CARE HOMES FOR OLDER PEOPLE
Blenheim Lodge North Road Minehead Somerset TA24 5QB Lead Inspector
Shelagh Laver Unannounced Inspection 1st July 2008 09:00 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 Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Blenheim Lodge Address North Road Minehead Somerset TA24 5QB 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) 01643 703588 linda@blenheimlodge2.wanadoo.co.uk WEST SOMERSET HOME (BLENHEIM LODGE) Limited Nicola Hudson Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 34. 28/01/08 Date of last inspection Brief Description of the Service: Blenheim Lodge is registered with the Commission for Social Care Inspection to provide personal care for up to 34 residents over the age of 65 years. A Board of Governors who serve voluntarily administer the home as a Charitable Trust. Blenheim Lodge is situated close to the town and seafront in Minehead. Blenheim gardens are nearby and enjoyed by many residents residing at the home. Accommodation is provided over three floors. A passenger lift is available to the first floor and there is a stair lift to the second floor. The home has three assisted bathrooms and two shower rooms available for service users. A call bell system is provided and grab rails have been installed in communal hallways. Nicola Hudson has been appointed as manager in May 2008 but is not yet registered. Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. At the Key Inspection of 28/01/08 a number of requirements and recommendations were made and the home was rated as poor. The staff at the home have made a concentrated effort to address the issues identified and this key inspection was positive. Whilst the overall rating for the home is adequate personal care and daily living in the home are rated as good. There has been regular contact with the home since the last inspection including Random Inspections carried out on 21/03/08 15/04/08 and 23/05/08 to monitor the progress and action taken to address the requirements and recommendations. Somerset Social Services Somerset Partnership and the Community Nursing teams worked together to assess people in the home and to offer advice and support. A series of strategy meetings were held to review and monitor progress and to safeguard people in the home. We agreed that there would be no new admissions to the home in the first half of the year although one lady who had been receiving respite care wished to become a permanent resident. This was agreed. The lady concerned was clear that she wanted to stay at the home and that it was meeting her needs. She said that the staff were “very good” and moved to a room with a wonderful view of the sea. Throughout the random visits the home appeared clean, tidy and welcoming. People were spoken with in the conservatory and in their rooms. There were regular visitors to the home. Some were aware that improvements were taking place and were satisfied with care in the home. Following assessments some people moved to homes that could better meet their needs. Initially acting manager Libby Cooper led the improvements by producing and progressing an action plan whilst continuing to head up the staff team. Nicola Hudson has been appointed as manager and has been in post since May 2008. It is proposed that in future Mrs Hudson will be the registered manager and Mrs Cooper will be the Care Manager. Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 6 An Annual Quality Assurance Assessment was received in July 08. This gives information about the achievements and plans of the service and indicates areas for further improvement. At this key inspection there were 23 people living in the home. Relatives and staff spoke to the inspector. Records relating to care, recruitment and training of staff and maintenance of the building were inspected. The manager and care manager were available and provided all required information. On the day of the inspection the lift was out of order. People ate lunch in the upstairs sitting room and all who possibly could used the stairs. One person said she was “was very fed up” that she was not able to go outside to the park as usual. What the service does well:
Blenheim Lodge is situated opposite a park and has easy access to both the seafront and the town. This enables relatives to take people out regularly and some people who are mobile really enjoy their surroundings. At this key inspection there was evidence that people were very pleased with the care they received at the home. People often commented on the kindness of staff. It was clear that management and staff are committed to the continued improvement of the home and welfare of the people who live there. There is evidence that some peoples’ health improves at Blenheim Lodge. The activities co-ordinator is imaginative and offers a range of activities and trips out. The home has been redecorated and is well furnished. Domestic staff take pride in their work. Bedrooms are pleasant and comfortably furnished. Some have wonderful views. Planning and documentation for people coming for respite stays is of the same satisfactory standard as for people coming to stay permanently. During the inspection a relative of a person receiving respite care asked to speak to the inspector. She wished to comment on the improvements to the home. “People are happier.” There were comments about the help that her mother was getting to become more mobile since being in hospital. “She has had encouragement and help to use her frame and walk.” People were pleased with the activities. “They have activities regularly. There are quizzes, bingo, chair aerobics”. One person was pleased with the environment and her own room. “This is a beautiful room. People are polite and kind. Confidentiality is good. They wont discuss anything about other people.” Health care was said to be “ Very good. Doctors come as soon as you need them. ” In one care plan a relative had written “We are very impressed with the excellent care X continues to receive. We have read and support the care plan.”
Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 7 Staff spoken to were positive and spoke of the training provided. One person said “I have finished my NVQ3. I am working my way through the drugs training. I am enjoying this. It is brilliant. We have done lots of training lately.” Two new members of staff were positive about the induction that they had received in the home. What has improved since the last inspection?
