Inspection on 17/01/06 for Bentley Care Home

This inspection was carried out on 17th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Bentley Care Home 09/07/07

Bentley Care Home 06/06/06

Bentley Care Home 01/03/05

Bentley Care Home 21/10/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

Thames House

Creative Support

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

CARE HOMES FOR OLDER PEOPLE Bentley Care Home 2 Bentley Road Liverpool Merseyside L8 3SE Lead Inspector Peter Cresswell Unannounced Inspection 08:45 17 and 19th January 2006 th 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 Bentley Care Home DS0000056187.V279370.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. Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bentley Care Home Address 2 Bentley Road Liverpool Merseyside L8 3SE 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) 0151 548 1988 info@argylecaregroup.com Argyle Care Group Limited Care Home 58 Category(ies) of Dementia - over 65 years of age (39), Mental registration, with number disorder, excluding learning disability or of places dementia (19) Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 38 (DE(E) ) Nursing Care and Personal Care in the overall number of 58 Annexe: 19 Beds (MD) Nursing Care and Personal Care in the overall number of 58 The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection To accommodate one named service user with Dementia (DE) under the age of 65 in the overall number of 58 Date of last inspection: 1 June 2005 Brief Description of the Service: The Bentley Care Home was converted from three large houses and provides accommodation on three floors for up to 58 service users. Residents with dementia tend to be located in the main building (‘Bentley House’), and those with mental disorder in the building that faces on to Greenheys Road (the ‘Bentley Unit’ or annexe). The home has a number of Chinese service users and employs some staff who speak different Chinese languages. The home is close to Princes Park and is convenient for local amenities on Lodge Lane, Princes Park Health Centre and bus routes to Liverpool City Centre. The home has a wellmaintained walled garden and off-road car parking. The Bentley’s present owners own a number of other homes. The current manager has previously been registered as manager of other care homes and was formerly the deputy manager of The Bentley. She is not yet registered by the Commission for Social Care Inspection but at the time of the inspection her application was being processed by the Commission. Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days, the inspector returning on the second day to finish examining records and the medication system. The inspector talked to eleven residents and a number of staff during the inspection. He also observed a staff meeting chaired by the manager. The inspector toured the whole building, and examined records - including care plans and safety records - and medication. What the service does well: What has improved since the last inspection? What they could do better: The owners have not completed the programme of redecoration and refurbishment of the home due to be finished by December 2005 as agreed following the last inspection, though the work is under way. The home therefore still does not yet provide a satisfactory environment for its residents. Sufficient qualified nurses are employed but the home needs to increase the number of care staff with at least NVQ2 in order to provide sufficient qualified staff. Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 6 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. Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 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 Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 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): 3, 4. The home carries out pre-admission assessments, ensuring that residents are appropriately placed and therefore receive care that meets their needs. Confusion over the home’s registration categories creates the possibility of inappropriate care being provided. EVIDENCE: Prospective residents are assessed by the manager or a senior nurse before being admitted. The Bentley makes particular efforts to meet the needs of its small community of Chinese residents (mainly elders) by employing Chinesespeaking staff and providing a Chinese TV channel. A new pre-admission assessment form had been used for recent admissions. There are a number of issues concerning the home’s registration category and the type of residents for whom it can care. When the Argyle Care Group was registered as owners they submitted a business plan which aimed within three years to provide separate units for residents under 65 with mental health problems and for older people with dementia. The original business plan also envisaged a separate unit for older people receiving personal care only, but this was not in the event reflected in the home’s registration and is not now Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 9 part of the Registered Person’s plan. The main part of the home (‘Bentley House’) now mainly accommodates older people with dementia, with the ‘Unit’ (the annexe) providing mainly for people with mental health problems. However, many of the residents at the time of registration did not fit into these categories and the different categories of residents were not clearly separated in the two units. This situation has persisted and the Registered Person has been reluctant to insist that people move into different parts of the home. Therefore, for instance, there are six older people with no mental health problems still in the Unit, where they have lived for a number of years. This situation was accepted by the National Care Standards Commission (the forerunner of the CSCI) at the time of registration. Matters have been complicated further since then by the admission to the Unit of new residents who have mental health problems but are over 65. The three-year limit envisaged for the creation of discrete units comes to an end in December 2006, so the Registered Person now needs to devise a plan setting out how this is to be achieved. In addition, the Registered Person must seek a variation in registration to reflect the fact that people with mental disorder over the age of 65 are resident in the home. A suitable variation could give some flexibility for the future. The Bentley does not normally provide intermediate care so standard 6 does not apply. Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 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, 8, 9, 10. Care planning is good and helps staff to focus on the needs of service users. The basic systems for organising medication are sound but recording was not always accurate which could potentially expose residents to some risk. EVIDENCE: The residents’ files examined contained detailed care plans and risk assessments. Key workers regularly review care plans and daily reports are linked to the different elements of the care plans. Residents’ wishes in the event of their death were recorded on the files though in some cases it was evident that the resident had been reluctant to discuss the issue (in one case considering it a ‘stupid question’). The home liaises with medical and mental health professionals and this is recorded on case files. ‘Care plan prompts’ are a summary of the care plan for day to day consultation by staff. The plans would be easier to amend following review if they were kept on computer. Medication is administered using a monitored dosage system. There were some minor mistakes in the recording of medication. For one resident, six tablets had been signed as having been administered but were still in the blister pack. In another case it was not clear from the records if the tablets administered Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 11 had been those prescribed by the hospital from which the resident had been discharged. In this case there was no reason to believe that that the wrong amount had been administered. The amounts involved in both instances were not large but only a relatively small number of cases was sampled and it is important that all medication is accurately recorded and any discrepancies accounted for. The temperature of the fridge in which medication is stored was checked and recorded every day. The home does not have any controlled drugs but has a CD cupboard for when any are prescribed. Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 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, 13, 14, 15. The home arranges some activities that enhance the residents’ quality of life. Meals provided meet the dietary and cultural needs of the residents, most of whom said that they enjoy the food. EVIDENCE: Many residents go out of the home on their own or with other residents, and are free to receive visitors in the home at any time that suits them. The manager has begun to help organise a range of activities and some staff have been designated as activities organisers, though this runs alongside their existing duties. The organisation of activities was one of the items discussed at the staff meeting that the inspector observed. The existing programme of activities includes ‘in house matinee’ films, which are shown on the newly purchased (very) large screen TV in the main lounge, ‘pampering’ and bingo. Several residents said that they enjoy the bingo but did not talk about any of the other listed activities. The manager is proposing to introduce more activities tailored to individual tastes and one or two of these are listed on the activities programme. Staff also spend time talking to residents in the lounges and in one to one activities. The Registered Person may wish to consider the appointment of a dedicated activities organiser who would not have any other duties. There are several Chinese residents (mainly older people) in the home and specialist Chinese TV channels are available for them, both in a lounge and in their bedrooms. Some residents have particular individual interests which Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 13 they pursue in the home; one is particularly interested in computers, another is a keen accordionist who entertains the other residents with his skills. The menu is varied and always offers a choice to residents. The main meal is in the evening and a Chinese option is available once a day. This is also available to non-Chinese residents, though they do not often choose it. Curry has been added to the menu since the last inspection and the chef said that it has proved popular. The chef and the manager seek to encourage healthy eating in the context of residents having freedom of choice and the chef expressed an interest in further training in this area. Whilst in theory there is a free choice for breakfast, one resident was told that he could not have egg on toast as the hot breakfast of the day (in addition to cereals) was bacon. The manager said that this did not reflect either policy or normal practice so staff should be reminded of this. Most residents said that they usually enjoy the meals in the home though one or two expressed unspecified dissatisfaction with them. It may be worthwhile conducting a more detailed survey of residents’ tastes when the menu is next changed, as it is periodically. There are separate dining rooms in Bentley House and the Bentley Unit. Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 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 and 18. Procedures for complaints and adult abuse allegations are in place, providing protection for residents EVIDENCE: The Bentley has appropriate complaints and adult abuse policies and procedures in place. Details of complaints are kept in the home but no information on a recent complaint investigated by CSCI was available. All complaints received need to be listed in the complaints book to serve as a central record. Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 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, 23, 24, 25, 26. The standard of décor in the Bentley Care Home is generally poor and does not provide a comfortable environment for most residents. EVIDENCE: Following the last inspection the Registered Person advised the Commission for Social Care Inspection in writing that an action plan was to be put in place dealing with all of the redecoration and refurbishment that is required. This was to be completed in December 2005 but it has not been completed. Some progress has been made with redecoration but the programme was far from complete and the overall environment remains unsatisfactory. New carpets were being fitted throughout the Bentley Unit during the inspection and the manager said that the rest of the re-carpeting was due to be completed soon. The following matters require attention as a matter of priority: * The floor covering for both staircases is bare and worn and they need to be carpeted; Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 16 * Some bedding (in a small number of rooms) was worn and torn and must be replaced; * Residents in all bedrooms with vinyl flooring must be reassessed and carpets fitted unless their particular needs indicate that an impermeable surface is required (rooms 27, 28, 30, 32, 33, 10, 19, 8, 3, and 2); * Some bedrooms had carpets which need to be replaced, in particular rooms 23 and 14. * All unsuitable bedroom door locks - in particular mortice locks that can be locked from the outside only or can be locked from the inside without emergency access - must be replaced, preferably with locks which can be opened from the outside in an emergency and from the inside in a single movement. The external bolt to the toilet near room 17 must be removed; * Damaged or unsuitable bedroom furniture must be replaced, in particular the bedside cabinet in room 28, chests of drawers in rooms 35 and 12a, bedside lamp in room 9; * The wall near the bed in room 25 must be cleaned and if necessary redecorated; * The en suite extractor fans in rooms 17, 4, and 3 must be repaired; * Ceiling tiles in bedrooms 30, 12a, and the bathroom by room 2 are badly stained and need to be replaced; * The following bathrooms need to be redecorated/refurbished: near room 11, near room 22 (no lock), near room 8; * The main dining room and smaller lounge in Bentley House need to be redecorated and carpeted (the manager said that the main lounge was to converted to a dining room and the dining room into a lounge); * A number of doors did not close fully into their rebate and must be adjusted to ensure that they close fully and therefore retain their effectiveness as fire doors; * Carpets in most of the corridors were splashed by paint and need to be replaced; * The smoking room in the Unit basement should be redecorated; * The carpet in the smoking room on the first floor needs the be cleaned or replaced and one of the chairs needs to be replaced; * Replace the cracked Georgian wired glass window in the main doorway; * Repair or replace the broken coffee table in the main lounge. Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 17 This list should not be considered exhaustive as the inspector was not able to see all of the bedrooms. An additional inspection will be made before the 31 March 2006 to assess progress. All bedrooms and lounges have alarm call points fitted and during the inspection these were answered promptly. The home was clean and generally odour free on the days of the inspection. Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 18 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. Sufficient staff are deployed to meet the needs of the residents in Bentley House but there are insufficient care staff qualified to NVQ2 in place throughout the home. There are not enough staff in the Bentley Unit on the day shift. The home’s recruitment policies ensure that appropriate checks are carried out, protecting residents from unsuitable applicants. EVIDENCE: There were 17 residents in the Bentley Unit and daytime staffing consisted of one qualified nurse and two care assistants, plus ancillary staff. This was reduced from three care staff when occupancy was low and now needs to be increased to three care assistants, especially given the mixed needs of the residents. The rota indicated that staffing in Bentley House was adequate. Four new members of staff have been employed since the last inspection and the proper checks had been carried out before they started work except that in one case the manager could not find the CRB check. This member of staff was temporarily removed from duty and will be reinstated to work under supervision when a POVA First check (an urgent check against the Protection of Vulnerable Adults register) has been completed. The home has a training programme in place and recent training has included Moving and Handling, Dementia Care, and Elder Abuse. Argyle Care’s training manager is based at The Bentley. Of 33 care assistants only three have NVQ2 or better and one is qualified as an enrolled nurse; six care staff are currently studying for NVQ2, due to complete in March/April; and a further 16 are due to Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 19 start a course in February. The home has therefore failed to meet the target of at least 50 of care staff to have NVQ2 by the end of 2005 and a major training exercise is needed to achieve this. Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 20 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, 35, 36, 38. The manager has a clear understanding of areas in which the home needs to be improved in order to provide a comfortable environment for the residents. Recording of health and safety precautions is not always adequate, potentially exposing the residents to risk. EVIDENCE: The manager is an experienced nurse and manager, with previous experience of running a home. She is still not registered as manager but has applied for registration and at the time of the inspection the Commission for Social Care Inspection was completing checks on her application. Despite the manager’s best efforts the Registered Person has been unable to open individual accounts for all of those people on whose behalf money is kept, so it is still kept in a “Bentley Residents” account. Accurate records are kept of the amount kept for each person and if a resident has larger amounts of money it is transferred to an interest bearing deposit account, with interest divided proportionally. The Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 21 home does not yet have a formal quality assurance procedure, though it does get feedback from residents and relatives. The Registered Person is considering seeking ‘Investors In People’ (IIP) status and this was discussed at the staff meeting. IIP would provide the framework for a quality assurance system. Fire safety training records were not clear and checks on smoke alarms and emergency lighting had not been carried out regularly according to the records. The manager said