Inspection on 12/09/06 for Bartlett`s

This inspection was carried out on 12th September 2006.

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 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

Bartlett`s 05/02/08

Bartlett`s 09/01/06

Bartlett`s 10/08/05

Bartlett`s 07/02/05

Bartlett`s 01/06/04

Bartlett`s 08/01/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Bartlett`s Peverel Court Portway Road Stone Aylesbury Bucks HP17 8RP Lead Inspector Mike Murphy Unannounced Inspection 12th September 2006 09:30 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 Bartlett`s DS0000022953.V304244.R02.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. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bartlett`s Address Peverel Court Portway Road Stone Aylesbury Bucks HP17 8RP 01296 747000 01296 747740 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) Peverel Court Limited Gloria Ncube Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: Bartletts is registered to provide personal care and accommodation for twentyfour older people. The home is privately owned and is situated on the outskirts of Aylesbury and Stone. There are some amenities within the village of Stone and ample social and recreational facilities in the market town of Aylesbury. Bartletts is a large, Victorian country house, set in its own grounds. The home has been refurbished to meet the needs of residents, whilst maintaining many of the original characteristics of the house. All but one of the bedrooms provides single room accommodation. All bedrooms are fitted with en-suite facilities and there are ample bathrooms and toilets within close proximity to all sleeping and communal areas. One lounge is situated on the ground floor adjacent to the dining room. There is a quiet lounge on the first floor. The home is well decorated. There is an experienced manager and care team. Fees are between £550 and £800 per week. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one inspector over the course of one day in September 2006. The inspection methodology included discussion with the general manager and registered manager, with staff and residents. It also included examination of care plans and other documents, a tour of the home and grounds, consideration of information supplied by the registered manager in a pre-inspection questionnaire and of comment cards completed by residents, relatives, and health and social care professionals in advance of the inspection. Overall, the inspection finds that this home is providing a good service to residents, relatives and other stakeholders. The environment is generally good. The home is located in very pleasant grounds and the interior provides a range of accommodation for residents. It is an older building however, and will always require an ongoing programme of refurbishment to maintain a comfortable and safe environment. The home’s procedures for the assessment of prospective residents are satisfactory, and the quality of its arrangements for planning and providing care are good. It appears to liaise well with health services in the local community and, from feedback received over the course of this inspection, has the confidence of local health and social care professionals. The residents seem comfortable here and are well supported. Staff describe it as a good place to work. Policies and procedures for the protection of residents are good and staff have access to regular training on a range of subjects including POVA (Protection of Vulnerable Adults). The home is now meeting the standard in relation to NVQ qualifications and at the time of this inspection just over 50 of staff had acquired NVQ2 or above. The registered manager is experienced in the care of older people. This inspection concludes that this home is providing a good and valued service to residents and their families. What the service does well: There is an experienced manager and care team. There are sufficient staff to meet resident’s needs. The home is set in pleasant extensive grounds and has been refurbished to provide comfortable accommodation for residents. The medication management at the home is good and residents receive their medication in a safe and timely way. Bartletts is a comfortable and wellmaintained home. The residents said that they enjoyed living there. The home was clean and tidy and free from offensive odours, protecting residents from infection. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 6 The home carries out quarterly surveys which monitor its performance across a range of activities. The results, including those of previous quarters for comparison, are reported to residents, staff and other stakeholders through a regular newsletter. 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. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 7 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 Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 8 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): 3, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are assessed prior to admission to ensure that the home is able to meet the person’s needs. Prospective residents and the relatives may visit the home to meet staff, view its facilities and have any questions or concerns answered. The visit aims to ensure that the resident is comfortable in accepting the offer of a trial admission and that the home is likely to be able to meet their needs. EVIDENCE: Enquiries may be made direct or through a health or social care professional. An initial enquiry is most often made by telephone. This is followed up by a visit to the home by