Inspection on 04/07/07 for Bakewell Cottage Nursing Home

This inspection was carried out on 4th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bakewell Cottage Nursing Home 20/05/07

Bakewell Cottage Nursing Home 06/06/06

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bakewell Cottage Nursing Home Bakewell Cottage Nursing Home Butts Road Bakewell Derbyshire DE45 1EB Lead Inspector Angela Kennedy Key Unannounced Inspection 09:50 4th July 2007 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 Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bakewell Cottage Nursing Home Address Bakewell Cottage Nursing Home Butts Road Bakewell Derbyshire DE45 1EB 01629 815220 01629 815330 bakewellcottage@westwickgroup.com Info@Westwickgroup.com The Westwick Group of Businesses Limited 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) Vacant Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2006 Brief Description of the Service: Bakewell Cottage is a sympathetically extended period home, which was previously a local community hospital. The home is located near to the centre of Bakewell where a variety of amenities are available. Accommodation is provided on three floors, which can be accessed at two levels. Two lifts provide access to all parts of the building and 38 service users can be accommodated in 34 single and 2 shared bedrooms. Bakewell cottage provides personal care with nursing. Some bedrooms are equipped with en suite facilities. There is a range of lounges and dining areas. The home is well maintained both internally and externally. A large garden area with a patio is provided to the side of the building, which creates a pleasant sitting area for residents. Support services are provided locally with residents having a choice of GP and other support services accessed on request. At the time of inspection the weekly fee at Bakewell Cottage was £620. Items not covered by this fee included: Hairdresser Varies dependent on requirements Chiropody £10 per visit Newspapers/Magazines Varies dependent on items purchased. Optical treatment (this does not Varies dependent on treatment include eye test) Toiletries Dependent on items purchased. Further information regarding the home and the current scale of charges can be obtained by contacting the home directly by telephone or email. The providers website also has information about the home along with photographs and the most recently published inspection report. Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 5 Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over approximately 7 hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with residents and their representatives. The inspection was focused on assessing compliance with defined key National Minimum Standards. The commission had requested the service to complete a pre inspection questionnaire and the information provided within this questionnaire has also been used to inform this inspection report. Care home surveys were sent out to residents and twenty were returned prior to this inspection. The opinions within these surveys have also been used within this report. The acting manager was present at the inspection and the area manager, who oversees the quality assurance systems within the Westwick Group of residential homes, was present for part of the inspection visit. Some of the staff team were spoken with to ascertain their views of the service and their opinion of the training and support provided to them. Three residents were case tracked and two of these residents were spoken with. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at plans and other documents relating to that persons care, talking to staff regarding the care they provide, talking to the resident if they are able to communicate or observing the care they receive. Several other residents were also spoken with at this inspection visit. What the service does well: Bakewell Cottage is well furnished and attractively decorated to provide a homely environment for the residents. The communal areas are light warm and clean, there is wheelchair access to the garden area, which is attractively and safely maintained. The staff team demonstrated a caring, friendly and respectful approach to residents and comments made by residents and their representatives were positive regarding the care and support provided. Residents confirmed that the standard of the catering is good and that there is choice of menu items provided. Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 7 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. Bakewell Cottage Nursing Home DS0000065048.V337922.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 Bakewell Cottage Nursing Home DS0000065048.V337922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service To ensure people’s needs can be met at Bakewell Cottage, an assessment of their needs is undertaken before admission is agreed. EVIDENCE: One resident who had lived at Bakewell Cottage for many years did not have an assessment of their needs undertaken before they moved into Bakewell Cottage, but there was sufficient information that demonstrated that information pertaining to this persons needs was gathered directly following admission. The other two residents files seen had needs assessments in place and these had been undertaken before they had moved into the home. Where residents had been admitted with the involvement of social services the appropriate assessment documentation was on file. For residents admitted without the Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 10 involvement of social services (privately funded residents) an assessment had been undertaken by the home prior to admission. These assessments addressed all areas of care including personal, health and social care, and included prescribed medication. Care plans were developed from the information gathered in the needs assessment. The care surveys completed by fifteen residents and their representatives confirmed that they had received enough information prior to moving in to the home to enable them to make an informed decision about Bakewell Cottage. Of the other five surveys returned the majority of residents said they couldn’t remember what information they had received before moving into Bakewell Cottage and one resident had indicated that they had not received sufficient information before moving in. Further assessment regarding the information provided to prospective residents was not undertaken at this inspection visit. Bakewell cottage does not