Inspection on 22/12/05 for Benvarden

This inspection was carried out on 22nd December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Benvarden 13/08/09

Benvarden 13/09/07

Benvarden 19/07/06

Benvarden 05/07/05

Benvarden 25/01/05

Benvarden 25/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Benvarden 110 Ash Green Lane Exhall Coventry West Midlands CV7 9AJ Lead Inspector Sandra Wade Unannounced Inspection 22nd December 2005 08:55 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 Benvarden DS0000004212.V274096.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. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Benvarden Address 110 Ash Green Lane Exhall Coventry West Midlands CV7 9AJ 02476 368354 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) Ms Diane Hughes Ms Diane Hughes Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: Benvarden is registered to provide residential care for up to 14 older people. Nursing care is not provided at Benvarden, community health care services and support are accessed through GP surgeries, district nurse services etc. The home is situated midway between the city of Coventry and the town of Bedworth and is close to the M6 motorway. Public transport is available from just outside the home; local shops and a post office are within walking distance. Benvarden is a converted large detached house providing domestic, homely accommodation. It has a dining room, two adjacent lounges and a large conservatory. There are 10 single bedrooms, 6 with en suite facilities and 2 double bedrooms with en suite facilities. There is a 6-person lift, a laundry and domestic style kitchen. The home has pleasant gardens with a patio overlooking a school playing field. There is car parking for visitors to the front and side of the home. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second visit to Benvarden for this inspection year this focused on those issues outstanding as well as standards not assessed from the last inspection. The inspection commenced at 8.55 and a full day was spent at the home. On arrival, most of the residents were sitting in silence in the lounge area with the television on a low volume. The inspection process included discussions with staff and residents as well as a brief tour of the home to confirm compliance with standards and regulations raised at the last inspection. Policies and procedures for the home were also reviewed. What the service does well: What has improved since the last inspection? Since the last inspection the manager has taken action to provide disposable gloves and aprons in all areas required such as the laundry to ensure good infection control management within the home. Radiator covers are now available in the majority of areas within the home to reduce the risk of burns to the residents. Liquid soap and paper towels are now provided in all communal toilets and bathrooms for use by staff and residents to improve hygiene practices within the home. Four new beds and new curtains for the lounges have been ordered to improve the environment for the residents. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 6 What they could do better: 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. Benvarden DS0000004212.V274096.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 Benvarden DS0000004212.V274096.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): 2,3,4, Each resident is issued with a written contract/statement of terms of conditions upon admission to the home. Residents are assessed prior to moving into the home to make sure the home can meet their needs but they do not receive a letter to confirm that the home can meet their needs as required by the Care Home Regulations. EVIDENCE: Each resident is issued with a Statement of Terms and Conditions when they are admitted to the home, which includes details of the room number, they have been allocated. It is still not clear what action the resident could take if the home were in breach of their contract. Assessment records are in place for each resident and identify care needs and actions required to meet them. It is still not evident from files viewed that the manager writes to residents to confirm the home can meet their needs. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 9 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 Each resident has a care plan but it is not clear that all needs are being identified so that staff can ensure they are addressed. Medication management is in need of review to ensure this process is managed safely. Residents feel they are treated with respect and systems are in place to maintain privacy. EVIDENCE: Each resident has a care plan detailing their care needs and there is a section on each care plan, which should detail staff actions required to address these. It was noted for one resident that the care plan for foot care stated they had ‘gout’, there were no actions detailed on how staff should manage this. The mobility care plan for this resident was not specific in identifying the areas of mobility this person would need assistance with. The bathing care plan was not specific in identifying whether the resident preferred a bath or shower and how often but did state the hoist is to be used. It was noted that on the care plan for pressure areas this resident was actually being showered and not bathed. