Inspection on 06/06/06 for Bentley Care Home

This inspection was carried out on 6th June 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 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

Bentley Care Home 09/07/07

Bentley Care Home 17/01/06

Bentley Care Home 01/03/05

Bentley Care Home 21/10/04

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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 8:30 6 and 7th June 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.V288889.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. Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 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 Mrs Bernadette Roberts 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.V288889.R01.S.doc Version 5.2 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 17th January 2006 Date of last inspection 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. Older 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 residents and employs some staff who speak different Chinese languages. The home is close to Princes Park and is convenient for Princes Park Health Centre, local amenities on Lodge Lane and bus routes to Liverpool city centre. The home has a well-maintained walled garden and off-road car parking. The Bentley’s present owners, Argyle Care Group, own a number of other care homes. The manager of the Bentley Care Home is qualified and experienced and since the last inspection has been registered by the Commission for Social Care Inspection. Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 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 talk to some residents, staff and to finish examining some records and the medication system. The inspector talked to many residents and a number of staff during the inspection. The inspector toured the whole building, and examined records - including care plans and safety records - and medication. Three residents returned survey forms to the inspector and a visiting professional also returned a comment card. The Registered Manager completed a CSCI pre-inspection questionnaire before the site visit. What the service does well: What has improved since the last inspection? What they could do better: Further redecoration and refurbishment is needed in some areas of the home. Staff supervision is still not properly in place. The Bentley does not yet have 50 of care staff with NVQ2 and needs to continue its training programme. The Registered Person needs to review the situation concerning administrative and clerical support to ensure that professional staff are able to concentrate on the provision of care. Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 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.V288889.R01.S.doc Version 5.2 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.V288889.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is adequate. Residents are assessed before moving into the Bentley and are encouraged to visit the home before making a final decision, helping them to decide if the home is the right one for them. The home’s service user guide and Statement of Purpose are outdated, so prospective residents do not have an up to date guide to the facilities offered. EVIDENCE: Two residents had been admitted since the last inspection and they had been assessed by the manager before being admitted. The assessment had been done in the form of a draft care plan. The care plans were handwritten as the home was temporarily without a computer. The assessment and the plan dealt with issues such as mood, orientation, sleep, communication and mobility. The inspector spoke to one of the new residents, but he could not recall the details of his arrival at the home. The service user guide was out of date, referring to, for instance, the previous manager, who left the home over a year ago. The Statement of Purpose had been reviewed recently but still needed some updating (for instance it refers to the now defunct NCSC rather than the Commission for Social Care Inspection). Contracts were on file. There are still some issues concerning the categories of residents admitted. Seven residents in the ‘Unit’ (the wing for younger people with mental health issues) are aged Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 Page 9 over 65 and eight residents in the ‘House’ (for older people with dementia) do not have dementia. The Registered Person must submit an application for a variation to reflect this situation, as required at the last inspection. The conditions of registration will also need to be amended at that point as they are now out of date (the manager is now, of course, registered). The standard fee for the Bentley Care Home is £498 a month. The home does not provide intermediate care, so standard 6 does not apply. Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 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, 11. Quality in this outcome area is good. Care planning is good and helps staff to focus on the needs of service users. Medication is well organised. EVIDENCE: Residents’ files all contained a care plan with separate sections on mood, behaviour, communication, dressing, socialising, nutrition and physical well being. Care plans also included a section on death and dying, though some residents had been reluctant to engage with this issue. They contained Waterlow scoring to assess the risk of pressure sores and appropriate risk assessments. Staff complete daily reports which address key elements of the care plan. The plans are reviewed every month by the manager or her deputy, though there was not much detail in the record of the reviews. The home liaises with medical and mental health professionals and this is recorded in case files. No residents have pressure sores and the Tissue Viability Nurse is contacted if even a possibility of a sore is identified. Most of the files included a detailed pen picture drawn up by staff with the help of residents and their relatives. Most of these drew a vivid picture of the resident and complemented the care plans. Some