that the checks had been done by the handyperson but there was no record of this and all checks need to be properly recorded. The kitchen was clean and well organised and records of fridge and freezer temperatures were kept. Some items in the dry stores were past their sell-by date and the chef disposed of them during the inspection. The manager needs to arrange for an audit of the dry stores and ensure that food stocks are regularly rotated. Sharp cooks’ knives were kept in the dry stores room but the door was not locked. The room is accessible to residents as it is on a main corridor near the main lounge and must be kept locked at all times if knives are to be kept there. On the first morning of the inspection in particular, several fire doors were propped open, one by a fire extinguisher. If doors need to be kept open for the convenience of residents they must be fitted with an approved device which holds them open and closes if an alarm is sounded. Fire doors that are propped open are not effective as fire doors and present a hazard to staff and residents. A number of freestanding radiators were in various rooms in the home, and those few that were switched on were extremely hot, presenting a risk to the residents. The manager said that these had been used when the central heating had broken down and had been left out, though they were no longer needed. This sort of heating equipment must only be used in an emergency and then should be the subject of a risk assessment. They should be safely stored when not being used. The radiators were removed before the end of the inspection. The manager and her deputy have begun a programme of staff supervision and appraisal and need to make further progress with this. Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 22 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 2 2 3 3 2 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 x 2 Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP4 Regulation Care Standards Act 2000 (13(3)) 13(2) Requirement The Registered Person must apply for a variation of registration to ensure that the home is accommodating residents within its registration category. The Registered Person must arrange for the recording and safe administration of medicine. (Originally required by 1 June 2005) The Registered Person shall maintain a summary of complaints made. This can be done in a complaints book and by keeping records of any complaint made. (Originally required by 1 June 2005). The Registered Person shall ensure that all parts of the home are kept clean and reasonably decorated and must therefore carry out the following: * Both staircases must be carpeted; * Some bedding (in a small number of rooms) was worn and Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 24 Timescale for action 01/06/06 2 OP9 19/01/06 3 OP16 22(8) 01/03/06 4 OP19 23(2) 01/04/06 torn and must be replaced; * Residents in all bedrooms with vinyl flooring must be reassessed and carpets fitted unless their particular needs indicate that an impermeable floor covering is required (rooms 27, 28, 30, 32, 33, 10, 19, 8, 3, and 2); * Some bedrooms had carpets which need to be replaced, in particular rooms 23 and 14. * All unsuitable bedroom door locks - in particular mortice locks that can be locked from the outside only or can be locked from the inside without emergency access - must be replaced, preferably with locks which can be opened from the outside in an emergency and from the inside in a single movement. The external bolt to the toilet near room 17 must be removed; * Damaged or unsuitable bedroom furniture must be replaced, in particular the bedside cabinet in room 28, chests of drawers in rooms 35 and 12a, bedside lamp in room 9; * The wall near the bed in room 25 must be cleaned and if necessary redecorated; * The en suite extractor fans in rooms 17, 4, and 3 must be repaired; * Ceiling tiles in bedrooms 30, 12a, and the bathroom by room 2 are badly stained and need to be replaced; Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 25 * The following bathrooms need to be redecorated/refurbished: near room 11, near room 22 (no lock), near room 8; * The main dining room and smaller lounge in Bentley House need to be redecorated and carpeted; * A number of doors did not close fully into their rebate and must be adjusted to ensure that they close fully and therefore retain their effectiveness as fire doors; *Carpets in most of the corridors were splashed by paint and need to be replaced; * The smoking room in the Unit basement should be redecorated; * The carpet in the smoking room on the first floor needs the be cleaned and one of the chairs needs to be replaced; * Replace the cracked Georgian wired glass window in the main doorway; * Repair or replace the broken coffee table in the main lounge. 5 OP27 18(1) The Registered Person shall 01/03/06 ensure that sufficient staff are working at the care home and in particular should deploy an additional member of day time care staff in the ‘Bentley Unit’. The Registered Person shall take 19/01/06 adequate precautions against the risk of fire and in particular must ensure that fire safety checks are carried out and recorded and DS0000056187.V279370.R01.S.doc Version 5.1 Page 26 6 OP38 23(4) Bentley Care Home 7 OP38 13(4) 8 OP38 13(4) that fire doors are kept closed unless an automatic self-closing device is fitted. The Registered Person must keep all parts of the home free from hazards and must therefore: * keep locked any room in which kitchen knives are stored. * only use freestanding temporary heaters in an emergency and subject to risk assessment. The Registered Person must eliminate all risks to the health of residents and must therefore ensure that food stocks are rotated and food is not used beyond its use by date. 19/01/06 19/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard 12 27 33 Good Practice Recommendations The Registered Person should consider the appointment of a dedicated Activities Organiser. The home does not have 50 of care staff qualified to NVQ2 and needs to take steps to meet this target as soon as possible. The home should develop a formal quality assurance procedure. Bentley Care Home DS0000056187.V279370.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Bentley Care Home DS0000056187.V279370.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!