provide intermediate care; therefore standard 6 is not applicable to this service. Bakewell Cottage Nursing Home DS0000065048.V337922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of residents are set out in their plan of care and are based on their individual needs. The medication practices in place ensured residents’ welfare was maintained EVIDENCE: The information provided within the three residents files seen was detailed and informative, which enabled the staff team an individualised ‘picture’ of each resident. This information included individual’s personal history such as their childhood memories, education, holidays, general interests, upbringing, occupation, family history and food preferences. One of the residents case tracked had been admitted to Bakewell Cottage less than 24 hours prior to this inspection visit and therefore care plans had not been developed. However the information that had been sought when Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 12 assessing this person’s needs was detailed, and provided staff with the information they required to ensure the correct level of support could be provided to this person in all areas of health, social and personal care. The other two residents files contained care plans that were detailed and directed the staff team on the level of support and care each person required to ensure their needs were met. Care plans had been reviewed each month to ensure any changing needs were identified and the correction action taken to enable needs to be met. Al care plans had been signed and dated by staff, however there was no written evidence to demonstrate that residents or their representatives had been involved in the development of their care plans. This was discussed with the acting manager. Risk assessments were in place that addressed all identified areas of risk such as, moving and handling, nutrition, falls and pressure sores. These assessments were regularly reviewed, which again demonstrates that the staff are proactive in ensuring any changing needs are quickly identified and the correct measures are put into place to address this. Records were maintained of professional health care input such as visits from doctors, district nurses, chiropodists, dentists and opticians. A chiropodist visited the residents at Bakewell Cottage on a six weekly basis to provide foot care and a domiciliary optician provided annual eye tests for residents. Residents were able to choose their own health care specialists if they preferred and the acting manager confirmed that some residents chose to visit their own opticians. A dentist was available within Bakewell for residents. However the services of a domiciliary dentist were not provided at Bakewell Cottage for any residents who wished to use this service. Discussions took place with the acting manager and area manager regarding this and it was agreed that this should be further explored. Daily notes were kept for each resident that ensured good communication between the staff team was maintained. The medication practices were looked at and good systems were in place regarding the receipt, administration, safekeeping and disposal of medication. None of the residents on the day of this inspection were self administering their medication. Discussions took place with the manager regarding risk assessing any resident who wished to self-administer their medication in the Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 13 future, this was to ensure individuals had the capacity to retain and administer their own medication safely. Residents were very positive regarding the level of care and support provided by the staff team. Comments included, “the staff are extremely efficient and kind in an unobtrusive way, they are very dedicated” and “as a relative we have always been impressed with the standard of care … receives”. Observations of staff with residents appeared positive, friendly and caring. Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were involved in activities according to their individual interests and capabilities, and had the opportunity to maintain and develop important family relationships and friendships. The meals provided were balanced and nutritional and in general enjoyed by residents. EVIDENCE: A member of the care team was designated as the activities coordinator each afternoon to ensure activities were undertaken. Activities within the home included a variety of board games, reminiscence sessions, music sessions and video/film entertainment. Residents were able to go into Bakewell with staff support and were able to participate in day trips out to local attractions. Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 15 A hairdresser visited Bakewell Cottage twice a week and was at the home on the day of the inspection. Many of the residents used the hairdresser, although some residents chose to continue using their own mobile hairdresser and some went out to local hair salons. Comments from residents in general were very positive and included, “ there is a very friendly atmosphere here and activities and outings are arranged very regularly” and “ although I seldom wish to join the activities, it is always open to me to join in should I wish to”. Two of the twenty care home surveys returned from residents and their representatives indicated that there were few activities available for them to participate in. Unfortunately these two surveys did not provide any contact details to allow the inspector to discuss these issues further. It is therefore suggested that issues such as these be addressed within the homes quality assurance systems. (Please refer to standard 33). The staff at Bakewell Cottage openly encouraged visiting and residents spoken with confirmed this. A kitchen and small sitting room were available for residents and their relatives to use, although the acting manager stated that visitors rarely used this facility. Through observation it was apparent that residents were able to exercise as much control over their lives as possible. Some residents were spending time in their rooms either alone or within the company of other residents, and some residents were within the communal areas of the home, and some were seen walking around chatting to other residents and staff. One resident spoken with stated that they would normal go for a walk in the afternoon, but due to the weather they were unable to do so. Two of the residents were able to manage their own finances, and for those residents who were unable to do