Inspection on 23/04/08 for Sandhurst Lodge

This inspection was carried out on 23rd April 2008.

CSCI found this care home to be providing an Adequate service.

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

Sandhurst Lodge 29/04/10

Sandhurst Lodge 01/04/10

Sandhurst Lodge 01/12/09

Sandhurst Lodge 05/11/09

Sandhurst Lodge 23/10/09

Sandhurst Lodge 13/10/09

Sandhurst Lodge 02/10/09

Sandhurst Lodge 22/04/09

Sandhurst Lodge 30/04/07

Sandhurst Lodge 20/09/06

Sandhurst Lodge 27/06/06

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sandhurst Lodge 58 Ampthill Road Bedford Bedfordshire MK42 9HL Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 11.00a 23rd April 2008 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.V362570.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.V362570.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 01234 352051 F/P 01234 352051 sandhurst_lodge@yahoo.co.uk Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Dr Surinder Kumar Gulati Vacant Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 4 Type of registration No. of places registered (if applicable) 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.V362570.R01.S.doc Version 5.2 Page 5 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th April 2007 Brief Description of the Service: Sandhurst Lodge is registered to provide residential care to 10 older people who may have dementia and or physical disabilities. The building was converted from its original purpose of a large Victorian style dwelling to its current state. It is located in a busy main road in the heart of Bedford town within close proximity to the local hospital and amenities. The accommodation is distributed over three floors that are accessible via a staircase and a shaft lift. All service users have single room occupancy and the lounge and dining rooms are situated on the ground floor. The fee is in the range of £425 - £504. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 23/05/08 over 6 hours 05 minutes by Pursotamraj Hirekar and Sally Snelson. The manager and the proprietor coordinated the inspection through out. The method of inspection included study of care plans, risk assessments, personnel records, staff deployment duty rota, relevant care delivery documents, discussions with manager, proprietor, staff, 2 visitors of service user, conversation with service users’ and partial tour of the building. Letter and documentary evidence received from the manager, in response to the feedback given on inspection, annual quality assurance assessment (AQAA) – provider’s self-assessment received is included for analysis and preparation of this report as well. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: What has improved since the last inspection? The provider was in the process of recruiting a part time consultant with relevant health and social care background to mentor and support the manager in assessing and meeting the needs and aspirations of the service users’. The provider and the manager have made good efforts to comply with the outstanding requirements from the previous key inspection for example fire risk assessment and occupational therapist audit has been carried out and changes introduced in some areas. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 7 What they could do better: 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 Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 8 be made available in other formats on request. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 9 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.V362570.R01.S.doc Version 5.2 Page 10 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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments were completed to assess the care needs of people considering using the service. EVIDENCE: The statement of purpose prepared by the home was reviewed and was displayed on the notice board. The revised statement of purpose did not include items not covered by the fee and current address of the commission. In response to the feedback, the home has sent a copy of the revised statement of purpose to the commission. Prior to admission, the provider, in the absence of the manager, had assessed the new admission to the home whose care we case tracked. This admission assessment had been completed in sufficient detail to ensure that an informed decision could be made as to whether the staff team could meet the needs of the person. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 11 Because the people living in the home had such diverse needs and diagnoses, and staff training information records were not updated at the time of this inspection, to evidence that the staff team had the necessary skills and qualifications to meet their needs. However, the statement of purpose contained information on staff qualification and training and the annual quality assurance assessment prepared prior to this inspection also covered staff NVQ 2 & 3 qualification information. The manager provided an updated record of staff qualification and training after this inspection, which was satisfactory. Intermediate care was not provided at the time of this inspection. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 12 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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans and risk assessments had not been written in sufficient detail to ensure that the care needs of the people at the home would be met in a consistent and safe way. EVIDENCE: All of the people living at the home had a file containing some plans of care. The plans had not been written in sufficient detail to ensure that anyone working at the home could provide the necessary care. However, this had been bought to the attention of the manager by the Local Authority commissioning team and work had commenced on producing plans in more detail. The one plan that had more detail was shown to us and we believed that if this work were built upon care planning would improve. In both of the care files looked at in detail, in addition to insufficient information the files did not start with details of the person and did not give the reader easy access to relevant information. For example the date of birth, contact details of the next-of-kin and diagnoses were missing. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 13 There was an absence of plans for some activities and conditions. One of the people case tracked had a diagnosis of type-two diabetes. None of her care plans made reference to this, or how the condition should be managed. Few had plans for mobility and continence and these areas were covered in a broad plan about personal care. We referred the manager to the list of plans in standard three to use as a base line. All of the people living at the home had been nutritionally assessed, and regularly weighed but this information did not run alongside a care plan for eating and drinking. It was also unclear when assessments indicated a marked change how this was managed. For example one of the people tracked had put on three to four pounds every month since the beginning of the year. Staffs were able to tell us that her condition had improved and she was more content, but we did not read this, and could have believed that she was for example, retaining fluid. The daily notes had been well written and often told the reader how care was provided. Staff must ensure that this information is also included in the plans of care. Also staff must take care when completing documentation that they do it accurately, and date and sign all entries. Medication procedures in the home were correct. Medication was signed in, stored and administered correctly. We were able to reconcile the medications, including the controlled drugs. However there was some poor documentation for example one had not been recorded as coming into the home, and there were some gaps in the recoding on the Medication Administration Record (MAR chart). As part of the reconciliation of the medicines we were confident that medication had been given but an error in documenting administration could lead to a second dose being given. We were also concerned that staff were administering a pain reliever that was prescribed, to be given four times a day, as and when the person needed it. The prescription must be altered to ensure that this is with the GP consent and staff are administering as prescribed. We advised the manager to ensure that the staff initials used to sign the MAR charts were recorded so that it could be identified who had been responsible for the administration of the medication. The staff that were giving medication had been trained to do so. Throughout the inspection we noted that staff treated people living and visiting the home with respect. Personal care was carried out in people’s own bedrooms and all staff knocked before entering a person’s private space. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems and support to service users in maintaining personal relationships is good, and enhances the service users’ quality of life. Staff would involve people living at the home in activities, but there was nothing to suggest the frequency or the consequences of these activities. EVIDENCE: Some of the people living at the home were able to go out independently, go to day centres or out with family members, but for others their contact outside Sandhurst Lodge was limited. When we started the inspection at 11am, not all of the nine people living at the home had chosen to get up and be in the communal areas. Therefore the two staff on duty were helping people with personal care and talking to those who were up. After lunch staff provided a number of different activities and appeared to have the skills to involve people who found it difficult to concentrate in something that stimulated them both mentally and physically. Unfortunately, once again documentation did not support this. People preferences were not recorded and Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 15 there were no care plans to support activities. However, post this inspection the manager had sent across a detailed activity plan for service users’. Visitors reported that they were welcomed into the home, could come and go as they pleased and felt part of the home. There was little evidence at the time of the inspection of other people visiting, such as church or music groups. Two of the people living at the home did not have English as a first language and it was not apparent how staff were meeting their cultural needs. People were able to make choices about when they got up and what they ate, but we did witness people being encouraged to group together. For example staff preferred the residents to be in the lounge than wandering around. One lady enjoyed sitting in the garden with her afternoon tea. We inspected over lunchtime. The planned meal was not that on the menu plan and not displayed so there was no clear documentation as to what had been eaten. The menu plan we saw appeared to provide people with a balance nutritious diet, and the fact people were putting on weight and not getting pressure sores supported this. People were given a meal of fish cakes, sauce, mashed potatoes, cauliflower, and carrots; all of the vegetables were fresh. People told us that the meal was very nice, and it appeared and smelt good. Drinks were served with the meal and people were encouraged to eat in the dining room. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff and service users said they knew how to raise concerns however there was evidence that these were not always resolved to their satisfaction. In addition concerns raised by Bedfordshire County Council had not been resolved in a timely manner. EVIDENCE: Safe guarding adults from abuse leaflet was displayed in the dinning area. The complaints procedure is included in the information booklet about the home, known as the statement of purpose. Service users indicated they were informed of the process to make a complaint or express concerns about the provision of care provided at the home. A service user said they had not experienced any problems or had any concerns about living at the home. Comments received from a service user; “I am happy here, staff are good”. However, prior to this inspection we received information that one person who lives at the home had raised concerns with the manager following an alleged incident between themselves and another service user. When this wasn’t resolved to their satisfaction they went to the local hospital and raised the matter. The manager subsequently dealt with this under the safeguarding procedures. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 17 Information received from the manager before the site visit stated that 3 safeguarding adults’ referrals have been made. In response to the strategy meeting of safeguarding adults an improvement plan was developed by the home, which appeared satisfactory. 1 staff member has been referred to the Protection of Vulnerable Adults List since the previous key inspection. Staff demonstrated a good awareness of their role, responsibility, and procedures they are required to follow in relation to any allegation or suspicion of abuse. Staff were confident to whistle-blow on bad practice and confirmed that the manager or the provider is available at all times should any concerns arise. The manager also through discussion demonstrated a good understanding in this area and was aware of the local guidance in reporting procedures. However, the manager was not clear as to regulation 37 notifications to the commission of the incidents and accidents that may happen at home. Staff from Bedfordshire County Council had raised concerns with us prior to this inspection. They told us that they had been trying to work with the home in a supportive way following deficits they had identified following the review of a person who lives at the home. Despite several visits to the home and advice from their staff they had seen little improvement. On the day of this inspection the manager and the provider had presented a detailed improvement plan, in response to the concerns raised by Bedfordshire County Council, which appeared satisfactory. However, the actions need to be monitored to evidence improvements. Service users can choose to manage their own money if they are able to do so. Records in the care file are kept for money held in safekeeping for the service user, which service user can get their money at any time. The manager described the process for recording and handling service user’s money, which ensures the service user’s money is protected. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 18 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): 19,21,22, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed, to the home as per the recommendations made in the occupational therapist audit report, to ensure the environment is well maintained for the service users to live in. EVIDENCE: There had been no major structural changes to the home but the providers’ are planning to extend, having purchased the house next door. We toured the building and found it to be clean, tidy, and free of any odours. We were concerned, that because of available space, a lot of staff information such as supervision programmes and off duty rotas were on display in the dining room, which did not make it feel homely. The provider told us that the extension would include a staff area. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 19 We noted that the door to the laundry was continually left open by staff. When visiting the laundry, by opening one cupboard were able to have access to cleaning fluids, which could be harmful to the people living at the home with a diagnosis of dementia. We also had easy access to plastic gloves and aprons, which if used inappropriately can be harmful. Service users’ rooms that were seen contained personal items for example a service user had a budgie (pet), photographs, and pictures. Grab rails were also in place to assist residents with their mobility. The sitting areas in the home were clean and tidy and no odours were detected throughout the home. The provider and the manager confirmed during the feedback of this inspection that regular water temperature checks would be carried out and records maintained. Since the last inspection a fire risk assessment has been carried out and an occupational therapist had assessed the home and had written a report. All recommendations were made in the report were considered by the home. However, there are areas that require attention, for example the bathroom on floor 2 and shower on floor 3 require improvement and at the time of the inspection people did not have the option of having a bath, but only a shower. The provider of the home stated that all the recommendations would be implemented during the construction work for the extension, for which planning permission work was in progress. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 20 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, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems in place for the recruitment of staff are sufficient to protect service users. The staff training records needed regular updating to reflect the current staff profile including their qualification and training. EVIDENCE: The staffs are deployed to satisfactory levels and the staff rota reflected this. The interaction of staff with the service users was good, showed there was a good rapport both verbal and non-verbal communication used and a good understanding. The home has a good recruitment procedure, having staff appointed upon receipt of two satisfactory references, Protection of Vulnerable Adults (POVA) first check, and Criminal Records Bureau (CRB) check. However, the staff those who have been working prior to the change of new ownership, their references were not available on the staff records. The provider was asked to put a note explaining the staff employment situation in their individual files or may arrange for additional references. The information received from the manager before the site visit stated 100 of the staff team had attained National Vocational Qualification (NVQ) level 2. Some staff training records showed that staff have attended a variety of courses and workshops including health and safety, food hygiene and management of medication. Staff through interviewing described other training Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 21 that they had undertaken including the National Vocational Qualification in Care. However, the all the staff training record needed updating to reflect the current qualification status of individual member of staff. The commission had received an update of staff qualification and training post this inspection. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 22 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 & 38 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The service users health and safety are managed appropriately protecting them through reducing risks in this area. The internal quality assurance system and procedures need to be robust enough to ensure the quality of life goals of all the service users are met and they are evidenced through systematic documentation. The staff supervision needed regularisation, to ensure well-supervised staff attend to the service users needs. EVIDENCE: The manager has not maintained her knowledge of the requirement for notification to the commission of incidents and or accidents under regulation 37. Discussion with the manager evidenced that she has been on a learning curve. Guidance and advice regarding regulatory matters are published on the Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 23 commission’s website and consideration needs to be given by the manager to reviewing the site on a regular basis to keep updated. This is particularly important with significant changes having taken place over the last 12 months which will continue. The manager is a registered general nurse, awaiting registered manager’s award notification and planned to start NVQ level 4 in the month of May 2008. The provider was in the process of recruiting a part time consultant with relevant health and social care background, to provide mentoring and hands on support to the manager. Staff supervision was not regular, the manager had confirmed post this inspection, that the staff supervisions have been now regularised. The minutes of the staff team meeting was available and showed how information is shared with staff, concerns raised by staff are addressed in the best possible way, which benefits the service users. The home needs to establish a continuous internal quality assurance system and procedure, to ensure that the quality of care provision and delivery is of always-high standard and the service users’ quality of life goals are addressed. The home could also seek the views of service users and their relatives and other key stakeholders as well, through the use of questionnaires. This needs to be carried out and an explanation, on how the home has then used these views to influence and further improve practice in the home is recorded. The information received from the manager before the site visit confirmed there is a programme of servicing and testing of equipment, maintenance, and fire detection and emergency equipment. Risk assessments are in place for the home, service users, and staff. Documents pertaining to the management of Fire, environmental Health and internal safety checks were seen. All were upto-date and demonstrated that required safety measures were in place to meet the relevant legislation in this area. Staff and their training records confirmed that they had been trained in a variety of Health and Safety areas including moving and handling and food hygiene. Monies managed on behalf of service users at the home were examined; computerisation of accounts was in place to ensure an audit trail was in place. The manager and the provider were responsible for the management of service users’ money. Service users’ spoken to reported that they found the provider and the manager to be a very good listener and all felt that they were very easy to talk to and that they trusted them. Staff said that they found the provider and the manager to be very committed to the care of the service users and approachable. One of the service users family member said ‘my family and my mother have nothing but praise for the way the provider has reorganised and also improved the running. Our mother in particular is always full of praise for her’. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 24 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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 3 X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP7 Standard Regulation 15 Requirement Care plans must be thoroughly written for all areas of care provided to a service user to ensure that all staff is aware of the care needs, and these plans must be kept under review. Staff must identify any risks to the people who use this service, and assess and record in the plan of care. Care must be taken that medication procedures are followed and that there is documentation to support the procedure. There must be a planned record of activities that reflects the interests of the people living at the home. People living at the home must not have access to areas or equipment that could cause harm. The home must evidence the manager has undertaken periodic training to update her knowledge, skills and competence, whilst managing the home. DS0000064699.V362570.R01.S.doc Timescale for action 16/06/08 2 OP8 3 OP9 13(4) 16/06/08 13(2), 12(1)(a) 01/05/08 4 OP12 5 OP19 6 OP31 12 (4) (b) 16/06/08 13 (4) (a) 16/06/08 9 (2) (b) 16/06/08 Sandhurst Lodge Version 5.2 Page 26 7 OP36 18 (2) 8. OP25 13 (3) (4) (a) (c) 9. OP18 12 (1) The home must ensure that each individual staff member receives formal supervision at least 6 times a year. The home must evidence that the water is stored and distributed at a temperature to prevent risks for people using the services. The home must ensure to make proper provision for the care, health, and welfare of service users where appropriate. 16/06/08 01/05/08 16/06/08 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 OP13 2 OP14 3 4 OP21 OP30 Refer to Standard Good Practice Recommendations The management should try and encourage more community contact for those who can not get out and have few visitors There should be more documentation to provide evidence that the care provided is the choice of the person living at the home. The home should continue to consult the recommendation made in the occupational therapist report and implement. The home should evidence and update staff qualification and training records regularly. Sandhurst Lodge DS0000064699.V362570.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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