Inspection on 05/07/05 for Benvarden

This inspection was carried out on 5th July 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 22/12/05

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 CV7 9AJ Lead Inspector Sandra Wade Unannounced 5 July 2005 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 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 E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 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 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 PC 14 Category(ies) of OP registration, with number of places Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 25 January 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 E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place between the hours of 7.30am and 6.40pm. This was the first visit for this inspection year and staff in the home co-operated fully with the inspection. The inspection process included a tour of the home, talking with the Manager, examining care plan records, discussions with staff, residents and visitors and a review of policies and procedures of the home. On arrival at the home most of the service users were up and the cook was preparing breakfast. What the service does well: What has improved since the last inspection? Since the last inspection a review of medication has been carried out to improve the way medications are managed. Recruitment practices have improved in that all checks as required are being implemented including criminal record checks before new staff start to work in the home. The manager is now making more thorough checks to make sure that new residents admitted do not have needs which she cannot meet. Staff training is being addressed on an ongoing basis and since the last inspection staff have completed food hygiene training and medication management training. Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 6 Heat controls have been pursued for radiators within service user rooms so that they can adjust the temperatures when they need. Improvements to the garden area have been made and some new lounge chairs have been purchased. 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 E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 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 standard(s) 2,3,4 Each service user is issued with a written contract/statement of terms of conditions upon admission to the home. Service users 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 service user 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 was not clear what action the service user could take if the home were in breach of their contract. Assessment records are in place for each service user and identify care needs and actions required to meet them. The manager currently does not write to service users to confirm the home can meet their needs but gave a commitment to address this. Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 Each service user has a care plan but it was not clear that all needs are being identified so that staff can ensure they are addressed. Some practices in regards to the management of medication need to be changed to ensure medication management is safe. Service users felt that they were being treated with respect but there are issues regarding the privacy of service users which need to be addressed. EVIDENCE: Care plans are in place for each service user which give an outline of their care needs. In addition the home had obtained background history of the service users to assist in developing the care plans. Care plans in place contain limited information in regard to the staff actions required to meet the needs of service users. It was not clear from the records of one service user how staff should manage a broken limb. Moving and handling information was not contained within the mobility care plan. A care plan identified that a service user wore glasses but did not state the actual problem ie whether the service user only wore the glasses for reading or required them all of the time due to poor sight. Another care plan contained a sheet called “pressure sore monitoring” and identified a pressure sore. Care Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 10 records confirmed this service user had developed this sore in May. No care plan had been devised for the management of this and the District Nurses had not been informed to give specialist treatment and advice as required. Care plans are being reviewed monthly but it was not evident that actions identified in the reviews had been incorporated into care plans so that staff were giving the care required. One record stated that a resident had developed a sore mouth, although staff were able to report verbally what they did to action this, no care plan had been developed at the time when this had been identified. Details of when professional visits are made are being documented such as those from District Nurses and GPs but the reasons for the visits and the outcome of the visits are not always recorded on the medical sheet which could result in staff being unclear on any treatment or care required. Daily records are being completed each day for each resident but they are not linked to the care plans and it is therefore not possible to be sure that the actions identified in the care plans is actually being carried out. Records confirmed access to specialist services including Opticians and a Chiropodist. Medications are stored in a locked cabinet within the managers office but it was observed that only one member of staff gives out medications passing backwards and forwards to the cabinet while it remains open. It was established that there is not always someone in the office when the medications are being given to the resident which leaves the medications unattended which is not a safe practice. There were various medications that did not contain their original labels and names had been written on them. This practice suggests that medication which is not prescribed is being given to residents, this is not a safe practice. In addition there were various medications in use which had not been prescribed by the GP which service users had purchased themselves. No clear ‘Homely Remedies’ policy was in place for these medications to make sure they were safe for the service users to take in addition to their other medication. Medication records did not always state how many tablets/capsules had been received following delivery so that staff could check that the amount given and the amount left were correct. Items such as pairs of glasses and dentures were being stored in the medications cabinet which is not considered appropriate storage location. Current arrangements for the storage of controlled drugs are not in keeping with safe medication guidelines. Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 11 Prescribed medications should be stored in a locked cupboard or trolley. Various different types of prescribed creams were found stored in the downstairs bathroom which is not in keeping with the safe medication management procedures. A medication chart for one service user made reference to the cream being stored in the bathroom. Service users said that staff knocked their doors before entering their rooms and during the inspection staff were seen to treat service users with respect. It was noted that some bedrooms did not have working locks on the doors so that service users had the choice to lock their doors for privacy. There were also no locks to doors within the ensuite bathrooms used in the double rooms. In one of these rooms the toilet and bathroom is linked to the bedroom and is also used as a communal bathroom, there are 2 doors into this area. Staff said that service users only use the toilet at night and it is used as a bathroom at other times. As there is no lock on one of the doors, there is no guarantee that someone will not enter this room when in use. Incontinence pads and personal items were not labelled and were being stored in the downstairs bathroom as opposed to service user bedrooms. Pads should be stored out of view to maintain service user dignity. It was noted that the service user’s walking aids were being stored in the hallway and not next to them in the lounge where they could access them independently. Service users were therefore reliant on staff to collect them each time they wished to get up and walk reducing their independence. Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 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 standard(s) 12 Activities are provided within the home but these are limited in terms of providing sufficient social stimulation and it was not clear that these activities matched the preferences of the service user so that they enjoyed participating. EVIDENCE: The manager acknowledges that the provision of social activities and recreation is not as good as it could be. Service users made varying comments in regard to social activities, one said that they participated in the homes activities sometimes but the important thing for them, was to have something to do. It was acknowledged that the hairdresser visits the home and bingo takes place. During the inspection several of the service users were sitting in their chairs asleep at various periods throughout the day. Mental and social stimulation was lacking and this was confirmed in discussions held during the inspection. Other activities include visits to church, sing songs and exercises. One service user said that they had to amuse themselves. Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 13 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 standard(s) 16 Service users know who to complain to and complaints made are followed up and acted upon by the manager but complaints procedures are not clear on what the complainant can expect from the investigation process. EVIDENCE: A complaints policy is in place but this is mainly directed at how staff should deal with a complaint when received. A complaints policy for service users and visitors was not seen on display in the home to provide guidance on how to make a complaint and provide details of how this would be handled. Three complaints had been received by the home but two of these were regarding how visiting professionals handled the care of a resident. The other complaint was regarding the attitude of a member of staff and had been addressed by the manager to the satisfaction of the service user. Records were in place of all complaints but they did not indicate clearly whether the complaints had been upheld or not upheld. Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 14 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 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 service users. Sufficient numbers of toilets and bathrooms are available but washing and drying facilities within them need to be improved. The main communal areas and bedrooms within the home are kept clean but there are some practices within the home which are not hygienic and which need to be improved to ensure service users are being cared for in a clean and safe environment. EVIDENCE: There are two lounges which are split by a set of double doors plus a dining room and large conservatory. There are ten single bedrooms, six with en suite facilities and two double bedrooms with en suite facilities (one of these ensuites is also a shared communal bathroom). The home has pleasant gardens with a patio overlooking a school playing field although it was noted that the patio contains several large uneven slabs which could present a trip hazard to the service users. Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 15 On the day of inspection the lounge/dining areas plus the service user bedrooms were found to be clean and tidy. The home is being maintained on an ongoing basis and the manager stated that the front of the house had been recently painted. Some areas of the carpet in the communal areas had tape holding down the areas where it had been joined which could become a trip hazard over time. The manager stated that she has obtained a quote for the replacement of the carpet and this would be done in due course. On viewing the toilets and bathrooms it was noted that some toilet roll holders were broken and liquid soap and paper towels are not being used in all communal toilets and bathrooms to maintain good infection control practices. Hand towels are currently being used but in one of the rooms no towels were available. In the shower room the call bell is over the shower area as opposed to the toilet area which is more likely to be used independently by a service user. Service users would not be able to reach the call bell if they fell from the toilet or required assistance. Fire Exit doors on