CARE HOMES FOR OLDER PEOPLE
Sandhurst Lodge 58 Ampthill Road Bedford Bedfordshire MK42 9HL Lead Inspector
Dragan Cvejic Unannounced Inspection 27th June 2006 09:00 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.V299523.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.V299523.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 01234 352051 Dr Surinder Kumar Gulati Mrs Bee-Suan Wong Care Home 10 Category(ies) of Dementia (10), Mental disorder, excluding registration, with number learning disability or dementia (10), Physical of places disability (10) Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: One service user under the age of 65 from MH category. Date of last inspection 18/10/2005 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. Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a planned statutory inspection. The site visit, as a part of the inspection process, was carried out on 27th and 28th June and in total lasted for 11 hours. Two out of 8 current service users were case tracked on the first day and a bed ridden service user was case tracked on the second day of the inspection. The owners were present; Mrs Gulati on both days and Mr Gulati briefly on the second day of the site visit. Two staff members and the other service users also contributed to the inspection with their comments. A tour of the house provided environmental information, in addition to documents held in a policies file. The change of ownership happened in November of the previous year and this was the first inspection since then. The inspection demonstrated the need for working towards the National Minimum Standards in relation to the changes since then and the outstanding requirements from the previous inspection. What the service does well: What has improved since the last inspection?
New owners concentrated on improvement of the environment. The garden was recently paved with nice bricks and provided a very pleasant place where service users sat. The access from the lounge to the garden enabled frequent use of both communal areas. New laundry equipment, a washing machine and a tumble drier improved infection control measures in the home.
Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 6 Bedrooms were decorated regularly and contributed to the cleanliness of the home. What they could do better:
The new owners were trying to respond to shortfalls by prioritising tasks. Although the first actioned requirements were on environment, the emphasis was now, rightly, put on care procedures and direct support and help to service users, but the amount of work needed was significant. This is illustrated in the number of requirements set after this inspection. The home needed to devise a service user’s guide to complete documentation that would provide sufficient detail to prospective service users. The fee needs to be presented in this document. Although the admission process was recorded and prepared, the owners need to ensure that prospective service users are properly assessed by appropriate people. The lack of a manager would influence admission. The trial period would need to be clearly set and respected. The home would need to draw up an action plan on how they were planning to meet the service user’s needs, in particular for the user who temporarily used the dining room to sleep in overnight. Some extra equipment, such as a remote pull call bell was necessary for a bed ridden service user, so that her needs could be met. The lack of a permanent manager affected individual care plans and risk assessments. There was inconsistent quality in these working documents and it was not easy to clearly establish individuals’ needs or actions to minimise risks. The home provided various activities, but would need to consider different and person centred activities for all users, including the bed ridden and non-English speaking user. The size of the home allowed staff to prepare and cook food, but this arrangement was not clearly presented in documents and, with the employment of a permanent manager, this would need to be reviewed and addressed. The same refers to domestic staff, as the home did not employ a domestic, but used care staff for domestic tasks. Staff confirmed that they were trained and supported. A staff member stated that she received supervision even more often than once in two months, but the records of supervision were inconsistent in staff files. Both service users and staff stated that the rota ensured enough staff per shift, but all stated that there were occasions when staff did not have enough time to sit and talk to users. The owner, Mrs Gulati, filled this gap by being present in the home more than full time, but her presence was not recorded or demonstrated on a rota or anywhere else. The home had questionnaires for service users to provide their comments, but the quality assurance process was not systematic and needed to be set properly, so that the action could be used effectively. Service users spoken to confirmed that they wanted the home to help them with their finances. However, two service users without representatives did not have accounts. The records of money held on behalf of service users were
Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 7 correct, but the lack of the accounts must be addressed and a solution found to ensure full protection of service users’ interests. Fire precaution measures were respected to the level they were normally respected in an ordinary home. The status of residential home required much better fire arrangements and precautions. The doors kept open by wedges, as service users wanted, were not sufficient in terms of protection and needed to be addressed differently. New owners will need to employ a permanent and skilled manager in order to ensure progress towards meeting National Minimum Standards. 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. Sandhurst Lodge DS0000064699.V299523.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.V299523.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 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 admission assessment was not clearly and accurately devised and the home did not meet the needs of some service users. EVIDENCE: The new owners reviewed and updated the statement of purpose. The home did not use a separate service users’ guide, but instead the home’s brochure. This arrangement meant that the fee was not presented in documents given to potential users. Also, conditions for admission were not the same as described in the admission policy. Service users’ files contained a detailed and well accumulated pre-admission documents for service users. The needs of three service users checked against their needs recorded in care plans were not met. One did not use her bedroom for night rest, the other, bed-ridden user could not call staff if she needed to, the third, who was just discharged from hospital did not have current up-date needs in his care plan.
Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 10 The admission procedure stated that the trial period was 4-6 weeks, but the new owner stated that it was 8 weeks. It was not clear how and who would carry out admission assessments under new management, as the home did not have an appointed manager. Sandhurst Lodge DS0000064699.V299523.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 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: Service users’ documentation was held in two files for each individual. Three care plans inspected showed inconsistency. A care plan for a user discharged from hospital was not updated. Another file sated that a user was on a specified medication (an inhaler), but the owner stated that that was not the case. This and other inaccuracies could put service users at risk. Dignity and privacy of able users were respected, but this did not spread to the less able. One service user felt more comfortable sleeping in a dining room, but privacy and dignity, comfort and general needs were not met by this temporary arrangement and there was no planned action to permanently resolve this problem. A bed ridden user stated using her native language: “They look after me very well, but I would like to talk to someone more. I have to shout to call them, or
Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 12 to ask another user to call staff for me.” (This statement was translated by the inspector). The owner admitted that another user would greatly benefit from a potential staff member who would speak her language. The home relied on a relative and the occasional visit of an interpreter to communicate with a service user who did not speak English. There was evidence of engaging external professionals in the care process, such as a CPN and a consultant-psychiatrist. Service users confirmed that they were seen by health professionals, by a chiropodist and other allied health care workers. Medication was handled appropriately and records were accurate and correct. The previous owner, who was a current temporary manager, ensured medication safety. The users’ wishes in case of a death were recorded in their files. Sandhurst Lodge DS0000064699.V299523.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service users could enjoy daily routine as they preferred, but the organised activities did not meet all users’ needs. Meals and mealtimes were relaxed, and a choice was offered, but the cooking depended on care staff. EVIDENCE: Four more able users benefited from a structured daily routine and activities organised by the home. The other four, less able, did not have stimulating activities appropriate to their conditions which they could contribute to and benefit from. All service users spoken to confirmed that they had very good family and friend contact. A service user without family members visiting him was close to staff and used them for social support. Service users were able to exercise their autonomy and choice in many aspects. Two users used to go out together. All able users had some small amounts of their money with them. Service users relationship in the home was visibly friendly, supportive and family like, where they communicated with understanding, support and help. On both days of the site visit, users were observed interacting patiently and friendly.
Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 14 Service users stated that they chose the menu at their meetings. A choice was offered between two meals each day. Users could eat where they wanted, in the dining room, in their rooms or in the lounge. Staff were observed helping users who needed help with eating. However, the food was prepared by the acting temporary manager on weekdays, and two staff on weekends, with help from the night staff who prepared ingredients. Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home did not update all written complaints procedures and could cause confusion for service users. The protection of their financial interests was also unresolved and not arranged. EVIDENCE: Various documents in the home contained various complaints procedures. A policy file contained an outdated procedure. The statement of purpose contained a revised procedure. The complaints procedure in users’ files was also out of date with wrong instructions on how to complain. Although the home offered a family style of care, the financial protection of service users was not ensured. Current records were accurate, but a service user was in a position to borrow money from the owner’s, as his personal allowance and account were not transferred when the previous Power of Attorney arrangement collapsed with the change of ownership. Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,24,26 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: Since the change of ownership, the environmental standards improved significantly. New paving was laid in the garden, making it more appropriate for service users’ conditions and, subsequently better used. The requirements regarding decór were responded to. The wall was repaired so that wall paper was not peeling off it. Flooring was renewed in certain areas. The home looked nice, clean and bright. Service users were comfortable in the home. All case tracked rooms were within the standard requirements and service users stated that they had all they needed there. The dining room arrangement was affected by a user staying there overnight to sleep. This restricted access and was not providing sufficient comfort for this user or others.
Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 17 There were a few tasks identified during the site visits, such as oiling the doors to prevent squeaking, securing extension leads along skirting boards; and as a main and urgent need, supplying a remote call bell for a bed ridden service user, who could not reach the call bell point installed on the wall. Some doors were still wedged open, as service users wanted, but this measure reduced fire safety and an alternative solution must be sought. Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing was an element that the new owners would need to analyse and reorganise to ensure that users needs were met practically and not only through the comments made regarding this by service users. EVIDENCE: Service users stated that the staff number on duty was sufficient to respond to their needs. The rota showed that 2 staff were working on day shifts with the third person overlapping some time in the morning and in the afternoon. However, the new owner was also present and supported and helped service users, but was not recorded as working on the rota. The rota did not indicate the roles of staff. The home did not employ domestic staff, but expected care workers to fulfil domestic duties. Meal preparation was also done by the acting temporary manager on weekdays and by the care staff on weekends. One staff member was covering night duty. However, the expectation of staff to respond to domestic and catering tasks within their care shift meant reduced care time was offered to service users. Service users’ comments contained elements related to the time they spent with care workers: “I wish I could talk more with staff”. I’d like to go out more with staff”. Staff commented that they would benefit if the home had domestic staff and that sometimes an extra member of staff was needed to respond timely to users’ needs.
Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 19 Technically, the rota did not show staff surnames, did not indicate night shifts apart from the working time and the acting manager was not planned to work as a supernumery. Staff files contained personal documentation and included training certificates, NVQ certificates, some supervision notes and CRB disclosures. Job descriptions were held in the home’s policy folder. Files were inconsistent, one of three checked files did not contain references, the other did not have supervision notes and one CRB disclosure was in the rota folder. Staff stated that they felt supported, had regular supervision and had good training. Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although the home operated in a committed manner, the safety of service users was not ensured. EVIDENCE: The home did not have an appointed manager. The home was managed by the combination of new owner and the previous owner who stayed to help and fulfil only some management tasks related to safety of service users. This position and role was not covered by a contract. Technically, the home did not have a manager. The atmosphere in the home was very friendly and relaxed. Staff felt supported and encouraged to express their initiative. Service users trusted the owners, the staff and each other. Although equal opportunity was respected, two service users would benefit from someone else in the home speaking their
Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 21 native language. The new owner wished to employ an Italian speaking member of staff and was preparing the recruitment advertisement. The home had a questionnaire for service users to express their views of the services and provisions, but there was no set quality assurance system in place. The home encouraged families to help service users with their money. Some users wanted to have some money with them, some wanted the home to support their financial management of their personal allowances. One service user did not have an account and the previous Power of Attorney arrangement cancelled by the change of ownership and a new one was not set, leaving a user technically without access to his money. Although the records were accurate, the arrangement for the home to lend him some money was not the solution. The manager stated that a social worker was also involved in this process, but the difficulties had not been overcome and the prospects of finding the solution were bleak. Staff confirmed that they received regular supervision, but the arrangement for this provision was not satisfactory. The acting temporary manager provided supervision to some staff and the owner provided to the rest of the staff team. The records were not up to date in half of the staff’s records. Records held in the home were not up to date, were inconsistent and needed an organised and a systematic approach to be sorted. Safe working practices were not in place. The doors were kept wedged open jeopardising fire safety. Some falls and minor accidents were recorded but not reported to the CSCI. Some individual risk assessments were not updated when users’ conditions changed or they came back discharged from hospital. Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 1 1 2 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 1 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 2 X 2 X 3 X 3 STAFFING Standard No Score 27 1 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 1 X 1 2 1 1 Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 23 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 Timescale for action The statement of purpose did not 30/09/06 cover all required aspects of the provisions, was not accurate in relation to policies and must be further improved. The home must devise a service 31/10/06 users’ guide that complies with the requirements set in the Care Homes Regulations. The home must arrange and 31/10/06 document admission assessment for new users to be carried out by a suitably qualified or trained person and to be documented accurately in policies and procedures. The home must ensure that the 30/09/06 assessed service users’ needs are met and include respect for privacy and dignity of a user who currently uses the dining room to sleep in; as well as the assessed and updated needs of others. The care plans must accurately 30/09/06 describe the needs of service users, must state how these needs will be met and must be reviewed when changes in the assessed needs occur.
