Inspection on 28/02/06 for Bishopsmead Lodge

This inspection was carried out on 28th February 2006.

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

Bishopsmead Lodge 22/01/08

Bishopsmead Lodge 12/07/07

Bishopsmead Lodge 02/01/07

Bishopsmead Lodge 27/06/06

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

CARE HOMES FOR OLDER PEOPLE Bishopsmead Lodge Vicarage Road Bishopsworth Bristol BS13 8ES Lead Inspector Vanessa Carter Announced Inspection 28th February 2006 09:30 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 Bishopsmead Lodge DS0000066339.V286845.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. Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bishopsmead Lodge Address Vicarage Road Bishopsworth Bristol BS13 8ES 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) 0117 935 9414 0117 935 9424 None Mimosa Healthcare (No4) Limited Marcia Dawkins Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51) of places Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager must be a RN1 or RNA on the NMC register Date of last inspection Brief Description of the Service: Bishopsmead Lodge Nursing Home is a purpose built care home, designed to accommodate up to 51 persons over the age of 65 years. The home is a twostorey building with lift access to the first floor. There are 43 bedrooms for single occupancy and four shared rooms. All rooms have ensuite facilities including a toilet and wash hand basin. The home has recently changed ownership and is now under the new management of Mimosa Healthcare, a Nottingham based company who are expanding into the West Country. Along with Bishopsmead Lodge, Mimosa purchased three other care homes in the Bristol area – Honeymead Manor in Bedminster, Sunnymead Manor in Southmead and Kingsmead Lodge in Shirehampton. This home is located in the residential area of Bishopsworth on the south side of Bristol close to local shops and the library. Car parking is provided to the front of the property, and to the rear is a small paved area where the residents can sit outside in the warmer weather. Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a planned inspection that took place over one day. There are currently only 25 people in residence – the whole of the ground floor is vacant. This was a full inspection with the majority of standards being assessed. Evidence has been gained from:• Information provided by the manager in the pre-inspection questionnaire • 12 service user comment cards • 9 relative comment cards • a tour of the home • speaking with a number of the residents • speaking with the home manager • speaking with registered nurses and nursing care assistants. The service provided at the home has previously given cause for concern, not only to inspectors from the CSCI, but to Social Services Departments, the PCT, and relatives of residents. It has now been under new ownership for one month, and whilst it is too early to “not be concerned”, there is a sense that staff are more motivated to improve the service, standards of care, and the life of the residents who live there. CSCI were notified of one serious concern since the last inspection, which has been substantiated. The home are expected to change working practices as a result of this. CSCI will continue to monitor the homes performance to ensure that standards are raised. What the service does well: What has improved since the last inspection? Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 6 Improvements in the way complaints are dealt with means that residents can be assured that any complaints they have will be listened to and acted upon. Improvements have been made to the recruitment practices, and this means that new staff will have undergone all the necessary pre-employment checks, and are the right people to work at the home. 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. Bishopsmead Lodge DS0000066339.V286845.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 Bishopsmead Lodge DS0000066339.V286845.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): 1, 2, 3, 4 and 5 Residents are provided with detailed and comprehensive information about the home. They can be assured that their needs will be met because of the home’s pre-admission assessment procedures. EVIDENCE: The homes Statement of Purpose and Service Users Guide, (Welcome Pack) has been updated to reflect the changes in ownership and management. A new copy has been issued to all existing people in the home, and will be provided to all prospective residents and their representatives. The documents provide a detailed outline of the home and what services can be expected Also issued to each resident is the statement of terms and conditions of living in the home. Whilst signed copies were present for those longer-term residents, they were missing from all those persons admitted since December 2005. The manager must have systems in place to ensure that residents, relatives or representatives, receive and return this document. Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 9 The home undertakes comprehensive pre-admission assessments, prior to offering placement to any new resident, to ensure that the home is able to meet that person’s needs. The home uses a comprehensive assessment tool that covers all aspects of a person’s personal care needs, daily living, health and social care needs. The assessment of the most recently admitted resident was examined. The home uses a comprehensive assessment tool and the form had been signed by the assessor and dated. They evidenced that the assessment had been completed prior to admission to the home. The person had been visited on the hospital ward. The person had previously lived in a nearby care home, and the family had chosen Bishopsmead Lodge as it was located close to them. Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 and 11 Improvements are required with the homes care planning processes as there is the potential for some care needs to not be fully met. An improvement in the manner in which residents and relatives are always treated, would ensure that the home has a better reputation. EVIDENCE: Three care plans were examined, including that of the person who had been in residence for four weeks. Each of the residents had a large number (12-14) of separate care plans. Some of the plans were meaningless and entirely unnecessary, and did not have any relevance to the day-to-day care of the resident. The care planning documentation needs to be more concise, to make them an easy reference guide, and the information needs to be organised logically. Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 11 The care plans were drawn up from the information recorded in the “assessment based on aspects of daily living”, but specific examples were noted where information was not transferred onto a plan of care. Also, there is nowhere on this document to record tissue viability or skin integrity. One person, due to their specific health needs, had been identified as needing mouth care but there was no resulting plan. Another person with a high risk of developing pressure sores did not have the need for any pressure-relieving equipment on their bed highlighted, despite having already developed two sores. This last fact evidences that the home undertakes these assessments in a perfunctory way, with little thought to “outcomes and gaols”. Recording of daily bowel function is variable, one person’s records showing that they had a not had a bowel action for 19 days. Assurances were given that the records were unlikely to be accurate. This is not acceptable practice. A number of residents have their dietary intake, and fluid intake/output recorded but the quality of monitoring was poor. It seems that “multiple recordings” are made at the ends of shift, rather than as meals/drinks/output occurs. This is not good practice and is likely to be open to “guess work”. An examination of 2 wound care plans evidenced very poor practice. There were discrepancies in the recordings - for one person, photography showed two wounds whilst written recordings and wound mapping diagrams only referred to one wound. For the other resident, a photograph taken ten days previously showed a healing wound, when compared to the previous photograph, but a record in the notes, stated, “dressing removed from the leg because it’s healed. Photographs taken.” There was no wound care planning documentation in the person’s file, however this had already been filed away. Discussion with a registered nurse evidenced that the ‘foot’ was just being kept an eye-on now. The home must have more robust procedures in place to monitor skin integrity, and must keep clear and accurate records of the care given. On person with low body weight had a specific care plan written around their nutritional needs. Whilst this identified particular likes and dislikes, there was vast quantities of supplement drinks and foods stored in their room, including those not liked. This gives the impression of a lack of thought for the resident’s needs. The plans were supported by various risk assessments but these were not always helpful. One persons ‘resident handling assessment’ stated that mechanical aids were required to assist with moving but did not say what particular aids had been identified as appropriate. Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 12 “Core” risk assessments were attached to care files in respects of ‘slips, trips and falls’ – for one person there was reference to referral to the GP for physiotherapy services, due to the number of falls, but no review of the “core” assessment had been undertaken, or a specific care plan been written. For another resident, the risk assessment was entirely inappropriate in light of the fact they are completely bed-bound. One person’s nutritional assessment had not been completed; yet nursing staff had completed an evaluation. All these examples evidence that the staff are not competent in undertaking proper assessments of the residents needs, and then writing detailed care plans. This shortfall has the potential to place residents at risk from not having their care needs met. A record of visits by GP’s, chiropodists, opticians and any other healthcare professionals is maintained for each resident. Where appropriate a dietician’s advice had been sought. During the course of the inspection, the staff team were seen going about their duties in a kind, friendly and courteous manner, but residents reported that the staff do not always treat them with respect. All residents spoken to said that personal care was given in privacy. Whilst one resident stated that everyone was always kind, another said that some members of staff can sometimes be abrupt and unhelpful, particularly at night time. Another said that call bells can go unanswered for a considerable length of time, again at night time. Since the last inspection there has been one complaint concerning how the home dealt with the relatives and belongings of a deceased resident. The outcome of the complaint evidenced that the home fell far short of providing an adequate or compassionate service, and they were required to review their procedures, and to maintain adequate records. The home has previously arranged bereavement training, for some of the staff but the training provider cancelled the session at the last moment. The manager must ensure this is addressed particularly in light of this recent complaint. Bishopsmead Lodge DS0000066339.V286845.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 and 15 The quality of the resident’s lives would be enhanced if they had access to more meaningful activities. The residents benefit from meals that have improved. EVIDENCE: The home employs an activities organiser and a record of each resident’s involvement in the activities is maintained – they were not looked at during this visit. There was a very mixed response from the residents about the range of activities. One person said they “enjoyed the bingo” but two people reported “it’s always singing, just because one person likes to do it, and always the same songs”. There is no time for 1:1 time with the staff due to them being busy. “Once, ages ago, I did a crossword with a care assistant and I enjoyed that”. One relative wrote on a comment card that “those residents in their own rooms should be looked in on more often” Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 14 The home has an open visiting policy and visitors are asked to sign in at the front door, to comply with fire regulations. None were seen on the day of inspection due to the bad weather. It was evident from discussions with residents that they able to choose where they like to be for the day and where they take their meals. “I sometimes have my meal in my room and I sometimes go to the dining room”. One person said they liked to spend their time in the small lounge as it was quiet and “I have the TV to myself”. The chef advised that the menu’s have been reviewed. He is now able to adhere to the planned menu, due to alterations to ordering of food supplies. “We are having pancakes tonight” and this is a change from the plan, but traditional. The chef explained that the timing of the midday meal has been moved to 1pm as previously lunch had been served too soon after breakfast. Three residents stated that this was much better and that they had been asked about the change. The chef is aware of the residents likes, dislikes and specific dietary requirements. In the comment cards from residents and relatives there were positive comments regarding the improvements in the meals. Bishopsmead Lodge DS0000066339.V286845.