the corridors upstairs were very stiff to open which could present a fire safety risk to service users. One of the doors downstairs by room 4 was also found to be very stiff to open. The doorbell to the home is not sufficiently loud enough to alert staff within the home. The front door to the home is stiff and a member of staff struggled to open it. The side door is also stiff to open which again could present a fire safety risk. The manager said that temperature controls and radiator covers had been fitted to some radiators to prevent burn risks to the service users. There are still some radiators which need covers fitting and the manager gave a commitment to also look at any hot pipework which may need lagging. The manager advised that valves had been fitted to the hot water taps in service user areas to control water temperatures and prevent any scald risks to the residents. It was not evident that the temperatures are being monitored to ensure they are operating within safe guidelines all of the time. Some of the taps tested were operating above the recommended temperature. Some hot water taps did not work properly. No water came out of some taps unless they were left on for a period of time. The manager acknowledged that this was an ongoing problem which she has tried to resolve. The laundry was viewed and baskets were seen for dirty laundry but not for clean. There were no disposable gloves or aprons available in the laundry and no liquid soap or paper towels for staff to wash their hands. The hot tap on the sink is damaged. Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 16 Various items are being stored in the laundry area and rugs are in use on the floor which would make it difficult to thoroughly clean the floor area to maintain good infection control practices. Access to the laundry is either through the kitchen or from outside, it was not clear what container or process the staff are using to transport the laundry safely. The manager said that staff do not bring dirty laundry through the kitchen. No procedure for managing the laundry within this home was seen to confirm that effective infection control practices are being used. There is no dedicated sluice facility within this home for cleaning commodes. The manager confirmed that the service user shower/toilet area is currently used to empty and rinse the commodes before they are taken back to the rooms and cleaned with disinfectant. This practice does not comply with effective infection control procedures. The home has not been inspected to confirm compliance with the Water Supply (Water Fittings) Regulations 1999. Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 r The deployment of additional non-care duties for both night staff and day staff impacts on the amount of care hours that should be provided to meet the needs of the residents. The procedures for the recruitment of staff are not robust to ensure that all safeguards are accessed to offer protection to service users living in the home. EVIDENCE: The home aim to have 2 care staff on duty during the day to care for 14 service users. The manager works in a supernumerary capacity. There is a dedicated cook who works from 7.30am to 2pm each day and the manager confirmed that care staff undertake kitchen duties after this time but the hours allocated to these duties were not on the duty rota. The duty rota for the home did not indicate any staff to do cleaning or laundry duties. The manager advised that she was in the process of organising someone to do the cleaning for the home. The nights are covered by one waking member of staff and one sleeping. Staff confirmed that the waking night staff person undertakes all of the laundry duties including washing, drying and ironing. This practice reduces the number of care hours being provided at night and therefore could impact on quality of care and meeting the needs of the service users. The Residential Staffing Forum have issued guidelines to care homes on staffing and this suggests that the home should have 2 care staff on duty at all Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 18 times purely for undertaking caring duties. It is not evident from duty rotas that any extra staff hours are being provided to cover the additional non caring duties. Duty rotas currently do not make the designations of staff clear due to poor photocopying it is therefore difficult to see who is in charge when the manager is not on duty. Of the 14 care staff employed, three of them have attained a National Vocational Qualification II in Care to assist them in providing more effective care and services to the residents. Arrangements are in place for other staff to complete this training. Training certificates are held on staff files and the manager confirmed that training is being addressed on an ongoing basis. The most recent staff employed had previously worked at the home and the manager had retained their recruitment records. New references etc had not been followed up in line with the Commission’s recruitment standards to ensure staff continued to be considered safe to work with vulnerable adults. It was not clear what positions these staff had been employed for and a new criminal record check had not been pursued for one member of staff. Records did not contain sufficient information to confirm that staff employed are both physically and mentally fit to carry out their role. Recent photo identification was not available on files as required. Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,37,38 The quality of the service provided is being formally monitored but outcomes were not evidenced to confirm the home is being run in the best interests of service users. Record keeping within the home needs to be improved in some areas to demonstrate the services users are receiving the care and services the home says they are providing. Arrangements are in place to ensure service user financial interests are safeguarded. There are some health and safety matters which require attention to ensure the home is safe for service users. EVIDENCE: The manager has implemented a generalised service user satisfaction survey but the outcome results had not been published. The manager advised that any comments made on surveys were actioned on an individual basis but as this information had not been recorded there was no evidence of this. Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 20 Service user meetings do not take place regularly to enable service users to have the opportunity to give their views on the home in a more formal setting. The manager said that she does not deal with any money belonging to service users as they all have relatives who can support them with this. Any necessary items are purchased by the home and invoiced to the service users family as appropriate. Lockable drawers are available in the home for those service users who wish to keep any money or personal possessions locked away. Records viewed as part of this inspection are indicated within each section of this report with any actions as required. No policies were in place in regard to head injuries and aggression to guide staff on how to deal with these matters. It was clear from viewing accident records that not all accidents had been reported to the Commission so that actions taken could be viewed and deemed as appropriate. Staff spoken to confirmed they had completed training in moving and handling, first aid and were due to attend food hygiene training later in July. Fire training had not been completed. It was clear that responses given in regards to how to tackle a fire in the home were different suggesting fire training for staff needs to be pursued promptly so that service users can be guided in a safe manner in the event of a fire. There were numerous door wedges and implements being used to hold doors open which do not comply with fire precautions as these doors would be left open in the event of a fire and could spread the fire quicker around the home. Some doors did not close properly due to locks that had been fitted previously being removed and there were many doors that were stiff to open which could present a fire safety risk to service users. Health and Safety records confirmed the following checks had been undertaken:Gas 18.11.04 5 Year Electrics 16.6.04 Portable appliance testing – 16.6.04 Hoists 14.4.05 and 15.3.05 Legionella 4.1.05 Lift 2.5.05 Employers Liability Insurance 6.4.05 Fire extinguishers contained stickers confirming their last check. A fire risk assessment was not in place which identified fire risk areas within the home and actions that needed to be taken to reduce or remove these risks. It was also not evident that staff are undertaking regular fire drills so that in the Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 21 event of a fire, effective procedures are followed. Various portable electrical appliances had no test stickers to confirm they were safe. Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x 2 x x x 2 1 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 Standard No 16 17 18 Score 2 x x x x 2 x 3 x 2 2 Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 23 YES 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. Standard OP4 OP37 Regulation 13 12 (1) (a) 14 (1) (d) Requirement The Registered Person must ensure that there are guidelines in care plans regarding how behaviour that challenges should be handled, giving clear instructions to staff to follow. (Outstanding from January 05 inspection) Timescale for action 31.8.05 2. OP7 OP37 12, 13 The manager must write to service users following their assessment to confirm the home can meet their needs. Care plans for service users 31.8.05 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. Care staff need to use service user care plans when writing daily records so they can report against each care plan. Daily records must demonstrate that the care prescribed has been given. Changes in care as identified during care reviews must be Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 24 reflected in care plans. 3. OP8 OP37 17 (1) Schedule 3 (p) 13 (1) (b) Any pressure sores identified by staff must be followed up promptly with the District Nurse as appropriate. A care plan for the treatment of the pressure area/sore must be devised and specific actions identified to manage this. The medical visits form in service user care plans needs to detail the reasons why a visit/call was made and the outcome of these. 4. OP9 OP37 13 (2) The registered person shall make 31.7.05 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. Labels on medication must not be removed. Medications must only be used for the service users they have been prescribed for. All incoming medications must be checked and recorded on the Medication Administration Record (MAR). Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 25 31.7.05 All prescribed medications must be kept in a locked medication cabinet. Creams such as Aqueous cream can be kept in a service users room within a locked area. Medications must not be kept in bathroom areas. A Homely Remedies Policy must be implemented in regard to the use of homely remedies in the home for service users. This is to ensure that homely remedies being used are deemed safe by the GP in regard to other medications being taken. 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. Inappropriate items stored with medications are to be removed. 5. OP10 12 (3) (4) (a) The manager needs to review 31.8.05 the use of locks of bedrooms doors to maintain privacy. Any locks fitted must comply with fire precautions and advice should be sought from the fire officer as appropriate. Locks to the bathroom/ensuite in the double rooms must be pursued to maintain privacy. The manager must ensure that Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 26 a specific procedure is put in place during night time to lock the upstairs bathroom door to protect the privacy and dignity of the service users whose ensuite is shared with this bathroom. Risk assessments must be devised for those service users who are dependent on a walking aid and also require staff assistance to walk and those who can use walking aids independently. The manager must ensure that the service users independence and safety is not compromised by storing zimmer frames out of reach making service users dependent on staff to collect them. 6. OP12 16 (2) (m) (n) The manager must ensure that a programme of social activities and recreation opportunties are made available to service users which are appropriate and suitable for them. Service users will need to be consulted in developing an activities schedule for the home which should be placed on display. A complaints procedure must be developed which makes it clear to service users and visitors what process to follow when making a complaint. This must include contact names, addresses and telephone numbers as appropriate. The manager must ensure that the slabbed area within the garden is even and safe for service users to use. An action plan to address this matter is to be fowarded to the Commission. 