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 10 It was noted this resident has ‘Ischaemic Disease’ but this is not mentioned in the care plans in place. The care plan review for November, which was documented on a separate sheet, stated that this resident had been having angina attacks and needed to be monitored. This was not reflected in the staff actions on the care plan. It was noted that the care plan reviews are not based on a review of each of the residents needs to identify if any changes in care are required. Reviews were generalised. An action is identified for this residents weight to be monitored monthly. The last weight recorded was June 2005. Daily records are being completed for each resident each day and it is evident that the home are accessing specialist services such as dentists, opticians, district nurses when required. It was noted that one resident had swollen and weeping legs and the care plan stated that the District Nurses were to monitor. No staff actions were detailed in regard to monitoring any concerns or observing the legs between district nurse visits and it was not evident that the home were keeping their own notes on the progress or deterioration of this persons wounds. The home should ensure they have sufficient records regarding a residents wound care as records kept by District Nurses belong to them and are removed from the home when the course of care prescribed has been completed. It was noted from the weight charts for this resident that they had lost weight and were of a low weight. The records showed that the resident was last weighed in May and there was no indication of actions taken to address the loss of weight. The sheet stated that “no nutritional concerns noted” and daily records stated that the resident was eating and drinking well. The care plan review stated that this person was being tested for anaemia and was still on antibiotics for a chest infection. Care plans did not reflect this information so that any appropriate staff actions to meet care needs could be specified. A review of medications was undertaken to confirm issues from the last inspection had been addressed and it was found that there are practices, which still need review. The home have changed the storage of their controlled drugs to a metal case but this is still not sufficient to comply with the Royal Pharmaceutical Guidelines in ensuring this medication is secure and safe within the home. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 11 Where medications had not been supplied for this prescribing period due to medications being left over from the previous period, the number of medications available had not been carried forward on the medication charts so that staff were clear how many tablets/capsules they were starting with. This applied to Calcichew, Paracetamol and Ramipril. This prevents medications being audited effectively. E45 cream had not been signed for on the Medication Administration Records (MARs) to confirm it been applied and there was no indication as to how this should be applied as the instructions were “as directed”. A medication 150ml Polytar AF liquid was found to be prescribed in October 2001 and expired in May 2003. This was being kept in the resident’s room. It was not clear from discussions with staff whether this was still required. The manager was advised to dispose of this with immediate effect and take appropriate actions to establish if the resident still required this medication. The code ‘F’ was detailed on the MAR but this had not been defined so that it was clear what this meant. Two Paracetamol were prescribed for one resident and this had been crossed out and changed to ‘one’ it was not clear who had made this change or that this had been agreed with the GP. Lansoprazole was prescribed stating ‘take one daily before food’. This was being given at 9pm. It was advised that this be investigated, as 9pm is not a time when residents have a meal. Earax and Olive Oil were in the medications cabinet with no name. It appeared these were homely remedies. No Homely Remedies policy was evidenced as being in place. It was difficult to establish the correct dosage of Warfarin was being given for one resident due to the MAR charts not being clear. The amount available at the beginning of the prescribing period had not been documented. A discussion was held in regard to how Warfarin details should be recorded so that it is clear on dosages given and it was advised that details recorded on the INR card are always held in the home. Resident felt that staff were respectful and confirmed that staff announce themselves before entering their bedrooms. One resident said that it was ‘pointless’ staff knocking their door because they were wearing a hearing aid and would not hear them. This person said staff usually came in and gently touched their arm to alert them staff are there. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 12 Mail received at the home was observed to be delivered to residents and this included Christmas cards. The manager said that residents are welcome to use the home mobile phone for both incoming or external calls. Residents spoken to were not concerned about having a lock on their bedroom door. The manager was advised to ensure this matter was discussed with all residents and their responses recorded and to include any actions in a maintenance plan for the home. A staff procedure on locking the upstairs bathroom door to protect the privacy and dignity of the residents in the en-suite which is shared with this bathroom has not been done but at the time of this inspection there were no residents in the bedroom with this en-suite. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Activities are provided within the home but these are limited and there is no activity programme in place, which the home can demonstrate, matches the preferences of the residents. Residents are able to maintain contact with family and friends and can exercise some choices over the way services and care is provided within the home. Menus are not fully detailed to confirm a wholesome and balanced diet is being given but residents enjoy the food provided. EVIDENCE: An activity schedule was not seen within the home although there are some activities being provided. On the day of inspection there was a church band playing Christmas Carols in the home. The manager said that they have a volunteer worker who visits each Wednesday afternoon to provide activities to the residents, which include bingo, chats, head and hand massage, hangman and quizzes. The manager said that care staff also do some activities with the residents. One resident said they had a television and radio and they were quite happy with that. