Inspection on 09/07/07 for Bentley Care Home

This inspection was carried out on 9th July 2007.

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 06/06/06

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 09:00 9 and 12th July 2007 th 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.V335980.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.V335980.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.V335980.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. Within the overall number of 58 persons: To accommodate one named person with Dementia (DE) under the age of 65 in the `Bentley House` wing. To accommodate five named persons over the age of 65 (OP) in the `Bentley House` wing. To accommodate four named persons over the age fo 65 with mental disorder (MD/E) in the `Bentley House` wing. To accommodate one named person over the age of 65 with past or present dependence on alcohol (A/E) in the `Bentley House` wing. To accommodate one named person under the age of 65 with past or present dependence on alcohol (A) in the`Bentley House` wing. Up to 19 persons with mental disorder under the age of 65 (MD) Nursing Care and Personal Care to be accommodated in the`Bentley Unit` wing. To accommodate three named persons over the age fo 65 with mental disorder (MD/E) in the `Bentley Unit` wing. To accommodate one named person over the age of 65 (OP in the `Bentley Unit` wing. Up to 39 persons with dementia over 65 years of age (DE/E) Nursing Care and Personal Care to be accommodated in the`Bentley House` wing. 23rd January 2007 Date of last inspection Brief Description of the Service: The Bentley Care Home (generally known as ‘The Bentley’) was converted from three large houses and provides accommodation on three floors for up to 58 people. It has been a care home since the 1980’s. Older residents with dementia tend to be located in the main building (‘Bentley House’), and younger people with mental disorder are in the building that faces on to Greenheys Road (the ‘Bentley Unit’ or annexe). A number of Chinese residents live at the Bentley and the home provides Chinese television channels and Chinese meals for them. The home is close to Princes Park in the Liverpool 8 area 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. The standard fee is £498 a month. Bentley Care Home DS0000056187.V335980.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit which took place over two days, the inspector returning on the second day to examine the medication system and check some staff recruitment records. The inspector talked to many residents, the Registered Manager and a number of staff on the first day of the site visit. He toured the whole building, and examined records including care plans, staff files and safety records - and medication. A number of survey forms were sent to residents, including some in Chinese language. Four residents and one relative returned survey forms to the inspector – one of them in Chinese. The Registered Manager completed a detailed CSCI preinspection questionnaire before the site visit. What the service does well: What has improved since the last inspection? What they could do better: Although the basic systems for the administration of medication were sound, there were several errors in individual cases. Further redecoration and Bentley Care Home DS0000056187.V335980.R01.S.doc Version 5.2 Page 6 refurbishment is needed in some areas of the home, especially the bathrooms, though finance is now in place to carry this out. The staff supervision has fallen behind. The Bentley does not yet have 50 of care (non-nursing) staff with NVQ2 but its NVQ training programme continues with this goal in mind. The home normally employs some Chinese speaking staff but at the time of the inspection there were none employed. However, the manager was taking action to employ some. The owner still needs to keep the situation concerning administrative and clerical support under review to ensure that professional staff are able to concentrate on the provision of care. 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. The summary of this inspection report can be made available in other formats on request. Bentley Care Home DS0000056187.V335980.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.V335980.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5. Quality in this outcome area is good. 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 right for them. The home’s service user guide and Statement of Purpose are regularly reviewed, so prospective residents have an up to date guide to the facilities offered, though there are still some minor inaccuracies. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service user guide and the Statement of Purpose are kept under review. However, whilst the service user guide is readable ,well presented, and contains much useful information for residents, it still does not include all of the information required by Regulation 5. Also, the Statement of Purpose still refers to the ‘Care Standards Commission’ (the NCSC) which was abolished in 2005 and replaced by the Commission for Social Care Inspection. The home’s registration has been varied since the last inspection to reflect the fact that there are still some younger people in the ‘Bentley House’ wing (the main part of the building, which is mainly for older people) and some older people in the ‘Unit’ (for younger people with mental health problems). One Bentley Care Home DS0000056187.V335980.R01.S.doc Version 5.2 Page 9 relative, in a survey sent to the inspector, said that she felt that male ‘mentally ill’ residents should be in a separate section. This may not be practical at the moment but it does highlight the importance of continuing progress towards having a totally clear distinction between the two units. It has taken time to work towards clearing the matter up as residents become settled in the particular accommodation in which they have lived, in some cases for several years. One older person is in the process of moving to the Bentley House wing as it has become difficult to meet her needs in the annexe. The resident and her family have agreed to this. People are assessed by the manager before they are admitted to the home and copies of the assessments are kept on file. The pre admission assessment includes information about behaviour, risks, mood, elimination, sleep and mobility. The assessments are used as the basis of detailed care plans. 