Care Home: Blandford Lodge

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What the care home does well The home and staff team are small and as such can provide consistent support for the people living in the home. The people living in the home commented positively on the staff, activities and meals provided. Staff had a sound knowledge of the needs of the people living in the home. The information written about the people living in the home considered their identified needs and how these were to be met. What has improved since the last inspection? The Manager had updated the information about the home that is available for the people living in the home. Staff had received medication training and this was being offered on an ongoing basis. The Manager had completed guidelines for when people needed medication on an as and when basis. The Manager now had appropriate recruitment checks in place and staff did not work unsupervised without the appropriate checks being in place. A fire risk assessment was now in place. What the care home could do better: In order for the welfare of the people living in the home to be considered, the home`s medication systems, including the recording and checking of medication, need to be reviewed. Staff need to have information and training on subjects relevant to the needs of the people living in the home. The Manager should be available to manage and work in the home on a regular basis. The safety and welfare of the people living in the home must be considered at all times. Fire doors must not be kept open unless fitted with appropriate door releasing equipment. CARE HOME ADULTS 18-65 Blandford Lodge 4a Blandford Waye Hayes Middlesex UB4 0PB Lead Inspector Sarah Middleton Key Unannounced Inspection 20th January 2009 09:40 Blandford Lodge DS0000027125.V364620.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 Blandford Lodge DS0000027125.V364620.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. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blandford Lodge Address 4a Blandford Waye Hayes Middlesex UB4 0PB 020 8573 0129 0208 573 0129 blandfordlodge@yahoo.co.uk 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) Poucarshing Luchmun Poucarshing Luchmun Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2007 Brief Description of the Service: Blandford Lodge is a care home for four people with mental health needs. It is a detached family house with a garden, in a quiet residential area on the Hayes/Southall border, close to the Uxbridge Road. It is within reach of local shops and bus routes to larger neighbouring shopping centres. The home has four single bedrooms, two downstairs and two upstairs, a lounge/diner, kitchen, two toilets, bathroom and shower room. Outside there is a patio that acts as a smoking area. The Registered Provider is also the Registered Manager and he is supported by his wife the Deputy Manager and support staff. There is a minimum of two staff on duty during the day, with one sleeping in at night. The Registered Provider and his wife live close by. The fees start at £750 per week and will vary depending on assessed need. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. An unannounced visit was made on the 20th January 2009. Before the visit we looked at: Information we had received since the last visit on 31st January 2007; The Annual Quality Assurance Assessment (known as the AQAA). The AQAA gives us evidence to support what the home says it does well, and gives them an opportunity to say what they feel they could do better and what their future plans are. During this visit we: Talked with the people who live in the home, staff, the Manager and one relative; Looked at information about the people living in the home and well their needs are identified and met; Looked at other records, which must be kept; Checked that staff had the knowledge, skills and training to meet the needs of the people they care for; Looked around the building to make it was clean, safe and comfortable; Checked what improvements had been made since the last visit. We told the Manager and the Deputy Manager what we found at this visit. What the service does well: The home and staff team are small and as such can provide consistent support for the people living in the home. The people living in the home commented positively on the staff, activities and meals provided. Staff had a sound knowledge of the needs of the people living in the home. The information written about the people living in the home considered their identified needs and how these were to be met. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Blandford Lodge DS0000027125.V364620.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 Blandford Lodge DS0000027125.V364620.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is provided to new people considering moving into the home. People are assessed prior to moving into the home. EVIDENCE: We briefly viewed the updated information given to people when they are moving into the home. This contained details of the Commission and the numbers of people accommodated in the home. We viewed an assessment completed before the person moved into the home. This looked at various aspects of the person’s life, such as their mental health needs and any particular behaviour the home needed to be aware of. A care plan was also seen from the local authority. We saw a record of the trial visits. The self assessment the Manager had completed (known as the AQAA) stated that people are encouraged to visit the home before making a decision to move into the home. One person informed us that a family member had visited the home to help them make a decision. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 9 We were satisfied that the home takes steps to gather as much information as they can before confirming a person can move into the home on a trial basis. Blandford Lodge DS0000027125.V364620.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are recorded and were being met. People are encouraged to make daily decisions about their lives. People can take assessed risks and these are recorded and monitored. EVIDENCE: The Manager explained to us that he completes the information written about each person. A member of staff is named as the person’s keyworker and they then review and monitor the needs of the person each month. We viewed two people’s files. Both files contained details of the person’s needs and how these needs could be met and addressed by the staff team. One file needed a photo of the person, which was brought to the attention of the Manager. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 11 People had signed the information written about them. The Manager is considering ways to involve the person more when writing about the person’s needs and issues. One person spoken with confirmed they had seen the information written about them. Although the person did not agree with all the information written they did recognise that staff needed to record issues and potential risks. We viewed a sample of daily notes, which record what the person has done each day, along with any concerns. Overall those seen were informative for the staff team. The people living in the home did not have an advocate. Most of them have some family support and input into the care they receive. If people are able to go out alone, without a member of staff then they are encouraged to do so. This is monitored and reviewed on a regular basis to ensure the person is safe in the community. The self-assessment, (AQAA) completed by the Manager noted that the home could include professionals, friends and relatives a bit more when there are difficulties in supporting people with their rights to making choices. Overall the home aims to support people to make daily decisions about their lives. The Manager was aware of the need to re-write some information that had originally been recorded some years earlier. Although information is reviewed on a regular basis, the Manager is keen to have information typed so that it is easy to read and can be updated quickly. We viewed a sample of risk assessments. These clearly noted the person’s potential and likely risks posed to themselves or others. The information seen was detailed and recorded the action staff would need to take if they suspected a person was presenting or facing a risk. We were pleased to see that much consideration had been given to recording identified risks, as it is crucial in supporting a person in a safe environment. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to take part in the activities they enjoy and choose to engage in. People are encouraged to maintain social relationships with their family and friends. People’s rights are respected and recognised by the staff team. People are offered a well balanced diet. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 13 EVIDENCE: Overall people are independent and can go out without a member of staff. The Manager is aware that this needs to be regularly reviewed, as some people might need additional support due to their particular needs. We spoke with one relative who supports a person to access places on a daily basis. This had also been noted in the self-assessment (AQAA) completed by the Manager. The relative is aware that the home is not able to provide one to one support every day of the week and so has decided to provide this level of support. This would need to be reviewed on an ongoing basis to ensure this situation is manageable for all concerned. The people living in the home attend various community places. One person informed us that they regularly attend church, whilst another has found numerous drop-in centres, cafes and social clubs that they attend. Most of the people have a freedom pass, which enables them to use public transport for free. One person has yet to find the community places they wish to use and this is being looked at by the staff team. The Manager was aware that he needed to update the activities schedule. A future aim noted in the selfassessment (AQAA) records that the Manager would like to employ an activities co-ordinator in the next twelve months. We were informed that holidays have been offered but that the people living in the home had not taken these offers up. Day trips are offered usually in the summer months. Staff spoken with said that activities also take place in the home, such as art, looking at newspapers and cooking. One person living in the home also confirmed that these groups are available for people to attend. Staff recognised the importance of supporting people to develop skills that will assist them if they are able, in the future, to move to more independent accommodation. Relatives and friends can visit the home and people can use the house telephone to make contact with family or friends. Some people have their own mobile telephone. One person spoke of visiting their family on a regular basis. The residents are not given a front door key but they can lock their own bedrooms. People receive their own post. There are house meetings held on a weekly basis and evidence of these meetings were seen. One person described to us how they write in the house book about what they had been doing and any other comments they want to make about the home. They also confirmed that their views are listened to and usually acted on. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 14 We viewed the kitchen and saw a sample of menus. These provided people with a varied diet. Those people asked said they enjoyed the food and could ask for alternatives if they wanted something different. Fresh produce was seen in the fridge. The staff team recognised that healthy meals needed to be on offer for people to promote a well balanced diet. Staff were aware that when people were out in the community they could be eating whatever they wanted to. We were satisfied that the home promotes a varied and appetising menu for the people living in the home. Blandford Lodge DS0000027125.V364620.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can receive personal support in their preferred way. The health needs of the people in the home are assessed and were being met. The shortfalls in the medication systems could place a person at risk. EVIDENCE: We were informed that the people currently living in the home could manage their own personal care tasks. There are times when staff need to remind people to change clothes or to bathe. The people living in the home have daily choices such as, when they get up or go to bed. All the people in the home have a GP and see other health professionals such as dentist and chiropodists. The home had recently introduced a form that records any medical appointments attended. One person sees a specialist and they are supported to these appointments by a member of staff. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 16 We looked at the medication systems within the home. There were no controlled drugs in the home and no one was self-medicating. Medication was kept in a locked cupboard in the office. Staff receive both training from both the Manager and via different sources, such as the local Pharmacist and more recently through a long-distance learning course. Half the staff team had completed this new long distance course with the others still to study for this. The Manager was happy with this course as staff had to work through a series of workbooks before they received a certificate demonstrating their awareness and knowledge of this subject. We also saw the protocol for when medication is administered on an as and when basis. We checked one person’s medication and this was all correct at the time of the inspection. The second person’s medication had errors identified by us and by the Manager, who was present during these checks. The first error was in the recording of the medication delivered in December 2008. There had been one delivery made to the home that had been recorded on the Medication Record but not in the book where all the amounts of medication delivered and sent back to the Pharmacist must be recorded. The Manager also explained that he recorded what the Pharmacist delivered without actually counting the medication that was in bottles or boxes. The Manager must count and check the medication delivered into the home so that he is sure it is correct. A requirement was made for the recording and checking of medication to be accurate within the home. We then counted all the loose medication, (those that were in boxes and bottles) for one person. The Manager was aware that he needed to purchase a counting tool so that medication was checked and counted in a safe way. There were two medications that were not correct at the time of the inspection. One medication had too much leftover. The Manager explained that the amount delivered could have been wrong, and as stated above, as these were not counted at the time they arrived in the home it was difficult to know what had happened. The Manager stated there had been previous issues with the Pharmacist used and we advised the Manager to talk again with the Pharmacist so that the number on the bottles and boxes are the amounts being delivered into the home. The Manager confirmed he counted the medication in the home but these checks needed to be evidenced and carried out on a more regular basis. Regular counts and checks assist in ensuring that few errors occur and if they do, they are quickly identified and sorted. The Manager must be confident that the people living in the home are receiving their prescribed medication. This currently could not be confirmed due to the mistakes noted above. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 17 A requirement was made for the Manager to carry out full checks and counts on a regular basis and records all these checks. Blandford Lodge DS0000027125.V364620.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can express their views and these will be listened to. There are systems in place to protect people from abuse. EVIDENCE: The home has received no complaints. A complaints procedure was seen in a person’s bedroom. All the people spoken with said they would speak to the Manager if they had any concerns. There have been no adult abuse allegations or investigations. Staff attend ongoing training on this subject. The Manager was advised to obtain a copy of the updated “No Secrets” document when it is published later this year. We counted and checked the personal finances of two people. These were correct at the time of the inspection. All money is kept locked away and checked on a regular basis. The home provides different levels of support for each person. Some people need full support with handling and managing their money, whilst others hand money over to the staff team for safekeeping. All financial transactions are recorded. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 19 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a welcoming and safe home. EVIDENCE: We carried out a tour of the home and viewed most rooms. The Manager and Deputy Manager explained that the kitchen is going to be updated, as this room is looking dated and in need of modernising. Some of the flooring has been replaced in the home and there are plans to replace more of the flooring, which is necessary in particular in the living room. We were informed that the bathroom would also be updated later in the year. There is a room at the end of the garden that the Manager is looking to store documents that are needed but not used everyday. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 20 It was noted during the inspection that most of the light bulbs in the light on the ceiling of the living room were not working. These were replaced during the inspection. There was also a bare light bulb in the small hall with no lampshade. This was sorted out during the inspection. The Manager must ensure that attention is paid to these small things, as they can make a home welcoming and inviting. Those bedrooms seen were bright, clean and tidy. People are encouraged to keep their rooms clean, along with support from the staff team. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 21 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, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A small, competent and effective staff team supports the people living in the home. Recruitment checks are in place on all members of staff. EVIDENCE: We viewed the rota and there is always one person working at any one time, with often a second member of staff also working. Staffing levels alter according to appointments and events taking place. The Manager supports staff to study for an NVQ and the majority of the members of staff have obtained a suitable qualification or are in the process of studying for one. To enable information to be shared and support to be given, staff meetings take place. Generally the staff team is stable, which provides consistent support for the people living in the home. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 22 We viewed two staff employment files. All necessary checks had been carried out, such as obtaining two references and checks on the history of the person. The Manager does not let any new member of staff work unsupervised without initial required checks being carried out. All new staff receive an induction. A member of staff spoken with confirmed they had received a detailed induction. The Manager uses a detailed induction workbook that can take several weeks to work through. We discussed the home also having a more basic introduction to the home, which could be used for the first few days. The Manager stated that this used to be used and he will consider re-introducing this for new staff. We viewed a sample of individual training records. These recorded the training that had been attended. Overall those records seen showed that the staff team received ongoing training. This is delivered in various ways, from external training providers and in house, sometimes using DVD’s as a form of providing information to the staff team. The Manager was aware that staff need to learn from different sources in order to gain relevant knowledge and skills. We discussed with the Manager the benefit in developing an overall training plan of the whole staff team. This could evidence at a glance what courses and training needed to be booked for the team, including the Manager. The Manager will consider introducing this for the home. A member of staff confirmed they had not received any mental health training. This was discussed with the Manager, as all staff need ongoing training on various aspects of mental health, such as the legislation and different types of mental health conditions. A requirement was made for this to be addressed. Overall the Manager needs to ensure that the staff team are informed and aware of relevant and new legislation and practice that will occur for people living in residential care homes. Staff are already aware of the Mental Capacity Act and will need to be aware of the practices and procedures around the Deprivation Of Liberty. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 23 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): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home would benefit from the Manager being available full time. Systems are in place to gain the views of the people living in the home. The health and safety of the people needs to be promoted at all times. EVIDENCE: The Manager has owned and managed the home for several years. He is a trained nurse. He has continued to work full time as a Nurse, whilst managing this home and more recently another small home. This was discussed with the Manager, who was aware that we were concerned about this ongoing situation. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 24 This issue had been raised at previous inspection visits and now the Manager owns and manages a second care home we stressed the importance of being available to manage both these services effectively. The self-assessment (AQAA) stated that the Deputy Manager would be applying again to become the Registered Manager in the next twelve months. The Manager did not refer to this during this inspection visit. As this has been an ongoing concern a requirement was made for the Manager to address this situation. We looked at how the home monitors its progress and how it seeks the views of the people living in the home. Surveys are usually given to the people living in the home on an annual basis. This had not been done since 2007 and the Manager informed us that these would be sent out in the near future. House meetings also occur, where people can express their thoughts and opinions of the home. We discussed with the Manager the need to develop and produce a report that included details such as improvements made in the home and areas still to be addressed. The home should have ongoing aims and objectives in order to meet the changing needs of the people living in the home. The Manager agreed to complete a report each year and make this available. We viewed a sample of servicing records. Those seen, such as Gas Safety Record and Portable Appliance Test were up to date. The home’s water supplies had not been tested for Legionella since 2004 and the Manager agreed to carry a test after the inspection visit. It is recommended for the home to be tested for Legionella on a regular basis. A fire risk assessment had been completed in 2007 and the Manager was advised to ensure it remains relevant for the home and meets the current fire regulations. It was noted that several fire doors had been propped open throughout the inspection visit. Should people want their doors to be kept open then appropriate equipment needed to be fitted so that in the event of a fire these doors would automatically close. This was brought to the attention of the Manager and Deputy Manager and a requirement was made for this to be addressed. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 25 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 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 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 2 x 2 x 3 x x 2 x Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? 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 YA20 Regulation 13(2) Requirement Timescale for action 31/01/09 2. YA20 3. YA35 4. YA37 5. YA42 In order to protect the welfare of the people living in the home, there must be regular checks and counts of all the medication in the home. Evidence of these checks must be available for inspection. 13(2) To protect the safety of the people living in the home medication records must be accurate and reflect medication that has been carried forward and/or administered. 18(1)(c)(i) To ensure people are supported by staff who have satisfactory knowledge and skills, the training programme needs to include mental health subjects. 8(1)(b)(iii) To ensure the home is managed appropriately, the Manager must be available on a day-to-day basis. 23(4)(c) To ensure the home protects the people living and working in the home, all fire doors must be closed or fitted with appropriate door releasing equipment. 21/01/09 31/05/09 30/04/09 16/02/09 Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 27 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 YA42 Good Practice Recommendations It is recommended for the home to have regular tests and checks for Legionella. Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Blandford Lodge DS0000027125.V364620.R01.S.doc Version 5.2 Page 29 - 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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