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 14 Other residents said that there was a board game activity in the home most days including bingo, draughts, dominoes but they did not do any exercises. Residents are able to maintain contact with their family and friends and it was evident that visitors to the home are made very welcome. Residents didn’t feel they had much choice over the food provided but said they enjoyed the food given. Choices of meals and drinks are not fully demonstrated on menus although residents and the manager said if they did not like something an alternative would be offered. One resident has made the choice to have a cooked breakfast each day and this is being given. This resident also had requested a beer each day and it was observed this was being given. Residents do not currently have the choice to lock their doors, as appropriate locks are not fitted. Resident meetings are not held. The manager said she had tried to instigate these but they had not been successful. The manager said she chats with residents each day so they know what is going on in home. Records were not available to demonstrate resident consultation on the management of the home is taking place. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Residents know who to complain to and know complaints will be followed up by the manager as appropriate. An abuse policy is available within the home but not all staff have completed training in this area to ensure residents are fully safeguarded. EVIDENCE: The complaints procedure has been updated since the last inspection but it was noted this does not contain the name of the manager or the address and telephone number of the home so that people who may choose to write to the home know who to send it to. It was advised the policy is put on display in the home. An abuse policy and procedure is in place but staff have not attended training on abuse to ensure they can recognise this and understand what actions they must take should they observe this. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 16 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, 21, 25, 26 On the whole the environment is maintained to a good standard but some matters require attention to ensure the environment is safe for residents. Sufficient numbers of toilets and bathrooms are available. The main communal areas and bedrooms within the home are kept clean but some actions are required to confirm procedures relating to hygiene are being carried out. EVIDENCE: The above standards were reviewed in regard to those matters identified at the previous inspection only. The manager advised that she had obtained a quote for the slabbed area in the garden to be levelled and made safe and this showed that it would be a considerable expense to address. The manager has still to make a decision on how this matter is to be resolved. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 17 In the meantime risk assessments must devised and in place for any resident who uses the garden to ensure their safety. The manager explained that there had been actions taken to address the door closures on the doors, which are heavy and stiff to open, but despite this action there are still some of the doors, which some residents would find hard to open independently. The resident’s bedroom door, which did not close properly at the last inspection, has been addressed. The manager is considering alternative actions in regard to doors and door closures, which may include replacement doors. The manager stated that the door bell for the home has been changed on several occasions but it was evident during the inspection this is still not sufficiently loud enough for staff to hear depending on where they are in the home. The bathrooms and toilets were viewed and the broken toilet roll holders have been replaced. The location of the call bell lead in the shower room has not been moved to ensure the pull cord can be accessed by residents from the toilet area. It was noted that there is no signage on the bathroom and toilet downstairs or on the door into the lounge. The home should ensure this is addressed to aide residents in their orientation of the home. The majority of the radiators in the home have been fitted with radiator covers to prevent burn risks to residents. Some of the pipework is still to be lagged and there are two radiators, which are still to be covered. There were no records available of hot water temperatures to confirm these are being regularly monitored and are operating at safe levels to prevent scald risks to residents. Some of the hot taps are not operating effectively and the manager advised that a new plumber has now been instructed to check all of the water problem areas within the home. Since the last inspection actions have been taken to improve infection control practices within the home including the provision of disposable gloves and aprons and the use of liquid soap and paper towels in communal areas. The hot tap has been replaced on the sink used for sluicing in the laundry but there is no separate wash basin for staff to wash their hands. The home are now using the ‘red bag’ system for heavily soiled items which means any heavily soiled lined can be washed in the machine within a red bag. A laundry procedure is not in place confirming how the laundry should be sorted, washed and managed. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 18 It was not evident that there are clearly labelled baskets for dirty and clean laundry. The manager confirmed that a water inspection had been arranged with the Water Authority for 10 January 2006 to confirm compliance with the Water Supply (Water Fittings) Regulations 1999. