Inspection on 07/05/09 for Bakers Court Nursing Centre

This inspection was carried out on 7th May 2009.

CQC found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bakers Court Nursing Centre 25/03/10

Bakers Court Nursing Centre 23/07/08

Bakers Court Nursing Centre 28/02/08

Bakers Court Nursing Centre 25/04/06

Bakers Court Nursing Centre 19/01/06

Bakers Court Nursing Centre 18/04/05

Bakers Court Nursing Centre 06/09/04

Bakers Court Nursing Centre 13/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 06/08/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Bakers Court Nursing Centre 138-140 Little Ilford Lane Manor Park London E12 5PJ Lead Inspector Anne Chamberlain 7 th and 8th Unannounced Inspection May 2009 2 p.m. Version 5.2 Page 1 DS0000007352.V375344.R01.S.do c This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 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 stringch@bupa.com www.bupa.co.uk BUPA Care Homes (ANS) Ltd Mr Christopher Stringer Care Home 78 Category(ies) of Dementia (78), Mental disorder, excluding registration, with number learning disability or dementia (78), Old age, of places not falling within any other category (78), Physical disability (78) Bakers Court Nursing Centre DS0000007352.V375344.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 with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (of following age range: 55 years and over) Dementia - Code DE (of following age range: 55 years and over) Mental disorder, excluding learning disability or dementia - Code MD (of following age range: 55 years and over) Physical disability - Code PD (of following age range: 55 years and over) The maximum number of service users who can be accommodated is: 78 23rd July 2008 2. 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 for up to 78 people with general nursing needs, physical disability, dementia or/and a mental health diagnosis. The centre is situated in the 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. They are 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 Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 5 dementia), while the second floor unit provides continuing care. The premises are fully wheelchair accessible. The designated catering team provide 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. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection was carried out on behalf of the Care Quality Commission and the terms ‘we’ and ‘us’ will be used throughout. The service submitted an Annual Quality Assurance Assessment (AQAA) before the site visit. This document was well completed and provided a great deal of useful information about the service. The duration of the site visits was ten and a half hours over two days. We were assisted by the registered manager of the service, the deputy manager and various staff members. We spoke with residents and relatives. As part of the inspection we looked at the files of five residents and four staff. We also viewed key documentation and records. We inspected the arrangements for the administration of medication and made a tour of the home, including the kitchen. We would like to take this opportunity to thank all those who contributed to the inspection for the assistance and co-operation. What the service does well: Assessment is thorough and prospective residents and their relatives are involved. Care plans and risk assessments are of a high standards, detailed and meaningful. They are regularly audited. The administration of medication is sound and carefully audited on a regular basis. Healthcare is robust and referrals made promptly to appropriate specialists. The environment of the home is good and there are regular structured activities provided by dedicated staff. The home considers community involvement and where residents cannot go out tries to bring the community in to the home to them. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home undertakes thorough assessment of the needs of prospective service users. Intermediate care has not been provided. EVIDENCE: We viewed the files of five residents. The home continues to use the QUEST assessment tool which has been further developed since the last inspection. The Quest assessment tool incorporates risk assessment which is integrated into the needs in a useful and meaningful way. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 10 The manager advised us that assessments generally have taken place in hospital prior to discharge to the home. The assessor undertakes to establish whether or not the prospective resident has the mental capacity to decide where they want to live. If not they discover if the person has a relative, advocate or social worker to assist them. An assessment of need is then undertaken. The files evidenced this to be the case and the assessments to be of a satisfactory standard, clear and comprehensive. The home has had no referrals for intermediate care since the last inspection. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Health and personal care needs are clearly stated and met. Medication practice is sound and service users are treated with dignity and respect. They are treated with sensitivity and respect at the time of their death. EVIDENCE: A further QUEST assessment is undertaken when a person is actually admitted to the home. The assessments are then updated on a weekly basis. Areas of assessment include allergies, health and personal care, mental state and cognition, eating and drinking and medication. A system of scoring is used and there is a box for further comments. One resident was assessed as needing bed rails and there was evidence of a discussion of this need, with her daughter, also a completed check list for the bed rails was seen along with a Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 12 restraint form and risk assessment for them. One resident was deemed to need a sight test and we noted that this had accordingly been arranged. A significant proportion of the residents of the home are quite poorly and we noted that palliative care needs assessments are undertaken. Individual files include a life map which gives good social history information, including details like where the person was born, how many siblings they had, whether they have sons and daughters themselves. We made the suggestion to the manager that rather than just have categories for ‘married’ and ‘single’ a category ‘divorced’ could be added. We noted that a range of tools are used to determine and monitor health needs. Waterlow charts are completed and a nutritional assessment tool. If necessary blood sugar is monitored, and residents are weighed regularly. Temperature, pulse and respiration charts are completed. It was also noted that some errors had occurred on a Waterlow charts where a resident’s gender had been wrongly scored and where some incorrect figures had been entered. This had not triggered any inappropriate actions but it was pointed out to the nurse for the floor, who readily accepted that some errors had occurred. Residents have personal plans which are based on the findings of the QUEST assessment. Personal plans were of a good standard. Plans viewed included details of visual impairment, communication hearing, lifestyle, social and sexuality needs Details like a person needs large print, or has a tendency to urinary tract infections, or likes a cup of tea and a biscuit last thing, were positively noted. One care plan actually noted that a resident needed a new pad on her spectacles and there was a plan to get this remedied. Favoured toiletries were noted on care plans The manager states in the AQAA that personal plans are reviewed monthly and updated as necessary. He also stated that care plans are regularly and frequently audited by the deputy manager. It was positively noted that documentation was fully completed and routinely signed, often by residents as well as staff, and dated. Residents files have a section for professionals to write their notes in and we saw that these had been used and the entries signed by a variety of professionals. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 13 We inspected the arrangements for the administration of medication and looked specifically at the Medication Administration Record (MAR) charts for the residents whose files we were viewing. We balanced a random sample of medications and noted that in one case the stock of medication was not correct. The nurse for that unit told us that the prescription had been only partly filled by the pharmacist and there had been a delay in getting the balance so this resident and she had actually run out of a medication and missed a dose one evening. The label for the medication had been stuck into the diary to remind staff that the medication was needed but there had been no telephone call to the General Practitioner (GP) and no incident sheet completed. The care plan did not record the omission. We checked the medication policy and it did not state that the GP should be consulted for advice of any likely affects of underdosing. It did not state that an incident form should be completed either. We recommend that the organisation revisit the medication policy with regard to under dosing. We noted that returns of medication to the pharmacy are entered on yellow sheets in the medication folders and signatures are obtained. Medication for destruction is placed in a green bin and the contractor who collects it signs for it, with a code for each binful. We noted that tablet counters have now been supplied to the floors. We viewed the recording and storage of controlled drugs and were quite satisfied that all necessary safeguards are in place. The deputy manager stated that the controlled drugs are audited every week. We noted that a new system has been introduced for the recording of allergies. A sheet is placed in front of the MAR sheets for each resident and if they have an allergy this is written on a red background. If they have no allergies this is also stated, but against a green background. The Deputy manager stated that MAR charts also record any allergies and if the pharmacist fails to complete the section, it is amended by the home and the pharmacist is asked to FAX a correct MAR chart immediately. The deputy manager advised that she undertakes audits of the medication for each floor about every ten days. We noted from the AQAA that personal plans are based on the choices and preferences of residents. We observed respectful and pleasant interaction Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 14 between staff and residents on the day of the inspection. We noted that residents files are kept in lockable cabinets on the nursing station. We noted that some residents had ‘end of life’ plans on their files. The manager stated that the homes will establish whether the person would like to die in the home or to be referred to the local hospice or even go to hospital. Not all files viewed had ‘end of life’ plans but it is understood that the home is alert for the right moment to broach this sensitive subject. The manager stated that the home always sends a letter of condolence to families following a death and sometimes flowers. The manager stated that each floor has a copy of Newham’s safeguarding procedure and the organisational policy is followed in conjunction with this. We were satisfied that the home would handle any allegation or suspicion of abuse appropriately. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a social, culturally sensitive lifestyle, with personal choice and preference, choice and control. The food is nutritional, wholesome and appealing and dining conditions are pleasant. EVIDENCE: The AQAA states that the hours for activity co-ordination have been increased to 24 hours per week and that weekend activities are encouraged, although this is still in development. There is a structured activities programme and we saw a room where the activities organisers store their large range of activities equipment. On the day of the inspection the residents had a buffet VE day celebration lunch. The food looked very good and the atmosphere round the table was jolly. The activities co-ordinator told us that activities include, Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 16 community tea week (tea tasting and cakes), attendance at day centres, line dancing and knitting. The home took part in an initiative to knit squares and make a very big patchwork blanket. A log is made of what activities residents have participated in and this is filed in their personal file so this aspect of their lives can be monitored. There is an open visiting policy and visitors were seen on both days. We took the opportunity to speak with two relatives. The manager told us that there are a range of initiatives for involving residents in the community and involving the community in the home, with parties of school children visiting. There was evidence that service users are supported to exercise choice and control over their lives. One care plan stated that a resident liked to have her bedside lamp left on overnight. Another resident we noted has an Independent Mental Capacity Advocate (IMCA). The AQAA states that residents are encouraged to personalise their rooms and to handle their own money should they wish to. The system for delivering nutritional and appealing meals is called Menu Master. Residents are asked to choose their meals for the next day. The AQAA states that they are encouraged to participate in the development of the menu’s and there is always an alternative choice. The home has developed the practice of making their own nutritional supplements. Further the manager stated that the chef goes to see residents who need additional nutritional input but have delicate appetites, and produces high calorie treats to tempt them. We inspected the kitchen and found it very clean with stocks of properly kept and varied foods. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are protected from abuse and their complaints are taken seriously. Processes for dealing with safeguarding and complaints are sound. EVIDENCE: Since the last inspection the home has separated the safeguarding material from the complaints material, although safeguarding issues are still logged as complaints. There have been seven complaints since the last inspection, some upheld or partially upheld and one inconclusive, but all resolved to the satisfaction of both parties. There was evidence that the home deals appropriately with complaints. We spoke with a relative who had made a complaint to the Primary Care Trust (PCT) about the care of her mother in the home. The manager had a copy of the complaint and with permission we advised him of our discussion with the complainant.. Some of the issues were already contained in the letter, but some were new. The complainant is not satisfied with the quality of care and the ethos and attitudes of the home. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 18 We had already spoken to another relative of this resident the day before and she had expressed herself very satisfied with the home saying there had been a great improvement in the resident’s condition since she had been there. We advised the relative who had complained, and the manager to speak to each other. He said that the plan was to ask the family to elect a spokesperson and to have a meeting with himself. We cannot comment on the above mentioned complaint which is in the process of investigation, but we felt that the system for complaining and the acceptance and resolution of complaints were all working well. The home also records compliments it receives and shared some of these with us. They showed that relatives of some were most appreciative of the service. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment of the home is well-maintained. It is clean, safe and comfortable and there are sufficient lavatories and washing facilities. EVIDENCE: We made a tour the home including the kitchen and gardens. Many residents had their doors open so we were able to glance into rooms as we passed and one room was entered for a discussion with the resident. Residents rooms are en-suite. They are pleasant and personalised. There are sufficient numbers of bathrooms and toilets and they are clean and safe. The corridors are clean and safe. However one area close to the nurses station on the second floor did smell of urine and felt a little tacky underfoot. The dining rooms were cheerful Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 20 and pleasant. There is work going on in the garden and it was looking tidy and quite colourful. The environment was safe and generally well maintained. The décor was satisfactory. We did note one chair on the second floor which had a loose arm. We advised the manager who said he would get the maintenance man to glue it straightaway. The AQAA states that all staff have received training in the prevention and control of infection and we saw the Basic Infection Control - test paper which staff complete to evaluate their training. There are bottles of hand scrub strategically placed around the building and the manager stated that the staff try to educate visitors to use them. If someone is unwell with something which could be infectious the staff ask them to keep to their rooms for 24 hours to prevent spread to others. The manager said that in the light of the recent influenza epidemic he has stock piled supplies of gloves, aprons and sterile fluid. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents’ needs are met by the staff group who care for them safely. Recruitment policy is sound and staff training is comprehensive. EVIDENCE: The home provides 24 hour support including waking night staff. The nurse to resident ratio in the home is 1:12 in the continuing care unit, with 4 carers, 1:22 on the general nursing unit with 4/5 carers and 1:21 on the mental health unit with 4 carers. The nurse on the mental health unit is a registered mental health nurse with substantial experience. The staff are trained and supervised and there is a good mix of skills. NVQ application is encouraged. The policies and practices of the home underpin safe and robust recruitment. We inspected four staff files. All had completed an application form, been interviewed, references taken up, and a Criminal Records Bureau (CRB) disclosure had been obtained for them. The AQAA also tells us that Protection Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 22 of Vulnerable Adults (POVA) and National Nursing and Midwifery PIN checks are also made. We would recommend to the manager that he ensure he has the dates of employment of previous jobs confirmed by referees, as it was noted that these did not always match perfectly. The manager keeps up to date records of staff training on a matrix. In this way he can identify training needs and plan for them. The AQAA states that mandatory training is up to date and we found this to be generally so. The manager agreed with us that core basics to be renewed within two years include: Manual Handling, Adult Safeguarding, Health and Safety, Food Hygiene, Fire and First Aid (unless the certificate for this lasts longer) Two workers whose training we checked had undertaken a range of appropriate training but needed to update their food hygiene training. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, 37 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well run and managed in the best interests of the residents. The financial interests of residents are safeguarded and their health and safety is promoted and protected. EVIDENCE: The registered manager of the home has qualifications and experience to run the home and he has worked there for many years. Since our last inspection when issues around privacy and dignity were raised, we felt that standards in this respect had improved. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 24 The best interests of service users are integrated into assessment, care planning and the delivery of care. The organisation has a quality assurance system which audits key areas. The results are checked on Regulation 26 visits which are conducted by staff from outside of the home. BUPA conducts an annual survey called Surveying Our People. We were satisfied that a substantial amount of quality assurance work is undertaken. The home has a health and safety manual. On the day of the inspection Control of Substances Hazardous to Health (COSHH) products were safely stored. The manager advised us that all preparations come into the home diluted which makes them safer. We were impressed with the colour chart system which is used to ensure that opened perishable food stored in the refrigerator, are disposed of in a timely fashion. From our observations during the inspection we felt that the record keeping in the home was very good. We noted from the AQAA that a number of important policies have not been updated since 2006 and we trust that the organisation will update them by the time they are three years old. Bakers Court Nursing Centre DS0000007352.V375344.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x 3 x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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. 2. Refer to Standard OP9 OP29 Good Practice Recommendations The organisation should review the medication policy with regard to missed medication. The manager should ensure that referees confirm dates of employment for staff as stated on the application form. Bakers Court Nursing Centre DS0000007352.V375344.R01.S.doc Version 5.2 Page 27 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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