Inspection on 16/01/06 for Bearwood Nursing Home

This inspection was carried out on 16th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bearwood Nursing Home 12/02/10

Bearwood Nursing Home 29/09/09

Bearwood Nursing Home 02/06/09

Bearwood Nursing Home 25/07/07

Bearwood Nursing Home 06/11/06

Bearwood Nursing Home 22/08/05

Bearwood Nursing Home 28/09/04

Bearwood Nursing Home 19/05/04

Similar services:

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 Nursing Home 86 Bearwood Road Smethwick West Midlands B66 4HN Lead Inspector Richard Eaves Unannounced Inspection 16th January 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 Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 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 Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bearwood Nursing Home Address 86 Bearwood Road Smethwick West Midlands B66 4HN 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) 0121 558 8509 0121 555 5182 Bearwood Nursing Home Ltd Chiedza Edith Ndoro Care Home 74 Category(ies) of Dementia - over 65 years of age (42), Old age, registration, with number not falling within any other category (60) of places Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user (male) identified in the variation report dated 21.1.2005 may be accommodated at the home in the category of LD. This will remain until such time that the service users placement is terminated. Two service users (male and female) identified in the variation report dated 21.1.05 accommodated at the home in the category of OP may be 60 years and over. This will remain until such time that the service users placements are terminated One service user (female) identified in the variation report dated 21.1.05 may be accommodated at the home in the category of MD(E). This will remain until such time that the service users placement is terminated. Service users to include up to 60 OP and up to 42 DE(E), not exceeding the total number registered for. Service users in the category DE(E) may be 60 years and over. One service user (male) aged 55 years and over, identified in the variation dated 17.11.05 may be accommodated at the home in the category of OP. This will remain until such time that the service users placement is terminated. 22nd August 2005 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Bearwood Nursing Home is a large converted building, which has been registered since 1988. The home provides nursing care for up to 74 elderly residents and is privately owned by Mr and Mrs Sandu who purchased the home in January 2004. The two-storey building has a large car park to the front and patio/gardens to the rear. A porch entrance leads to a spacious reception area, which is staffed during daytime hours. Seating and a drinks machine are available in this area. Lounge and dining rooms are provided on both the ground and the first floor for communal use. Accommodation is provided in a combination of single and double rooms some having en-suite facilities. The home is close to local amenities and is on a local bus route. Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by one inspector over one day. The focus of the inspection was on the delivery of care and included case tracking. The inspector had opportunity to speak with many of the service users and those able to communicate were positive regarding life at the home and they all appeared content. There was a relaxed atmosphere among service users and staff. The inspection also included a tour of the building, meeting with service users and inspection of records. What the service does well: What has improved since the last inspection? The care planning process has been developed to better take account of potential problems arising from known conditions. Servicing arrangements for baths have been improved to ensure they are kept available ensuring the range of bathing opportunities is maximised. The management of hot water has been improved by developing the monitoring and recording process. Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 6 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. Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 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 Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 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): 1–5 The home provides good sources of information about the home and invites prospective service users to visit and spend time at the home prior to admission to enable them to make an informed decision about entering the home, this is confirmed by contract. Pre-admission assessments are undertaken by the most experienced staff and confirmation is given to the service users that their needs can be met by the home. EVIDENCE: The statement of purpose and service users guide have recently been the subject of review and are an excellent source of information for current and prospective service users. The assessment process is thorough, including all activities of daily living and an extensive range of risk assessments, all assessments are subject to monthly review. The file documents information of the service user or representatives involvement in the assessment process. Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 9 Each case file includes a contract and a letter confirming that the agreed assessed needs can be met by the home, the letter also invites prospective service users to take the opportunity to visit and trial the services offered. The home does not offer an intermediate care service. Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 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 - 11 Health care needs of service users are fully met. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Medications are well managed all facilitating the promotion of service users health. Service users are treated with respect and their privacy upheld. Staff have been developed to provide care at the time of service users dying with sensitivity and respect. EVIDENCE: The care plans were seen to be drawn from the assessed needs process and were relevant and maintained to a good standard. The care plans reflect actual care requirements and the service users preferences of how it is to be given. Since the previous inspection contingency plans for diabetes and epilepsy have been developed. Care plans and risk assessments are reviewed at least monthly with the involvement of the service user their representative. Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 11 Medication administration is undertaken by nursing staff using the NOMAD monitored dosage system provided by 8pm Chemist who also undertake the quarterly monitoring visit and issues a report on standards at the home, these were seen to be satisfactory. Discussion with staff and observation of practice confirms that medication administration record (MAR) charts are completed at the time of administrating the medication. The MAR charts examined were completed accurately. Arrangements for all aspects of medication management are robust The case files include records of the individuals stated preferences for their daily routine such as rising, retiring and bathing. The staff record the life story for each resident that gives insight and understanding of the person of how they were prior to their admission to the home. A limited programme of training is included in the NVQ units and the Nursing staff have experience in care of the dying. Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 12 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): 11 – 15 The home provides a limited but well-organised and varied social and recreational activity programme that provides interest and pleasure for the residents. An open visiting policy assists service users to maintain contact with their family and friends. Many aspects of care evidences that service users exercise choice and control over their lives. Meals at the home are wholesome and meet the nutritional needs of service users while reflecting choice and taste. EVIDENCE: The home has an activities programme that is displayed on the main notice board and which forms the basis of routine events which is expanded by more ad-hoc and spontaneous events such as exercises, music and movement, entertainers, individual shopping trips. One service user attends a day centre. Hairdressing, aromatherapy, manicure and pedicures are regularly available. The spiritual needs are met with frequent church visits and services and a number of service users attend the temple close by. Visitors spoken with said they felt they are welcome at any time and five of the six relative comment cards respondents stated that staff made them welcome. Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 13 Care plans identify residents individual likes and dislikes and choices about their individual routines, these are carried out flexibly to provide for choice of the moment. The menus provide for a balanced and nutritious diet and is well received by the residents many able to recall the choices offered at each of the meals and that the three main meals offered a cooked option. The menus have been assessed as nutritionally sound and are put together using a high proportion of fresh produce. Each meal has a choice that meets cultural wishes Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 14 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 – 18 The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Service users rights are protected and staff demonstrate excellent knowledge and understanding of adult protection issues which contributes in providing an environment safe from abuse. EVIDENCE: The home has an appropriate complaints procedure and maintains a detailed record of the complaint investigation and the outcome, six internal complaints were recorded and resolved to the complainants satisfaction. Advocacy services are displayed in the main reception area and the manager identified that the electoral roll is completed each year and confirmed that postal votes had been arranged for the last election. Service user meetings are held monthly and are a good platform for developing ideas whether in respect of planning events or adapting the menus. The home has robust procedures for responding to any suggestion of abuse and training is given to staff in adult protection procedures. Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 15 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 & 26 The home provides a good standard of décor, furnishings and managed services providing a safe environment and an attractive, comfortable and homely place to live. The home is clean, free from odours and hygienic. EVIDENCE: The premises are generally well maintained and in good decorative order overall and subject to a programme of redecoration currently the first floor layout is being revised and the second phase is underway. During the inspection a bed was seen to be fitted with a single bedrail. The home was found to be clean, hygienic and free from odours, each floor has sluice disinfection facilities and the modern laundry is fitted with washing machines with sluicing and disinfection programmes and all surfaces are washable. The hot water supply to staff hand wash sinks is very hot and not compatible with good hand washing practice. Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 16 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 The home benefits from a stable staff group, with good levels of qualification and experience who are a good match to providing consistency of care to the service users. EVIDENCE: An inspection of the staffing rotas demonstrates that the home maintains satisfactory staffing levels. The home has a high proportion of staff qualified at or above NVQ level 2 and exceeding the 50 standard. Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 17 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 - 37 Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities and service users benefit from this consistency. The home regularly reviews its performance which includes consultation and seeking the views of service users and their families and evidenced that it is acted upon. The sound financial management of the home and arrangements for safekeeping of their money safeguards service users interests personal and financial. Staff receive supervision and direction to ensure that the service users receive consistent quality care. The best interests of service users are safeguarded by the homes record keeping, policies and procedures. Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 18 EVIDENCE: The home is managed by a well qualified and experienced manager who meets regularly with staff and service users. Service users views are in addition regularly surveyed using a range of questionnaires that between them cover all aspects of service. A quarterly surgery is held for relatives to proactively seek their views about the service and notes and actions / responses are also kept. A sample of supervision records were inspected and these show that supervision session topics are relevant and the process is on target to achieve at least 6 sessions a year for all staff. Records required by regulation and the schedules are maintained and kept up to date. Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 19 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 3 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 X Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP25 Regulation 13(4)(a) Requirement The registered manager must provide safe supply of hot water at staff hand wash points of sluice, kitchen and laundry to promote good hand-washing practice. Previous timescale 30.11.05 not met. Is included in programme of development underway. The responsible person will provide and maintain cold smoke seals on all fire doors. The registered manager must ensure that service users assessed as requiring bedrails have them fitted in pairs and ensure safety guidelines are met Timescale for action 31/03/06 2. 3. OP19 OP22 23(4)(c)i 16(2)(c) 31/03/06 31/01/06 Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bearwood Nursing Home DS0000052879.V274819.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. 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