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 Staffing arrangements for the home are not fully confirmed within records all of the time to be sure there are sufficient care hours being provided to meet the needs of the residents. Staff training specific to the care needs of the residents has been completed by some staff to ensure resident’s needs are effectively supported. The procedures for the recruitment of staff are not robust to ensure that all safeguards are accessed to offer protection to residents living in the home. EVIDENCE: One resident said they were able to independently manage their care most of the time but if they needed assistance staff would help them. One resident said “staff are very good”. All comment cards completed by residents and forwarded to the inspector confirmed that residents felt they were treated well by staff. At the time of inspection there were 12 residents in the home. The manager aims to have two care staff on duty during the day with one waking night carer and one sleeping. On the day of inspection there were sufficient numbers of care staff on duty in accordance with the needs of the residents. It is however not clear how many of these care hours are being allocated to other duties. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 20 Duty rotas seen still do not show the staff who are completing laundry duties or whether any cleaning is being done during the weekend. The manager advised that she has now asked the cook to prepare the evening meal before she leaves so that care staff do not have to do any food preparation after 2pm. The night staff hours are not indicated on the duty rotas so that it is clear there are sufficient hours being provided. The manager confirmed that night staff do the laundry which could reduce the number of care hours being provided at night and therefore could impact of the quality of care provided. Duty rotas need to be specific on the times staff are carrying out this practice. Staff training is being addressed on an ongoing basis. Of the 15 care staff employed, there are five care staff who have achieved an National Vocational Qualification (NVQ) II in Care to help them provide more effective care to the residents. The manager advised that there are an additional seven staff who are currently undertaking this. The manager advised that there had been some difficulties in accessing the assessor, which had delayed some staff completing this training. A review of staff records was undertaken and it was evident that these did not contain sufficient information to confirm all recruitment checks as required had been carried out. Records did not contain two written references, date of staff commencement, full and clear employment histories, Protection of Vulnerable Adult (POVA) checks to see if the staff names were on this register, criminal record checks or information to confirm staff were in good health to carry out their role. The manager was advised that poor recruitment practices meant the residents were not fully safeguarded and an Immediate Requirement Notice was issued to the home for a full review of staff files to be undertaken and any outstanding checks to be carried out with immediate effect. The manager advised that she had taken photographs of all staff and these were stored on the camera and just needed to be transferred onto their files. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,37,38 Residents live in a home, which is run and managed by a dedicated manager who is of good character. Quality systems are not fully developed to show that the home is being run in the best interests of the residents. Further work is required in regard to record keeping within the home to show that the home do what they say they do. There are some health and safety matters, which require attention to ensure the home is safe for residents. EVIDENCE: The manager of this home is also the Registered Owner and is a qualified State Registered Nurse (SRN), she also has a Diploma in Basic Management. She is currently undertaking training to achieve the NVQ IV Registered Managers Award which she is hoping to complete by March 2006 and she has undertaken other training linked to her role such as food hygiene, infection control etc. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 22 The manager was observed to be very caring and supportive towards the residents and it was clear she shares a good rapport with them as well as the visitors to the home. The manager has a good knowledge of the needs of residents and frequently works alongside staff. The manager said that quality questionnaires had been done but she had taken them out of the office to evaluate them and produce a report on the outcomes. Due to these questionnaires not being available in the home it was not possible to evidence that quality monitoring had taken place. The manager advised that she had attempted to start resident meetings but this had not been a success. The manager was advised to seek appropriate and alternative systems, which can demonstrate that residents are being consulted on how the home is operated. It should be noted that the manager acknowledged that record keeping within the home is in need of improvement and she had therefore taken actions to employ a person to help develop these for the home. A review of health and safety was undertaken in regards to issues identified at the last inspection. The location of the call bell in the shower room is still not sufficiently close enough to the toilet that is also in this area to ensure residents can reach it if required. This could impact on resident safety if not addressed. The gas safety check for the home was noted to be overdue but records forwarded to the inspector confirmed other safety checks such as those for equipment in use in the home and the lift etc had been carried out. A fire risk assessment was not available in the home to confirm practices in place to safeguard the residents from fire. The manager was advised to take immediate actions to address this matter and advice was given. It was not evident that all staff have undertaken fire training and there were also staff who had not completed first aid. The manager stated that she does talk to staff about fire precautions but there were no records available showing what had been discussed in regard to fire or details of who had participated in these discussions. Door wedges are being used in the home and the manager advised these are used by cleaner. It was not evident that the manager had undertaken a review of those residents who like to have their door open to assess if magnetic devices are required which are linked to the fire alarm. