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: Katrina Derbyshire Date: 0 2 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): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Dr Surinder Kumar Gulati 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 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
Care Homes for Older People Page 2 of 10 Brief description of the care home 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:
This unannounced random inspection was undertaken on the afternoon of 2nd October 2009 by one Regulatory Inspector. The Care Quality Commission had been contacted on the morning of the 2nd October 2009, concerns were raised that staffing levels and recruitment systems were not sufficient at the home. The focus of this visit was to look at recruitment practises and staffing levels, we did not follow up on any previous requirements that were made at the last key inspection. Therefore those requirements showing at the end of this report are not outstanding because they have not been met by the home, but because we have yet to assess their compliance. We looked at the staff rota and met those staff on duty at the time of the inspection. The rota showed that a manager who had been employed via an agency had left two days prior to this visit. The owners reported that they had already taken steps to recruit to the post and this was to be advertised in the local press. One of the owners was acting up in the position of manager until a new manager is appointed. We looked at the staffing rota for the current week, alongside a random selection of other rotas going back to March 2009. These showed that there were 3 staff on duty throughout the day and two waking night staff and a sleep in duty person throughout the night. At the time of this inspection there were 8 people living in the home. We then examined the staff files of 6 people employed since March 2009 to look at recruitment practises. None of the files contained health checks or declarations and this needs to be actioned and was discussed with the owners. 3 of the 6 staff employed had only one written reference and one staff member had none in place within the staff files, only verbal references had been taken for this person. One member of staff, who did have two written references in place, had no previous employment history on their application form. There was one employer details entered under the most recent employment section of the application form; it was explained this business had closed so you were unable to secure a reference from them. However there were two written references, it was explained this was from a past employer where they had worked for two years in a laundrette. The checking of the accuracy and verification of information supplied within an application is a requirement. The documents also in use for references did not allow for their authenticity to be validated either. The other member of staff who had two references in place detailed within their application form that their previous role was that of a carer. However neither reference on their file detailed that they had been employed as a carer. Again it was not possible to verify the authenticity of the references due to the format that is used. It was also noted that most staff had been employed following a POVA First check, prior to the receipt of a CRB. This practise should only occur in exceptional circumstances.
Care Homes for Older People Page 4 of 10 Therefore staff had worked at the home with only a POVA First check and without two written references for a period of time. We left an immediate requirement about recruitment of staff at the home, we said that no one is allowed to work in the home until they have two written references and a POVA first check as a minimum. We contacted the service by telephone after we left, we did this to check that the immediate requirement had been acted upon by the owner. The owner confirmed that it had, cover was being arranged and Representatives from Social Services were also helping. 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 1 29 19 A POVA First check as a 03/10/2009 minimum must be secured alongside two written references and all other matters listed within schedule 2, (one reference from the most recent employer) prior to commencement of employment of staff. This is to verify the suitability of the person to work with the people who use your service To safeguard the people living at the home. 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!
