Inspection on 01/09/05 for Bourne House Nursing Home

This inspection was carried out on 1st September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bourne House Nursing Home 06/06/06

Bourne House Nursing Home 22/11/05

Bourne House Nursing Home 28/10/04

Bourne House Nursing Home 19/05/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Bourne House 45 Langley Avenue Southborough Surbiton KT6 6QR Lead Inspector Diane Thackrah Unannounced 1 September 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. Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bourne House NH Address 45 Langley Avenue, Southborough, Surbiton, Surrey, KT6 6QR 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) 020 8399 6022 020 8390 9394 jag@irh-homes.com London Residential Healthcare Limited Care home 40 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (40) Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 28th October 2004 Brief Description of the Service: Bourne House is a registered care home providing nursing care for up to fourty people who have dementia or physical disabilities. The home is a large detached property situated in a residential area of Surbiton, with access to public transport systems, churches of a number of denominations, local shops and leisure facilities. The home is owned and managed by London Residential Healthcare Limited. Accommodation is provided over three floors. Passenger lifts are available in the home. There is a large, well maintained garden to the rear of the premises. Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 1st September 2005 between 12.15 and 16.30. A partial tour of the premises took place and care records were examined. The Registered Manager and three staff members were spoken with. Some service users were also spoken with, and these expressed their satisfaction with the service. It was not possible to discuss the service with other service users, due to the complexity of their dementia. It was noted however, that all service users appeared comfortable, relaxed and well cared for. What the service does well: What has improved since the last inspection? Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 6 The home has collected a large amount of information about local advocates and external agents. This has been made available to service users, their families and friends. There have also been small changes to the activities programme. More activities are now carried out in small groups, or one to one sessions, and this has been beneficial to the current service user group. The home has been inspected by the local fire officer and found to meet with safety Regulations. What they could do better: One service user has been admitted to the home, despite them having a condition that the home is not registered to cater for. Discussion with a staff member and examination of care records indicate that this service user’s needs are currently being meet. A Requirement has therefore been made that the home applies for a variation in service user categories. However, the home must not admit any other service user who’s needs are not reflected in the home’s certificate of registration. There is a need for staff training to ensure that the needs of this new service user are meet adequately. There is a need to ensure that all staff members are sufficiently trained in the safe handling of medication. Recent poor handling of medication by staff members has had potential for placing the well being of service users at risk. Staff members must not store wheelchairs in bedrooms other than that of their owners, and it is necessary that written consent is gained regarding the use of a service user’s bedroom as a hairdressing room. Ideally, this practice should not occur. Minor repairs are required to the furniture in bedroom 34. There must be a satisfactory Criminal Records Bureau and Protection of vulnerable adults check in place for all staff members prior to them commencing work in the home. The only exception to this is were staff members are new to living in the UK. In these circumstances, the home must apply for a police clearance check in the staff member’s country of origin. This must be in place prior to the staff member commencing employment. There have been delays in reporting incidents in the home. The Commission for Social Care Inspection must be notified in writing, without delay, of any incident, detailed in Regulation 37, which occurs in the home. Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 7 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. Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 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 standard(s) 1, 3 and 4. There is a Statement of Purpose and Service User Guide which detail the aims and objectives of the home, and services provided. Prospective service users therefore have the information required to make an informed choice about moving into the home. The home continues to carry out assessments of needs for prospective service users so that service users can be assured that their needs will be met. However, service users whose needs do not fall within the home’s categories of registration must not be admitted, as there is potential that theirs, and existing service user’s needs will not be met. EVIDENCE: The home has a Statement of Purpose and Service User Guide. Both documents have been produced in a clear format and contain all information required by Regulation. These documents have been produced in a written format, but can be provided in other formats on request. A copy of the Service User Guide is provided in each bedroom. A Requirement was made at the last inspection of the home regarding the need to include information about the home not providing oxygen, to be included in the Statement of Purpose. The Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 10 Registered Manager said that there has been a change in policy, and service users will now have access to oxygen in the home. It is therefore no longer a Requirement that the Statement of Purpose be amended. A Requirement is made later in this report regarding the need to apply to the Commission for Social Care Inspection for a variation in service user categories. If this variation is approved, there will be a need to amend the Statement of Purpose to ensure that it accurately reflects the range of needs that the home is intending to meet. An assessment document is completed for each service