Inspection on 12/10/05 for Bluebell Lodge Care Home

This inspection was carried out on 12th October 2005.

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

Bluebell Lodge Care Home 15/05/08

Bluebell Lodge Care Home 26/11/07

Bluebell Lodge Care Home 07/02/07

Bluebell Lodge Care Home 29/06/06

Bluebell Lodge Care Home 25/05/05

Bluebell Lodge Care Home 29/11/04

Bluebell Lodge Care Home 11/05/04

Bluebell Lodge Care Home 20/11/03

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

CARE HOMES FOR OLDER PEOPLE Forest Lane House Care Home Forest Lane House Forest Lane Chippenham Wiltshire SN15 3QU Lead Inspector Alison Duffy Unannounced Inspection 12th October 2005 09:55 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 Forest Lane House Care Home DS0000040675.V258615.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 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. Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Forest Lane House Care Home Address Forest Lane House Forest Lane Chippenham Wiltshire SN15 3QU 01249 443501 01249 447506 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) Chippenham Limited Mrs Ann Elizabeth Macdivitt Care Home 19 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (1), Old age, of places not falling within any other category (19) Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users who may be accommodated in the home at any one time is 19. Not more than 1 service user aged 65 years and over with a mental disorder may be accommodated at any one time. Not more than 1 service user in the age range 50 - 64 years may be accommodated at any one time. This person may only occupy the accommodation referred to in the variation application dated 27 March 2004 for respite or intermediate care and for a period not exceeding 4 weeks (except by prior consultation with the Commission). This bedroom is numbered 19 and located on the first floor immediately next to the medication storage room. The room may not be used for any mental disorder placement. 25th May 2005 Date of last inspection Brief Description of the Service: Forest Lane House is registered to care for nineteen older people. Within the nineteen places, one room is fully designated to respite care. The home is located in a residential area of Chippenham. There are 16 single rooms and one twin. All contain en-suite toilet or bathing facilities and are located on both the ground and first floors. A passenger lift is available to give level access to all areas. The communal areas of the home consist of two lounges and a separate dining room. All areas are comfortable, homely and furnished to a good standard. The current owners took over responsibility of Forest Lane House in March 2003 and currently have two other care homes, in Kent and Suffolk. Mrs MacDivitt was appointed manager in September 2003 and works on a full time basis from Monday to Friday. There are generally three care staff on duty during the morning and this reduces to two during the afternoon and evening period. At night two members of staff undertake a waking night. The home does not provide intermediate or nursing care. Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 09.55am and 5.15pm on the 12th October 2005. The Inspector undertook a tour of the premises and spoke with a number of residents within the lounge and within private accommodation. Discussion also took place with Mrs Ann Macdivitt, the Registered Manager and a number of staff members. Daily records, care planning information, personnel records and the fire log book were viewed. The inspector also observed the serving of lunch. The CSCI Pharmacy Inspector examined the medication systems. Feedback was given to Mrs Macdivitt at the end of the inspection. What the service does well: What has improved since the last inspection? Since the last inspection, residents’ daily records have improved significantly. A new care-planning format has been devised which if implemented with careful consideration, will be an effective system. The medication systems have improved with the implementation of a new system creating greater organisation. Staff have now been given adult protection material for reference and dementia care training has been arranged. A risk assessment in relation to radiators has been devised with arrangements made for those considered to be high-risk areas. Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 6 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. Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 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 Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 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): 3 Although improvements have been made within the assessment process, greater attention is required to ensure key information is addressed within individual plans of care. Careful consideration must be given to the level of care and complexity of need that the home is able to cater for. In such instances, greater support and intervention is required from other specialised services. The home offers respite but not intermediate care. EVIDENCE: Since the last inspection a number of residents have been admitted to the home. Mrs Macdivitt also reported that two members of staff were currently undertaking an assessment of a prospective resident in hospital. Written documentation regarding two new admissions was viewed and in both cases, assessments from the placing authorities were in place. The assessments contained detailed information. One resident however portrayed complex needs