30.9.05 7. OP16 OP37 22 31.8.05 8. OP19 OP38 23 (1) (a) (2) (o) 13 (4) (a) (c) 31.8.05 Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 27 Action is to be taken to address the various doors within the home which were stiff to open including the front door, to ensure these do not compromise fire safety. An action plan with dates to address this matter is to be sent to the Commission. All service user doors must close properly. The doorbell to the home needs to be suffifciently loud enough for staff to hear from all areas of the home. 9. OP21 23 (2) (a) (n) (4) 13 (4) Broken toilet roll holders are to be repaired. The location of the call bell in the shower room is to be reviewed so that the pull cord can be accessed from the toilet area. 10. OP25 23 (2) (J) 13 (4) The manager is to confirm a date 31.8.05 for the remaining radiator covers to be fitted. A review of any hot pipework should also be undertaken to identify any areas where this may need to be lagged. Hot water temperatures in service user areas must be monitored regularly (eg 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. Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 28 31.8.05 11. OP26 13 (3)(4) 16 (2) (j) 23 (1) (d) The Registered Persn shall ensure the care home is conducted so as to promote and make proper provision for the health and welfare of service users. After consultation with the environmental health authority make suitable arrangements for maintaining satisfactory standards of hygiene in the care home. To include the following:The use of liquid soap and paper towels in communal toilets/bathrooms for use by both staff and service users. Clearly labelled baskets for clean laundry must be available. Disposable gloves and aprons must be available within the laundry for staff to use. The hot tap on the sink in laundry is to be replaced. Liquid soap and paper towels must be available in the laundry for staff to wash their hands. The laundry floor must be easily cleanable to maintain good infection control practices. The use of rugs in this area is to be reviewed. A clear procedure for managing soiled laundry is to be developed including methods for transporting this from the main building to the laundry area. The manager should consult standard 26.5 when devising this policy. Procedures for sluicing and the 31.8.05 Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 29 cleaning of commodes are to be reviewed with the Infection Control Officer. This standard stipulates that sluicing facilities are to be provided separately to service users bathrooms and toilets. The manager is to organise an inspection by the Water Authority to confirm the home is operating in compliance with the Water Supply (Water Fittings) Regulations 1999. An action plan is to be forwarded with timescales to address the above matters. 12. OP27 OP37 18 (1) (a) 17 (2) Schedule 4 Duty rotas must indicate any 31.8.05 care hours allocated to non caring duties so that specific care hours provided can be established. Staff who are completing cleaning and laundry duties plus catering duties after 2pm must be indicated on the duty rota to demonstrate sufficient numbers of staff and hours are being provided for these services. Designations of staff need to be clearly indicated on the duty rotas. 13. OP28 18 (1) (a) The manager is to confirm when staff who are currently undertaking their NVQ II have completed this to demonstrate sufficient numbers of staff are suitably qualified to carry out their role effectively. Recruitment procedures need to be reviewed to ensure all appropriate checks are made on 31.10.05 14. OP29 Op37 19 Schedule 2 31.8.05 Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 30 staff employed. This includes checks for those staff who may have left and returned to the home. Recent photos of staff must be obtained for purposes of identification and Criminal Record checks for new staff must be followed up which include Protection of Vulnerable Adult checks. Records must confirm that staff are both physically and mentally fit to carry out their role. The Manager must demonstrate 31.10.05 that any quality systems introduced enable all service users 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 service users and the Commission. This should demonstrate the results and outcomes of any satisfaction surveys and any actions taken as a result of them. The manager is to develop a policy and procedure on the management of aggression and head injuries. All accidents must be reported to the Commission. A prompt date for all staff to complete Fire Training is to be confirmed. Door wedges and other weighted devices must not be used to prop doors open within the home. Where service users require their doors to be left Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 31 15. OP33 OP37 24 16. Op38 12 (1) (a) 23 (4) 13 (4) 37 31.8.05 open, an appropriate door retention device (eg magnetic device) which is linked to the fire alarm is to be fitted. An action plan with dates to address this matter is to be forwarded to the Commission. 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. 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. Refer to Standard OP2 OP7 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. It is recommended that the home implement a nutritional assessment tool and implement the use of body charts when service user injuries or pressure sores have been identified. Any creams applied to service users within their room should be recorded on an additional monitoring sheet which can be kept in the service users rooms provided this is kept out of view. (This is in additon to the MAR which must be signed to comfirm application). It is advised that service user meetings are introduced to the home so that they can give their views on the running of the home in a more formal setting. 3. OP9 4. OP33 Benvarden E53 S4212 Benvarden V236565 60705 stage 4.doc Version 1.40 Page 32 Commission for Social Care Inspection 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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