CARE HOME ADULTS 18-65
Blandford Lodge 4a Blandford Waye Hayes Middlesex UB4 0PB Lead Inspector
Robert Bond Unannounced Inspection 23rd November 2005 10:00 Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 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 Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 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 Adults 18-65. 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. Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Blandford Lodge Address 4a Blandford Waye Hayes Middlesex UB4 0PB 020 8573 0129 0208 573 0129 blandfordlodge@yahoo.co.uk 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) Mr Poucarshing Luchmun Mr Poucarshing Luchmun Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: Blandford Lodge is a care home for three service users with mental health needs. It is a detached family house with garden in a quiet residential area on the Hayes/Southall border, close to the Uxbridge Road. It is within reach of local shops and bus routes to larger neighbouring shopping centres. The home has three single bedrooms, one down and two upstairs, a lounge/diner, kitchen, two toilets, bathroom and shower room. Outside there is a patio that acts as a smoking area. The Registered Provider is also the Registered Manager and he is supported by his wife as deputy manager, and eight other support staff. There is a minimum of two staff on duty during week days, only one at weekends when there are fewer service users present, with one member of staff sleeping in at night. The Registered Provider and his wife live close by. Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Inspector spent three hours at the home and spoke to the Registered Manager, a member of staff, and two service users. He toured the premises and was shown a service user’s bedroom with their permission. He examined in detail the care file of the latest service user to move in, and the staff file of the most recent member of staff to commence their employment. The Inspector checked the extent of the home’s compliance with the requirements and recommendations from his previous inspection. He inspected the home against 18 of the Key Standards of the National Minimum Standards (NMS) and found that 9 were met, and 9 were only partially met. The Inspector made 15 requirements, 5 of which are restated from the last inspection having not been achieved within the timescale set. The Inspector also made 4 recommendations. What the service does well: What has improved since the last inspection?
Two of the three service users have now been issued with individualised terms and conditions. An improved version of the home’s complaints procedure has been written though not yet implemented. A copy of the London Borough of Hillingdon’s Adult Protection policy has been obtained, but staff have not yet been trained in its use, and the home’s own adult protection policy has not yet been updated. The service user’s bedroom that needed to be redecorated ahs been but the hot water temperature is incorrectly set. Loose telephone wires in the kitchen have been clipped to the skirting board, but this also needs to be done in the lounge/dining room and corridor. Cleaning materials have been
Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 6 locked away in a cabinet in the bathroom. Rubble has been cleared away from the front and back of the house, but the patio has not yet been completed. The deputy manager, Mrs Luchmun wife of the proprietor, has now applied to become the Registered Manager. The shower has been completed, and the trip hazard at the entrance to the shower has been marked. 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. Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS5. The outcome for NMS 5 is not fully met for the reasons stated below. EVIDENCE: The Inspector asked to see individualised terms and conditions for all three service users. He was shown documents that had been issued to two service users but was told by the Registered Manager that despite the third service user having been resident since July 2005 (four months), an individualised terms and conditions document for him had not yet been produced. See Requirement 1. Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS6: The outcome was not fully met, for the reasons stated below EVIDENCE: The Inspector examined in detail (case-tracked) the care file for the most recent service user. He found that an assessment of the care needed had been provided and that a CPA care plan was in place that had been reviewed. The service user and his relative had signed their agreement to these. The home had produced its own care plan which indicated which aspects should be reviewed fortnightly and which aspects reviewed monthly. However this had taken place in August 2005 and there were no entries on the care plan since. The Registered Manager explained that he was acting as the key worker but was training support workers to take over this role. He said aspects of the care plan had been reviewed and this was documented in the care notes, but had not yet been entered up as changes or updates in the care plan, where they should be signed by the key-worker and the service user. See Requirement 2 and Recommendation 1. Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. The outcomes for all these standards are fully met. EVIDENCE: One service user has been referred to The Links Project in Greenford for computer training, one day a week initially. His mother is purchasing a computer for him to use in his room. He visits his mother’s home each weekend. A second service user goes to a local church and a café, daily. A third service user has been referred to a local day centre for attendance. All three have the opportunity to play football and volleyball in the park, and to enjoy barbeques in the back garden. Their relatives visit when they are able to. Meals are produced according to a four-weekly cycle, with service user substitutions possible on the day. Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The outcome was fully met EVIDENCE: The Inspector examined the home’s records of administration of medication and found no errors. Service users are enabled to take their own medication at lunchtime when they may not be in the home. Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The outcomes for these standards are partly met. EVIDENCE: NMS 22: The Inspector asked the support worker on duty for a copy of the home’s complaints procedure and was shown one pinned to the notice board in the lounge/dining room. This was not the updated policy that the Registered Manager subsequently produced. See Requirements 3 and 4. NMS23: The Inspector asked to see the home’s updated Adult Protection policy. The Registered Manager could only produce then old one but the Support Worker was able to find the London Borough of Hillingdon’s ‘Safeguarding Adults’ booklet. The Registered Manager reported that he had put staff forward for the appropriate training at Hillingdon but that this had been cancelled by Hillingdon for some reason. See Requirements 5 and 6. Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The outcome for Standard 24 is not fully met due to the number of concerns raised below and under Standard 42. The outcome for Standard 30 is met. EVIDENCE: NMS24: The Inspector toured the home and found the following. Loose telephone wires along the skirting boards in the corridor outside of kitchen and in the lounge/dining room. See Requirement 7. The seats and backs of all three dining chairs were soiled. See Requirement 8. The hot water in one service user’s bedroom was excessively hot despite thermostatic mixer valves having been fitted. See Requirement 9. The home was found not to have a thermometer for measuring the temperature of water. See Requirement 10. NMS30: The home was seen to be clean and hygienic. The support worker was seen to be cleaning the bathroom and toilet during the inspection. Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 33 The outcome for NMS 32 is not fully met. Those for NMS 33 and 34 are not fully met. EVIDENCE: NMS32: The Inspector asked the Registered Manager how many of the support staff had NVQ level 2 qualifications and was told that three had the qualification and three were undertaking it. The requirement is that at least 50 are so qualified by the end of this year. See Requirement 11. NMS33: The Inspector asked the support worker for the current weeks staff rota. From this it appeared that on four days out of the last seven, only one member of staff was on duty instead of the previously agreed two. The Registered Manager explained that at weekends, one service user spent the day at his mother’s, and another spent time at church, therefore only one member of staff was rostered to be on duty at weekends. The Inspector agreed to this. The Registered Manager explained that the other two days in question were when he was due to be on duty but was sick, when his wife covered his shifts. The Inspector noted however that on one of these days she was rostered to be on duty in any case. Hence in order to full fill the requirement that two staff be on duty each weekday, another support worker should have come on to work that day, and if that was the case, his/her name must be recorded on the rota. See Requirements 12 and 13
Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 15 The Registered Manager reported that his wife, the deputy manager, had recently submitted the application forms to become herself the Registered Manager. The Inspector is keen that the Proprietor ceases to be the Registered Manager as he has substantial work commitments elsewhere. NMS34: The Inspector asked the Registered Manager for the recruitment file of the latest person to be employed. It was explained that this person had not yet started work pending receipt of a CRB disclosure, and no proper file existed to be inspected. The Inspector therefore examined the file of the last employee to start work. It was noted that the only references supplied were personal ones. A recommendation was made at the last inspection that a reference should be obtained from the previous employer. The Regulations have now been amended to make this a requirement. It is not being restated here however as it was dealt with in the last inspection report as it is the same recruitment file that was examined previously. It was noted that this file did not contain any evidence of an interview having taken place. It did not contain a copy of the employment contract given to the member of staff. The file did not contain a copy of the employee’s job description. The file did contain some supervision notes but these were headed ‘Supervision/Interview Record’ and the last supervision was dated April 2005. The Registered Manager reported that formal supervision had taken place since then but the notes were kept elsewhere. See Recommendations 2, 3, and 4, and Requirement 14. Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The outcome is not fully met for the reasons stated below. EVIDENCE: NMS42: The Inspector checked the recording of temperatures for the refrigerator which were fine. The temperatures of the freezer however were not being recorded. Requirement 15. The other Health and Safety issues are recorded under Standard 24. Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score N/A N/A N/A N/A 2 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 N/A N/A N/A N/A Standard No 24 25 26 27 28 29 30
STAFFING Score 2 N/A N/A N/A N/A N/A 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score N/A 2 2 2 N/A N/A CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Blandford Lodge Score N/A N/A 3 N/A Standard No 37 38 39 40 41 42 43 Score N/A N/A N/A N/A N/A 2 N/A DS0000027125.V260600.R01.S.doc Version 5.0 Page 18 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 YA5 Regulation 5 (b) Requirement Service users must have an individual statement of terms and conditions. THIS IS RESTATED FROM THE PREVIOUS INSPECTION. TIMESCALE OF 01/09/05 WAS NOT MET. Service user care plans must be produced, reviewed and consulted upon in line with this regulation The home’s complaints procedure, leaflets and posters (AS DISPLAYED) must show that complaints may be made directly to the CSCI at any time. THIS IS RESTATED FROM THE PREVIOUS INSPECTION.TIMESCALE OF 01/09/05 WAS NOT MET All staff must be trained in applying the revised complaints procedure The home’s adult protection procedure must refer to and be compatible with the London Borough of Hillingdon’s ‘Safeguarding Adults’ procedure. THIS IS RESTATED FROM THE PREVIOUS INSPECTION. TIMESCALE OF 01/09/05 WAS NOT MET.
DS0000027125.V260600.R01.S.doc Timescale for action 01/01/06 2 YA6 15 01/01/06 3 YA22 22 01/01/06 4 5 YA22 YA23 18 (1)(C) 13 (6) 01/01/06 01/01/06 Blandford Lodge Version 5.0 Page 19 6 YA23 13 (6) 7 8 9 YA42YA24 YA24 YA42YA24 13 (4) (a) 23 (2) (d) 13 (4) (a) 10 YA42YA24 23 (2) (p) 11 YA32 18 (1) (a) 12 13 YA33 YA33 17 (2) Sch4 (7) 18 (1) (a) 14 YA34 17(2) Sch4 (6) 15 YA42 23 (2) (C) All staff must be trained in applying the London Borough of Hillingdon’s Safeguarding Adults procedure. THIS IS RESTATED FROM THE PREVIOUS INSPECTION, THE TIMESCALE OF 01/10/05 WAS NOT MET. Telephone wires in the corridor and lounge/dining room must be secured. The dining chairs must be replaced or recovered and kept clean. The temperature of the hot water in all bedrooms must be controlled to be 42 degrees Centigrade = or – 2 degrees The home must obtain a suitable thermometer to check water temperatures, and record the hot water temperatures through out the building at least monthly. 50 of care staff to achieve NVQ level 2 in care by the end of 2005. THIS IS RESTATED FROM THE PREVIOUS INSPECTION. The staff roster must show exactly who worked when. The registered person shall ensure that at all times sufficient numbers of staff are working in the care home Staff files must contain all the information set out in Schedule 4 (6) of the Regulations and include a record of the employment interview, the job description and the signed employment contract. Freezer temperatures must be taken and recorded daily 01/02/06 01/12/05 01/01/06 01/12/05 01/01/06 01/01/06 01/12/05 01/12/05 01/01/06 01/12/05 Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 20 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 YA6 YA34 YA34 YA34 Good Practice Recommendations It is recommended that the present registered manager ceases to be the key-worker for all the service users as he has work commitments elsewhere. The supervision record should have the word ‘interview’ removed from it. All supervision notes should be kept together. More comprehensive staff files should be set up for all staff including those interviewed but not yet employed. Blandford Lodge DS0000027125.V260600.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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