user as part of the admissions procedure. This ensures that the needs of each service user can be properly assessed and planned for. A senior staff member visits prospective service users in their home, or in hospital to assess their needs. Records were available detailing the assessed needs of the most recent admission. This included information about their health and medical condition, weight, personal care required and social needs. The home aims to offer specialist care to people who have dementia, or a physical disability. Toilet doors have been painted a bright colour to aid identification for service users and there is a variety of aid and adaptations provided throughout the home. The Registered Manager said that the small group, and one to one activities are provided. There is one full time and one part time Registered Mental Nurse working in the home. Some staff members have received training in the needs of people who have dementia and on going training is provided in conditions associated with old age. The home is not registered to provide a service to people who have schizophrenia, however, one service user, who has this condition, has been admitted in the last year. Care records detail that the home is currently meeting the needs of this person and discussion with one staff member confirmed this. An application must be made to the Commission for Social Care Inspection for a variation in categories of registration to ensure that the home’s certificate of registration accurately reflects the situation in the home. There is also a need to provide staff members with training in the needs of people who have schizophrenia. This is to ensure that appropriate and professional support is provided. Only service users whose needs are reflected in the home’s categories of registration may be admitted. Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 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 standard(s) 7, 8, 9 and 10. There are, in general, good arrangements for addressing the personal care needs of service users; this allows service user’s needs to be met. However, there have been incidences were medication has not been handled safely by staff members. This places the health and safety of service users at risk. In general, service users are respected and have their dignity upheld. Some practices however, do not fully uphold service user’s rights. EVIDENCE: Individual plans of care are in place for each service user. These are generated from a detailed assessment of need. Plans examined covered all aspects of health, personal and social care needs. Risk assessments were detailed in each plan, including risk assessments regarding moving and handling. There were records detailing that care plans are reviewed at least monthly and changed to reflect changing needs. Of four care plans examined, two had been signed by the service user’s representative and two had not been signed. It is recommended that further opportunities are made available to service users and their family members to read and sign care plans. A record should be maintained were this offer has been declined. Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 12 Discussions with staff members highlighted that they were aware of the needs of service users, and able to meet these. All service users are registered with a local GP at the point of moving into the home. One service user’s care records detailed that an optician, social worker, psychiatrist, GP and chiropodist saw them regularly. Another service user’s care records detailed that the home had made arrangements with their GP for their medication to be reviewed. Nutritional screening occurs and weight is monitored. The home has written policies and procedures in place for dealing with the receipt, recording, storage, handling, disposal and administration of medication. Medication is stored in a locked cupboard and there are facilities for handling controlled medication. Medication and Medication Administration Records were examined for four service users. These were found to be in good order. The Registered Manager advised that recent spot checks of medication have highlighted serious shortfalls, by some staff members, in the safe handling medication. Incident reports regarding this were not made available to the Commission for Social Care Inspection at the time, nor were they available at the time of this inspection. These must be made available without delay so as to allow for further investigations to be made if necessary. This standard will be examined in further detail once necessary information is provided by the home. The Registered Manager said that all staff members who administer medication have received training to do so. However, there were no records detailing training in the safe handling of medication for one staff member responsible for administering medication. All staff members who handle medication must have received training to do so. The arrangements for ensuring dignity and respect when providing personal care were detailed in the care plans examined. Staff members spoken with demonstrated an awareness service user’s rights in relation to being treated with respect and having their dignity upheld. Staff members were also observed to interact appropriately with service users during this inspection. This included being seated whilst feeding service users and knocking on bedroom doors before entering. One service user’s bedroom was being used as a ‘hairdressing room’ at the time of this inspection. The Registered Manager said that the service user’s family member had granted consent for this, however, there were no records to reflect this. It is recommended that this agreement be confirmed in writing. It is also recommended that an alternative space be sought to use as a hairdressing room, so as not to impinge on the privacy of the occupant of this room. Another service users bedroom was being used to store four wheelchairs. Service user’s bedrooms must not be used as storage areas. Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 13 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, 13,14 and 15. Social activities are well organised and provide some stimulation for service users. Service users are given opportunities for exercising personal choice and therefore retain some control over their lives. Meals are nutritious and balanced and offer a healthy and varied diet for service users. EVIDENCE: At the time of this inspection a number of service users were noted to be spending time in the communal lounges enjoying conversations with staff members or visitors. There is a television in the main lounge, but this was not switched on. The Registered Manager said that the television is switched on only occasionally, as current service users prefer this. There are two part time activities organisers who provide structured activities on a daily basis. There have been a number of trips recently including bus rides to a local garden centre, shopping centre and park. Entertainers have also visited the home. The home encourages visitors and a number of service users were seen to be spending time with visitors during this inspection. ‘Friends of Bourne House’ meetings are held regularly were relatives and friends are invited to meet and discuss issues relating to the home. Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 14 The home does not handle service user’s finances, but does retain small amounts of money on service user’s behalf. There has been a recent incident of theft of one service user’s money from the home; this is addressed in Standard 18 of this report. Good efforts have been made to provide service users and their relatives and friends with information about how to contact independent advocates. This information is made available in the entrance hall of the home. Service users are encouraged to personalise their bedrooms. Bedrooms viewed all contained personal possessions and were homely in appearance. A meal of sausage casserole and fresh vegetables, followed by trifle was served for lunch during this inspection. Meals were nutritious, well presented and service users appeared to be enjoying them. Appropriate support from staff members was available. Specialist, religious and cultural diets can be catered for. There were written menus displayed in the home, however, these were out of date. The Registered Manager said that menus are normally up to date, but due to lack of access to the home’s computer, would not be available for one week. A recommendation is made regarding this issue. Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 15 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) 18. Vulnerable adults procedures in the home are generally adequate and ensure that service users are protected from abuse. However, there have been failures to notify the Commission for Social Care Inspection of significant events in the home in a timely fashion, this has potential for service users best interests not being safeguarded. EVIDENCE: The home has adopted the Protection of Vulnerable Adults policy developed by the Royal Borough of Kingston Upon Thames. One staff member spoken with demonstrated an appropriate knowledge of adult protection issues, including whistle blowing. Staff training profiles indicated that staff members undergo training in the protection of vulnerable adults during their induction programme. Investigations are currently ongoing in the home as a result of a number of thefts. Records indicate that the home has responded appropriately by keeping relevant parties informed. However, there was a delay of one month from the first incident to the Commission for Social Care Inspection being informed. The Commission for Social Care Inspection must be notified in writing, without delay, of any incident of theft in the home. An issue regarding the delay in reporting other incidents to the Commission for Social Care Inspection has been addressed in Standard 9. A Requirement is made in relation to these issues. Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 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 standard(s) 19 and 26. The home is, in general, maintained, decorated and furnished to a good standard and facilities are clean and safe. This ensures that most service users live in a pleasant, homely and comfortable environment. There is a need for minor improvements in this area to ensure that all service users benefit from living in a well maintained environment. EVIDENCE: Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 17 The home is situated on a residential street close to Surbiton centre. There is a large, very well maintained garden to the rear of the home. Parking is available in the home’s car park. The home was well maintained, comfortable and homely at the time of this inspection. A maintenance worker is employed and there are regular checks on maintenance standards with records kept. Furniture provided throughout the home was generally of good quality. However, one bedroom contained a broken desk and badly fitted headboard. These issues must be addressed to ensure the comfort and safety of the service user occupying this room. The local fire officer has carried out an inspection of the home in 2005 and found it to comply with safety regulations. The Registered Manager advised that the home also complies with the requirements of the local environmental health department. CCTV cameras are not used in the home. The home was very clean and free from offensive odours. The laundry is sited well away from the kitchen and there is a contract for the collection of clinical waste. Policies and procedures are in place to deal with the safe handling of clinical waste. Staff members receive in house infection control training. Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 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 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 numbers and skills mix of staff members are sufficient to meet the needs, and ensure the safety of the current service user group. The procedures for the recruitment of staff are not robust and therefore do not fully provide the safeguards to offer protection to people living in the home. EVIDENCE: Staffing levels, evidenced in staff rotas, and in numbers on shift at the time of this inspection were found to be appropriate and safe, in accordance with the care and social needs of the service users. There is a skills mix of staff including care and nursing staff, cleaners, a cook, administration workers, activities coordinators and a maintenance worker. The home also employs up to six nurses from overseas on ‘supervised placements’ These workers carry out care tasks, whilst receiving supervision to convert their overseas nursing qualification into one that is recognised in the UK. Staff recruitment files were examined for a random sample of four staff members. Each file