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 3 2 X X 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X 2 2 Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 24 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 OP4OP37 Regulation 14(1)(d) Requirement The manager must write to service users following their assessment to confirm the home can meet their needs. (Outstanding from July 05) Care plans for residents must be reviewed to ensure they contain detailed actions that staff must take to meet their needs. In particular specific instructions on how to manage service users with mobility difficulties. Daily records must demonstrate that the care prescribed has been given consistently. Changes in care as identified during care reviews must be reflected in care plans. (Above outstanding from July 05 inspection) Timescale for action 28/02/06 2 OP7OP37 12,13 28/02/06 Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 25 3 OP8OP37 17(1) Sch3 13(1)(b) 4 OP9OP37 13(2) The manager must ensure that 28/02/06 the home maintain their own records in regard to any wounds or care needs being addressed by district nurses. The manager must be aware of progress or deterioration of health of these residents and any actions required by staff to observe or monitor residents between district nurse viists. The registered person shall make 31/01/06 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. Current procedures for managing medications are to be reviewed in line with the guidance document Royal Pharmaceutical Guidelines The Administration and Control of Medicines in Care Homes” to ensure safe practices are carried out at all times. The Manager is to review the current storage facilities for controlled drugs in line with the above guidance. The manager must arrange for regular audits of the medication to be undertaken to ensure medication is managed effectively on an ongoing basis. Audits are to be documented to demonstrate they have been done. Medications no longer in use must be returned to the Pharmacist. (Above outstanding from July 05) Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 26 5 OP9OP37 13(2) The registered person shall make 28/12/05 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. The Manager is to comply with the Immediate Requirement Notice to review all medication in regard to the following matters:All incoming medications must be checked and recorded on the Medication Administration Record (MAR). (Outstanding July 05) A Homely Remedies Policy must be implemented in regard to the use of homely remedies in the home for residents. This is to ensure that homely remedies being used are deemed safe by the GP in regard to other medications being taken. (Outstanding from July 05 inspection). Any codes used on the MAR must be clearly defined. Records must demonstrate that Warfarin is being managed and recorded appropriately. The manager is to confirm this in particular for the resident identified during the inspection. The ‘Polytar’ liquid prescribed in 2001 with an expiry date of May 03 must be disposed of. Action must be taken to identify if this is still required by the resident. MARS must be completed for any creams prescribed for residents to show whether they are/are not being used. (Above outstanding from July 05) Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 27 6 OP12 16(2)(m) (n) The manager must ensure that a programme of social activities and recreation opportunities are made available to residents which are appropriate and suitable for them. Residents will need to be consulted in developing an activities schedule for the home which should be placed on display. (Outstanding July 05 inspection) The registered person shall having regard to the size of the care home and the number and needs of service users provide, in adequate quantities, suitable, wholesome and nutritious food, which is varied… In this regulation “food” includes drink. The manager must ensure menus demonstrate the full choice of food and drinks available and confirm if menus have been nutritionally balanced by a Dietician. 31/03/06 7 OP15 16 31/03/06 8 OP18 13(6) The registered person shall make 31/03/06 arrangements, by training staff, to prevent residents from being harmed or suffering abuse or being placed at risk of harm or abuse. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 28 9 OP19 OP38 23(1)(2) 13(4) The manager is to devise a maintenance plan for the home with dates to address the following and send a copy of this to the Commission:The manager must ensure that the slabbed area of the garden is safe for residents. (Issue outstanding from July 05 inspection). Risk Assessments are to be devised with immediate effect for any resident who uses the garden which demonstrate actions to reduce or remove the safety risks. Further action is to be taken to address the various doors within the home which are stiff to open. (Issue only part met from July 05 inspection). Further action is required to ensure the doorbell to the home is suffifciently loud enough for staff to hear from all areas of the home. (Issue from July 05 inspection). Signage for the home is to be addressed so that residents can orientate around the home and locate communal areas easily. This applies to bathrooms, toilets and lounge areas. 