DS0000064699.V299523.R01.S.doc Version 5.2 Page 24 Requirement 2 OP2 5 3 OP3 14 4 OP4 12,13 5 OP7 12,13 Sandhurst Lodge 6 7 OP8 OP8 12,13 12,13 8 OP10 12,13 9 OP12 12 10 OP14 16 11 OP15 16 12 OP16 22 13 OP18 13,16 14 OP19 23 A plan for the solution for a user who used a dining room for night sleep must be identified. 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. 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 arrange for service users’ financial matters for the service users who needed help to have personal accounts and transfer legally the power of attorney to an appropriate individual. The home must provide evidence of how the food preparation is organised and not to rely on the temporary, covering manager for this task. The home must arrange for a consistent complaint procedure to be present in the home and make service users aware of it. The up-to-date complaints procedure must be displayed in the home. 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
DS0000064699.V299523.R01.S.doc 15/08/06 15/08/06 15/08/06 31/10/06 30/09/06 31/10/06 15/08/06 30/09/06 30/09/06
Page 25 Sandhurst Lodge Version 5.2 15 OP19 23 16 OP22 23 17 18 OP27 OP27 18 18 19 OP27 18 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 the dining room as her place to sleep and limiting access to the dining facilities and a payphone. This must be resolved differently. The doors must not be wedged open and an alternative solution for this must be sought. The owner needs to forward the plan on how to address this issue to the CSCI. Call bell points must be accessible in all users’ areas and include remote controls for bed ridden service users. Staff rota must contain staff roles, contain all shifts and list all persons working in the home. Staff files must contain required documents, currently held elsewhere (such as CRB, supervision notes, training certificates, references etc.) Arrangements must be made for ancillary staff to be employed in the home in such numbers to carry out domestic tasks. 30/09/06 30/09/06 15/08/09 30/09/06 31/10/06 20 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
DS0000064699.V299523.R01.S.doc Version 5.2 Page 26 Sandhurst Lodge 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. Arrangements must be made to ensure that satisfactory cover is gained for each shift on the rota and the name of staff recorded accordingly. Previous timescale 30/12/05 This requirement was not met and has been reinstated following this inspection. A staff training and development plan must be made available in the home that details all the training undertaken and future training for staff in accordance with the National Training Organisation workforce. Previous timescale 30.06.05 and 30/03/06 Although the staff received appropriate and up-dated training the training plan for the future must be drawn up. The home must have an appointed manager and be able to show the manager’s file with the required accompanying documents. The home must have a manager in post and appropriate documentation to demonstrate that. Quality assurance process must be in place to ensure measured quality of the services and provisions. The home must ensure financial protection of service users. This applies in particular to service users without an account and to
DS0000064699.V299523.R01.S.doc 21 OP27 18 30/09/06 22 OP30 12 30/09/06 23 OP31 8 31/10/06 24 OP31 8 30/09/06 25 OP33 24 31/10/06 26 OP35 13 30/09/06 Sandhurst Lodge Version 5.2 Page 27 27 OP36 18 28 OP37 17 29 OP38 23 the role of Power of Attorney prepared to be undertaken by the new owner. Supervision records must demonstrate the quantity and quality of supervision sessions provided to staff and be up to date and planned for the future. The records kept in the home must be accurate and updated regularly and whenever there was a change. 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. The home must inform the CSCI of any notifiable incidents/accidents. The home must produce an improvement plan based on the listed requirements and send it to the CSCI 31/10/06 31/10/06 30/09/06 30 31 OP38 OP38 37 24A 15/08/06 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. 1 Refer to Standard OP5 Good Practice Recommendations The home should provide clear information about the duration of the trial period for prospective service users. Sandhurst Lodge DS0000064699.V299523.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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