Inspection on 25/05/06 for Bonehill Lodge

This inspection was carried out on 25th May 2006.

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

Bonehill Lodge 09/12/08

Bonehill Lodge 30/06/08

Bonehill Lodge 20/09/07

Bonehill Lodge 17/10/06

Bonehill Lodge 21/02/06

Bonehill Lodge 05/07/04

Bonehill Lodge 29/04/04

Bonehill Lodge 23/10/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bonehill Lodge 62 Park Lane Fazeley Tamworth Staffordshire B78 3HZ Lead Inspector Mrs Mandy Brassington Key Unannounced Inspection 25 May 2006 09:45 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 Bonehill Lodge DS0000004919.V298708.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. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bonehill Lodge Address 62 Park Lane Fazeley Tamworth Staffordshire B78 3HZ 01827 280275 F/P 01827 280275 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) Bonehill Limited Mrs Tina Joyce Boyland Care Home 26 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (26) of places Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 Brief Description of the Service: Bonehill Lodge is a residential home situated in the suburbs of Tamworth, Staffordshire, having access to local amenities and public transport. The home looks out onto open countryside and has a paved area to the rear and a small area of landscaped garden to the front of the home. The home provides a service for 26 older people and is also registered to care for 6 individuals who suffer with dementia. The three-storey property provides residential accommodation on both the ground and first floor, having 22 single occupancy and 2 shared bedrooms, ensuite facility is provided within a number of bedrooms. The first floor is accessible via a passenger lift. Bathrooms and toilets are located throughout the home and in close proximity to bedrooms and communal areas. The property has a large lounge, divided into two separate areas, which leads to a dining area equipped with essential furnishings to meet the needs of the service users. There is a conservatory, which leads to a small paved garden. The registered provider is Bonehill Ltd who has overall responsibility for the home. The manager of Bonehill Lodge informed the Commission for Social Care Inspection on 25 May 2006, during the visit, that the fee level for Bonehill Lodge is between £335 and £420 per week. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered all of the core standards. The inspection took place over 7.5 hours by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. Prior to the inspection visit, survey information has been obtained from service users and their relatives. Eight comment cards were received back from service users; six comment cards were received from relatives and one comment card from a General Practitioner. Feedback has been included within this report. A tour of the home was undertaken. The inspection included an examination of records, indirect observation, discussions with six service users, the manager, and the staff on duty. Case tracking of four care plans was undertaken. Four staff records were examined and observation of daily activities took place. The inspector ate lunch with the service users. An Immediate Requirement notice was issued on the day of the inspection for one requirement and a further twenty-two requirements and three recommendations were made as a result of this visit. Eight requirements have been carried over from the last inspection. This was considered to be an adequate inspection in relation to the overall care provided, though the home is still failing to meet a number of the National Minimum Standards and the Care Homes Regulation, and there are a significant number of long-standing requirements; the home will be subject to additional monitoring visits to ensure compliance with statutory requirements. What the service does well: The home provides a good standard of residential care, for older people in a homely atmosphere. Personal care provided and staff interaction with service users was very good and there was a high level of satisfaction from those living at Bonehill Lodge. Service users confirmed that they liked living there, were well cared for and stated the staff treated them well. Staff observed had a knowledgeable and positive attitude towards service users. During the inspection, staff were heard offering choices and enabled the Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 6 service users to make decisions. Staff were courteous and were observed providing care in a sensitive and dignified manner, using appropriate forms of communication. Service users and relatives commented, ‘my mother has wonderful care’ ‘staff are very friendly, all the staff are good’ ‘I have no grumbles about the staff, they always do the best they can’ ‘I like living here and my family can visit me’ What has improved since the last inspection? What they could do better: There remains a number of long standing requirements that have not been addressed. Requirements must be addressed to meet the National Minimum Standards and Care Standards Act 2000. The home must ensure there are robust recruitment practices. A registered person may allow a new member of staff to start work at a care home as long as an enhanced CRB has been applied for and all other elements of Schedule 2 have been obtained including a POVA Check. The previous report identified that there was no evidence of specialist activity or stimulation for people with dementia. The home also has many small corridors and a neutral colour scheme, and is hard to navigate through the building without getting lost. Consideration should be given identifying areas and individual rooms. The home does not meet