Inspection on 26/09/07 for Bearwardcote Hall Residential Home Ltd

This inspection was carried out on 26th September 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 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

Bearwardcote Hall Residential... 17/09/08

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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 Bearwardcote Hall Residential Home Ltd Heage Lane Etwall Derby Derbyshire DE65 6LS Lead Inspector Helen Macukiewicz Unannounced Inspection 26th September 2007 09:20 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 Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.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. Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bearwardcote Hall Residential Home Ltd Address Heage Lane Etwall Derby Derbyshire DE65 6LS 01283 734669 01283 732810 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) Bearwardcote Hall Residential Home Ltd Mrs Jacqueline Thompson Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection Newly Registered Service Brief Description of the Service: The accommodation at Bearwardcote Hall was developed from a former private residence. Set within surrounding countryside near the village of Etwall, and approximately 8 miles from Derby City. There is an infrequent bus service nearby and some facilities such as G.P., shop and churches in the village of Etwall. The accommodation is over 2 floors and consists of lounges, kitchen, bedrooms and dining room. A passenger lift services the first floor. The Inspection report is kept in the Managers office and there is a notice informing people of its availability. The weekly fees range between £365.00 and £410.00. Additional costs include Dentist, Chiropody, Hairdresser and some toiletries. Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and lasted 7.5 hours during one day. 4 preinspection questionnaires were received from people living in the home or their advocates. Findings from these questionnaires are included in this report. The Manager had completed a self-assessment of the home and information from this was used in the planning of this inspection. Computer held records of all contact between the Home and the Commission for Social Care Inspection since the last Inspection were also referred to in the planning of this visit. During this Inspection discussion with people who use the service and their relatives took place. Time was spent in discussion with the Manager and staff. Three residents care files were looked at in detail and their care was examined to see how well records reflect care practices within the home. Relevant records belonging to the home were also examined such as complaints and policy documents. A brief tour of the home took place including some bedrooms. What the service does well: There are clear admission procedures in place. People’s care files were clearly set out, well completed and easy to follow. All medication records seen were completed in full. The storage of medicines was good. Care files contained a good assessment of people’s social needs and social history. They were very person-centred. One visitor confirmed that staff were respectful to their relative and felt they had enough privacy. One relative said they had spoken to the Deputy Manager about a minor concern and the matter had been dealt with straight away, to their satisfaction. Staff said they receive supervision and have annual appraisals, both of which are recorded. There was a list of dates for these in the staff office. Staff said that they feel supported by the senior management team. One relative, in their completed pre-inspection questionnaire wrote ‘They (staff) treat people in the home as individuals, with affection, care, respect and humour. It feels like a proper home’. A relative spoken to on the day of the Inspection said ‘the staff are very welcoming here’. Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Information about the home for the general public and residents (The Statement of Purpose and Service Users Guide) needed amending in both documents so prospective residents are clear about what accommodation is on offer. There are high levels of people living in the home, who have some form of mental health problem. This will be something that the Manager will have to address through the Homes’ registration if this trend continues, to ensure the home is operating within the correct category of registration. There was not much evidence of social activity or one to one interaction time with staff taking place. On the day of the Inspection, staff were busy completing tasks and there was little activity taking place in the main lounge area, when observed. It was suggested that residents would like to know if lunch was going to be served later to avoid a prolonged wait at the dining table. Feedback from a number of people suggested that they did not feel as comfortable raising concerns through a ‘formal’ complaints system, and that this was a barrier to them raising concerns. Feedback from some residents suggested that the staff do not always respond to calls for assistance in a prompt way during the daytime and occasionally drinks have been missed. Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 7 The Manager was not aware of a change in legislation that had taken place so recruitment files did not support that all the required pre-employment checks had been undertaken. 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. Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.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 Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.