and although information had been stated within the initial assessment, it had not been transferred to the plan of care. Discussion with and Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 9 assessments from other professionals such as a tissue viability nurse and the mental health team, in this instance were also required. Without advice, support and intervention from others, Mrs Macdivitt was informed that the potential for not meeting the individual’s complex needs was present. In such an instance, consideration should be given regarding the appropriateness of the placement. The Inspector spoke to a few residents new to the home although the depth of feedback varied. It was apparent that one resident felt totally settled and was convinced that moving to Forest Lane House had been the right decision. Contentment was evident although it was acknowledged that the transitional period had been difficult due to personal circumstances. Other residents, recently admitted appeared settled and were observed interacting with both residents and staff. At the last and subsequent inspection a requirement was made to ensure that following assessment, a letter confirming the resident’s needs would be met within the home, would be sent to the resident or their representative. Mrs Macdivitt reported that this matter has not been addressed and therefore remains outstanding. Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 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, 9 and 10 Shortfalls within the care planning process continue and therefore residents are at risk of not having their individual needs met. The new care planning format if implemented appropriately with careful consideration, is a significant improvement on the existing process. A system for the safe handling of medication is in use in the home, however the procedures must be followed correctly to ensure that residents are not put at risk. There is evidence to confirm that residents are respected and their privacy is maintained. EVIDENCE: At the last inspection it was noted that care plans did not reflect individual need and therefore a requirement was made to address the shortfalls. Through looking at various care plans it was evident that information continues to remain limited. Mrs Macdivitt reported that a new care planning format was in the process of being devised and therefore all required additions were due to be applied to the new format rather than the old. The inspector was shown the Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 11 proposed documentation and agreed that the format was much improved. However, on completion, set topics and standard phrasing would require greater detail. Mrs Macdivitt was also informed, that flexibility would be required when following the format in order to ensure that key themes were not missed. Within discussion and viewing documentation it was evident that some conditions and behaviours require management guidelines. Such matters include challenging behaviours, refusal of personal care and barrier nursing. It was also noted that there are currently some combined issues with limited eating and drinking, poor mobility and incontinence. Mrs Macdivitt was informed that nutritional, manual handling and pressure care management assessments are required. The intake of fluid and food should also be monitored and documented within systems such as charts. At the last inspection many of the daily recording sheets were poorly organised. It was evident that sheets were not always completed; many were mixed with other residents’ notes and all made reference to the residents’ Christian name only. A requirement was therefore made to address these issues. Within this inspection it was evident that new printed forms with key information had been developed and the system was now much more organised and professional in appearance. Greater detail with less subjective language was also in place. Improvements were seen in the home’s handling of medication. A new medication system using dossette boxes has been installed, which has improved the organisation of the medication. A procedure for administering and auditing the medication records was available. There are records kept of medication entering and leaving the home although additions to the medication administration record were not signed. On one occasion ambiguous instructions were written. ‘As required’ medication for one resident is given regularly yet this use is not supported by the prescriber’s instructions or the care plan. A serious omission was seen in the administration of one medication. Mrs Macdivitt was informed of the need to investigate this and report the findings to CSCI. All residents spoken with confirmed satisfaction with staff members and expressed that his or her privacy and dignity were respected at all times. Staff were observed knocking on doors and residents were spoken to with their preferred form of address. Residents confirmed that all personal care was given appropriately and staff respected residents’ wishes of wanting to spend time in their room. Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Activities within the home appear limited at this time, yet residents appear satisfied with this and enjoy their solitary interests. Residents are encouraged to follow their preferred routines and make their own choices. A varied menu is in place and the food appears appetising with residents’ satisfaction evident. EVIDENCE: All residents spoken with reported that they are able to follow their preferred routines and choose how they spend their day. Residents are therefore able to get up and go to bed at preferred times and spend time in their room as required. Some residents reported that they are happy to spend all day in their room undertaking solitary interests such as reading, crosswords and television. It was reported that the home did have an excellent activities organiser although she left and a replacement is proving difficult to find. Residents reported that some activities such as quizzes are provided although these are ‘not the same’ and therefore participation is limited. Some residents reported that they wouldn’t join in through preferring their own company. Another stated that they had tailored their interests to their own room and their general well being on a daily basis. Mrs Macdivitt agreed that activities have Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 13 recently been more limited although this is generally based on lack of interest and residents not wanting to ‘do anything.’ All residents confirmed that the food is very good and since the staff have been undertaking meal arrangements, the food has returned to ‘sensible, good home cooking’. Residents described variety to the meals and reported that alternatives are provided if the main course is disliked. Meals are served in the pleasant dining room although trays are provided to individual rooms as required. Menus are provided within display formats although Mrs Macdivitt reported that changes to menus or alternatives are not recorded at this time. Mrs Macdivitt was informed of the need to undertake this. Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 14 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 The complaints procedure is readily accessible, has been updated and now contains information as required. Staff have access to adult protection material yet training is required to promote awareness, therefore minimising the risks of abuse to residents. EVIDENCE: At the last inspection a requirement was made to up date the home’s complaint procedure in order to state the Commission for Social Care Inspection rather than the National Care Standards Commission. It was noted that this matter had been addressed, as the complaint procedure on the notice board was up to date. Residents spoken with reported that they would inform a family member or talk to Ann, if they had a problem. Since the last inspection, the CSCI has received a concern, which was investigated by Mr Mackey, the home’s Director. In between this inspection and the writing of this report however, a formal complaint has been received. Mr Mackey has been asked to address the concerns within the home’s complaint procedure and respond accordingly. At the last inspection it was of concern to the inspector that the staff on duty were not aware of and could not locate a copy of the Wiltshire and Swindon Vulnerable Adults procedure. In response to this, Mrs Macdivitt has given all staff a copy of the shortened ‘No Secrets’ documentation and a copy is also available on the notice board. Mrs Macdivitt reported that all staff have signed to demonstrate receipt of the information although this was not seen on this Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 15 occasion. A requirement was also made at the last and subsequent inspection to ensure that all staff have adult protection training which includes local policies. Mrs Macdivitt reported that accessing such training has been difficult although further training providers are being sought. In the interim period a video, which meets Sector Skills training targets is planned. It was agreed that this must be undertaken as a priority as the requirement has been outstanding over previous inspections. At the last inspection one resident spoke of needing to shout in order to attract attention as he couldn’t reach the bell and had had his extension chord removed. The extension chord had been replaced during the inspection although staff must ensure that all call bells are easily accessible. For example during this inspection one resident did not have a call bell as a member of staff had ‘forgotten, as often happens’, to place it near the armchair when in a seated position. Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 16 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): 24, 25 and 26 Residents are encouraged to personalise their rooms as they wish. While it is acknowledged that risk assessments have been developed in relation to radiators, insufficient progress has been made in the fitting of such. Greater attention is therefore required in order to minimise the risks to residents. EVIDENCE: Forest Lane House consists of one twin and sixteen single rooms. All have ensuite toilets and some also have bathing facilities. All rooms are personalised to varying degrees and residents reported that they are able to bring items of furniture in on admission. The rooms are light, warm and comfortable. Many however have radiators, which have not been covered. Following a requirement at the last inspection a risk assessment has been undertaken and Mrs Macdivitt reported that radiators identified as high risk, are being fitted with cool surface radiators by the end of November 2005. Hot water regulators are also planned throughout the building by November 2005. Although a risk assessment is in place regarding radiators, the inspector felt that some adjustments were required. For example one resident who is prone to falling Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 17 had been assessed as low risk due to staff assisting with all personal care. The incidents of nighttime waking and moving around however had not been taken into account. A further requirement to revisit the risk assessment and continue speedily with the programme of fitting covers has therefore been made. Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 18 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 and 29 Staffing levels are being maintained as required by the previous Registration Authority. Serious shortfalls within the recruitment procedures, despite being identified at the last inspection, place residents’ at risk of poor practice and abuse. EVIDENCE: Forest Lane House continues to have three members of care staff on duty during the morning period and this reduces to two for the afternoon and evening shift. There are two waking night staff. The home has a domestic assistant and the position of cook is currently vacant. Some care staff and the administrative assistant are currently covering this. Mrs Macdivitt reported that in the event of a care staff member cooking, an additional carer is deployed to cover caring duties. Mrs Macdivitt generally works during the week and is not an integral part of the working roster. At the last inspection it was noted that although maintaining staffing at agreed levels, there was one entry within a daily record stating a resident was told by a staff member ‘they didn’t have long to talk as there were only two staff on duty.’ It was noted that staffing levels had not been reviewed although residents did not refer to such during this inspection. All feedback regarding staff was positive with many comments such as ‘they’re really helpful and kind’ and ‘they work hard.’ Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 19 Since the last inspection the home has had one new member of staff. Within written documentation however, the start date was not evident. A requirement was made at the last inspection regarding this and Mrs Macdivitt reported that it was currently being done through the new system on the computer. The requirement is therefore repeated. At the last inspection it was noted that the recruitment procedure within the home was poor and needed greater attention to ensure protection. A number of requirements were made including the gaining of two written references and a POVAFirst and CRB check. It is concern to the inspector that despite this, the most recent member of staff commenced employment without a POVAFirst check. Mrs Macdivitt was once again informed that any appointment must be confirmed following the receipt of two written references and a POVAFirst check. They must then be fully supervised until their CRB disclosure is received. Training was not assessed on this occasion although Mrs Macdivitt reported that the NVQ programme is progressing well with the majority of the team having NVQ level 2. At the last inspection a requirement was made regarding the need for all staff to have dementia care and challenging behaviour training. Mrs Macdivitt has arranged a session in November, which will be repeated to enable all staff to attend. Discussion took place with Mrs Macdivitt regarding the depth of the subject and therefore it was recommended to have further sessions as an ongoing programme. Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 20 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): 36 and 38 Formal staff supervision is limited giving the potential for poor practice and unmet need. Residents’ safety is compromised through insufficient attention to health and safety matters. The planned fitment of individual hot water temperature controls will considerably reduce the risk yet radiator covers are required to enable full protection. EVIDENCE: At the last and previous inspection a requirement was made to ensure all staff have formal supervision. Mrs Macdivitt reported that the forms have been drawn up in order to record the session and supervisors have been identified. The practice however remains outstanding and therefore must be addressed. Mrs Macdivitt reported that sessions are planned and in the meantime, informal supervision is carried out on a daily informal basis. Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 21 At the last inspection a requirement was made to ensure all hot water outlets are monitored, with records kept. In the event of unpredictable or high water temperatures, individual fail-safe devices were required to be fitted. This was discussed with Mrs Macdivitt during this inspection, who reported that it had been decided to fit individual temperature controls throughout the building in all areas accessible to residents. At the last inspection it was noted that a number of windows on the first floor did not have restrictors. The inspector clarified the situation with the Fire Officer and was informed that any restrictor should be a result of a risk assessment. Mrs Macdivitt was therefore informed of the need to do this on an individual basis and incorporate such within the care planning process. As stated earlier in this report, risk assessments have been undertaken in relation to radiators. These however, require review and the programme of fitting covers must be progressed more speedily. While it is noted that all residents’ rooms have a number of radiators due to en-suite facilities, residents are currently at risk of injury and therefore this matter must be addressed as a matter of urgency. At the last inspection it was noted that all fire safety measures were being recorded within a small booklet, which did not give sufficient space for all checks. A recommendation was therefore made to revert back to using the full Fire Log Book and the CSCI forwarded Mrs Macdivitt a copy of all sheets to be used within. On checking fire safety it was apparent that the small book was still being used. The book demonstrated satisfactory testing of the fire alarms and the emergency lighting and a visual check of the fire extinguishers had been undertaken. It was also noted that within the alarm testing, alternate points had been used as advised. Documentation did not however demonstrate any fire drills or adequate staff fire instruction. Both matters were raised at the last inspection. Mrs Macdivitt reported that it was planned to use the larger Fire Log Book although this had not, as yet been put into practice. Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X 3 1 3 STAFFING Standard No Score 27 3 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 1 X 1 Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 23 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 OP3 Regulation 14(1)(d) Requirement The Registered Person must ensure that confirmation is given in writing detailing that the home can meet assessed needs before admission. This was identified at the last inspection. The Registered Person must ensure that key themes within the assessment process are identified within individual plans of care and are addressed with specialised services. This was identified at the last inspection. The Registered Person must ensure that all care plans fully reflect individual need, are up to date and detail how such needs will be met. The Registered Person must ensure that management guidelines for matters such as challenging behaviour and barrier nursing are in place. Guidelines regarding challenging Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 24 Timescale for action 12/10/05 2 OP3 14 and 12(1)(a) 12/10/05 3 OP7 15 31/12/05 4 OP7 12(1)(a) 30/11/05 5 OP7 12(1)(a) 6 OP7 12(1)(a) 7 OP9 13(2) 8 OP9 13(2) 9 OP15 17 Schedule 4, 13 13(6) 10 OP18 behaviour remain outstanding from the previous inspection. The Registered Person must ensure that pressure care management, in relation to the identified resident, takes into consideration poor food and fluid intake. This must be addressed with the Tissue Viability or Community Nurse whereby an action plan is agreed. The Registered Person must ensure that nutritional, manual handling and pressure care management assessments form part of the care planning process. Guidance should be sought from various health care professionals as appropriate. The Registered Person must ensure that written additions and alterations to the medication administration record are signed, dated and checked by two members of staff. The Registered Person must ensure that all medicines are only given in accordance with the prescriber’s instructions. These instructions must be clear and unambiguous with particular regard to ‘as required’ and variable medication. Guidelines for the use of these medicines must be stated in the care plan. The Registered Person must ensure that a record of meal provision is undertaken. This must include lunch and tea and any alternatives provided. The Registered Person must ensure that all staff receive adult protection training, which includes local policies. This was identified at the last inspection. The Registered Person must DS0000040675.V258615.R01.S.doc 11/11/05 30/11/05 12/10/05 12/10/05 12/10/05 31/12/05 11 OP18 13(6) 12/10/05 Page 25 Forest Lane House Care Home Version 5.0 ensure that all residents have access to a call bell system within their reach. This was identified at the last inspection. The Registered Person must ensure that the risk assessment regarding radiators is reviewed to incorporate an accurate reflection of risk. The programme to fit covers must be progressed with a matter of urgency with a proposal sent to CSCI regarding the anticipated timescale of completion. The Registered Person must ensure that a record of all staff members commencement dates is maintained. This was identified at the last inspection. The Registered Person must ensure a CRB disclosure is applied for and a POVAFirst check is undertaken before the commencement of a new member of staff. This was identified at the last inspection. The Registered Person must ensure all staff are aware of the policies and procedures within the home and receive formalised supervision. This was identified at the last inspection. The Registered Person must ensure that regular fire drills take place and all staff have fire instruction on a regular basis. This was identified at the last inspection. The Registered Person must DS0000040675.V258615.R01.S.doc 12 OP25 13(4)(a) (c) 30/11/05 13 OP29 17 Schedule 4, 6 30/11/05 14 OP29 19 12/10/05 15 OP36 18(1)(a) 31/12/05 16 OP38 13(4) (a)(c) 12/10/05 17 OP38 13(4) 30/11/05 Page 26 Forest Lane House Care Home Version 5.0 (a)(c) ensure that risk assessments are in place for all windows without restrictors on the first floor. In the event of any identified risk, a restrictor must be fitted. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP30 OP38 Good Practice Recommendations The Registered Person should ensure that dementia care is a regular topic within the home’s training plan. The Registered Person should consider reverting back to using the Fire Log Book in order to demonstrate fire safety. Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Forest Lane House Care Home DS0000040675.V258615.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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