so, facilities for the safe keeping of resident’s monies was available (assessed at standard 35). All residents had a private telephone line within their rooms and a portable telephone was available for any residents who wished to use this. Comments from residents and their representatives regarding the meals provided were positive, such as “… always eats and enjoys their meal, the standard is extremely high” and “always enjoys eating and meals always go very quickly” and “ food is excellent”. The menus were looked at. Choices at breakfast were varied and included cooked breakfasts, a variety of breakfast cereals and toast with preserves. During mid morning the cook was seen visiting residents to discuss the lunchtime meal and ascertain resident’s choice for the teatime preference, Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 16 which included a cooked option. The cook confirmed that alternatives to the lunchtime meal were available for any resident wanting them. The kitchen was staffed for the majority of the day and two cooks, one kitchen assistant and one breakfast assistant were employed. Bakewell Cottage Nursing Home DS0000065048.V337922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were aware of the complaints procedure and were confident that the staff team would promptly address any concerns they had. The training in place regarding safeguarding adults must be maintained to ensure residents are protected from abuse. EVIDENCE: The complaints procedure was displayed within the entrance area of Bakewell Cottage and within the written information about the home that is given to all residents. Bakewell Cottage had received four complaints within the last twelve months and all had been responded to within the 28-day timescale and all had been dealt with promptly and effectively. Nineteen of the twenty residents surveys returned confirmed that they would know how to make a complaint. All twenty surveys confirmed that they would know who to speak with if they were not happy. Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 18 All of the residents spoken with on the day of inspection confirmed they would know who to speak with and how to make a complaint if they needed to. The home has an adult protection policy and access to Derbyshire local authority adult protection guidance. No adult protection referrals have been made by the home or in relation to any resident at the home within the last twelve months. Safeguarding Adults training is provided in house by the area manager who holds a training certificate in safeguarding adults that was undertaken with the local authority. The training records in place at the home demonstrated that out of forty-nine staff, thirty-seven required training or an update in training on Safeguarding Adults. This was discussed with the acting manager and some members of the staff team. One member of staff confirmed that Safeguarding Adults was provided as part of the induction training and within NVQ training. However to ensure residents safety is maintained this training must be provided to all staff to enable them to maintain safe working practices and safeguard residents. Bakewell Cottage Nursing Home DS0000065048.V337922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A safe, attractive and well-maintained environment was provided for the residents at Bakewell Cottage and good standards of hygiene were kept. EVIDENCE: The layout of the home is suitable for its stated purpose and all communal areas were accessible to the residents, including the grounds. Bakewell Cottage was once used as a cottage hospital and has been well maintained with many of its original features still in place. A homely and comfortable environment for the residents is maintained with views that overlook well-kept and attractive grounds. Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 20 Since the last inspection the two new bedrooms, with ensuite wash hand basin and toilet, known as the garden rooms are now in use. These rooms are on the ground floor and have doors, which open onto an attractive patio and garden area. Opposite to these two bedrooms was a kitchen and sitting room, which as stated in standards 7 to 11 of this report, where for the use of residents and their visitors. The acting manager discussed plans for the renovation of a bathroom that was not used at present due to lack of moving and handling aids and the bath being too low. Bakewell Cottage had been awarded a grant to convert this room into a wet room/shower room for residents to access independently or with assistance as required. A programme of routine maintenance was in place and the maintenance person employed was responsible for ensuring maintenance work was completed. . Systems were in place to ensure that the spread of infection was controlled; this included the laundry area, which consisted of two rooms, one room being quite small next to a larger room where a washing machine with a sluicing facility was housed. Housekeepers were employed that undertook laundry and domestic duties and were on duty seven days a week. Residents and their representatives were complimentary regarding the standards maintained at Bakewell Cottage, such as “ my room, in fact the whole building is wonderful” and “we have nothing but praise for the standard of cleanliness” and “ my dads room is kept lovely and clean” and “this home is always fresh and clean, and cheerful. It is like a first class hotel. There are flowers and little extras that make all the difference between a good nursing home and a mediocre one”. Bakewell Cottage Nursing Home DS0000065048.V337922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of the staff team can meet resident’s needs, however to ensure residents are protected, further development is required to the recruitment records held and the mandatory training provided. EVIDENCE: The staffing levels provided were appropriate to meet the assessed needs of the residents and staffing rotas were in place to demonstrate this. However on discussion with some staff it was stated that staffing levels were at times low, due to sickness and holiday. Discussions took place with these staff and the acting manager to look at how this could be addressed and the implementation of a ‘bank’ of staff, that worked within the three homes owned by the provider was discussed. The acting manager confirmed that this option would be further explored. Comments from residents and their representatives were mixed regarding the staffing levels; many felt the staffing