Choice of home The statement of purpose has been reviewed and up-dated to include all information required. A service user guide has been developed and is readily available to prospective and current residents. All key staff undertaking pre-admission assessments are fully aware of the homes registration to provide personal care only. Personal care There has been a training event on the SHARP care planning system and care plan have improved. There is evidence that staff consult with the residents and /or their representatives in relation to assessment, care planning and review. Care plans were seen to be reviewed regularly. There is evidence that staff support people who live in the home with all health needs. Reference material and information was obtained in relation to specific medical conditions relevant to individual residents. There was evidence of visiting health professionals. A clinical specialist had visited to provide support to one person and the advice was available in the care file. Doctors visit the home regularly. Care staff are clear of the limitations of their role in current employment. Records in care plans showed that the district nurse team was visiting the home regularly and was undertaking all clinical nursing procedures. Files reviewed showed clear recordings of visits to undertake dressings and injections. Risk assessments have been put in place where requested and appropriate for example use of dental tablets. A review of records for people who needed their food and drink monitoring were seen to be complete and comprehensive. Arrangements have been made to ensure that medicines are recorded when received into the home and also that records are made when medicines re given to people. A staff signature has been drawn up showing all who administer medication. A copy of the Royal Pharmaceutical Society current guidelines for managing medicines in care homes has been obtained and the medication policies updated to reflect current good practice advice.
Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 8 Two signatures are obtained on any hand transcribed entries on MAR sheets. Staff have received training to ensure that the management of medicines in the home follows that defined in the homes medicines policy. Arrangements have been made to calibrate the “sit- on” scales to ensure accurate record of peoples weights. Complaints and protection. Arrangements have been made to prevent people in the home from being harmed or suffering abuse (or being placed at risk of harm and abuse.) The home has obtained a copy of the Department of Health ‘No Secrets’ guidance and a copy of the Somerset safeguarding adult’s procedures. All staff and the governing body have received training on adult abuse awareness. The board of governors have satisfactory POVA first and CRB checks in place. The complaints procedure has been up-dated and is publicised widely. No complaints have been received however managers and staff spoken with were aware of the procedure and understood the need for full investigation and recording of all complaints. Information about complaints in the terms and conditions of residency have been up-dated to make it clear that complainants are able to contact the Commission for Social Care Inspection at any stage of a complaint. Environment Considerable work has been undertaken to improve and up-date the environment. There has been extensive redecoration and re-carpeting throughout the home. New furniture has been purchased for the dining room. There has been an up-grade of all electrical fittings and sockets. A hair dressing facility has been installed. Work has been undertaken to guard some radiators and pipe work. The laundry has been re-organised cleaned and up-dated. It is decorated to an acceptable standard. There are separate areas for clean and dirty laundry, the flooring has been replaced. A foot operated pedal bin is in place. Foot operated bins have been purchased and are in place. All residents have been offered a key to their private room and this information is included in the service users guide. Consideration has been given to providing a loop system in communal areas as requested by residents. This has been discussed but is not possible at the present time. There have been improvements in the storage arrangements in the home. Cupboards have been reorganised and space has been made for equipment. Storage of clean bedding has been reviewed. There was a concerted effort to remove clutter and tidy the home. Staffing Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 9 There has been regular information sent to the Commission regarding the staffing levels in the home to ensure staffing levels are sufficient. The dependency levels in the home have been monitored and while staffing is not generous the numbers in the home have enabled staff to provide required care. Recruitment plans have resulted in the appointment of a new manager and additional qualified care staff. A training programme has commenced and further events are planned. Staff were seen to be committed to improvements in the home and at all inspections were seen to be kind and respectful to people in the home. Management and administration The Commission has been notified of events in the care home that affect the well-being of people who live in the home. The home has obtained an up-to-date copy of the Care Homes for Older People National Minimum Standards and Regulations and both the manager and care manager refer to this regularly. All staff have been made aware of the confidentiality policy in the home. There has been a review of people in the home who are able to provide first aid and additional training has been provided. All records are now kept securely. The passenger lift has been serviced and certified by a qualified person as fit for purpose. Electrical hard wiring has been examined and a certificate produced to evidence that the home is safe. All portable appliances have been tested and certified safe by a qualified person. All information relating to COSHH has been up-dated and accessible information is available. There has been a review of the storage of all hazardous substances and safe lockable storage has been seen. All staff have received training in fire safety. A fire risk assessment that includes a means of evacuation has been developed. The Fire service has visited the home and areas of non-compliance have been addressed. Care staff have undertaken training in moving and handling. The manager has sort the views of people who live in the home informally and has also begun a quality assurance system with questionnaires to people. The views of people who have come to the home for respite care has been recorded. Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 10 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. The summary of this inspection report can be made available in other formats on request. Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 11 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 Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 12 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. 1 3 There is a range of information available for people to assist them in making a choice of home. People who enter the home have a thorough assessment that ensures the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service Users guide has been up-dated to reflect the personal care that the home provides. There have been no new permanent admissions since the last Key inspection however one person who was a temporary resident has become permanent. People are booked regularly to come for respite care and two full assessments were seen. The manager is clear that she will only accept people to the home when she is sure that their needs can be met and this was confirmed by documents seen.
Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 13 People confirmed that they were visited by senior staff from the home prior to admission. Files contained detailed assessments and information from other health professionals including information from hospitals and assessments by Social Services. People in the home have been re-assessed by care and health professionals and all staff have a clearer idea of the care that the home can provide. Fees are currently £450 per week. Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 14 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is good. Care is planned and recorded. The health needs of people are met. Medication administration is safe. People are treated with kindness and encouraged to maintain independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were examined. They were detailed and gave staff clear instructions of the care needed. For example there was detailed guidance of the amount of fluids to be offered to one person. There was a detailed night care plan for one person who was unsettled. This included details such as “likes to sleep in the chair. Ensure analgesia has been offered.” For another person there was a very detailed care plan clearly indicating the persons’ individual needs. The inspector spoke with a district nurse who was visiting. This care plan did need up-dating in some areas as the person’s condition was changing rapidly. A fluid
Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 15 balance chart and change of position record must be implemented as soon as a person’s needs begin to change. There was documented evidence that the people had been consulted at the monthly review of the care plans. Files were signed and one person had written “I am happy and contented. No grumbles at all.” All care plans are reviewed with the resident and updated as necessary on a monthly basis. There are records of peoples monthly weights. One person had a clear plan to help her to maintain her weight. It was good practice that she had been actively involved in all aspects of this plan. There was evidence that people were visited regularly by GPs and nurses. It could be seen in care plans that regular reviews with GPs were held. Emergency visits were made to address urgent health needs. People have individual medication safes and can self- administer when appropriate. The home has reviewed medication administration procedures and provided staff with additional training. Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is good. People can chose how they spend their time in the home. There is an activities programme in place that is varied and seasonal. Meals are wholesome and well presented. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People can make choices about how they spend the day. A member of the night staff confirmed that people made choices about what time they got up. During visits to the home seasonal activities were seen. There was a very attractive Easter display and activities. The home employs a full time activities co-ordinator who compiles the monthly programme of events and completes detailed social care records. There is an emphasis on links with the community and individual preferences. The home is opposite a park and near to the seafront in Minehead. People go outside whenever they can often assisted by family. There is a monthly newsletter giving details of the events planned and news from people in the home. In July there was an open air church service in the park, an afternoon musical entertainment and a trip to a local beauty spot for tea.
Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 17 The activities co-ordinator said there was always scope for more 1:1 interaction as some people did not want to socialise with others whatever was planned. She was able to give an examples of how accessing a new radio had improved someone’s daily life. There are books available in the library in the home. Daily papers can be purchased. The conservatory faces the park and street and provides a point of conversation and interest. Food in the home was said be “good” and “plenty of it”. There are plans to review the menus and include lighter choices. On the day of the inspection the main choice at lunch was lamb chops. Although other choices are available people were not too clear about what these were. There were fresh vegetables available and staff were aware of individual preferences of people. Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 18 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. People spoken to during the inspection knew who to speak to if they had any complaints. Recruitment files contained evidence that all staff are appropriately screened before they are employed at the home. There are policies and procedures in place to protect people. Staff have received training in protection of vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has reviewed arrangements to prevent service users being harmed or suffering abuse. The current local guide-lines Safeguarding Adults in Somerset have been obtained. Staff training has been provided. Action has been taken when required. All staff and the governing body have received training on adult abuse awareness. The board of governors have satisfactory POVA first and CRB checks in place. The complaints policy and procedures have been up-dated. Information about complaints in the terms and conditions of residency have been up-dated to make it clear that complainants are able to contact the Commission for Social Care Inspection at any stage of a complaint. The complaints procedure is publicised widely. No complaints have been received however managers and staff spoken with were aware of the procedure and understood the need for full investigation and recording of all complaints.
Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 23 24 26 Quality in this outcome area is good. People live in a home safe and well maintained environment that meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home showed that over the past six months the home had received substantial investment. It has been redecorated and new carpets have been laid. The home now appears bright, clean and comfortable. Some rooms including bedrooms and an upstairs sitting room have lovely sea views. There is a choice of communal areas. New furniture has been purchased for the dining room. Bedrooms are spacious and comfortable. As rooms become available they are being completely redecorated and new furniture has been purchased. People have personalised their rooms with furniture and belongings. Maintenance has been undertaken to ensure the safety of the environment.
Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 20 There has been an up-grade of all electrical fittings and sockets. Work has been undertaken to guard some radiators and pipe work. The laundry has been re-organised cleaned and up-dated. It is decorated to an acceptable standard. There are separate areas for clean and dirty laundry, the flooring has been replaced. Storage of clean bedding has been reviewed. A foot operated pedal bin is in place. Foot operated bins have been purchased and are in place. A hair dressing facility has been installed. All residents have been offered a key to their private room and this information is included in the service users guide. Consideration has been given to providing a loop system in communal areas as requested by residents but it is not possible at the present time. Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is good. The skill mix and numbers of staff on duty meet peoples’ needs but must be regularly reviewed. The recruitment policy and practices in the home are adequate and protect people in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection there were six people on duty organised into teams for each floor. There is an emphasis now on team working and the organisation of staffing in the home has undergone a fundamental review. A number of bank staff are being recruited. There were sufficient domestic staff on duty to ensure that the home appeared clean and well cared for. A night care assistant had come into the home for an up-date on manual handling. There are two staff on duty at night. There is a training matrix in place to track the delivery of fire, manual handling and protection of vulnerable adults training. There has been training on care planning, medication and first aid since the last inspection. Three staff files seen and were seen to comply with recruitment requirements. A check list showing the dates that a member of staff started work and the dates that all records are received in the home would be helpful to ensure
Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 22 legislation is complied with. CRB checks had been undertaken and references have been obtained. It is good practice to ensure that two independent references are received. The interview process has been reviewed and standardised questions are now included in the interview process to gain a more objective view of candidates. New staff receive an induction based on Skills for Care. The Care Manager is still developing and reviewing the form and structure of this induction. Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 37 38 Quality in this outcome area is adequate. The management team is new and systems are still developing. The home is run in the interests of people who live in the home and is safe well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager Nicola Hudson is committed to gaining the required qualifications and to be registered with the Commission within six months. She has experience in administration and working in an environment providing services to older people.
Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 24 It is intended that Nicola Hudson and Libby Cooper will take on the roles of manager and care manager within the home each having specific responsibilities. At the key inspection clear job descriptions had not been drawn up detailing the responsibilities of the manager and the care manager. These are important to ensure that there is an appropriate staff structure in the home and all in the home are clear about peoples’ responsibilities. The monthly newsletter contains a note from the manager to people in the home up-dating them on developments and plans. There was an explanation about the fire practices and an apology for any disruption. Quality assurance systems have commenced with questionnaires completed by 14 of the 19 people who received them. They confirmed that people were very happy with care provided. A detailed questionnaire is sent to people receiving respite asking if the home would be recommended to friends. In both cases the answer was “yes.” The manager is planning to implement a supervision and appraisal system and to hold staff and residents meetings. There are contracts in place for key maintenance requirements. Maintenance requirements made at the last inspection have been addressed and there is now a system in place to monitor regular checks. There are records of monthly visits made by the home governors. Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X 2 X 3 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP31 Regulation 9(2b) Requirement The manager must register with the Commission and gain qualifications necessary for managing a care home. The system for reviewing and improving the quality of care in the home must be completed and formalised. A system for supervising staff must be fully implemented. Timescale for action 01/03/09 2. OP33 24 01/12/08 3. 4. OP36 OP30 18 2 18 (1) (a) (c.) (i) 01/10/08 All staff must undertake common 01/10/08 induction standards training. This will take time. Action has commenced. (Previous time scale. 01/07/08) Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP30 Good Practice Recommendations The manager should complete the staff training and development programme for the year based on the outcomes of staff appraisals and the skill requirements of the home. It is recommended that G.P homely remedies written authorisation be reviewed annually. The registered person should provide advice and guidance to staff on what the dependency scores mean and any action that needs to be taken. The advocacy policy should include the contact details of local advocacy services and the Commission for Social Care Inspection. It should also make clear that selfadvocacy is not always possible and that residents and their families have the right to contact external agencies. Significant efforts should be made to increase the number of staff qualified to NVQ level 2 or above. All policies and procedures should be reviewed and updated to reflect current good practice advice and give clear up-to-date information to staff. Formal staff supervision should be implemented and should cover the topics detailed in the national minimum standards 36.3. 2. 3. OP9 OP7 4. OP17 5. OP28 6. OP33 7. OP36 Blenheim Lodge DS0000016019.V366226.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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