. Currently the home does not return reports from the registered provider under regulation 26 of the care home regulations and this should now be considered as it forms part of the homes quality assurance processes. There is some daily management of resident’s personal allowance due to resident’s inability to manage these independently. Some records were seen and these are individualised. The homes policy statements were seen and include good practice guidance around receiving of gifts and staff responsibilities regarding management of resident’s finances. The general risk assessments form the basis of the health and safety management in the home. Records seen were up to date and he ongoing management ensures residents safety. It is recommended that the homes appointed fire marshal attends a recognised course to update her self. Legionella risk and the current arrangements for the management of risk of scalds from hot water outlets in baths were discussed. There is a need to ensure that circulating hot water is 50c plus and that thermostatic controls ensure hot water is delivered at no more that 43c. To this end thermostatic controls are required on the bath discussed. Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 25 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 Requirement All residents must be adequately assessed prior to admission so that the home can be assured that care needs can be met. The assessments must include relevant professionals or, failing this, an assessment by the home, which is thorough and includes all of the assessment headings under standard 3 of the National Minimum Standards. Care plans must include care interventions for all identified care needs. All care staff administering medicines must be appropriately trained using an accredited training package. The laundry floor and walls must be painted so that they can be effectively cleaned. The manager must ensure that al staff receive regular and ongoing supervision sessions at least 6 times a year. The registered person must ensure that the circulating temperature of hot water is of sufficient temperature to reduce DS0000005398.V302486.R01.S.doc Timescale for action 04/10/06 2 3 OP7 OP9 15 13(2) 01/01/07 04/10/06 4 5 OP26 OP36 23 18 04/10/06 01/01/07 6 OP38 13 04/10/06 Benridge Version 5.2 Page 27 7 OP38 13 any risk of legionella. The bath identified must be fitted with thermostatic controls to ensure safe water temperature to reduce any risk of scalds to residents. 04/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard OP7 OP7 OP9 OP9 OP10 OP18 OP26 Good Practice Recommendations The evaluations on the care plan should be in more depth and identify any progress [or not] made against the goals or objectives of the care. Relatives should be involved in all care planning on an ongoing basis. More regular returns of used stock medicines should be made so that a stockpile does not build up. The inspector recommends that a written feedback report is acquired from the supplying pharmacist following the next audit. It is recommended that permanent curtain type screens be installed in shared bedrooms so that residents and staff can more easily ensure privacy. Staff need to have an understanding of POVA and the home should access the training available from social services. Aprons should be supplied in the laundry area for staff to easily access. Commode contents should be emptied down toilets rather than the sluice in the laundry, which should reduce the risk of cross infection. Management should give some thought to developing orientation aids to assist residents in getting around the home. Management should respond to staff wishes for training to be provided in more diverse ways so that a mixture of approaches is apparent. 8 9 OP26 OP30 Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Benridge DS0000005398.V302486.R01.S.doc Version 5.2 Page 29 - 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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