Inspection on 23/05/05 for Blenheim Lodge

This inspection was carried out on 23rd May 2005.

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

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

Other inspections for this house

Blenheim Lodge 01/07/08

Blenheim Lodge 28/01/08

Blenheim Lodge 16/05/06

Blenheim Lodge 10/10/05

Blenheim Lodge 02/02/05

Blenheim Lodge 01/06/04

Blenheim Lodge 01/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Blenheim Lodge North Road Minehead Somerset TA24 5QB Lead Inspector David Kidner Unannounced 23 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Blenheim Lodge Address North Road Minehead Somerset TA24 5QB 01643 703588 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) West Somerset Home (Blenheim Lodge) Limited Mrs Linda Mary Vaughan Care Home 34 Category(ies) of Old Age - 34 registration, with number of places Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one service user on respite care as detailed in a letter to CSCI. Date of last inspection 2 February 2005 Brief Description of the Service: Blenheim Lodge is registered with the Commission for Social Care Inspection to provide personal care to 34 service users over the age of 65 years. A Board of Governors who serve voluntarily administers the home as a Charitable Trust. The Registered Manager is Mrs Linda Vaughan. Blenheim Lodge is situated close to the town and seafront in Minehead. Blenheim gardens are nearby and enjoyed by many service users 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. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted by David Kidner, Regulation Inspector and Brian Brown, Pharmacist Inspector over one day (4.75hrs). Part of the purpose of the inspection was to establish the progress that the home has made in relation to the requirements and recommendations made at the last inspection on the 02.03.05. A total of eight service users, some staff, one family member and close friends of another service user were spoken to at the time of the inspection. One Inspector toured the premises and viewed areas of the home. Service users were spoken to in private and in communal areas. The Inspectors viewed records relating to staff recruitment, care plans, administration of medicines and health and safety matters. The Registered Manager was not at the home when the Inspectors arrived but arrived prior to the inspectors leaving. The Inspectors were able to provide initial feedback to the Registered Manager. As a result of this unannounced inspection, five requirements and four recommendations were made. The Inspectors were made to feel welcome at the home and all staff were very helpful. What the service does well: What has improved since the last inspection? Since the last inspection the home has addressed a number of issues that have been raised at previous inspections so as to promote the safe handling, recording and administration of medicines. However, there are still some areas Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 6 that remain to be addressed. These are identified in the main body of the report. The home maintains a record of the temperature of the hot water outlets. Each bathroom has a bath thermometer and reminders for staff to ensure the bathing water is at an appropriate temperature. 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. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, The Manager ensures that the home conducts a detailed assessment of need prior to any service users being admitted to the home. The pre-admission process is well documented. Standard 6 is currently not applicable. Therefore, this standard was not assessed at this inspection. EVIDENCE: The inspectors viewed the care plan for one recently admitted service user. A detailed assessment using the SHARP care plan system had been completed prior to admission. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 &10 The home operates the SHARP system for care planning. Not all care plans viewed reflected current need. Service users have access to appropriate health care professions. The home has made some improvement in relation to the administration, recording and storage of medicines. Service users are treated with respect and their privacy is upheld. EVIDENCE: The inspectors viewed four care plans. Care plans were detailed including Waterlow Assessments, Nutritional Assessments, Manual Handling needs, Medication needs and written preferences and social needs. However, none of the care plans viewed contained the name and address of the person’s care manager. It was noted that not all care plans had been reviewed within the planned timescale. One person’s care plan did not reflect the current manual handling needs and another care plan had not been reviewed since admission, although a review date had been set. The inspectors discussed these matters with the Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 10 Registered Manager. An Immediate Requirement was issued at the time of the inspection to address these matters with immediate effect. One relative that the inspector spoke to confirmed that they had been involved in the review of their relatives care plan. The service users that the inspector spoke to unanimously stated that the staff promote their privacy and always knock on bedroom doors before entering. One service user stated that staff promote their independence in aspects of assisting with personal care. The inspector witnessed staff addressing the service users in an appropriate and professional manner. All staff administering medication have received training on the safe handling of medicines. Eye drops requiring refrigerated storage were being stored at room temperature. This was addressed during the inspection. The date of receipt of medication was not recorded on all occasions and when hand written entries were made on the Medication Administration Record these were not always dated. Some date expired medicines were found and also some prescribed items for people no longer resident in the home. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12.13 & 15 The home provides social, religious, and recreational facilities for those who wish to participate. This includes visits to local attractions and leisure facilities as well as some in-house activities. Family and friends are welcome to visit at any time of the day. The home displays a menu for lunchtime and visits every service user each morning to discuss the menu and offer alternatives if so wished. Hot and cold drinks are offered throughout the day. EVIDENCE: The inspector spoke to a number of service users who confirmed that they are offered various choices of activities including visits to garden centres and the local gardens. Several service users commented that they liked to sit in the communal lounges chat and watch television or listen to music. Some service users stated that they also liked the privacy of their own room. The home displays local church service times. Each care plan has a record of all activities that are undertaken. Some service users that the inspector spoke to stated that family and friends are welcome at any time and that they can meet with their relatives and friends in the privacy of their room. One service user stated that family and Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 12 friends are always offered a drink when visiting. Service users were being offered a variety of drinks at the time of the inspection. The Inspector met and spoke to friends and relatives of two service users. All spoke very highly of the services that their relative and friend are receiving. They also commented that they are made to feel welcome at the home. The home displays the main meal of the day on the menu board. However, some service users that the inspector spoke to confirmed that they are asked every morning if they would like the choice for lunch or would they prefer an alternative. The inspector did not view lunch being served. Some service users that the inspector spoke to commented that the food is very good, “it’s hot and nicely presented”. The dining room was nicely presented with napkins and condiments placed on the table. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home has a Complaint Procedure, Whistleblowing Policy and an Abuse Policy. EVIDENCE: The Complaints procedure was displayed in the home. Some services users stated that they feel that they are able to make comments about the service that they receive and would make a complaint if they felt it was needed. The Inspector viewed the complaints Log. There were no recorded complaints since the last inspection. The Inspector spoke to one of the most recently appointed members of staff. They confirmed that they were aware of the Whistleblowing and Complaints Policies as these were discussed at induction. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 25 &26 The home is very nicely decorated, homely, clean and maintained to a good standard. Steps are taken to ensure that the facilities meet service users needs and that the home is safe and free from hazards. The home provides specialist equipment to promote the service user’s independence. EVIDENCE: The home was very clean and tidy when the inspectors arrived for the unannounced inspection. It is nicely decorated and very homely in appearance. There were no malodours evident at the time of the inspection. Service users commented that the home is always clean and tidy. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 15 The communal lounge areas were being used by service users to enjoy views of the garden and sea. There is easy access to the town centre and the sea front. The home has three assisted bathrooms, two showers and adequate toilet facilities. The inspector noted that all these areas were very clean and well maintained. Appropriate hand washing facilities are provided. There is a passenger lift to the first floor and a stair lift to the second floor. The inspector noted that the hoists, specialist bath, wheelchairs, passenger lift and stair lift had up to date service histories. Grab rails are also sited around the home and other mobility aids are provided as needed. One service user commented that they are able to get around the home by using their mobility aid. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The home ensures that there are adequate staff on duty with appropriate skills to meet the needs of the service users. Recruitment procedures were not robust and did not fully protect service users. EVIDENCE: At the time of the unannounced inspection the inspector noted that there were three care staff on duty plus one senior carer. The Registered Manager was not at the home but was contactable by phone if needed. The rotas that the inspector viewed indicated that there are usually five staff working in the morning, four staff in the afternoon and three staff of an evening. There are two waking night staff. Service users, relatives, friends and staff commented that they feel that there is adequate staff on duty to assist and provide the care that is needed. Service users commented that staff will also “do the little things that make a difference”. This was explained by one service user who stated that “staff will knock on your bedroom door just to say hello and to make sure that you are alright.” Service users also commented that if they need to press the call bell staff respond appropriately. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 17 There have been three new staff appointments since the last inspection. The Inspectors viewed all staff files. The Registered Manager must ensure that the files contain all items as listed in Schedule 2 of the Care Homes Regulations 2001. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38 The home is pro-active in seeking the views of the service users, their family and friends. The home takes steps to ensure that the health, safety and welfare of the service users is promoted and protected. EVIDENCE: The inspector briefly viewed some of the returned questionnaires that had been distributed to service users and other interested stakeholders in May 2005. The inspector was advised that the audit of the questionnaires would be undertaken at the end of May 2005. It is expected that the home will share the findings of the audit with the service users and other interested stakeholders. At the time of the inspection a Regulation 26, Care Homes Regulations 2001, monitoring visit was being carried out. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 19 The inspectors viewed documentation in relation to fire safety. Weekly fire testing, monthly emergency lighting records, servicing of fire equipment and the service of the fire system were all up to date. Records are kept of all staff training. It was noted that 19 staff have received fire training during February 2005. The inspectors noted that two fire doors were propped open. This was brought to the attention of the Registered Manager. This practice must cease. The Registered Manager acknowledged this and took immediate action. Records are kept of all accidents at the home. The home audits all accidents as to what part of the day they occurred, reason for accident, access to the call bell and the outcome/action to take as a team. It is noted by the home that most accidents occur at night. The inspectors recommend that the Registered Manager should review the staffing levels at night in light of the number of accidents occurring during the night. Working practices may need to be adjusted to address this matter. The home must ensure that it obtains a Landlords Gas Safety Certificate. The home’s administrator confirmed with the Inspector after the inspection that this service has been arranged for 07.06.05. The home should forward a copy of this certificate to the CSCI. An Environmental Health Inspection was conducted on 04.04.05. Some recommendations were made. West Somerset District Council has arranged a follow up visit. All the service records for the hoists, specialist bath, wheelchairs, passenger lift and stair lift were all up to date. Records are kept of the temperature of the hot water outlets. The inspector noted that the records indicated that these were within safe limits. The inspector noted that the bath panel in one bathroom is still broken and has not been replaced. This was first identified at an Announced Inspection on the 01.06.04. The manager must address this so as to promote health and safety. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 x x 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 2 Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 21 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 7 Regulation 15(2) Requirement The Registered Manager must ensure that care plans are reviewed to reflect service users needs. The bath panel must be replaced in the identified assissted bathroom so as to promote health and safety. Fire doors must not be wedged open. The Registered Manager must ensure that the staff files contain all items as listed in Schedule 2 of the Care Homes Regulations 2001. The Registered Manager must ensure that the date of receipt of all medicines into the home is recorded. Timescale for action Immediate requiremen t issued. 01.07.05 2. 38 13 (4) 3. 4. 38 29 23 (4) c 19 13.06.05 13.06.05 5. 9 13(2) 01.07.05 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 38 Good Practice Recommendations The Registered Manager should review staffing levels at night in light of the number of accidents occurring during D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 22 Blenheim Lodge 2. 3. 4. 38 9 9 the night. The home should forward a copy of the Gas Safety Certificate to the CSCI once obtained. The home should date and sign all hand written entries on the Medication Administration Record charts at the time of making them. The home should have in place an audit system to remove all date expired medicines and medicines no longer required. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier, Taunton TA1 4AL 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 Blenheim Lodge D53_D02 S16019 Blenheim Lodge V228560 230505 Stage4.doc Version 1.30 Page 24 - 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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