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 and 18 An improved approach to all complaints ensures that residents and their representatives feel any concerns they may have will be listened to and acted upon. The arrangements for protecting residents from possible harm or abuse, would be improved by better staff training opportunities. EVIDENCE: The home’s complaints procedure is well advertised displayed in the main reception area and included in the home’s new statement of purpose and welcome pack. The manager undertakes a monthly audit of any complaints received and looks for common traits. A record is made of the outcome of the complaint. The information was logically maintained and organised. Residents spoken with during the course of the inspection, felt confident to raise concerns with the staff. One person said that there had been noticeable improvements in the way in which their concerns had been addressed, since the new manager had been in post. Since the last inspection CSCI have received one complaint, from recently bereaved relatives. The complaints were upheld and a number of requirements were made to ensure that the home looks at its practices, and adheres to any agreements made with families. Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 16 One complaint had resulted in concerns being raised with social services about the care of a resident, under “no secrets” and protection of vulnerable adult (POVA) protocols. The home followed expected procedures, in light of this incident. An investigation resulted in a number of staff being disciplined, and the family of the resident deciding to move their relative. There were no staff training records to evidence that the staff team have had any training in the care of vulnerable adults or abuse awareness, however the training matrix showed nine out of 34 staff having received training in 2005. Discussions with some staff demonstrated their awareness of their role and responsibilities in protecting the residents from harm or abuse, however none had attended training. The records for one staff member evidenced that the need for POVA training to further that workers development, had been identified in December 2005, but had not yet been acted upon. This does not evidence that the home ensures residents are safeguarded from harm or abuse therefore regulation 13.6 of the Care Standards Act 2000 is not met Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Residents live in a comfortable, well maintained, clean and tidy home which is free from any unpleasant odours. EVIDENCE: The home is a purpose built two storey building, with lift access from the ground to first floor. Car parking is available to the front of the building, and although there is an incline of the path up to the front door, there is level access into the home. The front entrance is secured with a key padded system, so the home is safe and protected. To the rear of the home there is a very small paved area, and the downstairs lounge opens out on to this area. The home meets all the standards required and has sufficient communal areas (lounges and dining rooms), bathrooms and toilets, to meet the needs of the 51 residents. Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 18 The home is well decorated throughout. The previous owners had no maintenance plan but dealt with matters on a “when needed basis”. Work is to commence in the upstairs unit soon, to address the creaking floorboards. Plans also include the removal of the kitchenette area from the upstairs lounge, and creation of additional storage space. The current arrangements where the sluice room door is locked, whilst being good practice does cause difficulties in working routines. There was a great deal of fuss to find the person with the keys, and this may encourage staff to take short cuts. Alternative options for securing the door should be explored. Currently the home has only 25 residents, and these are all accommodated on the upper floor. The ground floor has been unused for sometime, due to the plans of the previous owners, however remains fully functional and ready for occupation. The home have started a process of consultation with the existing residents to determine those who would like to live downstairs and will be making the necessary moves, and changes to staffing levels, in the near future. The home has equipment to assist the care staff with moving and transferring residents with impaired mobility. The recent servicing of this equipment has shown a number of items of equipment to be in need of minor repair and these are therefore out-of-action. Staff spoken with said there was still sufficient equipment to meet the needs of the residents. A number of new beds have recently been purchased and there will be a rolling programme of replacement of the others. The manager is also hoping to get new differing chairs for the lounge area – not “one size fits all”. Each bedroom had ensuite facilities of a toilet and wash hand basin. There are four shared rooms each with privacy screening in place. Residents are encouraged to bring in as much of their own furniture and belongings as they wish, but the home must maintain records (room inventories) of such, to prevent difficulties at a later date with relatives. The chest of drawers in room 7 must be replaced. The home is centrally heated and well lit with domestic style light fittings. Each bedroom has an opening window, fitted with width restrictors for safety. Emergency lighting is installed throughout the home and this is checked on a regular basis. On the day of inspection the home was warm and well lit The home was clean tidy and free from any offensive smells. Bishopsmead Lodge DS0000066339.V286845.