Care Home: Bathurst Lodge

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What the care home does well Care plans provide staff with sufficient detail to enable them to provide support consistently. Staff complete monthly care reviews for each person living in the home and this enables staff to address shortfalls where identified. The home provides people living there with a homely comfortable environment where they are supported by a committed and enthusiastic team. What has improved since the last inspection? Staff have started to complete accomplishment sheets for each of the people living in the home that identify exactly what steps people are taking and the support they require. Staff are supporting people to become more involved in the day-to-day running of the home. Risk assessments are in place to minimise potential risks while people are going about their day-to-day lives. People living in the home have a wider choice at meal times. Medication administration has improved since the previous inspection with the home now meeting all of the requirements made by the CSCI`s pharmacist inspector. Each person living in the home has a health assessment that identifies their needs and the steps other professionals and staff may have to take to meet them. The views of people visiting the home are now being sought and form part of the home`s quality assurance plan. Fire equipment throughout the home is now being checked by staff regularly which minimises potential risks. What the care home could do better: Financial recording for money held by the home should be reviewed to minimise the risk of any confusion in the future. CARE HOME ADULTS 18-65 Bathurst Lodge 74 Bathurst Road Gloucester Glos GL1 4RJ Lead Inspector Mr Paul Chapman Key Unannounced Inspection 21st November 2007 09:00 Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 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 Bathurst Lodge DS0000067438.V348374.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 Adults 18-65. 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. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bathurst Lodge Address 74 Bathurst Road Gloucester Glos GL1 4RJ 01452 552683 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) www.holmleigh-care.co.uk Holmleigh Care Homes Ltd Mrs Gillian Ruth Cornock Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability- Code LD The maximum number of service users who can be accommodated is 6. Date of last inspection 30th May 2007 Brief Description of the Service: Bathurst Lodge is a detached two storey, Victorian brick built property situated in a cul-de-sac. There is off-road parking to the front of the house and a good sized garden to the rear. The home provides living accommodation on the ground and first floor. On the ground floor there is a lounge, kitchen, dining room, shower room and two bedrooms. On the first floor there are five single bedrooms and a bathroom. Bathurst Lodge provides accommodation for up to six people with learning disabilities. The home is staff 24 hours a day, seven days a week. The property is one of a group of seven registered care homes in Gloucestershire that are owned by Holmleigh Care. The home has a Statement of Purpose that is available from the manager and a copy of the Service User’s Guide was available on the home’s notice board. The fees for the home range from £746.00 to £1293.00 per week. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This key unannounced inspection site visit was completed on November 21st 2007. It followed an unannounced random inspection that was completed on October 1st 2007. A random inspection report is not published and the findings of that report have been included as part of this inspection report. The manager was present throughout this site visit that lasted for a period of 4.5 hours. During this time we spoke to a member of staff, observed the interactions between staff and people living in the home, checked care and staff records and completed a tour of the premises. What the service does well: What has improved since the last inspection? Staff have started to complete accomplishment sheets for each of the people living in the home that identify exactly what steps people are taking and the support they require. Staff are supporting people to become more involved in the day-to-day running of the home. Risk assessments are in place to minimise potential risks while people are going about their day-to-day lives. People living in the home have a wider choice at meal times. Medication administration has improved since the previous inspection with the home now meeting all of the requirements made by the CSCI’s pharmacist inspector. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 6 Each person living in the home has a health assessment that identifies their needs and the steps other professionals and staff may have to take to meet them. The views of people visiting the home are now being sought and form part of the home’s quality assurance plan. Fire equipment throughout the home is now being checked by staff regularly which minimises potential risks. 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 be made available in other formats on request. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People that may wish to move into the home have access to accurate and relevant information to enable them to make an informed decision. Each person has a statement of terms and conditions that identifies what the home will provide. EVIDENCE: The previous key inspection report made a requirement that the home’s Statement of Purpose must be reviewed as the copies seen at the site visit were poorly organised. Whilst completing the random unannounced inspection, we (the CSCI) examined a copy of the home’s Statement of Purpose. This was seen to have been reviewed and re-organised. The previous key inspection report made a requirement that if a person is admitted to the home their needs must be assessed. Whilst completing the random unannounced inspection the manager stated that no one had been admitted to the home since the previous inspection was completed and therefore it is impossible to judge the home’s admission process. Any future admissions will be examined. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 9 The previous key inspection report made a requirement that each person’s statement of terms and conditions must be signed by either the person, or their representative. Whilst completing the random unannounced inspection the statement of terms and conditions for each of the people living in the home were examined. These are all now signed by the person or one of their representatives. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans provide staff with sufficient information to meet people’s care needs consistently. People are being empowered to make decisions about their lifestyles and have become more involved in the day to day running of the home. Risk assessments minimise potential risks to people while they are going about their lives. EVIDENCE: The previous key inspection made a requirement that care plans should provide enough detail to allow staff to support people consistently. Whilst completing the random unannounced inspection we examined the care plans for each of the people living in the home. The findings showed that the majority had been reviewed and re-written; now providing more detail to staff and promoting consistent practice. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 11 At this key inspection a member of staff spoke to us about their work with one of the people living in the home who is within the autistic spectrum. They explained that the person has a clear morning and evening routine that they feel should be followed. These routines are not recorded anywhere and a discussion took place about the importance of doing this to promote a consistent approach amongst the staff team. A recommendation of this inspection report is that these routines are recorded within the person’s care package. Since the previous inspection was completed staff have been writing monthly care reviews that identify what each person has been doing, care needs, health needs, family contact and any other significant events. Speaking with staff they stated that they thought this was a really good idea as it enables them to easily see what is going on in each person’s life. The manager has also introduced individual accomplishment sheets. The aim of this is for staff to complete them highlighting what the person achieved, any identified risks, what support was needed. This is good practice and allows the staff to clearly identify people’s strengths and what steps need to be put in place to further develop people’s skills. A requirement of the key unannounced inspection was that people must be empowered to make decisions about their lives and records of this should be kept. At the random unannounced inspection the manager and staff spoken with gave a number of examples of where they ask people to make decisions about their lives. It is difficult to evidence these decisions but the manager and her team must ensure that they achieve this. Speaking with staff at this inspection they provided further examples of people making choices about their lives. Observing the interaction between staff and people in the home they are respectful and people are given the opportunity to decide what they would like to do from day to day. On the day of the inspection 1 person was not attending day services and was able to get up when it suited them. Staff then supported them with their needs. The previous key unannounced inspection made a requirement that people must be given the opportunity to participate in the day-to-day running of the home. The random unannounced inspection provided a number of examples of people being more involved in the day-to-day running of the home. Examples included people being involved in preparing meals, completing domestic chores and going grocery shopping with staff support. At this key inspection staff spoke about people being involved in these activities. For 1 person a significant change has been their involvement in the grocery shopping. Staff explained that this used to be impossible but through using different methods to support the person they are now involved in grocery shopping regularly. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 12 The previous key unannounced inspection made a requirement that all of the potential risks to people must be assessed, minimised and managed appropriately to enable people to live fulfilling lifestyles. At the random unannounced inspection we examined risk assessments for all of the people living in the home. A good range of assessments were available and all had been reviewed regularly. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People lead varied and fulfilling lifestyles supported by the staff team. People’s rights to choice are being respected and the manager monitors this to ensure that the staff team promote this at all times. EVIDENCE: At this site visit we spoke to staff and examined records relating to the social activities people living in the home are involved in. People attend a local social club regularly with the support of staff and have also recently attended a fireworks and Halloween party. 2 people have been on holiday this year (to Weston Super Mare and Brean Sands). Due to the 3rd person being seriously ill their holiday has been re-arranged for January 2008. Each holiday was for an individual with staff support. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 14 On the day of the site visit 1 person was supported to attend the day service, whilst the other 2 people were staying home. Staff spoken with stated that 2 of the 3 people attend day services regularly, whilst the 3rd person is gradually being re-introduced to day services after a serious illness. In addition to day services a local college is also used. Staff support people to complete other activities including going for walks, going swimming and horse riding. An aromatherapist regularly visits the home. People are supported by staff to make use of the facilities in the local community. The manager explained that she has asked each of the key workers to identify at least 2 additional activities for each person to complete each week. By their own admission they feel that activities could be “more structured”. The manager explained that they write to 1 person’s parents monthly giving them a summary of what the person has been doing. At the previous key unannounced inspection feedback from parents was positive about the service provided at the home. The manager has written a protocol for the staff team about promoting people’s daily living skills. It states that staff must ensure people are asked to be involved in preparing their meals. All staff have signed the document stating they have read and understood the document. The staff have developed a picture menu book that is kept in the dining room. It contains pictures of complete meals and ingredients to enable people with communication difficulties to choose meals more easily by being able to point to pictures of meals they might like. Although the book contains a good selection of meals it needs to be developed further to provide greater choice. 1 person enjoys baking cakes and has started doing this on Sundays with staff. The record of the food eaten shows that people have a good choice of meals and other food to choose from. Drinks and snacks are available at all times. Meal times have changed in the home, the manager stated that instead of meals being “plated up” for each person they now use a selection of serving bowls and people are encouraged to choose what they would like and how much they would like. This is a good practice. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal care needs have been assessed and plans are available for staff to follow minimising the risk of people’s needs not being met. The risk of people’s health needs not being met have been minimised by an assessment being completed for each of them. Medication administration is now well managed and minimises potential risks to people living in the home. EVIDENCE: The previous key unannounced inspection made a requirement for each person’s personal care needs to be assessed and care plans to be developed to meet those needs. At the random unannounced inspection we examined care plans for each person living in the house. These have been reviewed since the previous inspection report and now provide greater detail to staff. This enables people to have their personal care provided as they wish and consistently by the staff team. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 16 The previous key unannounced inspection made a requirement that all of the people living in the home must have their health needs assessed. At the random unannounced inspection each person’s personal file showed that health care assessments have been completed. This document is excellent, comprehensive and provides staff and other professionals with all of the relevant information that may be required to support someone. As mentioned earlier in the report 1 person has been seriously ill since the previous key inspection was completed. They are now recovering and from speaking to staff and examining records this was well managed by the manager and her team. The previous key unannounced inspection made a requirement that when medication is administered to people living in the home it must be clearly and accurately recorded and given according to the doctor’s directions. There must be up to date medicine care plans to clearly describe how to use any medicines prescribed to use ‘as required’. This is to make sure that people receive the correct levels of medication. The random unannounced inspection showed that protocols have been developed for each of the people living in the home that ensures that this requirement is met. The previous key unannounced inspection made a requirement that when eye drops are administered to people in the home that the bottle must be replaced with a new bottle every four weeks so that risks to people from contaminated drops are reduced. Examination of the medication stocks at the unannounced random inspection showed that one bottle had been discarded after 28 days and was due to be returned to the pharmacist. A new bottle had been started and was dated when it was opened. The previous key unannounced inspection made a requirement to ensure that all staff who administer medication to people have completed and passed a formal training course about the safe handling of medicines, and are formally assessed as competent before they undertake this task. This is to make sure that people have their medicines safely. At the random unannounced inspection training records showed that 5 staff have completed recognised medication training since the previous inspection report was completed. The manager confirmed that only staff that have completed training will administer medication. The previous key unannounced inspection made a requirement that there is an up to date medicine policy and local procedures (including homely remedies) readily available in the home so as to provide all staff with precise direction about the way medicines are safely managed and handled in this home. The random unannounced inspection showed there is now an up-to-date medication policy available for staff, this can be found in the home’s medication cupboard. This is a specialised document for care homes published by The Royal Pharmaceutical Society. