CARE HOMES FOR OLDER PEOPLE
Sandhurst Lodge 58 Ampthill Road Bedford Bedfordshire MK42 9HL Lead Inspector
Mr Pursotamraj Hirekar Unannounced Inspection 20th September 2006 1:05 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 Sandhurst Lodge DS0000064699.V316408.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. Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Sandhurst Lodge Address 58 Ampthill Road Bedford Bedfordshire MK42 9HL 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) 01234 352051 F/P 01234 352051 Dr Surinder Kumar Gulati Mrs Bee-Suan Wong Care Home 10 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Physical disability over 65 years of age (10) Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 27th June 2006 Brief Description of the Service: Sandhurst Lodge was registered to provide residential care to 10 older people who may have dementia and or physical disabilities. The homes condition of registration included one service user under 65 with mental health needs. The building was converted from its original purpose of a large Victorian style dwelling to its current state. It was located in a busy main road in the heart of Bedford town within close proximity to the local hospital and amenities. The accommodation was distributed over three floors that were accessible via a staircase and a shaft lift. All service users had single room occupancy and the lounge and dining rooms were situated on the ground floor. The fee was in the range of £425 - £504. Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the report of the unannounced key inspection carried out on 20/09/06 over 7 hours by pursotamraj hirekar. The method of inspection included review of outstanding requirements, study of care plans, risk assessments, discussion with the service users’, staffs on duty, co owner, partial tour of the premises and observations. The co owner coordinated the inspection. What the service does well: What has improved since the last inspection? What they could do better:
The home must update the statement of purpose to cover all aspects of care delivery that would enable the potential service users’ for an informed decision. The home must devise a service users’ guide that complies with the standard 1 of the National Minimum Standards. The home must arrange pre-admissions assessments to be carried out by suitable professionals only, to have a comprehensive assessments and to be assured that the assessed needs would be met. After a rigorous needs and risks assessments, the home must develop a comprehensive care plan for all the service users’ that describe with clarity and provides the basis for the care delivery and must be reviewed when changes occur in the assessed needs. A review must be carried out on discharge of users from hospital to identify their changed needs and to plan how these needs would be met. This plan must include accurate and up-to-date risk assessments.
Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 6 Users’ privacy and dignity must be respected and the temporary measure of using a dining room as a sleeping area by one user must be resolved, as it seriously infringes privacy of that and other users. The effect on other users must be assessed. Appropriate activities must be identified and organised for all conditions that service users suffer from and include provisions for all service users. The home must ensure that the care staffs do not mix up their primary responsibilities with that of cooking and domestic work, which may have negative impact on the care delivery. The home must arrange help for service users who do not have a bank account or a representative to help them in dealing with their finances. Arrangements must be made to improve the comfort of the dining facilities for the service users. Now, the same requirement applies in relation to a user using the dining room as her place to sleep and limiting access to the dining facilities and a payphone. The home must carry out an audit of the home with the help of an occupational therapist and implement the recommendations made in the report of the occupational therapist. Arrangements must be made for ancillary staff to be employed in the home in such numbers to carry out domestic tasks. The staffing levels at nights must be reviewed to ensure sufficient numbers of staff are on shift at all times to meet the health and welfare needs of the service users. This review must take into account safety level at night and correspond to generic and individual risk assessments. The home must ensure to provide evidence that a registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. The home must develop a detailed internal and external quality assurance system and procedure and carry out a survey to ascertain the views of service users’ their representatives and professionals connected with care delivery and implement recommendations made. The home must ensure financial protection of service users. This applies in particular to service users without an account. The home must carry out staffs’ supervision for all staffs’ members that demonstrate efficient care delivery. Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 7 Arrangements must be made for the communal doors that were wedged open to be made safe by having alternative opening devices installed that will protect service users in the event of a fire. The home must inform the commission of any notifiable incidents/accidents that take place. The home must produce an improvement plan based on the listed requirements and send it to the commission. 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. The summary of this inspection report can be made available in other formats on request. Sandhurst Lodge DS0000064699.V316408.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 Sandhurst Lodge DS0000064699.V316408.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The written documentation that the home offered to potential service users was not complete and did not provide sufficient information. The pre admission assessment care plans were not provided on this inspection; in the absence of interim care plans for some service users, their needs and aspirations are at risk. EVIDENCE: Statement of purpose was revised and update on 11/07/06. The details now covered include staffing, philosophy of care, aims and objectives, fee range from £425/- to a maximum of £504/-, category of service users’ need clear mention, service user care needs, medical care, medications, care bell system, laundry services, library, TV, radio, video, admission criteria, social activities, fire precautions and procedure, religious service, visiting, telephone, postal service, complaints complements and concerns, meals and meal time, premises details, hairdressing, chiropody, optical and dental service, privacy
Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 10 and dignity. An attempt has been made by the provider to incorporate all the salient features of the services at the home, which was not comprehensive for an informed decision by the potential service users and visitors’. The service user guide was not made available on this inspection. The co-owner available on this inspection had suggested for 18/12/06 for completion. The home had 1new admission on the 31/07/06 the manager and the co owner had carried out the pre-admission assessment, which was not signed by the manager and was signed by the co-owner during the inspection. The interim care plan was not made available on this inspection, as they were not able to locate in the absence of the manager. The co owner had suggested completing the same before 19/12/06. There was no service user on this inspection for intermediate care. Sandhurst Lodge DS0000064699.V316408.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The assessed service users needs were not met and the home did not have a clear plan on how the needs would be met in the future. EVIDENCE: On this inspection 3 service users’ were case tracked. Service user –1 care plan included details such as personal care, toileting, medication, soft diet, communication skills, stimulation, mobility, environmental risks and signed by social worker from the Bedfordshire county council with a start date 31/03/06. And later reviewed by social services on 17/05/06. The care plan had no signature of service user or representative, key worker and manager. Service user – 2, care plan was not made available on this inspection as the manager was unavailable at the time of inspection. The service user had an injury on the neck; staff member on duty was not aware how it had happened. Service user’s daughter had come to visit, when asked, she had said while on the bed her mother had fallen on the chest of drawers that was next to the
Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 12 bed. This incident had happened a couple of weeks ago. However, the daughter had said that her mother is well and the home was taking care of her well and these accidents happens that’s OK. While going through the daily records, it was found that a service user went out of the home on 18/09/06 with out anyone’s notice. Someone found the service user on the road and informed the police and in turn, the police had brought the service user back to the home safely. The commission had not received any notification regarding the above 2 incidents and the co-owner had said that she was not aware of notifying the commission as it was a small incidents in her view. Service user –3 was using the dinning room for night sleep since January 2006. This problem has been identified and requirements were made in the previous report. The attempts made by the home to support the service user to use her bedroom for night sleeping did not yield enough result and the daily record dated 19/09/06, 18/09/06, 16/09/06, 15/09/06, 14/09/06 indicated that the service user was using lounge for night sleeping. The service user was admitted in January 2006 care plan dated 31/03/06 had recorded that the proprietor had arranged for service user to have bedding on the downstairs sofa in the communal area (lounge). However, the care plan reviewed on 17/05/06 had not recorded what arrangements were considered for night sleeping and bedroom as an alternative to use the communal space that is lounge for sleeping purpose. On the 28/08/06 the provider had discussion with the social worker form the social services for making alternate arrangements for the service users’ sleeping at night stay. However, the problem remains where it was. The service user speaks Italian and there were no personnel at the home who can converse in Italian with the service user. However, the home had put a page on the notice board with key English words translated into Italian. The home does not have a vacant bedroom on the ground floor. On this inspection, the co-owner had said that she was scheduled to meet the social worker on the 26/09/06 to follow-up. All the 3 service users’ case tracked, their care plans were not comprehensive. Service user –4 had the discharge summary from the consultant psychiatrist dated 12/06/06 recommended for medication and management plan. The home manager had carried out the risk assessment on the 28/06/06 but the outcomes of the risk assessments were not incorporated in the care plan. The medicine was stored in a secured place and was administered by the staffs on duty and their records were maintained. Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offered choice to service users in choosing their lifestyle, their activities and to form relationships as they wanted. EVIDENCE: The home had planned weekly menu in consultations with the service users’ and implemented the same, the service users’ spoken to enjoy their meals and meal timing. However, the nutritional assessments of service users’ were not provided on this inspection to correlate with the diet offered to individual service users’. The co owner said that a staff member would be employed before 04/01/07 for domestic tasks. The home had made appropriate arrangements for the service users’ to interact with their family members. The staffs on duty engaged the service users’, in walk, visit to a pub and games such as bingo and puzzles. The home had made appropriate arrangements for the service users’ to interact with their family members and relatives. Service users’ were looked after well, the service users’ and a family member of a service user spoken to have said. The service users and the staffs have good working relations that ensure personal support, as and when the service users’ need.
Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The protection of their financial interests was also unresolved and not arranged. The home had an effective complaints policy and procedure that enabled service users to express their opinions and potential dissatisfaction. EVIDENCE: The complaints policy and procedures were reviewed and updated in July 2006. There was no complaint recorded at the home since the previous inspection and the co-owner had confirmed that there was no complaint. The co-owner was planning to discuss with the social services for an arrangement of an advocate to manage the finances of service users’ who cannot manage money on their own or by their family members. The ensure financial protection of service users, the co owner was planning to discuss with the social services for finding an appropriate solution for managing the funds of service users’ who do not have bank accounts and were not in a position to operate the same. The co owner said she was not inclined to take any power of attorney to manage the service users’ funds. Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment was comfortable and pleasant for service users, clean and bright, but some safety points needed to be addressed to ensure the full protection of service users. EVIDENCE: The home was clean and tidy. The call bell points were now accessible to service users’ and include remote controls for bed ridden service users. Currently, there were 9 service users’ of which 1 service user was bedridden and does not come out and eat in the bed. Remaining service users’ use lounge and dinning area for eating food and medication. The communal area doors and the ground floor bedroom doors were wedged open. The co owner had said on this inspection that she would take the service of an Occupational therapist and implement the recommendations. Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Absence of fully staffed team may impair the achievement of consistent and appropriate care delivery. EVIDENCE: The co owner and 2 staffs have enrolled in the month of may 2006 for distance learning programme in Dementia with the Milton Keynes college distance learning programme. 2 staff records were seen on this inspection and their references; CRB’s, trainings received, application and contracts were found. However, the manager’s file was not made available on this inspection. The staff deployment rota had information about all staffs including the co owner about their working hours and shifts. There was only 1 night staff member on duty and the co owner was available on call. The co owner had also said that the home was not in a position to afford 1 more staff member for the night shift. The co owner was planning to appoint a staff member for cooking and domestic tasks. Currently, the care staffs’ were also responsible for cooking and day-to-day domestic tasks. Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The owner was committed to provide appropriate care delivery. But, the absence of a full time competent manager impaired the achievement of consistent and appropriate care delivery and management of the home. EVIDENCE: The home was under the leadership of new owners. The new owners had no previous background or experience providing social care and were dependent on the manager and the staffs’ for care delivery. The service users’ and their representatives spoken on this inspection had no complaints to make and have expressed satisfaction of the services they received. There were no concerns with regards to the outcomes of care
Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 18 delivery and service users’ satisfaction of services received. However, the preadmission assessment, risk assessments, cares plans and care plan reviews were not comprehensive, these were managed by the current manager and the co –owner. The home needed a competent manager to meet the out standing requirements and to run the home well. The owner has been making efforts to replace the current manager but with no success yet. Staffs’ were qualified and trained to provide appropriate service to the service users’. There were 2 incidents at the home since the previous inspection with 2 service users’. 1 service user had a fall on the chest of drawers in her bedroom and the other service user went out of the home without the knowledge of any staff member on duty and was brought in back by the police. The home had informed the commission with regard to these incidents. When asked, the co owner had said that she was not aware that these incidents needed notification to the commission. The co owner had sent in an action plan to the commission dated 21st September 2006, which indicated to meet all the requirements before 04/01/07. The numerous attempts made by the co owner to appoint a competent manager for the past 6 months were not successful. The home was having difficulties in recruiting a manager. The home was in the process of using the comment card it had developed to receive feedback from the service users’ family members and other professionals to ensure good quality of service was delivered. The ensure financial protection of service users, the co owner was planning to discuss with the social services for finding an appropriate solution for managing the funds of service users’ who do not have bank accounts and were not in a position to operate the same. The co owner was not inclined to take any power of attorney to manage the service users’ funds. 3 staffs’ files were seen on this inspection and only 1 staff’s supervision dated 01/08/06 was available and the rest 2 staffs supervision records were not available on this inspection. In response to the feedback given to the co owner as part of the inspection process, the co owner had sent in an action plan dated 21/09/06 with timelines to meet the outstanding requirements. Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 19 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 1 2 X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 2 11 X 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 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 2 X 1 Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 20 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 Requirement The home must review and update the statement of purpose to cover all aspects of care delivery that would enable the potential service users’ for an informed decision. (Previous time line 30/09/06) The home must devise a service users’ guide that complies with the standard 1 of the National Minimum Standards. (Previous time line 31/10/06) The home must arrange preadmissions assessments to be carried out by suitable professionals only, to have a comprehensive assessments and to be assured that the assessed needs would be met. After a rigorous needs and risks assessments, the home must develop a comprehensive care plan for all the service users’ that describe with clarity and provides the basis for the care delivery. The needs of service
DS0000064699.V316408.R01.S.doc Timescale for action 20/10/06 2. OP2 5 20/11/06 3. OP3 14 30/11/06 4. OP7 12,13 20/12/06 Sandhurst Lodge Version 5.2 Page 21 users, must state how these needs will be met and must be reviewed when changes in the assessed needs occur. (Previous time line 30/09/06) 5. OP8 12,13 A review must be carried out on discharge of users from hospital to identify their changed needs and to plan how these needs would be met. This plan must include accurate and up-to-date risk assessments. (Previous time line 15/08/06) Users’ privacy and dignity must be respected and the temporary measure of using a dining room as a sleeping area by one user must be resolved, as it seriously infringes privacy of that and other users. The effect on other users must be assessed. (Previous time line 15/08/06) Appropriate activities must be identified and organised for all conditions that service users suffer from and include provisions for all service users. The home must ensure that the care staffs do not mix up their primary responsibilities with that of cooking and domestic work, which may have negative impact on the care delivery. The home must arrange help for service users who do not have a bank account or a representative to help them in dealing with their finances. (Previous time line 30/09/06) Arrangements must be made to improve the comfort of the dining facilities for the service users. (30/12/05) Now, the same requirement applies in relation to a user using
DS0000064699.V316408.R01.S.doc 20/10/06 6. OP10 12,13 20/10/06 7. OP12 12 31/10/06 8. OP15 16 31/10/06 9. OP18 13,16 30/10/06 10. OP19 23 30/10/06 Sandhurst Lodge Version 5.2 Page 22 the dining room as her place to sleep and limiting access to the dining facilities and a payphone. This must be resolved differently. (Previous time line 30/09/06) 11. OP19 23 The home must carry out an audit of the home with the help of an occupational therapist and implement the recommendations made in the report of the occupational therapist. (Previous time line 30/09/06) Arrangements must be made for ancillary staff to be employed in the home in such numbers to carry out domestic tasks. 30/11/06 12. OP27 18 31/10/06 13. OP27 18 Previous timescale 30.06.05 and 30/02/06 The new owners must analyse staffing hours per shift to determine the appropriate number of staff per shift, care hours allocated to service users and take appropriate action to meet or exceed the minimum staffing level. The staffing levels at nights must 31/10/06 be reviewed to ensure sufficient numbers of staff are on shift at all times to meet the health and welfare needs of the service users. Previous timescale 30.5.05 and 30/02/06 This review must take into account safety level at night and correspond to generic and individual risk assessments. The home must ensure to provide evidence that a registered manager is qualified, competent and experienced to run the home and meet its
DS0000064699.V316408.R01.S.doc 14. OP31 8 31/10/06 Sandhurst Lodge Version 5.2 Page 23 15. OP33 24 stated purpose, aims and objectives. The home must develop a 31/10/06 detailed internal and external quality assurance system and procedure and carry out a survey to ascertain the views of service users’ their representatives and professionals connected with care delivery and implement recommendations made. The home must ensure financial protection of service users. This applies in particular to service users without an account and to the role of Power of Attorney prepared to be undertaken by the new owner. (Previous time line 30/09/06) The home must carry out staffs’ supervision for all staffs’ members that demonstrate efficient care delivery. Arrangements must be made for the communal doors that were wedged open to be made safe by having alternative opening devices installed that will protect service users in the event of a fire. Previous timescale 30.5.05 This requirement has not been addressed and extended time scale is set. (Previous time line 30/09/06) 30/10/06 16. OP35 13 17. OP36 18 31/10/06 18. OP38 23 30/10/06 19. OP38 37 The home must inform the commission of any notifiable incidents/accidents that take place. (Previous time line 15/08/06) The home must produce an improvement plan based on the
DS0000064699.V316408.R01.S.doc 23/09/06 20. OP38 24A 15/12/06
Page 24 Sandhurst Lodge Version 5.2 listed requirements and send it to the commission. (Previous time line 15/08/06). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Sandhurst Lodge DS0000064699.V316408.R01.S.doc Version 5.2 Page 26 - 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!