levels were appropriate in numbers to manage their needs/the needs of their relatives. Some stated that there were Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 22 occasions when they had to wait or had difficulty locating a member of staff; this appeared to be mainly at weekends. Of the twenty four care staff employed at Bakewell Cottage, fifteen had achieved a National Vocational Qualification (NVQ) at level 2 or above in care, and a further two members of staff were undertaking this training. This demonstrates that the care provided to residents is delivered by appropriately trained staff and indicates that the care provided is safe. Three staff files were examined and satisfactory criminal records bureau checks and the required identification documents were seen within all three. However two staff files did not contain the required two references, one of these being from their last employer. This was discussed with the acting manager who confirmed that all staff files would be updated as required to ensure all of the required recruitment documents were in place. It was also noted that the employment application forms did not request that the applicant provide written information regarding any gaps in employment. It was confirmed by the area manager that application forms would be amended to request this information. The homes induction package was seen and was in line with the recognised training standards required. The training record was seen and demonstrated that not all staff were up do date with mandatory training such as moving and handling and basic food hygiene and fire training. This was discussed with the acting manager who was unsure if the records held were up to date but confirmed that she would investigate this further. Staff spoken with felt that the training provided was good and one member of staff stated that she had undertaken moving and handling training as part of her NVQ training the previous day. This member of staff stated that other staff on duty had also been able to participate within this training and certificates were being issued regarding this. To ensure that all staff are practising safe working procedures mandatory training must be kept up to date and the records held must be maintained to demonstrate this. Bakewell Cottage Nursing Home DS0000065048.V337922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Bakewell Cottage was well managed and runs with the safety, welfare and best interests of residents foremost. EVIDENCE: The acting manager had been in post for one month at the time of this inspection visit. The acting manager has considerable experience within the management of older persons care homes, which spans over 17 years and is a dual trained registered nurse. Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 24 The acting manager has yet to apply for registration with the commission for social care inspection as the registered manager of Bakewell Cottage. Residents and relatives reported that the home appears well managed and that management and staff are approachable and communicate well with residents and visitors. Comments included, “generally we think the home is providing good care for our father and that when he is unwell the appropriate treatment and support is given”. Satisfaction questionnaires were developed for residents, relatives and staff. A method of publishing the results of these questionnaires had been established through newsletters that were sent out to residents and relatives. However it was confirmed that newsletters had not recently been sent out. The area manager stated that this was to commence again within the near future. Audits had been undertaken that looked at the responses provided within the questionnaires sent out to residents, relatives and staff and records were seen to demonstrate this. The acting manager confirmed that this information was made available to residents, relatives and staff. Residents meetings had not been held and this was discussed with the acting manager, and it was agreed that this would be a further opportunity for residents and their representatives to discuss any ideas or opinions they had regarding the services provided to them, and demonstrate how the residents influence the running of their home. Quality audits were also maintained in respect of the practices undertaken, such as medication audits, care plan audits and environmental audits. This demonstrates a proactive approach to maintaining safe and efficient working practices. On the day of the inspection visit the area manager was at Bakewell Cottage undertaking the monthly unannounced regulation 26 visit, that quality assesses the standard of care and services provided. The system for handling residents’ personal monies was examined and there was confirmation that there were suitable accounting procedures in place. The service and maintenance documentation indicated that residents are protected by robust procedures, with all evidence of gas and electrical services having been suitably checked/maintained. A Legionella test report was in place that demonstrated that risk reduction measures were in place to maintain residents safety. Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 25 The maintenance person tested fire alarms on a weekly basis; again this ensures a proactive approach to residents, staff and visitors’ safety is maintained. Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 26 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP18 Regulation 13 (6) Requirement Timescale for action 04/11/07 2. OP29 19 (1) (b) 3. 4. OP30 RQN 18 (1) (c) CSA 11 (1) Safeguarding Adults training must be provided for all staff to ensure residents are safeguarded from abuse and safe working practices are maintained. All the required recruitment 04/11/07 documentation must be maintained within staff files as stated in Schedule 2 of the Care Standards Regulations 2001 Mandatory training must be kept 04/11/07 up to date and records maintained to demonstrate this. The acting manager must apply 04/01/08 for Registration with Commission for Social Care Inspection. Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 28 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 OP7 Good Practice Recommendations Written evidence should be in place to demonstrate residents or their representative’s involvement in the formulation of care plans. Bakewell Cottage Nursing Home DS0000065048.V337922.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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