contained identification documentation, an up to date photograph, two written references, visa information, a statement of terms and conditions and completed application form. Documentation was not available detailing that a satisfactory Criminal Records Bureau or Protection of vulnerable adults check had been carried out on any of these staff members. A representative from the home advised that police checks are obtained in the country of origin for staff member s coming to work in the home directly from overseas. However, records of this were available for only one of these staff Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 19 members. Staff members must not commence work in the home until a satisfactory Criminal Records Bureau and Protection of vulnerable adults check is in place. Criminal Records Bureau checks are not portable. The home must apply for, and be in receipt of a new Criminal Records Bureau and Protection of vulnerable adults check for each new staff member prior to them commencing work. When staff members are employed directly from overseas, and have not previously worked in the UK, the home must apply for directly, and be in receipt of a police clearance check, from the county of origin of the worker. The Registered Manager agreed that those staff members, for whom there is not a Criminal Records Bureau, Protection of vulnerable adults, or police check, applied for by the home, would not work unsupervised until such checks were in place. Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 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 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) 31, 32 and 37. The home is, in general, managed properly and staff members receive guidance which allows service users to receive consistent and quality care. There have been some failures in record keeping and reporting which have potential for service users’ best interests not being safeguarded. EVIDENCE: There has been a change in Registered Manager since the last inspection of the home. The new manager is registered with the Commission for Social Care Inspection. The Registered Manager has worked in this home as a Registered General Nurse. She also has work experience as a senior nurse manager. She has a master’s degree, which incorporates management training. There is a clear management structure in the home and regular staff meetings are held. Responsibilities are shared between heads of departments in the home. Staff members spoken with said that they received support from the Registered Manager and that there was a clear sense of direction and Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 21 leadership in the home. The Registered Manager demonstrated a commitment to equal opportunities. In general record keeping and was found to be up to date, accurate and in good order. Service users have access to their personal records if this is their wish and all records seen were stored securely. However, a number of requirements have been made as a result of this inspection regarding records required by Regulation, not being available. This includes records necessary for the reporting of incidents in the home, staff training records, and documentation required for the safe recruitment of staff. Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 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 x x 3 3 3 x x x x 2 x Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 23 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 4 Regulation 12 (1)(a) Requirement Timescale for action 01.11.05 2. 4 12(1a)18 (c, i) 37 (1)(ag) 3. 9 4. 9 12(1a)13( 2)18(1c, i) The Registered Provider must: 1. Ensure that an application for a variation in service user categories is made to the Commission for Socail Care Inspection. This application must detail that one service user has a condition which falls outwith the catergories of the homes registration. 2. Ensure that no other service user is admitted to the home, whos condition is not reflected in the homes categories of registration. The Registered Provider must 01.12.05 ensure that there is staff training in the needs of people who have schizophrenia. The Registered Provider must 01.10.05 ensure that the Commission for Social Care Inspection is notified, without delay, of any event in the home which adversley affects the well being or safety of any service user, any incident of theft, or any other occarance detailed in Regulation 37. The Registered Provider must 01.11.05 ensure that only those staff members who have been trained Version 1.40 Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Page 24 5. 10 12 (4)(a) 6. 19 12(1a)16( 2c)13(4a) 7. 29 19 (1)(a) Sch4 in the safe handling of medication are responsible for handling medication. The Registered Provider must ensure that service users bedrooms are not used to store other service users wheelchairs. The Registered Provider must ensure that the headboard in bedroom 34 is fixed securley to the bed and that the broken desk in this bedroom is repaired or replaced. The Registered Provider must ensure that no staff member is employed to work in the home unlesss there is a satisfactory Criminal Records Bureau, Protection of Vulnerable Adults, or Police check in place. These documents must be made available for inspection. (This is a repeat Requirement. Timescale of 01.01.2005 has not been met) 01.11.05 01.10.05 01.10.05 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 7 Good Practice Recommendations The Registered Provider should provide further oppurtunities for service users, or their representitives to read and sign care plans. Records should be maintained were this offer has been declined. The Registered Provider should document that an agreement has been made that one service users bedroom may be used as a hairdressing room. This should include the signiture of the family member giving consent. Further consideration should be given to finding alternative space to be used for hairdressing. The Registered Provider should ensure that there is access to the homes computer at all times to allow menus to be printed. G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 25 2. 10 3. 15 Bourne House Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 26 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 Bourne House G53-G53 S26244 bournehse V211231 010905 stage 0.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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