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): Standards 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have enough information to choose a home that can meet their needs. EVIDENCE: There is a notice informing people that they may see the last Inspection report, this is kept in the Managers office. Information about the home for the general public and residents (The Statement of Purpose and Service Users Guide) was seen. There is also a brochure. Information includes the range of fees payable. The information is dated 2003. The Manager felt that the information was still relevant and said she had recently checked through the documents. The smoking policy for the home had changed due to recent legislative requirements. These changes needed amending in both documents so prospective residents are clear about Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 10 what accommodation is on offer. One relative confirmed that they had been given information about the home prior to admission. They had also been informed about the fees payable. There are clear admission procedures in place. There is also an emergency admission policy. Both procedures require staff to ensure an assessment of need is completed prior to accepting an admission. The deputy manager confirmed that all residents commence on a trial basis. Care files demonstrated that people’s care needs are assessed prior to admission and that this is then expanded upon when the person is admitted. Contracts were also seen in files. Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.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): Standards 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples care needs are met in the home although to sustain this, the way the home operates may need to be reviewed. EVIDENCE: Three people’s care files were looked at in depth. All contained an assessment of need and a plan of care. Assessment and review of the residents moving and handling, mental health, skin care, nutritional needs and risk of falls were seen. Documentation was clearly set out and easy to follow. People have their care needs reviewed three monthly then a full review six monthly. All care plans had been signed by the resident, to confirm their knowledge of them, and agreement to them. Reviews by Care Managers were recorded in the files. The principles of dignity and respect were recorded in care plans. Most residents felt their need for privacy and dignity was met although feedback Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 12 suggested that they were more likely to have this need met by the more mature members of staff. This was discussed with the Manager and Deputy who said they address this through supervision and training. One resident said ‘the care is excellent’. Care files and information around the staff office supported liaison with G.P’s, District Nurses, Hospitals and clinics. There were records of residents receiving the services of the Chiropodist, Dentist and Optician, and the hairdresser was visiting on the day of this Inspection. Residents and relatives confirmed the staff take residents to out patients and Doctors appointments. Of the residents who were consulted during this visit, three independently said that they had recently been disturbed at night by a resident who wandered into their room. This was discussed with the Manager who was taking appropriate action regarding this situation. There are high levels of people living in the home, who have some form of mental health problem. In the Managers pre-inspection information she recorded that a third of people in the home have dementia and that seven have other mental health needs. The staff have Dementia training, some to level II. However, the home is not registered for people with mental health problems. This will be something that the Manager will have to address through the Homes’ registration if this trend continues, to ensure the home is operating within the correct category of registration. All medication records seen were completed in full. The storage of medicines was good and where observed, the systems for administration of medicines were satisfactory. Staff confirmed that they have to undertake medication training before they can administer medicines. There was a homely remedies policy that was satisfactory. Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are able to participate in activity although a more varied and in depth day to day activity programme would ensure this area of need is fully met. EVIDENCE: Care files contained a good assessment of people’s social needs and social history. They were very person-centred. This included assessment of the resident’s preferred daily routine. Records in the staff office and in care files supported that a library van visits fortnightly, that consideration is given to people’s spiritual needs and that residents participate in occasional trips out. In her pre-inspection information the Manager recorded that ‘we have recently initiated a group which meets every Friday afternoon, this group focuses on arts and crafts and is led by a senior member of staff. This has increased self-worth among some of the residents.’ Staff confirmed that every Sunday one member of staff organises a sing a long, and on a Friday organises an arts and crafts session, although on a daily basis, there was not much evidence of social activity or one to one interaction Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 14 time with staff taking place. On the day of the Inspection, staff were busy completing tasks and there was little activity taking place in the main lounge area, when observed. Two residents said they felt that there was not much to do during the day, most residents who were able to express an opinion felt that this was partly due to the high levels of people living in the home who were unable, for whatever reason, to communicate, and also the high number of people living in the home with mental health problems. Residents were observed to move freely around the home. One visitor confirmed that their relative could move freely around the home. Other visitors were seeing their relative in their bedrooms so they could have some privacy to talk. Two residents confirmed that they have a walk in the grounds most days. Some residents were reading daily newspapers and some were watching television in their bedrooms. Most were in the main lounge area. One visitor confirmed that staff were respectful to their relative and felt they had enough privacy. Some residents had telephones in their bedrooms to make private calls on. Residents said that although they do not get a choice of food at lunchtime, the food is satisfactory and there is a choice at tea time. One relative said that their relative was a fussy eater, but had ‘never complained about the food’. Meals can be eaten in the resident’s bedroom if desired. Comments from residents suggested that lunch was sometimes late, which did not leave much of a gap before the tea time meal, it also meant they were waiting at the dining table for an extended period. This was not intended as a complaint, but it was suggested that residents would like to know if lunch was going to be served later. Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to complain and are safeguarded by the home although the complaints procedure does not meet the needs of some. EVIDENCE: In her pre-inspection information about the home, the Manager recorded that the home had received 2 complaints since the last Inspection, one of which had been upheld. There had also been 1 safeguarding referral made. The written complaints procedure for the home was satisfactory. This was included in the information about the home, which is given out to residents and enquirers from the general public. One relative said they had spoken to the Deputy Manager about a minor concern and the matter had been dealt with straight away, to their satisfaction. Two visitors and two residents said they felt they could make a complaint if needed. Feedback from a number of people suggested that they did not feel as comfortable raising concerns through a ‘formal’ complaints system, and that this was a barrier to them raising concerns. It was suggested from them that one to one discussion time with a representative of the Management team would enable them to feel more empowered. Issues raised at such discussions could be recorded as Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 16 concerns, differing only in the way the concern was received to other complaints. The written safeguarding procedure was on display in the staff office. Staff confirmed that they had received training on safeguarding this year. The Commission for Social Care Inspection is aware of the safeguarding referral and is satisfied that the home took appropriate action. There wads a safeguarding training manual in the office, which was very comprehensive. There were no issues relating to restraint in the care files seen. There was a restraint policy in the staff office, this was appropriate to the type of care given in the home and did not promote physical intervention by staff. Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in an environment, which meets their needs. EVIDENCE: A brief tour of the ground floor took place. Areas appeared clean and tidy. The Commission for Social Care Inspection are aware that the home has recently had a problem with an infestation of flies, which had been caused by local farming methods and which had arisen through no fault of the home. There was still a notable amount of flies around the home, but there was evidence that the number had decreased and that the Manager had taken appropriate action with regard to this matter through the Environmental health service, who were taking action to ensure this matter did not recur. Residents and relatives acknowledged the Managers efforts so far, and were hopeful that the Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 18 methods used so far to alleviate the numbers of flies would continue until the matter was fully resolved. Residents confirmed that they have keys to their bedroom doors, or have been offered these. Care files supported this. Feedback from a resident and another relative suggested that people could opt to change their bedroom if a space within the home was available. Residents and relatives said they like where the home is situated and the open countryside surrounding. Residents said they enjoy walking in the grounds. Since the last Inspection a new outdoor seating and recreational area has been provided. One relative said that they had always found the home to be clean and tidy. There is a waste disposal policy on display in the office. There are no laundry staff employed. Care staff undertake laundry duties in addition to care duties, when they have the time. They confirmed that these do not take priority over care duties and that they can be left. The laundry room did not look untidy or overfull. There were no complaints from residents about the laundry service. Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 to 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of trained staff although occasionally this does not ensure that all peoples care needs are met. Gaps in staff recruitment have the potential to leave people vulnerable. EVIDENCE: Staffing rotas showed that there were adequate numbers of care staff on duty. However, they do undertake additional ancillary tasks such as evening catering duties and laundry duties. Staff confirmed that they can get their work done although each shift is busy. Feedback from some residents suggested that the staff do not always respond to calls for assistance in a prompt way during the daytime and occasionally drinks have been missed. With the high level of people who cannot communicate, it is important that fluids are given at regular intervals to all people. In her completed pre-inspection information the Manager said that 65 of care staff have National Vocational Qualifications (NVQ) to level II or equivalent, 29 are working towards this. Staff themselves said that they undertake NVQ’s, which are part funded. Staff also undertake long distance learning courses and said they have recently undertaken a Dementia Care course, which they found relevant and useful. In the staff office there was a Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 20 list of staff who are due to attend Health and Safety and Infection Control training. Staff confirmed they receive all mandatory training updates. Staff in the home receive