the prospective resident and their relatives. At the visit the person has an opportunity to view the home, talk about its services, discuss their needs, and meet staff and residents. Where the enquiry progresses to a referral an experienced member of staff will conduct an assessment of need which is structured by the Standex ‘Long Term Assessment’ form. This assessment may be carried out in the person’s own home, another home or in hospital. The information acquired may be Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 9 supplemented by information from health (most often the GP) and social service professionals. In the case of referrals from social services the home has access to information relevant to the referral - such as the most recent assessment of needs. This process leads to a decision by both parties: by the prospective resident that they wish to consider the offer of a place, and by the home that it believes it can meet the person’s needs and wishes to offer a place. A decision to proceed leads to a trial admission of four weeks. During this time further information is acquired by the home. This is aimed at ensuring that the home has all the information it requires to meet the person’s needs. The home does not offer intermediate care therefore standard 6 does not apply. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 10 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, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents care plans are based on a thorough assessment of needs, are detailed, well written and support the provision of care appropriate to individual needs. Liaison with other healthcare agencies is good. Arrangements for the control, storage and administration of medicines are satisfactory and aim to minimise the risk of errors and potential risks to residents. EVIDENCE: The home uses the ‘Standex’ system for care planning and recording. The three care plans examined each contained a photograph of the resident, a comprehensive long-term assessment, assessments of pressure sore risk, mobility, falls (risk), moving and handling, personal care and social care (using Standex codes). One plan included referral to a dietician. The assessment lead to a care plan for each main problem. Progress is evaluated monthly. Evaluations included personal hygiene, mobility, depression, hearing, weight loss, reported pain, and sleep. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 11 It is felt that there may be a bias towards physical needs in the system. The system leads to social activities being recorded in coded form. There were few references to psychosocial aspects of residents’ lives. Daily reports tended to record only physical care provided. In one case there were no references to the resident’s feelings about a bereavement which had occurred just prior to admission. In two of the three plans examined the Standex papers were supplemented by a typed care plan. Care plans included evidence of referral to GP or other NHS services as required. The home works in partnership with NHS services as needed. These are most often GPs and district nurses. A Waterlow assessment (pressure sore risk assessment) is completed for each resident and where additional advice is required then the home makes contact with the district nurses. Residents are weighed on admission and each month. A BMI (Body Mass Index) of 18 or below would trigger a referral to a dietician. A chiropodist visits regularly. An optician or dentist will visit on referral. The services of an occupational therapist or physiotherapist are obtained through referral – either direct or via a resident’s GP. The activities co-ordinator organises gentle exercises and, where needed, staff support residents in walking around the grounds. The home has a policy governing the administration of medicines. This was last reviewed in November 2005. The policy includes the procedure for administering ‘homely remedies’ where required. Medicines are prescribed by the resident’s GP and dispensed by a local pharmacist. The home records medicines received and those returned to the pharmacy. The pharmacist runs a training course for staff (‘Medicines in Care Homes in Haddenham’) and carries out an audit of the home’s arrangements for the storage, control and administration of medicines twice a year. Staff competence in the administration of medicines is assessed by the registered manager. The home did not have arrangements for staff to attend an accredited course in addition to its own procedures and it would be advisable for it to investigate the options here. The medicines record for each resident includes a photograph of the resident and a note of allergies in red. Medicines are supplied in NOMAD monitored dosage system filled by the pharmacy. Medicines Administration Records include a copy of the medicines label supplied by the pharmacy. Records examined were in order. Arrangements for the storage of medicines are satisfactory. Some residents are prescribed Temazepam and the stock balance was checked against the record and found to be accurate. Staff take account of residents need for privacy and dignity. Personal care and medical examinations are carried out in bedrooms or bathrooms. Residents wear their own clothes. Other than in an emergency staff knock on doors and await an invitation before entering bedrooms. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 12 The home has a policy to guide staff practice in the care of a resident who is dying and on the death of a resident. Resident’s wishes are ascertained on admission. In such circumstances relatives may visit whenever they wish. One relative respondent commented ‘Dad died in his sleep in [date supplied] and the whole episode was treated with dignity and gentleness’. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents have opportunities to be on their own or with others as they wish. They may participate in activities as arranged by staff or pursue their own interests if they prefer. Residents may have visitors at any time. This supports residents in continuing to exercise control over their lives. The overall standard of food appears satisfactory and ensures that residents’ nutritional needs are met. EVIDENCE: Residents are free to exercise choice in relation to their daily routines and these are recorded in care plans. This was evident on the day of the inspection where some residents were sitting in the lounge and others preferred to be in their rooms reading, listening to music or watching television. A diary of planned activities for the week was posted on the notice board in the entrance hall. Activities include bingo and board games, exercises, arts and crafts, live entertainment in the home (in August 2006 this included jazz and dancing in a marquee and two singers), and trips out to places of interest and to a garden centre. Residents may have visitors at any reasonable time. All rooms have a telephone. An information pack is given to relatives at the time of admission and they also receive a copy of the home’s regular newsletter. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 14 Residents may bring personal possessions to the home with them. Residents may have access to their care records on request. Each resident receives a copy of the menu each week. Alternative dishes are provided where a resident requests it. Breakfast in the form of cereals, fruit, toast and tea or coffee is provided from 6.00 am to 9.00 am. A cooked breakfast is available from 7.00 am. Tea and biscuits is served mid morning at around 10.30 am. Lunch is served between 12.00 midday and 1.00 pm. This is a two course meal and is the main meal of the day. Choices in the menu’s submitted with the inspection papers included ‘Pork Casserole’ or ‘Fried Plaice’, ‘Lasagne’ or ‘Smoked Haddock’, or, ‘Cottage Pie’ or ‘Fishcakes with lemon’, all served with ‘seasonal vegetables’. Desserts included ‘Queen of Puddings, ‘Apple Pie’ or ‘Sticky Toffee Pudding’ and Cheese and Biscuits. Afternoon tea of tea and cakes is served at 3.00 pm. Supper is served from 5.30 pm and consists of soup or sandwiches or a lighter meal such as ‘Macaroni Cheese’, ‘Ham and Egg Salad’, and ‘Sausage Rolls and Salad’. Some dissatisfaction was expressed with the evening meal and the registered would be advised to seek a wider range of residents view on this. The registered manager said that a kitchen assistant and another member of staff go around with drinks at various times in the day. The home refers to a dietician for any specialist advice. Staff provide support to residents as required. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a system for recording and investigating complaints although some relatives do not appear to be fully aware of the procedure. The home has a robust framework of policy, procedure, reporting arrangements and staff training with regard to the protection of vulnerable adults. Together, these aim to protect residents from abuse and ensure that complaints are properly investigated. EVIDENCE: The home has a complaints policy and procedure which is made known to residents and relatives. The policy fully conforms to this standard. Two complaints have been received and dealt with over the last twelve months. Residents are registered to vote. The registered manager said that some choose to travel by taxi to the polling station at a local hall while others opt for a postal vote. The home has comprehensive arrangements for the protection of vulnerable adults (POVA). A policy governs these arrangements and was last reviewed in November 2005. It has a copy of the Buckinghamshire joint agency arrangements. Staff receive internal and external training. Two staff are POVA trainers. Training approaches include viewing a training video. The manager said that staff are reminded of the option of whistleblowing as well as making use of line management reporting arrangements. Residents have access to Age Concern advocates, two volunteers of which are still in regular contact with the home. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 16 Staff training planned for the latter part of this inspection year includes ‘Elder Abuse’ and ‘Dementia Awareness’. Staff interviewed during the course of this inspection said that there is a great deal of emphasis on the awareness and prevention of abuse in the home. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a good quality and well maintained environment which provides residents with a comfortable and safe place to live and which enhances the well-being of residents. EVIDENCE: The home is a large country house which has been converted for its present use. It is located in very pleasant and tranquil grounds, overlooking open countryside, a short distance from the centre of Stone. A driveway leads to the front of the home where there is plenty of space for parking. The accommodation is located over three floors. A passenger lift connects to all floors. The accommodation consists of 22 bedrooms – 20 single and 2 double rooms. All rooms have en-suite facilities. There are three living and dining areas on the ground floor. Most areas are accessible by wheelchair. In addition to the en-suite facilities there are three bathrooms, three showers and three Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 18 WCs. The bathrooms include a Parker bath and manual hoists to assist with moving and handling when required. Bedrooms visited were of a comfortable size and were well furnished. All areas of the home were tidy, clean and free of untoward odours. There is an ongoing programme of redecoration and over the last year this has included installing a new shower and tiling the walls in one bedroom, installing handling aids in WCs, redecorating four bedrooms as they became vacant, the conversion of a room to a hairdressing room on the first floor, new furniture for the lounge and dining room, and substantial refurbishment of the kitchen – “200 better” in the opinion of the Chef on the day of the inspection. There is a small area for smokers to have a cigarette to the rear of the building. This is not currently covered and residents who wish to smoke are exposed to the elements. The laundry is located in a separate building. It is spacious and well organised and appears adequately equipped for its purpose. It does, however, give the impression of being due for some thorough refurbishment. This is planned in connection with a new building development in the future. The managers have sought the advice of a gas engineer on the ventilation and heating of the laundry. It was thought that a solution had been found to the problem of providing adequate ventilation for the gas fired equipment while maintaining an adequate temperature for the laundry assistant to carry out her work. The coming winter will be the test. The grounds are very pleasant with extensive areas of lawn, mature trees and shrubs and views over open countryside. The manager said that they plan to create a wheelchair route around the grounds in the near future. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staffing levels appear satisfactory and the home provides training at all levels across a range of subjects. This helps to ensure that there are sufficient numbers of appropriately trained and supported staff to meet residents’ needs. EVIDENCE: The home calculates that it requires 453 hours of staff time per week. At the time of this inspection it provide 511 hours. In terms of staff numbers the home had one registered manager (a registered nurse), thirteen care staff and six ancillary staff. The ancillary staff comprised, a chef, kitchen assistant, laundry assistant, domestic assistant and handyman. These staff numbers allow for four care workers to be on duty in the morning, three in the afternoon (to 5.0 pm), four in the evening, and two at night. The registered manager is supernumerary. Seven of thirteen staff have acquired NVQ 2 or above. A local staff recruitment agency supports the home in recruiting staff. The manager interviews candidates and is responsible for the selection of staff. Two staff files were examined. Files included a recent photo of the staff member, completed application form, medical declaration, voluntary statement of any convictions, interview checklist, two references, POVA first result, Enhanced CRB certificate (where received), and induction programme. Files conform to the standards. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 20 A copy of the staff training programme for 2005 – 2006 was examined. This listed the training attended by to September 2006. This included fire drills, Fire Safety, Moving & Handling, Basic Food Hygiene, Infection Control, ‘Elderly Abuse’, Care of Medicines, First Aid, Health & Safety, Customer Care’, NVQ 2 and 3, ‘Skin Tears’ and for a smaller group of staff, ‘Falls and Fracture Prevention’, ‘Supervision Training’. ‘Assertiveness’ and Challenging Behaviour. Staff interviewed confirmed the home’s support for training – one describing it as “Excellent”. Staff induction comprises an introduction to the home and the ‘Skills for Care’ programme. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 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, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well managed home and feedback from residents, relatives and health and social care professionals indicate that it is providing good care outcomes for residents. Arrangements for health and safety appear thorough and aim to ensure the safety of residents, staff and visitors. EVIDENCE: The registered manager is a registered nurse and has had over six years experience in caring for older people, including three years as manager of Bartletts. She has acquired the Registered Manager Award. The manager is not responsible for any other registered service. There are clear lines of accountability within the home and to the general manager and the owner of the business (which also includes a nursing home and another care home). Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 22 The organisation’s business planning arrangements include a development plan for each service, including this home. The home has established systems of self-monitoring which include quarterly monitoring of a range of activities. Categories to date have included ‘care of resident’, ‘food’, ‘cleanliness and environment’, ‘staff’, ‘activities and entertainment’ and ‘manager’. Summary results of these surveys – and performance against a target figure over time are reported in periodic newsletters to residents and relatives. Response rates are variable but are said to be around 40 . A staff questionnaire is under consideration. 