31/03/06 Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 29 10 OP25 23(2) 13(4) The manager is to confirm a date 28/02/06 for the remaining radiator covers to be fitted. A review of any hot pipework is also to be undertaken to identify any areas where they may need to be lagged. Risk Assessments must be devised for any hot pipework or radiators, which could pose a burn/scald risk to residents until these matters are addressed. Hot water temperatures in resident areas must be monitored regularly (e.g. monthly) to ensure these are being maintained at a safe level. Hot water taps must operate effectively. Action is to be taken to test the water flow on all hot taps and address any taps where the flow or water pressure is poor. (Above outstanding from July 05). Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 30 11 OP26 13(3) 16(2) 23(1) The registered person shall make 28/02/06 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. This includes the provision of staff hand washing facilities in the laundry, which are separate from any sluice sink facilities. The manager is to confirm actions and dates to comply with this matter. Clearly labelled baskets for dirty and clean laundry must be available. (Outstanding from July 05 inspection). A clear policy and procedure for managing soiled laundry is to be developed including details of the methods used for transporting laundry from the main building to the laundry area. The manager should consult standard 26.5 when devising this policy and forward a copy of this to the Commission. (Outstanding from July 05 inspection). The manager is to confirm an inspection of the premises has taken place and that the home are complying with the Water Supply (Water Fittings) Regulations 1999. A copy of the outcome of the visit is to be forwarded to the Commission. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 31 12 OP27OP37 18(1) 17(2) Sch4 Duty rotas must indicate any 28/02/06 care hours allocated to non caring duties so that specific care hours provided can be established. Duty rotas must indicate any care staff hours allocated to cleaning and laundry duties as well as any catering duties after 2pm to demonstrate sufficient numbers of staff and hours are being provided for these services. (Above outstanding from July 05 inspection). The manager must be able to demonstrate that there are sufficient staff available to clean the home each day. The hours of the night staff need to be clearly defined on the duty rota. 13 OP28 18 (1) The manager is to confirm when the seven staff completing their NVQ II in Care have completed this to demonstrate the home employ sufficient numbers of trained staff. The manager is to forward an up-to-date training schedule for all staff showing dates of statutory training carried out. 30/03/06 Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 32 14 OP29OP37 19 Schedule2 The manager must comply with the Immediate Requirement Notice in regard to recruitment checks for staff. A review of all staff files is to be completed and any deficits in information rectified. Each member of staff recruited must have two written references, sufficient forms of identification including photo identification, a criminal records bureau check, a POVA check and a declaration of health to confirm they are fit to carry out their role. 31/12/06 15 OP33OP37 24 The Manager must demonstrate that any quality systems introduced enable all residents and their relatives/visitors to give their views about the home. A copy of the report in respect of any review conducted by the home must be made available to the residents and the Commission. This should demonstrate the results and outcomes of any satisfaction surveys and any actions taken as a result of them. (Outstanding from July 05 inspection) 30/03/06 Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 33 16 OP37 37 16(2)(a) The manager must have appropriate facilities for communication by facimile transmission to ensure records can be forwarded to the Commission without delay. The manager is to confirm actions to be taken to address this matter. 28/02/06 17 OP38 12 (1) (a) 23 (4) 13 (4) The location of the call bell in the 28/02/06 shower room is to be reviewed so that the pull cord can be accessed from the toilet area. The manager is to develop a policy and procedure on the management of aggression and head injuries. A prompt date for all staff to complete Fire Training is to be confirmed. A fire risk assessment must be devised to address fire risk areas within the home and actions required to reduce these risks. This needs to incorporate fire drills to ensure staff are competent in fire procedures. Door wedges and other weighted devices must not be used to hold doors open. (Above outstanding from July 05 inspection) The manager is to confirm the date for a gas inspection to be carried out. Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 34 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 OP2 Good Practice Recommendations It is advised that the Service User Contract for the home is reviewed to include the rights of the service user if the home is in breach of their contract. Staff should use the care plans for each resident when writing daily reports to ensure staff actions required to meet the care needs for each resident can be fully demonstrated. The manager should ensure that there are sufficient choices of meals on the menus for residents. This includes a choice of at least two main meals, vegetarian options where appropriate and full details of foods provided at Supper time which should be a suitably substantial ‘snack’. The complaints procedure should contain the name of the manager as a contact point plus the address of the home should a person wish to make a written complaint. Where service users require their doors to be left open, an appropriate door retention device (eg magnetic device) which is linked to the fire alarm should be considered. The manager is advised to undertake an audit of all those residents who may require this facility and confirm any proposed actions to address this. 2 OP7 3 OP14 4 OP16 5 OP38 Benvarden DS0000004212.V274096.R01.S.doc Version 5.1 Page 35 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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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