good levels of training and this is an area that the home does particularly well. Three recruitment files for staff were seen. The Manager was not aware of a change in legislation that had taken place so recruitment files did not support that all the required pre-employment checks had been undertaken. The following gaps were evident in some/all of the files seen:• • • • • One file had some discrepancies in criminal history. Although 2 references are always sent for, one file only had 1 returned. There was no written verification why the person had ceased working with vulnerable children/adults. A full employment history was not available; the application form does not lend itself to gaining this information. In two files the home was late acquiring a Criminal records check and had not acquired a POVA first check in the mean time, however, the manager reported that this was an exceptional circumstance and not usual practice. A statement as to the persons’ physical and mental wellbeing was not requested. • Staff said they receive supervision and have annual appraisals, both of which are recorded. There was a list of dates for these in the staff office. Staff said that they feel supported by the senior management team. Staff files that were seen contained a staff handbook, which they have to work through and there was a record of supervisions and appraisals that had been completed. A new induction programme has been acquired by the manager, which has been devised by the Leicestershire Social Care Development Group. This provides a level of foundation training, which the Manager believed was to the required standards. Staff confirmed they have an induction when they first commence employment and that they have to work with another more experienced member of staff for their first few shifts. One relative, in their completed pre-inspection questionnaire wrote ‘They (staff) treat people in the home as individuals, with affection, care, respect and humour. It feels like a proper home’. A relative spoken to on the day of the Inspection said ‘the staff are very welcoming here’. Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements for the home are adequate although gaps in legislative knowledge leave people vulnerable. EVIDENCE: The Manager is also the provider (owner). She has 20 years experience of managing the home. In her pre-inspection information she recorded that she has completed a Registered Managers Award this year. The manager was not aware of some changes in legislation that have taken place that affect requirements in terms of recruiting staff, and had not been accessing the Commission for Social Care Inspection professional website for Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 22 updates. This would enable the Manager to keep abreast of good practice as well as Legal requirements in the future. The lack of safeguards currently within the recruitment procedures means that residents have the potential to be placed at risk. The Manager and Deputy carry out short surveys through use of questionnaires with residents and their relatives. Residents and a relative confirmed they have been asked for their opinion using this method recently. There were also minutes of regular residents meetings conducted by a visiting Occupational Therapist. Residents and relatives were satisfied with the way the Manager handles their finances. The system used means that money is kept individually and deposits/withdrawals are signed for by the resident where possible Where seen, service records for equipment used in the home were all up to date. There was health and safety information in the staff office including health and safety and COSHH (Care of Substances Hazardous to Health) files. The Manager could demonstrate that she has taken action on the recommendations of the last Fire Officer’s Inspection report. Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 OP12 Regulation 16(2)(n) Requirement There must be consultation with residents about the activities they require. For those who are unable to communicate effectively, such as those people with dementia, a varied and regular social programme must be maintained which is appropriate to their needs. The system for receiving feedback/complaints must be amended to ensure it is appropriate to the needs of the residents. There must be sufficient allocation of staff on duty to ensure residents care needs are met. Staff must not be employed until all information required by Regulation 19 and Schedule 2 of the Care Homes Regulations 2001 has been received. Recruitment files must be able to support this to ensure residents are safeguarded. The Manager must ensure she updates her knowledge in terms of legislative changes that affect DS0000068383.V342128.R01.S.doc Timescale for action 30/11/07 2. OP16 22(2) 30/11/07 3. OP27 18(1)(a) 31/10/07 4. OP29 19(1)(a)( b)(c) 31/10/07 5. OP31 10(1) 31/10/07 Bearwardcote Hall Residential Home Ltd Version 5.2 Page 25 the home and good practice advice. 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 OP1 OP8 Good Practice Recommendations The information about the home (Statement of Purpose and Service Users Guide) should be amended to reflect the changes to the accommodation. The Manager should address through the Homes’ registration, the type of service provided by the home if this trend for accommodating a high number of people with mental illness continues, to ensure the home is operating within the correct category of registration. The manager should ensure all staff adhere to the principles of privacy and respect when caring for residents. Residents should be given advance notice if the lunch time meal is to be delayed to avoid unnecessary waiting times in the dining area. The efforts to reduce the number of flies in the home should continue until the problem has fully resolved. 3. 4. 5. OP10 OP15 OP19 Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Bearwardcote Hall Residential Home Ltd DS0000068383.V342128.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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