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 17 Since the previous random unannounced inspection was completed the manager has obtained a copy of a new BNF (British National Formulae) that provides information on prescribed medication. Records for medication administration were examined and seen to be in order. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are not put at unnecessary risks through staff being provided with guidelines to follow that safeguard them when they display behaviours that challenge. Records for the monies managed by the home are accurate but could be simpler to ensure there is no confusion in accounting in the future. EVIDENCE: The home has a complaints procedure. The manager stated that there have been no complaints since the previous inspection was completed. The CSCI have not received any complaints about the home. The previous key unannounced inspection made a requirement that the manager must ensure that guidelines are in place for each person that allow staff to manage behaviours effectively. At the random unannounced inspection guidelines for two of the people in the home were examined. The manager has developed a 13-step risk assessed management plan for each person. Both of the documents seen provided a good level of detail to the staff therefore enabling them to meet peoples needs consistently. None of the people living in the home manage their own money and it is kept securely in the home. All monies are checked daily at shift handover. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 19 At this inspection we checked each person’s monies with the manager and examined one persons financial records in depth. Although the financial records were correct the system used to record money coming into the home can be confusing. This led to what appeared to be a shortfall until further archived records were examined. The manager should review the system to ensure that this confusion does not happen in the future. This becomes a recommendation of this inspection report. Examination of training records showed that the majority of the staff team have completed training in safeguarding adults. It is a requirement of this inspection report that those staff who have not completed the training do at the earliest opportunity. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home’s communal areas provide people with a comfortable and homely environment that meets their current needs. Some outstanding maintenance issues need to be addressed in people’s bedrooms to meet their needs. EVIDENCE: A tour of the premises was completed with the manager. Over the past 12 months there has been substantial investment in the quality of the environment. This has involved a new kitchen and laundry being built/installed, the communal areas being decorated and a new bathroom being fitted upstairs. All of the communal areas of the home are decorated to a good standard and provide a comfortable and homely environment for the people living in the home. A couple of shortfalls were identified to the manager. The first being an aerial lead in the front room that needs to be attached to the wall. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 21 Secondly, the COSHH (Control of substances hazardous to health) cupboard is made from kitchen cupboards with locks fitted. At the time of this site visit 1 of these cupboards was unlocked. The locks were found to be extremely difficult to lock and it is recommended that the locks are replaced. All three of the bedrooms were seen with the manager. One has been decorated recently and a new carpet fitted, this room was missing a curtain and the manager stated that this would be addressed. Another person has recently moved from an upstairs bedroom to one downstairs. The manager stated that an aerial lead needs to be fitted in this bedroom, she has spoken to the provider about this but it is yet to be addressed. At present the person living in that bedroom is unable to watch TV in their room. The provider must address this. The bedroom of the other person living in the home requires decoration and has done for a significant amount of time. It becomes a requirement of this inspection report that this is addressed. The previous report also highlighted issues in two of the other bedrooms. These bedrooms are currently empty. In 1 bedroom the taps on the sink did not work, while in another a large amount of plaster was missing from under the window. The manager stated that both of these issues are still outstanding but will be addressed before anyone is admitted to the home. The home was clean and hygienic at the time of this site visit. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35, 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff have different roles and responsibilities around the home and the manager monitors these to ensure that they are being completed appropriately. Training records are available providing evidence that staff have the necessary skills to meet people’s current needs. EVIDENCE: The previous key unannounced inspection made a requirement that the manager must ensure that the staff team are completing the different responsibilities they have been given. At the random unannounced inspection the manager stated that she has been monitoring members of staff to ensure that these roles are completed. An example of this is ensuring that staff check the home’s fire safety equipment regularly. This has been an issue of the previous 2 inspection reports. This is now being addressed appropriately. The manager stated that they intend to complete a checklist/audit of this monitoring in the future. This became a recommendation of that inspection report. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 23 No new staff have been employed since the previous inspection was completed and as a result recruitment records were not examined. Staff training records were examined and showed that certificates were present for training that staff had completed. Speaking to a member of staff they explained that training is available when it is required and that they have nearly finished their NVQ (National Vocational Qualification) at level 2 in care. The previous key unannounced inspection made a requirement that all staff must receive regular supervision sessions. At the random unannounced inspection staff records were examined. They showed that all but two members of the staff team have received an annual appraisal and all staff have been regularly supervised. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager is monitoring the quality of the service and taking corrective actions to improve outcomes for people living in the home. Potential risks to people living in the home are minimised through the fire safety equipment being checked regularly. EVIDENCE: The previous key unannounced inspection made a requirement for the manager to develop a quality assurance system that involves the people living at the home. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 25 At the random unannounced inspection evidence was available that showing that the manager has implemented a number of different methods to gather information about the quality of the service. These include visitors being asked to complete forms about how they found their visit to the home, quarterly questionnaires are being sent to parents; completed questionnaires were seen and showed really positive feedback about the service. In addition to this the manager asks key workers/staff to complete a monthly care review for each person to provide information about what the service is providing. All of these areas help to build a picture of the quality of the service being provided in the home. At this site visit the further comments were seen from a parent and another care professional visiting the home. Comments seen were positive about their visit to the home. Discussing the home’s quality assurance with the manager we suggested that in addition to sending a quarterly questionnaire to parents asking for their opinions of the service, questionnaires could also be sent to other professionals involved with people living in the home. This becomes a good practice recommendation of this inspection report. Further to a conversation at a previous inspection the manager has completed an audit of the activities available to each person living in the home. As a result key workers have been asked to suggest 2 additional weekly activities that each person would like to do. This is seen as good practice. Regulation 26 visits are being completed monthly and the CSCI are sent a copy of the report. The previous key unannounced inspection made a requirement that the fire safety checks must be completed as prescribed by the regulations. This had been carried over from previous inspection report. At the random unannounced inspection the manager showed us that they had completed a review of the home’s fire risk assessment. This is now recorded on the fire services own risk assessment document. In addition to this the manager has also completed fire risk assessments for each of the people living in the home identifying risks particular to them. Each member of staff has completed a fire awareness questionnaire that has been used to raise staff awareness. Examination of the records for staff checking fire safety equipment showed that all equipment was being checked appropriately. These records were also examined at this inspection and continue to be checked appropriately. As highlighted earlier in this report there was an issue with the locks on the COSHH cupboard that needs to be addressed. Other information required to minimise potential risks to people were in place and COSHH data sheets were examined. The COSHH cupboard was found unlocked during this site visit. It must be locked at all times as people living in the home have access to the laundry. This becomes a requirement of this inspection report. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 26 Staff monitor and record the hot water outlet temperatures monthly. Fridge and freezer temperatures are monitored and recorded daily. Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 2 26 2 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 3 X X 3 X Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 28 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 YA24 Regulation 13(4) a Requirement The locks on the COSHH cupboard must be replaced, as at present they are difficult to use. Front Bedroom – A large amount of plaster is missing from under the front window and this must be repaired. This bedroom must also be decorated. Rear bedroom – The taps do not work on the sink and the room must be re-decorated. The other bedroom identified in the body of the report must be decorated. 3. YA42 13(4) a The COSHH cupboard must be locked at all times when not in use. 28/12/07 Timescale for action 01/02/08 2. YA25 23(2) d 28/12/07 Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 29 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 YA6 Good Practice Recommendations Guidelines should be written explaining the morning and evening routines of 1 of the people living in the home. This will promote a consistent approach by the staff. The financial recording system should be reviewed to minimise the risk of confusion in the future. An aerial lead should be fitted in the bedroom where it is required. 2. 3. YA23 YA26 Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Regional Office 4th Floor Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Bathurst Lodge DS0000067438.V348374.R01.S.doc Version 5.2 Page 31 - 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. 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