Random inspection report
Care homes for older people
Name: Address: Sandhurst Lodge 58 Ampthill Road Bedford Bedfordshire MK42 9HL one star adequate service 22/04/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Rachel Geary Date: 1 3 1 0 2 0 0 9 Information about the care home
Name of care home: Address: Sandhurst Lodge 58 Ampthill Road Bedford Bedfordshire MK42 9HL 01234352051 F/P01234352051 sandhurst_lodge@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Dr Surinder Kumar Gulati Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 10 Number of places (if applicable): Under 65 Over 65 10 10 10 dementia mental disorder, excluding learning disability or dementia physical disability Conditions of registration: Date of last inspection Brief description of the care home 0 0 0 2 2 0 4 2 0 0 9 Sandhurst Lodge is a care home registered to accomodate up to 10 people whose primary care needs on admission fall within one of the following categories: old age, dementia, mental disorder (excluding learning disabilities) and physical disabilities. The home is located on a busy main road in the heart of Bedford town within close proximity to the local hospital, amenities including transport links. The accommodation
Care Homes for Older People Page 2 of 10 Brief description of the care home is set out over three floors - accessible via a staircase and a shaft lift. All bedrooms are single occupancy and communal facilities include a small lounge and dining room on the ground floor. There is one assisted bath and one shower, which would not be accessible for people with a physical disability. There are no ensuite facilties and there is limited outside space. At the time of this visit, work was in progress to extend the home to create a further 7 bedrooms and more communal space. Information about the home is available within the Statement of Purpose (SoP) and Service User Guide (SUG). Both are available within the home along with a copy of the most recent inspection report for this service. Care Homes for Older People Page 3 of 10 What we found:
On 2nd October 2009, we carried out a random inspection of Sandhurst Lodge and left an immediate requirement notice relating to recruitment checks for staff working in the home. This resulted in 5 of the staff not being able to work until specified documents had been secured. The focus of this inspection, carried out on the 13th October 2009, was to assess compliance in relation to the immediate requirement notice that we left on the 2nd October. We did not follow up on any requirements that were made at our last key inspection of this service on 22nd April 2009. Therefore any requirements showing in this report as outstanding, are not outstanding because they have not been met by the home, but because we have yet to assess their compliance. In summary, we found evidence on this occasion that the owners were updating and improving the systems for recruitment and vetting checks. But there was still some work to be done to ensure that all staff files are fully compliant with the legal requirements for care homes. We looked at files for people working in the home on the day of the inspection. Copies of recruitment, vetting and training documents were seen. There was no evidence that anyone from the home had verified the authenticity of some of the copied documents. However we did see that this work had begun in other files. We saw one written reference for a member of staff that had been signed after their start date - meaning that the person had started work without proper documentation being in place. There was evidence that a verbal reference had been taken at the time and we were told that this practice had now stopped. Verification of peoples reasons for leaving previous care positions were not always recorded, and there was no declaration about one persons physical and mental fitness on file. We received an email from the home shortly after our inspection on the 2nd October to confirm that these matters were to be remedied by 16th October 2009. A contract of employment was not seen on file for 1 member of staff. We were told the person was new and on probation. This is required information. On the whole we found evidence that gaps in employment history were being explored and recorded for people working in the home. And files that we looked at contained satisfactory Criminal Record Bureau (CRB) disclosures and proof of identity documentation. We did see a reference for one person which contained information that raised some concerns. There was no written record to show that home had sought further information and assurance on this matter at the time. We were told that it had been dealt with verbally only. Rotas were seen and showed us that there were 3 staff on duty through out the day and there was 1 waking and 1 sleeping staff on duty at night - for the 8 people living in the
Care Homes for Older People Page 4 of 10 home. There was no manager in post at the time of our inspection and we were told that one of the owners was temporarily acting as manager, and that action had been taken to recruit a permanent manager. What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 5 of 10 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 9 13(2), 12(1)(a) Care must be taken that medication procedures are followed and that there is documentation to support the procedure. The home must make sure that medication records are maintained and up to date for all medication administered by staff at the home. To ensure that service users are protected and not placed at risk. 01/05/2008 2 9 13 29/05/2009 3 12 16 Activities provided by the 23/06/2009 home should suit the needs, preferences and capacities of the people living there. To ensure that people, particularly those with dementia, are given meaningful opportunities for stimulation. 4 15 17 Records of the food provided 29/05/2009 for people living at the home should be kept. To make sure that the diet provided, in relation to nutrition and any special Care Homes for Older People Page 6 of 10 Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action diets, is satisfactory. 5 19 23 The home must provide the 05/06/2009 commission (CQC) with written information, including timescales, to say how each of the environmental deficits recorded in this report is to be remedied. To ensure that the home is suitable for its stated purpose and meets the individual and collective needs of the people living there. 6 30 18 Training must be provided for all staff working at the home around the assessed needs of the service users. To ensure that people living at the home have their needs met and are in safe hands at all times. 7 31 9 The manager must apply for registration with the CQC. To ensure that she meets the fitness criteria for managing a registered care home. 8 33 26 The registered provider must 12/06/2009 carry out visits in accordance with this regulation and supply a copy of reports made from these visits to the CQC until further notice. To promote the well-being of the people living at the home.
Care Homes for Older People Page 7 of 10 14/08/2009 05/06/2009 Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 9 35 17 Up to date records for monies held on behalf of people living at the home must be maintained within the home. This should include any bank accounts and all incoming and outgoing payments. To ensure that service users monies are safeguarded. 29/05/2009 Care Homes for Older People Page 8 of 10 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 9 of 10 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 10 of 10 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