21 comment cards were received by CSCI in advance of this inspection: 8 from residents, 10 from relatives, and 3 from health and social care professionals. All eight resident respondents said that they liked living at the home, felt well cared for, were well treated by staff , had their privacy respected, and knew who to complain to if they were unhappy. Additional comments included “Evening meal is poor”, “By no means always (in answer to ‘Do you like the food?’), “…I am not a fan of bingo”, “Perhaps more trips out from the home could be arranged” and “I like living here. The staff are wonderful. The surroundings beautiful. It’s also nice for young children to visit. I wish more people would join in the entertainment which I enjoy”. All relative respondents stated that they were satisfied with the overall care provided, were made to feel welcome in the home, all but one that they are kept informed of important matters, and all but two that there were sufficient staff on duty. Four relative respondents said that they were not aware of the home’s complaints procedure and the same number that they did not have access to a copy of inspection reports on the home. Comments included “[identity]..very happy and gave great praise to the staff who are always kind and considerate…….At times the room has been dusty, dead flowers not removed, waste paper basket full but the love and care received far outweighs these things”, “two staff only on duty during the night” and “Resources could be used more effectively. New staff especially, should be better trained re; personal requirements of residents before being expected to meet the needs of said residents” Health and social care professional respondents all expressed satisfaction with the care provided, said that the home communicates well with them, that there is always a senior member of staff to confer with, that specialist advice was incorporated into the care plan and that staff demonstrated a clear understanding of residents needs. Overall, this small survey of three groups of stakeholders indicate a very good level of satisfaction with the home. It has highlighted some matters which require the attention of the registered manager. The home does not deal with residents monies. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 23 A system of staff supervision is in place and the home aims to ensure that staff receive one to one supervision every two months. Staff interviewed confirmed that they receive supervision and that records are retained. Systems for conducting staff appraisal are also in place. The home has ‘Investors in People’ accreditation. Arrangements for maintaining the health and safety of residents, staff and visitors appear satisfactory. These are governed by the organisation’s health and safety policy. Staff are trained in moving and handling, fire safety, first aid, food hygiene and infection control during the course of induction and periodic updates as required. A senior care worker is trained in training staff on POVA. Food hygiene training consists of four hours initially, followed by a one day course at Aylesbury College. The chef has undertaken training in HACCP (Hazard analysis critical control points). Training in first aid is carried out onsite by St John’s ambulance. The home has a contract with Chubb for the maintenance of fire safety equipment and emergency lighting. An inspection by the fire authority was last carried out in November 2005 and no requirements were made. COSHH (Control of substances hazardous to health) materials are stored in the cellar and data sheets are available in the staff office. Water temperatures are regulated at all hot water outlets in areas where residents have access. Samples of water have been tested for Legionella in August 2006. The manager said that work was still being carried out on the electrical wiring, therefore a certificate of safety had not yet been issued. PAT (Portable appliance testing) testing of appliances had been carried out. The boilers are fuelled by oil and the cooker and laundry equipment by LPG (Liquid petroleum gas). A CORGI engineer had visited on the week of the inspection and advised that some work was required. A new gas cooker was due to be installed in the kitchen. The lift had been checked in May 2006. Hoists checked in April 2006. Alarm system checked in July 2006. A contract is in place with ‘Grundon Waste’ for the disposal of clinical waste. Systems are in place for recording accidents to residents, staff and visitors. Records were examined. Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 24 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 3 3 N/A 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 3 17 3 18 3 3 X X 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 4 X 3 3 X 2 Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 25 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 Refer to Standard OP9 Good Practice Recommendations The registered manager should contact providers of appropriately accreditated courses in the administration of medicines with the aim of having one or more care staff trained to a higher level. The home should record more detail on psychosocial aspects of care in care plans, both in terms of residents’ interests, and of residents’ participation and experience of social activities. The registered manager should ensure that all relatives are informed of the homes complaints procedures. The registered manager should seek the views of residents on the quality of supper (to include the range of dishes, quality, quantity, and nutritional content). 2 OP12 3 4 OP16 OP15 Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bartlett`s DS0000022953.V304244.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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