Inspection on 05/02/08 for Bearwood House Residential Care Home

This inspection was carried out on 5th February 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Bearwood House Residential Care... 25/08/09

Bearwood House Residential Care... 19/07/06

Bearwood House Residential Care... 22/11/05

Bearwood House Residential Care... 30/06/05

Bearwood House Residential Care... 23/11/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bearwood House Residential Care Home 183 Bearwood Hill Road Winshill Burton-on-Trent Staffordshire DE15 0JS Lead Inspector Mandy Brassington Unannounced Inspection 5th February 2008 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 Bearwood House Residential Care Home DS0000061581.V358693.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. Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bearwood House Residential Care Home Address 183 Bearwood Hill Road Winshill Burton-on-Trent Staffordshire DE15 0JS 01283 561141 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) Mrs Judith Dena Griffin Vacant Care Home 21 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (21) of places Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2006 Brief Description of the Service: Bearwood House is a large Victorian detached house that has been extended to provide 21 beds. The home is registered for 21 older people, three of whom may have dementia care needs. The home is located on the outskirts of Burton Public transport and all amenities are close provided on three floors accessible by staircase double and nine single bedrooms, of which two the ground floor. on Trent in a residential area. at hand. Accommodation is and a shaft lift. There are six doubles and one single are on Communal facilities consist of two lounges and a dining room. There are four bathrooms, though only one was in use at the time of the inspection, and an adequate numbers of WCs situated throughout the home. Externally there are small gardens to the front, where access is by steps from the road. To the side and rear there are larger gardens all accessible to people who use the service. Car parking is restricted with additional on street parking adjacent. The aims of the home are to provide 24-hour care for people in a homely environment whilst enabling people to retain their independence. Care is provided by care assistants led by a Care Manager. District nurses, community psychiatric nurses and other professionals are accessed by the home when required. A local GP surgery and pharmacist service the home. Activities take place with family and relatives involvement. The Service User Guide did not reflect information relating to the fees in the home as required. The reader may wish to approach the care provider for up to date details of the fees payable. Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered the core standards. The inspection took place over 8 hours by one inspector who used the National Minimum Standards for Older people as the basis for the inspection. Prior to the inspection the manager had completed an Annual Quality Assurance Audit (AQAA) for the Commission for Social Care Inspection. Questionnaires were sent to people who use the service, staff members, and professionals supporting people in the home. Five General Practitioners, three people who used the service, and four members of staff responded with comments relating to the service. A tour of the home was undertaken and a meal was eaten with people who use the service. On the day of the inspection, the home was accommodating eighteen people. The inspection included an examination of records, indirect observation, discussion and observation of people who use the service, and staff on duty. Four Plans of care were examined along with four staff records. Observation of daily events took place. Inspection of the storage system and medication procedures was inspected. Twelve requirements and four recommendations were made as a result of this visit. This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 Star. This means that people who use the service experience adequate quality outcomes. What the service does well: Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 6 The service provides a comfortable home for people with a variety of communal areas to spend time in. People are able to chose to talk and join in activities, watch television or have time alone. The home provides a flexible activity programme according to individual’s preferences, including games, knitting, joining in music sessions and talking to others. People were able to develop good relationships with other residents and commented, ‘we’re good friends here, we all get on, and have a laugh together, you have to have fun don’t you’. People who used the service and relatives spoke positively about the staff, the care and support and attitude, ‘the staff can never do enough for you’, they always make sure you have everything you need’, ‘we can’t fault them, they’re lovely’. People were able to dress according to personal interests and receive support with personal care. People commented, ‘You can’t fault them here for looking after your stuff, it’s always cleaned and put back before you know it, it marvellous how they do it.’ There was a relaxed atmosphere between individuals and staff. Staff respected people’s preferences and were aware of the support required. All people were very comfortable in the presence of staff, who showed a commitment to providing a good service. Staff had developed good relationships with individuals and talked and laughed together. The choice and quality of food was good. People had a choice of drinks and had a glass of sherry with the meal. ‘the food here is splendid, excellent. They always make sure we have a choice of lovely meals’, ‘You can have anything, at any time and in the evening too, and there’s always fresh fruit you can help yourself too.’ Plans of care included information relating to support required as well as interesting and important information about the person, and their life prior to moving to the home. This included information relating to family, past jobs and experiences, holidays and interests. What has improved since the last inspection? Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 7 The service has recruited a manger within the home, who has continued to lead the team of staff. The manager previously worked as the Deputy manager in the home, and therefore has been able to provide consistency for people who use the service. The service provider has made plans to improve the bathing facilities for people and work is soon to start on an upgraded bathroom suite with an assisted bath. 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. Bearwood House Residential Care Home DS0000061581.V358693.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 Bearwood House Residential Care Home DS0000061581.V358693.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, 4, 5, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken, and prospective residents are given the opportunity to spend time in the home. Information about the home is available only in a standard format and is being reviewed to provide accurate information to prospective residents. EVIDENCE: The home has a Statement of Purpose available for all people in the home displayed in the Hallway. The registered person stated this document is to be reviewed to reflect the service provided. This was discussed with the registered person to ensure the complaints procedure was reviewed, as it is Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 10 unclear, and information relating to accreditation to a Local Authority needs to be removed. There is no reference to smoking in the Statement of Purpose and two people who live in the home smoke. There is no designated area for people to smoke and it had been agreed that people smoked by an exterior door. This needs to be included within the terms and conditions of occupancy and agreed upon admission. The Service User Guide is included within the Statement of Purpose. The registered person reported that this is also under review and all people will be able to have a copy; people did not have a copy at the time of the inspection. The Guide is to include details of the fees payable. There had been one recent referral to the home, and examination of records revealed that a full needs assessment was completed by the manager, along with a Care Management Assessment. The manager was confident that that from the assessment a decision could be made whether the home could meet people’s needs. It is recommended that the registered person record this decision in writing. Examination of records identified that the person had a plan of care devised in the first week. People living in the home and relatives confirmed that they were able to visit prior to deciding to move in and were able to view all vacant rooms. One relative stated that the registered providers visited the person shortly after moving to the home to ensure they were satisfied with the service. The home does not provide intermediate care. Bearwood House Residential Care Home DS0000061581.V358693.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 adequate. This judgement has been made using available evidence including a visit to this service. The delivery of personal care is individual and is flexible, with people having access to healthcare. Medication systems do not always follow safe practice guidelines to ensure people are not placed at risk. EVIDENCE: We inspected four plans of care, which contained a personal profile and a personal history. The key worker had spent time with the person and recorded important information about their life history. The information was wide and varied, including their best book, holidays enjoyed, favourite pets, family, and had they met anybody famous. Staff reported this information was extremely valuable and gave an important insight into who the person was, and how they came to be in the home. Discussion with people who used the service Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 12 confirmed they had shared this information with staff and enjoyed talking about their life experiences. The plan also included a support plan and identified individual’s needs, including for daily living, bathing, eating and drinking, tissue viability and medication. Where a risk had been identified, an assessment had been carried out and recorded measures to reduce the risk. One plan we examined included an assessment of risk for smoking in the bedroom. All plans included a moving and handling assessment. Key workers were responsible for reviewing the plans on a monthly basis. People had a Key worker file and any information obtained about the person, their life or current feelings and events were recorded. Staff reported this helped to identify any changes and also to ensure the person’s well-being. One plan we examined included an assessment and plan for pressure care. The manager reported that further advice is to be sought for tissue viability from the community nurse. At present the district nurse supports the person. A record of all health care appointments and any outcomes were included within the plan. Discussion took place with the manager regarding the need to review the plans to ensure they followed the new guidance of the Mental Capacity Act. This will be inspected on our next visit. From observation it was evident that staff respected people’s preferences and were aware of the support required. Staff were observed talking to people, sharing a conversation and laughing, and all people were very comfortable in the presence of staff. One person was observed being assisted to eat lunch in a sensitive and professional manner. The meal was well presented and the staff member sat next to the person, talked to the individual throughout the meal and assisted feeding at a pace to suit the person. In discussion with staff, comments were always appropriate and showed sensitivity. Staff were professional and courteous whilst showing genuine concern for people. The staff team was balanced and were of various ages and gender, to enable a choice of male or female support, and age related preferences when delivering personal care. All people were well presented and dressed in a style of their choosing. It was evident, that staff had ensured that individuals are able to receive support to address personal care issues and personal hygiene. People who used the Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 13 service commented, ‘You can’t fault them here for looking after your stuff, it’s always cleaned and put back before you know it, it marvellous how they do it.’ The Monitored Dosage system (MDS) was used and medication was stored in a locked trolley. Medication Administration Records (MAR) and observation of medication administration procedures were good. The MAR sheets also included a photograph of the person. A medication Fridge was located in the dining room. The fridge was not secure and could not be locked, and therefore was accessible to all people. One medication had been dispensed into a medicine tot, and staff reported this had been refused. It had been left in the fridge to administer later in the day with support from a relative. The medicines clearly recorded the specific temperature range of the medicine. The fridge did not have a thermometer, to ensure the medicines were stored in line with manufacturers guidelines. The home is required to provide secure facilities for storing all medicines. A record of maximum and minimum temperature is to be recorded daily. Medicines must be stored in line with manufacturers instructions. Suitable checks need to be made with the pharmacy to ensure the integrity of the medicines currently stored. Where the integrity has been compromised, medicines are to be disposed of and new medicines obtained. Bearwood House Residential Care Home DS0000061581.V358693.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are involved in meaningful daytime activities of their own choice, according to their individual interests, diverse needs and capabilities. People who use the service have the opportunity to develop and maintain important personal and family relationships. EVIDENCE: When we arrived at the home, people were sitting in the two lounge areas. One group of people were heard laughing and talking to each other. The staff and people who used the service were very welcoming and introduced themselves. The television was off and people commented, ‘we’re good friends here, we all get on, and have a laugh together, you have to have fun don’t you’. Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 15 Activities seen during the day included ball games, knitting and listening to music. Discussion with people revealed that the home has organised trips into the community, including a visit to Alrewas Arboretum and Twycross zoo. One questionnaire and one person commented that they preferred to stay in the home, but enjoyed to play Bingo. The home also provides an Entertainer on a monthly basis, which includes people being able to participate in playing instruments. The home does not have a structured activity programme but offers a variety of activities according to preferences each day. Activities tend to occur in the morning due to staffing levels in the home. People reported that the registered providers are always around to talk to and one person commented that one Provider helped her to play Bingo due to a visual impairment, ‘I cant read the card, so he always helps me.’ From discussion with people who use the service, and from observation of practices, individuals are able to retain control of their lives and were given opportunities to make informed decisions. One person reported, ‘The staff let me help out around the home, and do some jobs, I don’t like to stop doing things I can do.’ At lunchtime, some people ate in the main dining room; others ate in the lounge area. Staff reported people can chose where to eat their meals. One person said, ‘I always eat my meals in my room, I’d hate to go downstairs, this is how I like it.’ The main meal is served at lunchtime, and on the day of the inspection, the meal prepared was lamb with potatoes and vegetables, and pancakes for dessert as the visit took place on Shrove Tuesday. People had a choice of drinks and had a glass of sherry with the meal. One person stated, we also get a glass of sherry, some people choose not to, but I love it.’ The meal was relaxed with jovial banter between people who used the service and staff. Where support was required, this was sensitively given. The meal was unhurried and people were able to eat at their own pace. All people spoken with and from comments from questionnaires, reported that the food was of a high standard. Comments included, ‘the food here is splendid, excellent. They always make sure we have a choice of lovely meals’, ‘You can have anything, at any time and in the evening too, and there’s always fresh fruit you can help yourself too.’ Discussion with people who use the service confirmed there were no restrictions on visiting from family and friends, individuals are also able to stay away from the home with family members. The design of the home provides seating within the communal areas of the home, where individuals can entertain their visitors, in addition to the privacy of their own room. Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has an open culture that allows people to express their views, and concerns. The complaints procedure needs to be reviewed so people are aware of their rights and whom they can complain to. Staff are aware of the procedures for Safeguarding Adults and how to respond to an alert. EVIDENCE: The home has an open culture in relation to receiving complaints, and discussion with people who used the service and relatives stated they would feel confident raising a concern. The home had forms available to make a written complaint, although people need to ask staff for this form, which was stored in the adjacent office. The complaints procedure was not clear, and referred to National Care Standards Commission and the Commission for Social Care Inspection, and contact details for the Commission are out of date. It is required that the Complaints Procedure be reviewed and to be in a suitable and clear format. The manager agreed to make the complaints forms easily accessible to all people. Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 17 There have been no complaints received by us since the last inspection. Records demonstrate that staff have received training in Safeguarding Adults. From discussion with staff, individuals were clear on how to recognise signs of abuse and would report any suspicion. Staff confirmed a copy of the Safeguarding Procedure was available in the home. Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is comfortable, clean and warm, and has different communal areas for individuals to choose from. People are able to personalise their rooms according to their interests. Bathing facilities are being upgraded to ensure the facilities are suitable and meet the needs of people who use the service. EVIDENCE: The home is an attractive building located in a residential area of Burton. There are two open plan lounge areas. Each lounge area had a different purpose. One was being used to quietly watch television, whilst in the other Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 19 lounge people were talking to each other. Communal areas were comfortable and personalised by people who use the service. Bedrooms are on all three floors and there are six double rooms and nine single rooms. People who used the service confirmed they were able to view vacant rooms and make a decision regarding where they wanted to be prior to moving to the home. The bedrooms were of varying sizes, and all had a good range of furnishings and had been personalised by people to reflect their interests. The Providers reported that the ground floor bathroom is being replaced by March 2008, as this bath is not currently used. The plans showed that this would be an assisted bath. This will be inspected upon the next visit. There are two bathrooms on the first floor, staff reported only one is used as one is a corner bath and not suitable. It is recommended that this bathroom used by people be upgraded. The wood around the bath is soaked and paint coming away. The bath is discoloured. The bath panels on the baths are broken and have sharp edges, which could cause an injury when getting in and out of the bath. These are to be replaced. The second floor bathroom had water running at a very high temperature. Where there is full body immersion, thermostatic valves are required to ensure that people who use the service can bathe safely. The providers made arrangements for this to be addressed at the earliest opportunity. An assessment of risk is to be carried out to ensure that suitable measures are in place, to ensure the bathroom is made safe until the valves are fitted. Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 20 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. People who use service have confidence in the staff that care for them, and the staff team receive regular training to update their skills. Staffing in the home needs to reflect the support and dependency of people who use the service. The home has not carried out suitable pre-employment checks for all staff working in the home, which could place people at risk. EVIDENCE: On the day of inspection, there were eighteen people receiving a service in the home. Inspection of the staff rosters and discussion with the manager revealed the home has three shifts over a twenty four hour period, and on the day of the inspection there was: The manager worked from 8.00am – 4.00pm, 8.00am – 11am were in a supernumerary capacity. 1 senior care from 8.00am – 3.00pm 1 carer from 7.00am – 11am Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 21 2 house keeping staff working 9.00am – 11.00am and 10.00am – 2.00pm 1 cook working 8.00am – 1.00pm In the afternoon there was:1 senior care working from 3.00pm – 10.00pm 1 carer from 3.00pm – 10.00pm At night there are two waking night staff working from 10.00pm – 8.00am. The manager confirmed this was the usual pattern of shifts. Discussion with staff and observation of plans of care revealed there were a number of people who required support from two staff. During the afternoon shift, there were only two staff on duty and therefore people may be unsupervised for short periods of time. It is required that the service provider carries out a review of staffing in relation to support needs and dependency levels. A copy of the report is to be sent to us and to include details of any staffing changes as a result of the review. The previous visit identified that it had been that agreed the managers hours should reviewed, to allow the manager to also be supernumerary from 2.00 – 4pm to complete managerial duties. The manager is only supernumerary from 8.00am – 11.00am. The staffing review needs to identify the management hours. Inspection of four staff files revealed that two files contained all required documentation in relation to recruitment was available, including references, proof of identity and a Criminal Records Bureau Check. One person had started working in the home in January 2008. Inspection of records revealed that there were no written references, and a written explanation of the gap in employment had not been suitably explored and recorded. One person did not have required evidence to demonstrate suitable checks regarding permission to work in this country had been carried out. All required pre-employment checks are to be carried out prior to people working in the home. Discussion with the manager and staff, and records demonstrated that people have attended training for infection control, dementia care, moving and handling, and Food Hygiene. Staff need to receive training for the Mental Capacity Act to ensure staff are aware of the implications of the Act, and how this must be implemented. The manager recorded within the Annual Quality Assurance Audit (AQAA) that sixty percent of staff had achieved a National Vocational Qualification (NVQ). Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 22 The AQAA reported that the home has an equality and Diversity Policy and the home is an Equal Opportunities employer. The common Induction Standards completed by the staff supports the service policy. There was a relaxed atmosphere between individuals and staff. Staff were observed providing sensitive care and using appropriate communication. Discussion with staff and comments received from people who use the service and relatives clearly revealed that staff are committed to providing a good service and staff had developed good relationships with individuals. Comments received included, ‘the staff can never do enough for you’, they always make sure you have everything you need’, ‘we can’t fault them, they’re lovely’. Bearwood House Residential Care Home DS0000061581.V358693.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 adequate. This judgement has been made using available evidence including a visit to this service. The service focuses on the individual, takes account of equality and diversity issues, and works in partnership with families or close friends. Giving priority to both the provision of care and adherence to necessary legislation is needed to ensure the home provides a high quality service. EVIDENCE: The service has a Care Manager, although an application to begin the Fit Person process has not been submitted. The registered persons were notified Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 24 of the need to submit an application in August 2007. It is a concern to us that the home has been without a registered manager for this lengthy period of time. The staff team was being lead by a manager, and from discussion was committed to providing a good service and welcomed the challenge of becoming the registered manager. Prior to the Inspection the Registered manager completed an Annual Quality Assurance Audit (AQAA). All sections of the AQAA were completed and the information gave a reasonable picture of the current situation within the service. The evidence to support the comments made was satisfactory, although there are areas where more supporting evidence would have been useful to illustrate what the service has done in the last year, or how it is planning to improve. The registered manager recorded that all maintenance work, annual checks, mandatory training, testing of equipment and regular fire drills are undertaken. The Fire Officer visited the home in June 2007. All recommendations made as part of the visit have been addressed. Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 1 X 3 X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 X X 2 Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 (1) Requirement To review the Statement of Purpose to include up to date clear information about the home to ensure people have suitable information about the service. Each person is to have a copy of the Service User Guide and to include terms and conditions of occupancy and details of fees payable, in order that people know and understand the agreement with the home. To provide secure facilities to keep all cold stored medicines in order that people who use the service are safe. A record of daily minimum and maximum fridge temperatures is to be recorded to ensure the integrity of all medicines and the safe administration of those medicines. Suitable checks are to be made to ensure the integrity of the DS0000061581.V358693.R01.S.doc Timescale for action 30/03/08 2 OP1 5 (1)(a)(b) (bb) 30/03/08 3 OP9 13 (2) 06/02/08 4 OP9 13 (2) 06/02/08 5 OP9 13 (2) 06/02/08 Bearwood House Residential Care Home Version 5.2 Page 27 medicines currently stored has not been compromised. A new prescription is to be obtained where there is concerns to ensure people are administered safe and suitable medicines. 6 OP16 22 (1)(2) To review the complaints procedure to ensure it is in a suitable format and gives clear information to people about how they are able to make a complaint. The bath panels are damaged and are to be replaced to ensure that bathing areas are safe for people. Where there is full body immersion, thermostatic valves are to be fitted to the baths to ensure the health and welfare of people who use the service. The staffing provided in the home is to be reviewed in line with the needs and dependency levels of people who use the service. Suitable staffing must be provided in conjunction with this review. A copy is to be forwarded to the Commission. All required pre-employment records are to be sought prior to employment including two written references and evidence of work permit, to ensure people who use the service are not placed at risk. Staff are to received training for the Mental Capacity Act to ensure all staff are aware of the guidance and how this has an impact on work in the home. DS0000061581.V358693.R01.S.doc 25/03/08 7 OP19 23 (2)(c) 05/02/08 8 OP21 13 (4) 11/02/08 9 OP27 18 (1) 21/03/08 10 OP29 19 (1)(a)(b) 12/02/08 11 OP30 18 (c)(i) 05/04/08 Bearwood House Residential Care Home Version 5.2 Page 28 12 OP31 9 (1) The manager is to submit an application to begin the Fit Person Process following suitable Criminal Bureau Records Clearance with CSCI. 05/03/08 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 3 4 Refer to Standard OP4 OP21 OP27 OP38 Good Practice Recommendations To write to prospective residents to confirm whether needs can be met prior to admission To replace the bath suite and upgrade the bathroom facilities To review the supernumerary hours worked by the manger to ensure adequate opportunity to complete required duties To check water temperatures at all outlets on a monthly basis Bearwood House Residential Care Home DS0000061581.V358693.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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