specific needs of people with dementia. Activities within the home have commenced, though community and social activities do not take place. The requirement to review this area was not completed and is to be carried out to ensure service users have an opportunity Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 7 to access community activities; individuals are reliant on friends and family to take them out. The requirement to appropriately supervise staff six times per year is ongoing. It is essential that formal supervision begins and the manager is to be included in this process. The registered provider does not conduct monthly Regulation 26 visits. The Statement of Purpose and Service User Guide need to be reviewed to ensure they provide all the information necessary for prospective service users in order to help them make a choice about where to live. 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. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 8 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 Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 The quality in this outcome area is ‘adequate’. This judgement has been made using available evidence including a visit to this service. Individuals do not have access to a full range of information regarding the service provided, when having a trial visit and choosing whether to reside in the home. EVIDENCE: The Statement of Purpose and Service User Guide had not been amended and the requirement for including additional information, as included in the National Minimum Standards and Regulations remains outstanding. These documents need to accurately reflect the service provided. Four plans of care were sampled and statement of terms and conditions and a written contract had been completed. The contract available for inspection contained references to out of date legislation and incorrect information regarding registration of the home. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 10 The manager had carried out a pre-admission assessment of service users needs prior to individuals being admitted to the home, to establish whether the home had the capacity to meet their needs. The manager reported that the information gathered at assessment is transferred into the care plans. The home does not provide intermediate care. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. The quality in this outcome area is ‘adequate’. This judgement has been made using available evidence including a visit to this service. Care planning and health care monitoring has improved and there is evidence of assessment of risk; further work is required to plans of care include the support individuals require to meet identified needs. The home does not meet the specific needs of individuals with dementia and there are no therapeutic activities. EVIDENCE: The manager completes an initial assessment from which a plan of care is devised. Plans of care record assessment of care needs, social, emotional and health needs. The information recorded is limited and does not detail how identified needs are to be met. Care plans are to be reviewed to ensure a plan of how staff are to support individuals to meet identified needs. Assessments of risk have been completed for falls, and transferring and moving in the home. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 12 The manager is in the process of changing the care plan format and a clear record of all health professionals visits are maintained and a record of outcomes. Identified health needs are monitored, including fluids, where there is a risk of dehydration, and a weight chart. All service users are registered with a G.P. The manager is aware of the need to ensure that evidence is available to confirm that service users and / or their representatives are offered the opportunity to participate in the care plan and subsequent reviews. This evidence is being sought. The manager is speaking to relatives and carers in order that plans of care can include a ‘Life story’. One plan sampled included a life story, which recorded all major incidents in the person’s life and gave an excellent profile of the individual up to the point of moving to the home. Discussion with service users revealed all individuals were satisfied with the level of health support provided and when areas of concern had been raised, medical support had been sought. On the day of the inspection, there was a funeral and several members of staff attended. Service users stated they were asked whether they would like to attend and staff demonstrated sensitivity in supporting other residents. One individual was terminally ill and being cared for in their room, advice and support had been sought from the G.P. Family members were welcomed into the home and were able to spend time alone with their relative and to be involved with the care required. The home is also registered to provide a service for 6 individuals with dementia. The previous inspection identified there was no evidence to any specific services, facilities or stimulation to meet the needs of this group of residents. The manager is reviewing the care provided to people with dementia, but no specific therapeutic activities are currently provided. It is required that dementia care needs be met and appropriate support and stimulation be provided. Staff observed had a knowledgeable and positive attitude towards service users and feedback from service users was very encouraging about their relationship. Service users and relatives commented, ‘my mother has wonderful care’ ‘staff are very friendly, all the staff are good’ ‘I have no grumbles about the staff, they always do the best they can’. Medication is stored in a locked trolley in the dining room. The bracket on the wall was not secure and needs repairing. Within the medication trolley the provision of medicines were seen to be satisfactory, the MDS system is used Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 13 and a pharmacist reviews the system. Controlled drugs were accurately stored and recorded. No service users self-administer medication. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. The quality in this outcome area is ‘adequate’. This judgement has been made using available evidence including a visit to this service. Service users have access to a range of activities within the home. Individuals are reliant on friends and family members for community and social activities. EVIDENCE: Previous inspections had identified there was little emphasis focused on social activities within the home or in the community. The manager has implemented more activities within the home, and on the day of the inspection, individuals were able to participate in flower arranging. The flowers were later put on all dining tables. Activities organised for the week of the inspection included; exercise to music, ‘old time’ sing a long, manicure and hand care, tell me a story and bingo. Service users are still reliant on family members and friends for community activities. Discussion took place with the manager regarding a further review of activities to include opportunities outside of the home and for activities to be provided to suit individual’s cultural and religious needs. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 15 It was revealed that staff may provide transport to service users in their own cars. Appropriate insurance cover has not been in place. Where staff use their vehicle for work business insurance is to be provided. Family members and friends are able to visit the home on a flexible basis. Service users comments regarding daily activities included’ ‘sometimes we play cards and I can go out with my sister’ ‘it’s much better now we do some activities’ ‘I like living here and my family can visit me’. The previous inspection identified menus were to be reviewed to provide suitable alternative meals. This had not been completed and the menus still recorded alternatives, which did not provide for a balance meal. This requirement remains outstanding and menus are to be reviewed. At lunchtime the service users ate in the dining room. A meal was taken with the service users and the mealtime was relaxed and unhurried. The meal served was lamb hot pot, potatoes and vegetables or cheese and potato bake, and jam sponge with custard. Three service users confirmed the food was of a good standard. Only cold drinks were served with the meal. Discussion with service users revealed a preference for a hot drink; one service user did not drink anything with the meal, stating that she did not like cold drinks. It is required that service users have a choice of hot and cold drinks with their meal. The kitchen was inspected and found to be clean and tidy with a cleaning schedule completed. Additional storage facilities on the second floor were still being improved and therefore food was stored within the main kitchen during the improvement period. The kitchen is still in need of refurbishment; the manager reported that this is to be completed in July. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 16 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, 18. The quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to this service. The complaints procedure gives service users and their representatives a full understanding of the options available to them relating to making a complaint and a record of concerns are recorded. EVIDENCE: The home has a complaints procedure displayed in the front hall and in each bedroom. The complaints procedure has been reviewed to inform individuals that service users may contact the Commission. The complaints book was seen and was up to date with complaints or concerns appropriately logged. All the service users and staff spoken with confirmed they would speak with the manager in the first instance and would be confident in doing so. Family members manage personal finances for all service users. The manager had no concerns over individual’s finances and there was a safe facility to hold any personal monies or valuables on the property. Three records were sampled and were accurately maintained. Service users were registered to vote. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, 26. The quality in this outcome area is ‘adequate’. This judgement has been made using available evidence including a visit to this service. The Home is clean and tidy though requires a robust maintenance programme to ensure the home is adequately maintained. Risk assessments have been carried out to ensure specified areas of the home meet the needs of individuals with poor mobility, sensory impairments and dementia. EVIDENCE: A requirement was made in July 2005, for a maintenance plan to address all areas of work was required within the home and when this work was to be completed; this has not been addressed and the home remains in need of general repair and refurbishment. The providers are to forward a copy of future works to the Commission to identify the necessary repairs and maintenance required with timescales to complete the work. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 18 Hot pipe work remains in the home and in en-suite facilities. This requirement has not been fully completed. Additional visits will need to be completed to ensure this complies with Health and Safety regulations. The home was generally clean and tidy and communal areas were equipped with essential furnishings. The manager reported that the kitchen is to be refurbished in July 2006. A review of the environment in relation to colours and access to areas and individual rooms for people with dementia has not been done; further discussion took place with the manager regarding the need to ensure different areas of the home can be recognised and identified and individuals can easily orientate around the home. Risk assessments have been completed for the bedrooms on the first floor in relation to the corridors and the bedroom flooring has been addressed. The manager confirmed service users will not be placed in these bedrooms if there is a concern with mobility or require additional support. A sample of bedrooms was viewed. Bedroom two requires the bedside cabinet to be secured to the wall due to uneven flooring in the corner of the room. Bedrooms have been fitted with suitable locks and plans of care record whether service users are able and want to have a key. Individuals are able to personalise and furnish their bedroom and where individuals share a room screening has been provided. The manager is aware that any new admission must demonstrate a positive choice to share if moving into a double room. Bathrooms and toilets were situated throughout the home and were in close proximity to bedrooms. Water temperatures were recorded and a record maintained of any work required. Appropriate hand-washing equipment was provided at all sinks with the exception of the lower ground floor bathroom. The bathroom did not have toilet paper. During the inspection, it was noted that a urine specimen had been left for a significant length of time in the bathroom and was not attended to. This was reported to the manager who dealt with these issues. The bathroom is also used for storing wheelchairs and hairdressing equipment. The bath has a permanent hoist fitted and one side of the bath was not accessible. It is required that alternative storage facilities are provided to enable full access to the bathing facilities and to meet health and safety guidelines. The home has a Conservatory leading to the pathed area, where service users may smoke. The padded seating on the furniture is covered in plastic bubble wrap from when the furniture was delivered. The manager was informed that this is to be removed as it is not suitable and also presents as a fire risk. The round dining table in the lounge is unstable; this is to be repaired to a suitable standard. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. The quality in this outcome area is ‘poor’. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures are required to ensure appropriate checks are carried out prior to employment within the home to ensure service users are not placed at risk. EVIDENCE: Three new staff had started work as a support worker since the last inspection. Examination of staff records revealed two staff had started prior to a POVA check being returned. A registered person may allow a new member of staff to start work at a care home as long as an enhanced CRB has been applied for and all other elements of Schedule 2 have been obtained including a POVA Check. An immediate requirement notice was issued in relation to this practice. Additional pre-employment checks including obtaining references and copies of identity were carried out. Staff files contained a photograph. The Deputy manager has a contract and terms and conditions, but has been issued with a Job Description for a Care Assistant. It is required that an appropriate Job description be provided which clearly records the duties and responsibilities commensurate with this position. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 20 Staffing was provided on a 24 hour basis; on the day of the inspection, three carers worked from 8.00am until 3.00pm or 5.00pm and three carers worked from 3.00pm or 5.00pm until 10.00pm. There were two waking night staff. The shift times in the afternoon allowed for a flexible service and a thorough handover. The manager works flexibly across the shifts and there was a cook working from 8.00am until 2.00pm and two domestic staff providing seven hours cover during the day. The previous inspection identified staffing is to be reviewed in relation to the care and staffing provided to enable community activities, and additional support and assistance for activities for service users who have dementia. This review has not been conducted and remains a requirement. Discussion with one new member of staff revealed a comprehensive induction had taken place and new staff are initially able to work in a supernumerary capacity. Since the last inspection, staff have received further training for Fire safety and been involved in evacuation of the premises. It is recommended that a matrix be devised to clearly identify which staff have been involved with drills and evacuations. Inspection of training records revealed staff have not received up to date training for moving and handling. It is required that this be conducted to ensure the health and safety of staff and service users. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 37, 38. The quality in this outcome area is ‘adequate’. This judgement has been made using available evidence including a visit to this service. The manager has made improvements in the standard of care and services available in the home and is committed to developing the service to meet the National Minimum Standards. The manager and staff are not part of any formal supervision process. EVIDENCE: Quality Assurance Questionnaires had been sent to families in May and a good response had been received. The comments regarding the service and staff were positive though many raised the lack of activities within the home; the manager is addressing this. The manager was aware of the need to compile an annual review and to include views from professionals and stakeholders in the community. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 22 Residents meetings do not take place and there is no formal system for service users to contribute to the management of the home. It is recommended the meetings are conducted at regular intervals and be recorded. Monthly unannounced visits are not being conducted by the Proprietor. It is required that these are carried out on a monthly basis and a copy of the report to be available for inspection. Staff do not receive formal supervision. This requirement has been raised during previous inspections and must be addressed. The manager is also to be part of the formal supervision process. The health and safety of service users and staff were promoted with safe regular fire checks and drills, servicing of gas appliances, and monitoring the water system. The home does not have an Emergency Contingency Plan as part of a Fire Risk assessment. The home is to develop a plan for ultimate evacuation to a place of safety and consider the needs of the service users and staffing levels. Due consideration is to be given to access alternative accommodation and emergency contact numbers. This plan is to be reviewed regularly and updated to reflect any changes. Service users’ financial interests were safeguarded; service users were encouraged to look after their own financial affairs with the support of their families or representative. Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 2 1 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 1 3 2 Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 (1)(2) 5 (1)(2) Requirement To develop the Statement of Purpose and service users guide to reflect the service provided and include all details within Schedule 1 The home’s contract is to be reviewed in relation to changes in legislation and changes to the Commission To further develop plans of care to ensure all service users have a detailed plan and information relating to how the needs are to be met Evidence of service users and/or their representative’s involvement in the assessment, care plans and review. This requirement is outstanding from report 21/02/06 The manager is to carry out a review to demonstrate how the home meets the needs of individuals with dementia. A copy is to be forwarded to the Commission. This requirement is outstanding from report 21/02/06 Timescale for action 25/08/06 2 OP2 24 (1)(a) 01/08/06 3 OP7 15 (1) 24/07/06 4 OP7 15(1)(2) 25/08/06 5 OP7 24(1)(2), 12(4)(b) 25/07/06 Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 25 6 7 OP9 OP12 13(2) 16(2)(m) 8 9 OP15 OP15 16(2)(i) 16 (2)(i) 10 OP19 23(b) 11 OP19 23(2)(b) 12 13 14 15 OP19 OP20 OP20 OP21 13(4) (a)(c) 23(2)(c) 23(2)(g), 13(4)(a), 16(2)(c) 16(2)(j), 23(2)(j) 23(2)(a), 13(4)(a) 16 OP21 The medication is to be securely stored. The wall bracket is to be repaired Residents should be consulted regarding their social interests and make arrangements to enable them to engage in local, social and community activities. This requirement is outstanding from reports 01/02/04, 27/07/05, 21/02/06 Service users to be provided with a choice of hot and cold drinks at meal times Menus to be reviewed to ensure a balanced diet is provided daily. This requirement is outstanding from report 21/02/06 To ensure that the kitchen is refurbished to a suitable standard. This requirement is outstanding from report 21/02/06 A building maintenance programme should be developed to identify the necessary repairs and maintenance required. This requirement is outstanding from report 27/07/05, 21/02/06 Hot pipe work in the home including en-suites is to be covered The dining room table in the lounge area is to made stable The delivery plastic is to be removed from the conservatory furniture Appropriate hand washing facilities and toilet cleansing equipment are to be available at all times To remove wheelchairs and other equipment from the ground floor lower bathroom and store in a suitable place. DS0000004919.V298708.R01.S.doc 02/06/06 25/07/06 16/06/06 25/06/06 25/08/06 25/08/06 30/07/06 10/06/06 25/05/06 25/05/06 05/06/06 Bonehill Lodge Version 5.2 Page 26 17 OP29 19(1)(b) (i) 17(2) 18(1)(c) (i) 26(1)(2) (3)(4)(5) 18(2) 18 19 20 21 OP29 OP30 OP33 OP36 22 OP36 18(2) 23 OP38 23(4) New members of staff are to have applied for an enhanced CRB and a POVA Check returned prior to starting work. The Deputy Manager is to have an appropriate and suitable job description as Schedule 4 (6)(e) Staff to receive moving and handling training The proprietor is to conduct monthly unannounced visits and a copy be retained for inspection The registered person should ensure that all staff receive formal supervision at least six times per annum covering: a) all aspects of practice b) philosophy of care in the home; career development. This requirement is outstanding from reports 31/07/03, 27/07/05,21/02/06 The manager is to receive formal supervision. This requirement is outstanding from report 21/02/06 To carry out a fire risk assessment and to include an emergency contingency plan 25/05/06 25/06/06 25/08/06 25/06/06 30/07/06 30/07/06 30/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard OP19 OP38 OP38 Good Practice Recommendations To review the environment in relation to colours and identifying rooms for people with dementia To develop a matrix for recording staff fire training Staff to have appropriate insurance whilst using their own vehicles at work Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Bonehill Lodge DS0000004919.V298708.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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