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 and 30 Improvements in the numbers of permanent staff, and the training opportunities available for staff, would enhance the service received by the residents, and improve the quality of their lives. EVIDENCE: The home does not have a full compliment of staff at the moment and are therefore, having to use a lot of bank or agency workers. This means there is the potential for a lack of consistency in the care that residents will receive. A process of recruitment is in place but the manager is conscious that the profile of the home needs to be raised, and is keen to recruit the right staff. One lead nurse has already been recruited and is currently working through their induction programme. On the day of inspection there were two registered nurses, two senior health care assistants and two care assistants. There are dedicated housekeeping, laundry, catering and administrative staff in addition, to ensure that the resident’s daily living needs are met. The home currently has only two members of care staff who have achieved the NVQ level 2 in care, but six others are working towards the award. One of the senior carers, a qualified nurse in their own country can be considered as having equivalent qualifications. The home must ensure that it attains the requirement for a minimum ration of 50 trained members of staff, in order for residents to be cared for by staff who are skilled and competent. Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 20 Staff files of the most recently recruited members of staff were examined. They evidenced that the home follows robust recruitment procedures. All necessary checks are carried out prior to employment, to ensure that workers are suitable for care work. The manager supplied a training matrix that showed that the majority of staff need to receive training in all mandatory subjects (food hygiene, health & safety, POVA, fire, first aid and basic life support for example). The staff training records were not examined as according to the manager they were in complete disarray. The manager is aware of this major shortfall and will be addressing the needs of her staff team with senior management. Bishopsmead Lodge DS0000066339.V286845.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, 35, 36 and 37 An improving management structure, means that residents will live in a home that is better run. The manager is aware of those areas where improvements are needed. EVIDENCE: The home has been through a period of instability due to changes of manager and ownership, since the last full inspection, however things are now beginning to settle. The home manager has been in post since September and has completed the necessary registration process with CSCI. She is due to commence the registered managers award in the very near future. Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 22 The manager explained that she now has more autonomy to run the home, however will be backed up by an area support manager / senior management structure. The staff group needs to stabilise and strengthen, however has recently benefited from the recruitment of a lead nurse. One resident said that the home was much better since these permanent staff had been recruited, but that consistency of staff was still an issue. The manager is fully aware that this issue is important to the process of raising the homes profile. The home have a system set up whereby they hold personal monies for a number of residents. A random check of a number of ‘accounts’ evidenced good accounting systems. The home has an induction programme for new staff members to complete within 12 weeks of employment. The form allows for two observations of practice to be recorded, followed by the date deemed proficient. This 12-week period is also seen as the workers probationary period. At the end of the period the manager will have a meeting with the staff member, to discuss an ongoing training and development plan. Whilst the format is good, the one programme looked at did not follow the expected process to demonstrate competency. This shortfall has the potential to mean that residents will be looked after by staff who are not familiar with the practices and procedures of the home, and may not provide adequate care. Some of the homes records were looked at. In general the standard of the records was satisfactory but improvements are required with the recording of accidents/incidents and any follow up action that the staff have taken. Staff must ensure that they use the appropriate language in care planning notes, to prevent any misunderstanding (for example healing as against healed). Examination of the fire log evidenced that all the necessary checks and drills had been undertaken. The manager advised that a full “Health and Safety” inspection, arranged by Mimosa is booked for 13 March, therefore this standard has not been assessed on this inspection. However, during a tour of the home, it was noted that an air freshener unit had the flex trailing, where it could pose a hazard to both staff and residents. The extractor fans in the ensuite rooms are not working however this has already been addressed and replacement parts are on order. The chest of drawers in room 7 must be repaired or replaced. Bishopsmead Lodge DS0000066339.V286845.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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 10 1 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 2 2 X Bishopsmead Lodge DS0000066339.V286845.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 OP7 Regulation 15(1) Requirement Care planning documentation must accurately reflect residents needs and be kept up to date. (the previous timescale of 20/11/05 has not been met) Timescale for action 28/04/06 2. 3. OP7 OP10 15(1) 12(5)b 4. OP12 16(2)m 5. 6. 7. 8. OP18 OP24 OP30 OP37 13(6) 17(2) schedule4 19(5) 17(2) schedule4 Wound care plans must be clear and accurately kept Staff must always maintain good personal and professional relationships, with the residents and treat them respectfully. Residents must be consulted about their social interests and a range of appropriate activities be arranged for their enjoyment. All staff must receive POVA training or a refresher session. A record of personal furniture each resident has in the home. Staff training records must be kept and available for inspection Accident records must be completed and record all follow up action 28/04/06 28/03/06 28/06/06 28/08/06 28/03/06 28/06/06 28/03/06 Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7 OP19 OP24 OP27 Good Practice Recommendations Each residents care plans must be clear, concise, and easy to refer to. Alternative means of securing the sluice room door should be explored. The chest of drawers in room 7 must be repaired or replaced. A full compliment of registered nurses and care assistants be employed to prevent agency usage. Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bishopsmead Lodge DS0000066339.V286845.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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