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.V335980.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. Quality in this outcome area is adequate. Care planning is good and helps staff to focus on the needs of service users. Medication is generally well organised but recording needs to be improved to ensure residents’ safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a detailed care plan for every resident, with separate sections on moods, behaviour, communication, dressing, socialising, nutrition and physical well being. The home uses Waterlow scoring to assess the risk of pressure sores and carries out appropriate risk assessments. No residents had pressure sores at the time of the inspection. Staff complete daily reports which address key elements of the care plan. The plans are evaluated every month by the manager or her deputy, and the care plan is changed if necessary. The plans are written on a computer and can therefore be readily changed if necessary following a review. The home liaises with medical and mental health professionals and this is recorded in case files. Medication was checked by ‘case tracking’ a number of residents in each wing of the home. ‘Bentley House’ has its own spacious medication room. There are new medication trolleys in each wing. For most people the home uses a Bentley Care Home DS0000056187.V335980.R01.S.doc Version 5.2 Page 11 monitored dosage system, where medication is provided by the pharmacist in monthly blister packs. In one case where the monitored dosage system was not yet being used (a relatively new resident) there were several errors in the amounts of medication remaining. The manager felt that some of the tablets may have been spat out and an additional tablet administered by the staff in question. Such episodes must be fully recorded so that all medicines can be fully and accurately accounted for. One resident in the ‘Unit’ had consistently declined a particular drug and the nursing staff had decided that it should be administered ‘as required’ (PRN). They felt that he was more likely to take the medication on this basis and this had in fact been the case. The change was written on the Medication Administration Record sheet (MAR) but had not been signed. Any handwritten amendments to the MAR should be signed by two competent staff but significant changes such as this to the medication regime must not be made without the permission of the GP (or other prescribing doctor). In addition, where any medication is to be taken on a PRN basis there should be information available setting out the circumstances in which the medication should be administered. The home did not have any controlled drugs, but has suitable storage for them should any be prescribed. All residents (apart from those who have made a conscious decision to share) have single rooms so personal care can be given in the privacy of the resident’s own room. Care plans include a section to record residents’ wishes in the event of death, though some residents had declined the chance to discuss the issue. One such document recorded funeral plans in some detail including the resident’s proviso that as little money as possible be spent on it. A Buddhist resident had died recently and the manager had ensured that all of the appropriate religious rituals and customs were followed. The manager has researched the necessary information for the home to be able to deal appropriately with the death and funerals of the people of different religions and cultures who live in the Bentley. Bentley Care Home DS0000056187.V335980.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. The home arranges a range of activities that enhance the residents’ quality of life. There is a choice of meals to meet the dietary and cultural needs of the residents. Most residents say that they enjoy the food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are now two part time activities organisers at the Bentley, one for each wing, though one was off sick at the time of the inspection. Activities include swimming, massage, bingo, arts and crafts, computer lessons and trips out. A lot of people from both wings went on a narrowboat canal trip on the week of the inspection and enjoyed it very much. Everyone was getting ready for the Bentley summer fair, to be held on the following Saturday. A range of activities and attractions were planned, including a bagpipe band, and many residents were looking forward to helping out. Residents’ meetings include a ‘lay observer’ (a relative of a member of staff) to give a different perspective. Some residents wanted to work as volunteers in local charity shops and were supported by staff in applying to do so, but the shops were regrettably unwilling to accept their help. In the ‘Bentley House’ wing residents had been doing some handicraft work and one resident showed the inspector some of her impressive artwork. There was an orientation board in the ‘Bentley House’ corridor. A dog lives at the home, with one resident in the Unit taking particular responsibility for his care, and most of the Unit residents said they Bentley Care Home DS0000056187.V335980.R01.S.doc Version 5.2 Page 13 were very fond of him. Chinese TV channels are available for the home’s Chinese residents. Family and friends are encouraged to visit the home at any reasonable time and some also attend meetings at the home. The inspector spoke to one relative at the home who said that he felt the Bentley provided an excellent standard of care. He said ‘There are always staff around and they are always busy doing things with the residents.’ Meals for all residents are prepared by the chef in the main kitchen in Bentley House. There is a small ‘rehab’ kitchen in the Unit where some cold snacks can be prepared and stored. Residents who spoke to the inspector said that they enjoyed the meals at the Bentley. A full cooked breakfast is available every day for residents who want it. There are choices available at all meals and the chef prepares Chinese meals for the home’s Chinese residents. He has made every effort to familiarise himself with Chinese cuisine and there is usually one such option every day, normally at the evening meal. The Chinese dishes include, for example, steamed minced pork with mei chai, prawn foo yung and chicken with ginger. One relative commented in a written response that ‘being able to provide Chinese meals’ was one of the things the home did well. On the other hand a Chinese resident said in a written response (in Cantonese) ‘I would like to have Chinese meal every day’. It therefore seems that there is scope to extend the provision of Chinese food and it may be that this should be the subject of further consultation with the Chinese residents and their families. There was evidence of consultation with residents and their families at earlier meetings where decisions had been made, for instance, to serve Chinese tea alongside ‘English’ tea. Bentley Care Home DS0000056187.V335980.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. Procedures for complaints and adult abuse allegations are in place and provide protection for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Bentley has an appropriate complaints procedure and records any complaints. One relative commented that she knew who to complain to but would like the procedure to be put down on paper. It might therefore be helpful to re-issue the complaints procedure to relatives. Some staff are trained in the protection of vulnerable adults, two having recently attended ‘alerters training’ for instance. The owner’s training officer is to run a series of sessions on adult protection and all staff need to attend these sessions. One resident said that he found the staff very helpful – ‘you only have to ask’ – and that if he had a complaint he would ‘go to Bernie’ (the manager). Bentley Care Home DS0000056187.V335980.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. JUDGEMENT – we looked at outcomes for the following standard(s): 21, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is good. The Bentley provides a comfortable environment for its residents and further plans for improvement are in hand. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean and free of offensive odours. In ‘Bentley House’ the former main lounge and its attached small lounge have been converted to dining rooms. They provide a spacious, light environment for the residents to eat in. The former dining room has been carpeted and is now used as a lounge. The second lounge is now the TV lounge and has also been carpeted. The television in this room was too small for the size of room, and reception was rather poor, as it is on most televisions in the home. The manager said that a new large screen TV was on order. Contractors and suppliers have been contacted to try to improve TV picture quality but as yet nobody has been able to solve the problem. The dirty and old fashioned medi bath on the first floor has not yet been replaced but a new assisted bath is on a schedule of grantfunded improvements which includes the new large screen television, upgrading the shower room, upgrading the small kitchen in the Unit, new Bentley Care Home DS0000056187.V335980.R01.S.doc Version 5.2 Page 16 lounge furniture in the Unit and extending and landscaping the garden. The attractive walled garden is mainly used by residents from the Unit and the extension would make it more accessible to the older residents. The garden is well used and has been improved by the installation of two large gazebos, complete with chairs and tables. The dining room in the unit needs to be redecorated and the smoking room in Bentley House needs to be re-carpeted and have some new furniture. In addition to the shower room mentioned in the schedule, most of the bathrooms could do with some redecoration to make them more homely and welcoming. The manager said that these things were due to be done soon and finance was available for the work. Some extractor fans, such as in the Unit’s kitchen, need to be cleaned. The corridor and stairs to the basement are in very poor repair and decorative order. This area does lead to the home’s freezers and fridges and should be included in the redecoration process. All of the residents have single rooms unless they have freely chosen to share with someone else (e.g. partners). Some of the rooms show evidence of being personalised to reflect the interests and personality of the resident. The rooms vary in size; some of them are very spacious indeed, others are more basic, though all meet the National Minimum Standards. Bentley Care Home DS0000056187.V335980.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. The home has sufficient staff to meet the needs of its residents. It has a training programme to ensure that staff are sufficiently well trained to provide the appropriate care, but does not yet have sufficient care staff with NVQ2 to ensure that residents are at all times cared for by qualified (non nursing) staff in addition to the nurses. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Bentley employs six registered nurses, including the manager and her deputy, and the rota indicated that staffing in both wings of the house was adequate. The home employs four domestic staff and three kitchen staff including the chef. The clerical/administrative worker has still not been replaced, though some administrative duties are carried out by staff at other sites. As mentioned in the previous report, 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 does need 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 at all and the owner should review the situation. In the past the Bentley has had a number of Chinese speaking staff who were able to ensure there was proper communication with Chinese speaking residents. Most of these were students and have recently left. The manager is attempting to recruit further Chinese speaking staff via the Pagoda Chinese community centre in central Liverpool Bentley Care Home DS0000056187.V335980.R01.S.doc Version 5.2 Page 18 and adverts in the main Chinese supermarkets. In the meantime the home uses interpreters from the Pagoda when necessary. Recruitment files of staff employed since the last inspection contained evidence of the necessary checks having been carried out before they started work, though one POVA First (Protection Of Vulnerable Adults register) check could not be located. The employee’s Criminal Records Bureau (CRB) certificate was in place. If there is a delay in obtaining a CRB check then a POVA First (fast tracked) check is carried out to ensure that the person is not on the POVA register before they are allowed to start work under supervision. Residents attend staff recruitment interviews, complete appraisal forms and play a full part in the discussions about whether or not to employ the candidate. This is excellent practice and some of the residents’ assessments were quite detailed. There is now a full programme of NVQ training, organised by the owner’s group training officer, who is based at the Bentley. Over a third of the care staff now have NVQ2 and more staff are doing the training so the home should shortly meet the National Minimum Standard of 50 of care staff with NVQ2. Training planned for 2007 includes Mental Health Awareness, Tissue Viability, Dementia Care and Breakaway Techniques, much of it to be provided by outside trainers. Earlier in the year staff have attended training in the Mental Capacity Act, First Aid and Venepuncture. Bentley Care Home DS0000056187.V335980.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38. Quality in this outcome area is good. The Registered Manager provides positive leadership and operates some 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is an experienced nurse and manager who provides positive and enthusiastic leadership for the staff team. The home uses a range of quality assurance measures including questionnaires to residents and relatives. The manager actively pursues issues raised in the survey forms and they provide useful feedback to help improve the quality of care. However, the lowest rating in the surveys is ‘fair’, which hardly allows for a critical response. This particular form – which is used across the owner’s group of care homes should be reviewed. Fire safety records were up to date apart from, on the first site visit, the gas safety certificate, which was replaced by the second day of the inspection. Some fire doors were propped open, though most that were Bentley Care Home DS0000056187.V335980.R01.S.doc Version 5.2 Page 20 kept open are now fitted with approve ‘hold open’ devices. Fire doors are ineffective if they are wedged open. The staff supervision programme has lapsed and needs to be reinstated to ensure that staff development continues. The kitchen was clean and well organised. The chef is using the Food Standards Agency pack ‘Better Business, Safer Food’ as the basis of checking and maintaining safety standards for food. The Environmental Health Officer visited the home in June 2007 and reported that the home had ‘a satisfactory record of compliance’. There were some issues with fridge and freezer temperatures which she was re-visiting to check and the chef said that these were in hand. Bentley Care Home DS0000056187.V335980.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 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 4 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 3 18 3 3 3 3 3 3 3 3 3 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 3 3 x 3 2 x 3 Bentley Care Home DS0000056187.V335980.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The registered person must make arrangements for the recording of medicines and must therefore ensure that: * staff record the administration of medicines accurately; * changes to the frequency of medication are only made with the agreement of the resident’s GP; * any handwritten changes to the MAR sheets are signed by two members of staff. The Registered Person shall ensure that all parts of the home are kept in a good state of repair and must therefore carry out the following: * the medi bath is dirty and old fashioned; it should be replaced by a new assisted bath; * the ground floor shower needs to be resealed; * extractor fans, especially the one in the ‘Bentley Unit’ kitchen, must be cleaned and kept clean; * clean and decorate the basement stairs and corridor. The Registered Person shall take DS0000056187.V335980.R01.S.doc Timescale for action 12/07/07 2. OP19 23(2) 01/09/07 3. OP38 23(4) 12/07/07 Page 23 Bentley Care Home Version 5.2 adequate precautions against the risk of fire and in particular must ensure that fire doors are kept closed unless an automatic selfclosing device is fitted. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Where medication is to be administered ‘as required’ (PRN) there should be written guidance to staff as to the circumstances in which it is to be administered. 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. Care staff should receive formal, one to one supervision at least six times a year. 2. OP27 3. 4. 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