CARE HOMES FOR OLDER PEOPLE
Bakers Court Nursing Centre 138-140 Little Ilford Lane Manor Park London E12 5PJ Lead Inspector
Seka Graovac Unannounced Inspection 11:00 25 and 26 April 2006
th 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 Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 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. Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Bakers Court Nursing Centre Address 138-140 Little Ilford Lane Manor Park London E12 5PJ 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) 020 8514 3638 020 8553 2603 ANS Homes Limited Mr Christopher Stringer Care Home 78 Category(ies) of Dementia (0), Mental disorder, excluding registration, with number learning disability or dementia (0), Old age, not of places falling within any other category (0), Physical disability (0) Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. MINIMUM STAFFING NOTICE The home can admit anyone under the above category from the age of 60 years or older. 19th January 2006 Date of last inspection Brief Description of the Service: Bakers Court Nursing Centre is registered with the Commission for Social Care Inspection to provide care to up to 78 people with general nursing needs, physical disability, dementia or/and a mental health diagnosis who are over 60 years old. The centre is situated in Manor Park area of Newham and is easy to access by public transport. There is ample parking available for visitors within the grounds of the Centre as well as on the surrounding roads. The premises are purpose built and all the bedrooms are single with en-suite facilities, equipped with the nurse-call system, television and telephone point. The ground, first and second floor are connected via 2 lifts and the staircases. Each floor is run as a separate unit. The ground floor caters for people with general nursing needs, physical disability and mild to moderate dementia. The first floor is for people with a mental health diagnosis (including dementia), while the second floor unit provides continuing care. The premises are fully wheelchair accessible. The designated catering team provides three meals a day and also tray service for people who prefer to eat in their own bedrooms or are unable to leave their beds. Renault People Carrier is also available. Bakers Court Nursing Centre is owned by Bupa. Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced. It lasted approximately seven hours and was conducted over two days. The main aim of the inspection was to assess the care provision at Bakers Court Nursing Centre against the key National Minimum Standards for Care Homes for Older People and related Regulations. The inspector also checked the progress the Centre was making towards resolving the weaknesses that had been identified at the previous inspection in January 2006 (related to medication and record-keeping). On the first day of the inspection, the inspector focused on the care provided on the ground floor (general nursing, physical disability and mild to moderate dementia). She walked around the unit and spent some time talking with residents, their relatives and staff. She also scrutinised medication records and service users’ individual notes. Food related records were also seen, as the inspector visited the Centre’s kitchen. On that day, the management, senior staff and some carers were receiving in-house training. An NVQ (National Vocational Qualification) Assessor was also present in the Centre, helping staff with their NVQ. On the second day of the inspection, the inspector spent most of her time with the Registered Manager, viewing individual service users’ money records, staff files, health and safety related records and other documentation. What the service does well:
The Bakers Court Nursing Centre was well run and in best interest of service users. The service users and the staff who spoke to the inspector expressed their trust in the management of the home. Both service users and the staff told the inspector that the management was approachable, professional and helpful. The ethos of the Centre was positive and created an open atmosphere. The service users were appropriately placed at the Bakers Court Nursing Centre. The senior staff made sound decisions regarding admissions to the Bakers Court Nursing Centre based on comprehensive care and support needs assessments and service users’ choices. Written evidence was available in all the service users’ individual files that the inspector requested to see. Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 6 One service user told the inspector that he had known the Bakers Court Nursing Centre before he decided to move in, as his late wife used to live in it. He felt contented in the home. The other service user’s family members told the inspector that it was a right decision for their mother to move in when she did, how well she settled and how much their own lives have improved since then. The service users seemed comfortable and well cared for on the day of the inspection. They were well groomed and well dressed and were able to engage in interactions and conversations with the inspector with ease. Some of the comments they made: “I can’t say anything else about this place but praise”, “This is really a good home. I have got everything I need” and from one confused person: “I live in this room now. I wish I were in Cumbria. But the neighbours here are very nice and helpful. They always come, bring me food and ask if I need anything”. A relative told the inspector that the Bakers Court was: “Super”. The other one used the word: “Great” to describe it. The examined four service users’ individual files contained comprehensive care plans that were based on the appropriate assessments and were evaluated on a regular basis. The files contained evidence that the Centre had good liaison with other health care professionals in order to maintain and promote service users’ health and well-being. A community physiotherapist was visiting the Centre on the day of the inspection. Service users were supported to enjoy their food and fulfilling lifestyles in accordance with their needs and wishes. The Centre was participating in celebration of the World Cancer Research Day by fundraising and holding a special “Fruity Friday” in May. The visitors to the home who spoke to the inspector told the inspector how much they appreciated the care their relative received. “Staff always ring us to tell us how mum is. We can now sleep without worries.” The inspector’s observations and the individual service users’ notes further demonstrated that the Centre actively promoted service users’ relationships with their families and friends. Service users legal rights were protected. They felt listened to and safe. The Centre had appropriate procedures for handling complaints and protection issues, that were followed when it was needed. The inspector was told by one service user that the management successfully dealt with one incident that he expressed his concern about. “They are really good here. If you have any issues, you can speak to them about it. They will listen to you and try to help”, he told the inspector. The Registered Manager stated that there have been no protection issues raised within the Bakers Court Nursing Centre since the previous inspection. However, the Centre was providing a respite care (safe refuge) to an old person who was subject to the Local Authority’s safeguarding protocols.
Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 7 The Centre was also piloting a new Voting Scheme with Newham Local Authority. The candidates visited the Centre to talk with service users about their political believes and parties’ programmes. On the day of the inspection, a polling station was installed in the Centre itself. Service users were encouraged to vote, but also their independence was protected. Service users felt supported by staff who they described as having high standards and professional attitudes. The recruitment procedure at the Bakers Court Nursing Centre was thorough and included Criminal Records Bureau disclosures. The training plan for the Bakers Court Nursing Centre was also available. The staff received regular supervision and felt supported. A relatively new staff member told the inspector that she enjoyed her induction and was given a choice who she wanted to supervise her. All the areas of the Centre that the inspector saw were clean, well maintained and safe. The environment was tastefully furnished and service users seemed comfortable using it. One staff member told the inspector that Bakers Court looked like a palace in comparison with the other homes where she worked before. What has improved since the last inspection? What they could do better:
The quality of otherwise very good health care provided to the service users at the Bakers Court Nursing Centre was compromised by unsatisfactory recordkeeping related to administration of medicines to service users. The inspector was concerned that there were still gaps in service users’ medication administration records. This included insulin that, the inspector was later told, was actually self-administered under the supervision. The inspector was reassured that all the medication was administered as prescribed, apart from one case when the medicine was not available for a prolonged period of time, but the staff forgot to sign. Unsatisfactory record-keeping of administration of medication at the Bakers Court Nursing Centre was identified in the pharmacist-inspector’s report in October 2003. Despite the management’s efforts, the issue hasn’t been resolved.
Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 8 The requirement regarding the Centre’s dealing with medication had to be restated. In order to secure the safety and wellbeing of service users, the Registered Persons must ensure that the appropriate procedures for dealing with medication (including record-keeping) are implemented at all times. The inspector was made aware that following this inspection, the management liaised with the Nursing and Midwifery Council trying to secure compliance with legislation and professional nursing standards. Further two requirements and one recommendation were made at this inspection. The Registered Persons must ensure that at least 50 of care staff are qualified (NVQ level 2). The inspector gave the home until the end of this calendar year to secure compliance. The other new requirement is related to quality assurance. Despite the significant evidence that the quality of the care at the Bakers Court Nursing Centre was monitored, the Centre did not have a working Quality Assurance policy or strategy. The inspector was told that neither staff, service users’ or relatives’ meetings were held. Service users’ surveys that would look at their satisfaction with the care received at Bakers Court were not carried out in the last 12 months. The Registered Persons must develop and implement a Quality Assurance policy that would establish a system for reviewing and improving the quality of care at The Bakers Court Nursing Centre. The system must provide for consultation with service users and their representatives. The related reports must be published annually and made available to all interested parties. The inspector also recommended that the Registered Persons consider contracting a professional kitchen deep cleaning agency. 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. Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. The senior staff made sound decisions regarding admissions to the Bakers Court Nursing Centre based on comprehensive care and support needs assessments and service users’ choices. EVIDENCE: The service users were appropriately placed at the Bakers Court Nursing Centre. Their support and care needs were thoroughly assessed and written evidence was available in all the service users’ individual files that the inspector requested to see. One service user told the inspector that he had known the Bakers Court Nursing Centre before he decided to move in, as his late wife used to live in it. He felt contented in the home. The other service user’s family members told the inspector that it was a right decision for their mother to move in when she did, how well she settled and how much their own lives have improved since then. Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 11 The Service User’s Guide was given to the service users at the beginning of the admission process and this was recorded in their notes. The Manager was in process of reviewing the Centre’s Statement of Purpose in order to make it more in line with the staff and other changes. Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The quality of otherwise very good health care provided to the service users at the Bakers Court Nursing Centre was compromised by unsatisfactory record-keeping related to medication. EVIDENCE: The service users seemed comfortable and well cared for on the day of the inspection. They were well groomed and well dressed and were able to engage in interactions and conversations with the inspector with ease. Some of the comments they made: “I can’t say anything else about this place but praise”, “This is really a good home. I have got everything I need” and from one confused person: “I live in this room now. I wish I were in Cumbria. But the neighbours here are very nice and helpful. They always bring me food and ask if I need anything”. A relative told the inspector that the Bakers Court was “Super”. The other one used the word: “Great” to describe it. The examined four service users’ individual files contained comprehensive care plans that were based on the appropriate assessments and were evaluated on a regular basis. The files contained evidence that the Centre had good liaison
Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 13 with other health care professionals in order to maintain and promote service users’ health and well-being. A community physiotherapist was visiting the Centre on the day of the inspection. However, the inspector was concerned that there were still gaps in service users’ medication administration records. This included insulin that, the inspector was later told, was actually self-administered under the supervision. The inspector was reassured that all the medication was administered as prescribed, apart from one case when the medicine was not available for a prolonged period of time, but the staff forgot to sign. Unsatisfactory recordkeeping of administration of medication at the Bakers Court Nursing Centre was identified in the pharmacist-inspector’s report in October 2003. Despite the management’s efforts, the issue hasn’t been resolved. The requirement regarding the Bakers Court Nursing Centre’s dealing with medication had to be restated. In order to secure the safety and wellbeing of service users, the Centre’s Registered Persons must ensure that the appropriate procedures for dealing with medication (including record-keeping) are implemented at all times. The inspector was made aware that following this inspection, the management liaised with the Nursing and Midwifery Council trying to secure compliance with legislation and professional nursing standards. Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Service users were supported to enjoy their food and fulfilling lifestyles in accordance with their needs and wishes. EVIDENCE: The Centre had two activities organisers. One of them worked full time. The other one organised activities for service users for 50 of her working time, and spent the rest of her time working as a care assistant at the Centre. Finding out about the service users’ interests and preferences formed a part of the assessment and the care planning and evaluation process. Activities plans were displayed indicating that something was planned for every day. Service users, management and the care staff made positive comments about the activities organised. The inspector was told that tea-dances with a local school were popular and that service users enjoyed colouring large paper-eggs and bunnies for the Easter. They were also making paper-ties for the coming Father’s Day. The inspector was also told that dominoes games were becoming quite competitive. The Registered Manager told the inspector that the Centre was participating in celebration of the World Cancer Research Day by fundraising and holding a special “Fruity Friday” in May. Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 15 The visitors to the home who spoke to the inspector told the inspector how much they appreciated the care their relative received. “Staff always ring us to tell us how mum is. We can now sleep without worries.” The inspector’s observations and the individual service users’ notes further demonstrated that the Centre actively promoted service users’ relationships with their families and friends. Some service users were not too keen on food, while the others told the inspector that they really enjoyed their meals. Braised Beef in Red Vine Sauce or Liver and Onions with the choice of vegetables were on Menu on the day of the inspection. The chefs also catered for people with special requirements. Diabetic, halal, vegetarian food was also available and the Centre tried to respond positively to any particular food requests. All food related records were appropriately kept as required. The kitchen was well organised and clean at the time of the inspection. Cleaning schedule records were also available. The inspector noted that despite the regular cleaning, some kitchen equipment (i.e. cookers) was discoloured from extensive use over many years. The inspector recommended that the Registered Persons consider contracting a professional kitchen deep cleaning agency. Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Service users legal rights were protected. They felt listened to and safe. EVIDENCE: The Centre had appropriate procedures for handling complaints and protection issues. The inspector viewed the complaints-log that indicated that the complaints procedure was fully implemented. She was also told by one service user that the management successfully dealt with one incident that he expressed his concern about. “They are really good here. If you have any issues, you can speak to them about it. They will listen to you and try to help”, he told the inspector. The Registered Manager stated that there have been no protection issues raised within the Bakers Court Nursing Centre since the previous inspection. However, the Centre was providing a respite care (safe refuge) to an old person who was subject to the Local Authority’s safeguarding protocols. The inspector was also informed that some senior staff were in process of attending two-part POVA (Protection of Vulnerable Adults) Lead Person course. The Centre was also piloting a new Voting Scheme with Newham Local Authority. The candidates visited the Centre to talk with service users about their political believes and parties’ programmes. On the day of the inspection, a polling station was installed in the Centre itself. Service users were encouraged to vote, but also their independence was protected.
Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 17 Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Service users lived in a pleasant, safe, well maintained and clean environment. EVIDENCE: All the areas of the Centre that the inspector saw were clean, well maintained and safe. The environment was tastefully furnished and service users seemed comfortable using it. One staff member told the inspector that Bakers Court looked like a palace in comparison with the other homes where she worked before. The individual bedrooms that the inspector saw were personalised with photos and ornaments as the people who lived in them wished. The waste was appropriately separated and kept for collection or disposal. The inspector was informed that the Centre had its own incinerator. Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 19 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 and 30. Service users felt supported by the staff. Training and supervision were adequate. However, the Registered Persons must ensure that at least 50 of care staff are qualified (NVQ level 2). EVIDENCE: The Registered Manager stated that the staffing levels at the Bakers Court Nursing Centre haven’t changed and they seemed appropriate at the time of the inspection. One service user on the continuing care unit was still receiving one to one care for six hours every day. The inspector was told that this was very beneficial and this person was making significant progress. The inspector viewed four staff files and found that all of them contained the required staff records. The recruitment procedure at the Bakers Court Nursing Centre was thorough and included POVAfirst check and Criminal Records Bureau disclosures. The examined staff files contained copies of the training certificates and qualifications. The training plan for the Bakers Court Nursing Centre was also available. The management and some other staff were attending the in-house training about dealing with challenging behaviour, when the inspector arrived. An NVQ assessor was also on the premises. The service users commented that the staff were very kind and had high standards and professional attitudes.
Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 20 However, the Registered Manager stated that out of fifty-five care assistants, only sixteen (29 ) were qualified. Seven of them had NVQ in Care level 2 and nine had level 3. The inspector was also informed that the Centre was exploring a specific NVQ in Dementia Care with York University. The Registered Persons must ensure that at least 50 of care staff are qualified (NVQ level 2). Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 21 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, 34, 35 , 36, 37and 38. The Bakers Court Nursing Centre was well run and in best interest of service users. EVIDENCE: The service users and the staff who spoke to the inspector expressed their trust in the management of the home. Both service users and the staff told the inspector that the management was approachable, professional and helpful. The ethos of the Centre was positive and created an open atmosphere. The Registered Manager was supported by his Deputy and both of them were qualified and experienced in the care management field. The lines of accountability within the home were clear. The inspector observed the Registered Nurse who was in charge of the general nursing unit, delegating tasks with ease and responding with confidence to the queries by the inspector, staff and service users.
Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 22 The staff received regular supervision and felt supported. A relatively new staff member told the inspector that she enjoyed her induction and was given a choice who she wanted to supervise her. The inspector was shown records of monthly audits of service users’ individual Care Plans that the Deputy conducted. The Registered Provider also conducted regular monitoring visits and produced reports on the conduct of the Care Centre. The reports were available in the Centre and were also sent to the Commission for Social Care Inspection as required. Bakers Court Nursing Centre had the “Investors in People” award. However, despite the evidence that the quality of the provision at the Bakers Court Nursing Centre was monitored, the Centre did not have a working Quality Assurance policy or strategy. The inspector was told that neither staff, service users’ or relatives’ meetings were held. Service users surveys that would particularly look at their satisfaction with the care received at Bakers Court were not carried out in the last twelve months. The Registered Persons must develop and implement a Quality Assurance policy that would establish a system for reviewing and improving the quality of care at The Bakers Court Nursing Centre. The system must provide for consultation with service users and their representatives. The related reports must be published annually and made available to all interested parties. The home also employed two administrators, a receptionist and a maintenance staff. The service users’ money was pooled. The appropriate records were held that made clear how much of this money belonged to the individual service users at all times. The receipts that evidenced the expenditure and the signatures were also kept. The environment was well maintained and safe. All the health and safety related documentation that the inspector asked to see were available. This included: Portable Appliances Tests (PAT), Gas certificate, hoists and passengers lifts service records. Fire log contained all records indicating that fire-safety at the Bakers Court Nursing Centre was satisfactory. The last firedrill was performed night time in April. Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 23 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 3 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 4 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 3 Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes, one (medication) 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 OP9 Regulation 13(2) Requirement Timescale for action 31/05/06 2. 3. OP28 OP33 18 24 In order to secure the safety and wellbeing of service users, the Centre’s Registered Persons must ensure that the appropriate procedures for dealing with medication (including records) are implemented at all times. The previous target for compliance with this requirement expired on 31/01/06. The other pervious on 30/04/05. The Registered Persons must 31/12/06 ensure that at least 50 of care staff are qualified (NVQ level 2). The Registered Persons must 31/07/06 develop and implement a Quality Assurance policy that would establish a system for reviewing at appropriate intervals and improving the quality of care at The Bakers Court Nursing Centre. The system must provide for consultation with service users and their representatives. The related reports must be published annually and made available to all interested parties. Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 25 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 OP15 Good Practice Recommendations The inspector recommended that the Registered Persons consider contracting a professional kitchen deep cleaning agency. Bakers Court Nursing Centre DS0000007352.V290319.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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