care plans contained disclaimers if, for instance, a resident did not want to be disturbed at night. Many care plans are still handwritten and are therefore difficult to amend clearly. It would best if all Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 Page 11 care plans were typed and could be amended on a computer. At the time of the inspection the manager did not have access to a working computer. Whilst there is no national standard concerning the type and quality of office equipment, most homes the size of the Bentley do have the use of a computer and this certainly makes it easier to amend and update care plans and other essential documents. New computer equipment was delivered to the home by the Registered Person half way through the site visit. There was no schedule for a programme of full reviews of residents. A Community Mental Health Nurse commented that the staff at the home are helpful and knowledgeable and that the residents the nurse dealt with were happy with the care they receive. Between the two days of the site visit one resident with dementia was found to be missing. Staff promptly followed the home’s missing person’s procedure. The Registered Manager was called out late at night, the police and family were informed and staff carried out searches of the area. The resident remained missing overnight but was fortunately found safe and well the following evening. Medication is stored and administered separately in each unit. The inspector examined medication for a number of residents and all of the records were up to date and properly recorded. The home uses a monitored dosage system, where most medication is supplied by a community pharmacist in dedicated blister packs. The home did not have any controlled drugs, but has suitable storage for them should any be prescribed. Residents all have single rooms (apart from those who have made a conscious decision to share) so personal care can be given in the privacy of the resident’s own room. Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 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. Quality in this outcome area is good. The home arranges some activities that enhance the residents’ quality of life. There is a choice of meals and residents have helped to compile the new menu, which meets the dietary and cultural needs of the residents. Most residents say that they enjoy the food. EVIDENCE: Many of the residents, in the Bentley Unit in particular, go out of the home on their own or in the company of other residents. They can see visitors in the home whenever they want. The manager organises a number of activities and some staff have been designated as activities organisers, though this runs alongside their existing duties. The existing programme of activities includes ‘pampering’ and bingo, which was the only organised activity that residents talked about. Some trips out are planned for the summer. Staff spend time talking to residents in the lounges and, in the Unit in particular, spend time with residents on one to one activities. Staff often go out with residents if they want to go somewhere. There is scope for arranging more activities for the older residents in Bentley House in particular. Two volunteers, including a former employee, help for a few hours a week in the home. There is now a dog – Benji – in the Unit and all of the residents spoken to liked him and enjoyed helping to entertain him. 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 of the Chinese residents attend a Chinese luncheon club outside the home. The Bentley does employ some Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 Page 13 Cantonese speaking staff but there are still issues with residents who speak Mandarin or other Chinese languages and the Registered Manager said that it has been difficult to employ staff who speak their languages. Some residents have particular individual interests that they pursue in the home; one is particularly interested in computers, and was working on one during the site visit. The home is planning a newsletter, which will be largely compiled by the residents themselves. The home does have the use of a vehicle but it is of limited use as it cannot take wheelchairs and therefore cannot be used for all of the residents. The Registered Manager said that the home has started to sue the Dial And Ride facility to enable residents to take part in activities in the community. The menu has recently been revised following an extensive consultation with the residents. Several residents described how they had taken part in the review and all felt that they had been listened to. The new menu is varied and always offers a choice to residents. Cooked breakfast is available every day and residents confirmed that they could have any cooked items that they chose. The main meal is in the evening and a Chinese option is available once a day. Sometimes this is a variation of the main meal, prepared in a style to the taste of Chinese residents (on the day of the inspection, haddock steamed with ginger and spring onions). This option is also available to non-Chinese residents, though they do not often choose it and those spoken to did not seem especially aware of the possibility. Staff said that they always point all choices out when they ask the residents for their choices. The chef had responded to comments from Chinese residents and their families about the quality of the rice and had replaced it with a type more to their liking. Curry was on the menu for the lunchtime during the inspection and appeared to be a popular choice. Most residents, including those who completed the questionnaire, said that they usually enjoy the meals in the home. Each unit has its own dining room and there is an additional lounge/dining room in Bentley House. Some residents choose to eat in their room. The dining room in the Bentley Unit is rather gloomy as it is located in the cellar, but no alternative location is immediately obvious. Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. Quality in this outcome area is good. Procedures for complaints and adult abuse allegations are in place and provide protection for residents. EVIDENCE: The home has appropriate complaints and adult abuse policies and procedures in place. Details of complaints are kept in the complaints file but the only information available was correspondence from the Commission for Social Care Inspection. The home should keep a full record of an action taken in response to a complaint. Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 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. Quality in this outcome area was adequate. The standard of décor in the Bentley Care Home has improved and provides a comfortable environment for most residents, though further changes need to be made. EVIDENCE: Further progress has been made in the redecoration of the home and, in particular, most corridors have now been carpeted. The exterior of the home has been redecorated. It is planned to convert the main lounge in Bentley House to the dining room, with the - smaller – dining room becoming the lounge. This will involve some minor structural work, redecoration and the carpeting of the existing dining room, and no further progress has yet been made. The ‘smoking room’ on the top floor needs to be recarpeted and new carpet tiles were in the corridor, ready to be fitted. Other items of maintenance required were: * Poor television reception in a number of bedrooms. * Damaged floor in bathroom opposite room 28 * Some bedroom furniture needs to be replaced (e.g. chairs in room 5, 30). Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 Page 16 * The ‘new’ medi bath (in fact a used item) is dirty and old fashioned and should be replaced by a new assisted bath. * Lock on room 31 does not open from the inside in a single movement and should be replaced by a suitable lock. * Dining room needs to be redecorated when it becomes the main Bentley House lounge. * The flooring in the dining room in the Bentley Unit needs to be replaced. * A suitable lock must be fitted to the toilet by room 8. * The emergency call system must be adapted so that it can be used by residents with mobility problems who sit in their chairs in their room a lot. * A number of bedrooms are still fitted with mortice locks; these are not in use and would be dangerous if they were. They should be replaced by suitable locks. The home was clean and generally free from odours but on the second day of the inspection there was an especially unpleasant smell on the top floor and steps must be taken to make sure that this does not recur. Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. The home does not yet have sufficient care staff with NVQ2 and the training programme needs to be sustained to ensure that residents are at all times cared for by qualified staff. EVIDENCE: Staffing in the Bentley Unit (mainly younger adults) has been increased since the last inspection and there are now one qualified nurse and three care staff on duty as well as ancillary staff. This has enabled staff to spend more time on individual activities with service users. The rota indicated that staffing in Bentley House (older people) was adequate. The home employs four domestic staff and three kitchen staff including the chef. The Bentley also used to have a clerical/administrative worker but she has been moved to another home. Although she does some administrative work for the home this means that the Registered Manager and her deputy now have a greater burden of clerical tasks and paperwork. The National Minimum Standards and Care Homes Regulations do not specify a need for dedicated administrative staff; however, a home of the size and complexity of the Bentley needs a lot of time to be spent on administration and routine clerical duties. If these are done by professional staff, that time cannot be spent on other professional duties such as reviews, staff supervision and resident contact. It is unusual for a home of this size to have no on-site administrative staff and the Registered Person should review the situation. Three staff have been employed since the last inspection and the appropriate checks had been carried out before they were able to start at the home. Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 Page 18 The Argyle group training manager is based at the Bentley and the home has an active training programme. Seven care staff have NVQ2, six have started a course recently and ten more are due to start imminently. In addition, four staff are working towards NVQ3 and two have already gained the qualification. This means that 32 of care staff have NVQ2, compared to the target of 50 set out in the National Standards. The home does however have a programme that will enable them to meet the standard over the next twelve months. The deputy manager is studying for her NVQ4. Cleaning staff are also working towards NVQs. Other recent training (including refresher courses) includes Moving and Handling, Food Hygiene, Fire Training, Health and Safety, Infection Control, Adult Abuse, Medication, Dementia Care and First Aid. Five senior care staff have just begun a course leading to the Certificate in Team Leading, which should also help the home to make further progress with staff supervision. Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38. Quality in this outcome area is adequate. The Registered Manager provides positive leadership and has begun to operate quality assurance procedures to ensure that the home is run in the best interest of the residents. The home does not yet have adequate systems for staff supervision. EVIDENCE: The manager is an experienced nurse and manager, and has been registered by the Commission for Social Care Inspection since the last inspection. She and her deputy provide positive leadership for the home’s staff team. 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 detailed financial records were not checked again on this site visit. The Registered Person has decided not to pursue the possibility of gaining the Investors In People (IIP) award as discussed at the last inspection. This puts a greater emphasis on the need to implement the home’s own quality assurance procedures. The Registered Manager has organised a ‘quality circle’ to look at nutrition. The circle Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 Page 20 comprises five residents and five staff, including the chef. The circle meetings have led to further changes to the menu (which was only revised recently) including better choices at lunchtime in addition to soup and sandwiches. Several residents who had attended the quality circle meetings told the inspector that they had found the meetings valuable and had felt able to contribute. The Registered Manager intends to introduce the idea of the ‘quality circle’ to other areas of the home’s activity. Fire safety records were up to date apart from the gas safety certificate, which had expired in the last month. It is essential that a new certificate be obtained without delay. The electrical safety certificates required certain remedial work to be done and there was no evidence available to indicate that the work had been completed. The kitchen was clean and well organised. The chef is using the new Food Standards Agency pack ‘Better Business, Safer Food’ as the basis of checking and maintaining safety standards for food. This involves making certain checks at the beginning and end of the day, and signing to confirm that all of them have been done. Details are only recorded if action has to be taken to maintain safety standards (e.g. if a fridge temperature had to be adjusted). This means that fridge and freezer temperatures are still checked twice a day but are no longer recorded. The Environmental Health Officer has not visited the home since this system was adopted and will no doubt comment on how it is being operated. It may be that the specific checks to be carried out should be set out in a more detailed schedule and this should ensure that the fridge in the Bentley Unit is included in the daily checks. Some ‘Dorgard’ automatic door closers, which respond to fire alarms, have been fitted since the last inspection. One or two residents who spend a lot of time in their room like to prop their doors open; these rooms (such as room 28) must be a priority for fitting with Dorgards or similar devices as fire doors are ineffective if they are held open. Several bedroom doors did not close fully into their rebate and need to be repaired to ensure their effectiveness as smoke and fire barriers. The manager and her deputy have just begun a programme of staff supervision and appraisal but this is still at a very early stage. Qualified nurses are receiving training on supervision techniques. Progress in introducing formal staff supervision has been very slow. Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 2 3 2 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 3 2 Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? 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. 2. Standard OP1 OP4 Regulation 6 (13(3)) Requirement The Registered Person shall keep under review the service user’s guide and Statement of Purpose. The Registered Person must apply for a variation of registration to ensure that the home is accommodating residents within its registration category. (Requirement originally made for 01/02/06) The Registered Person shall ensure that all parts of the home are kept clean and reasonably decorated and must therefore carry out the following: * Television reception in a number of bedrooms must be improved. * Repair or replace the damaged floor in the bathroom opposite room 28. * Some bedroom furniture needs to be replaced (e.g. chairs in room 5, 30). * The ‘new’ medi bath (in fact a used item) is dirty and old fashioned and should be replaced by a new assisted bath. * Lock on room 31 does not DS0000056187.V288889.R01.S.doc Timescale for action 01/09/06 01/07/06 3. OP19 23(2) 01/09/06 Bentley Care Home Version 5.2 Page 23 open from the inside in a single movement and should be replaced by a suitable lock. * The dining room needs to be redecorated when it becomes the main Bentley House lounge. * The flooring in the dining room in the Bentley Unit needs to be replaced. * A suitable lock must be fitted to the toilet by room 8. * The emergency call system must be adapted so that it can be used by residents with mobility problems who sit in their chairs in their room a lot. * A number of bedrooms are still fitted with mortice locks; these are not in use and would be dangerous if they were. They should be replaced by suitable locks. 4. 5. OP26 OP38 23 23(4) The Registered Person must 07/06/06 ensure that all parts of the home remain free of offensive odours. The Registered Person shall take 01/07/06 adequate precautions against the risk of fire and in particular must ensure that: * fire doors are kept closed unless an automatic self-closing device is fitted; * up to date gas safety certificate is obtained; * evidence is provided that outstanding electrical work has been completed. Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 Page 24 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 OP12 OP16 OP27 Good Practice Recommendations There is scope for the organisation of more activities for the older residents (in Bentley House). The home should keep a record of any action taken following a complaint. The Registered Person should keep the situation regarding administrative work in the home under review so that professional and care staff are not unduly burdened by administrative and clerical tasks. The programme of NVQ training needs to be sustained in order to meet the target of 50 of care staff with NVQ2. The Registered Manager should continue to develop internal quality assurance, using the concept of ‘quality circles’. The daily checks under ‘Better business, safer food’ need to include the fridge in the ‘Bentley Unit’. 4. 5. 6. OP30 OP33 OP38 Bentley Care Home DS0000056187.V288889.R01.S.doc Version 5.2 Page 25 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. 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