Inspection on 30/07/07 for Bedewell Grange

This inspection was carried out on 30th July 2007.

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

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Bedewell Grange Campbell Park Road Hebburn Tyne And Wear NE31 2SL Lead Inspector Mr Clifford Renwick Unannounced Inspection 10:00 30 & 31 July & 2 August 2007 th st nd 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 Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bedewell Grange Address Campbell Park Road Hebburn Tyne And Wear NE31 2SL 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) 0191 483 8000 0191 483 3000 Barchester Healthcare Homes Ltd Maria Susan Scott Care Home 52 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (42) of places Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First inspection since new registration 1st February 2007. Brief Description of the Service: Bedewell Grange provides personal care for up to fifty-two older persons, with care staff available at all times over the twenty-four hour period. Nursing care is not provided at the home. The building has two-storeys. The first floor being accessed by stairs and a passenger lift. There are 48 single bedrooms and two double bedrooms all of which have their own en suite toilet facility. Car parking is available to the rear of the home. A large grassed area is available to the rear and side of the building, which has a pleasant seating area. Bedewell Grange is situated in a central area of Hebburn, close to the shops, bus route and local amenities. The home was originally opened in 2001 and during this time it has changed ownership the most recent change being February 2007. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key Inspection took place over two days on 30th & 31st July 2007, and was completed with a further half-day afternoon visit on 2nd August 2007. • • • • • • The judgements made are based on; the evidence available to the inspector before and during the inspection The Annual Quality Assurance Assessment (AQAA) supplied by the registered owner Discussions with several residents, four members of staff Discussions with the owners representative, deputy manager and external management team Examination of residents and staff files Discussion also took place with 2 relatives of residents. The inspector walked around the building looking at communal rooms, bathrooms, toilets and a number of resident’s bedrooms. And on 2 days had lunch with residents in both the ground and first floor dining rooms. The people who live in this home prefer to be known as residents; therefore this term of reference is used throughout the report. The registered provider is referred to as the owner in this report. At the time of the inspection the acting manager was on long-term sick leave. As this represents the first key inspection since the change in registration all 38 standards were looked at in order to make the judgements in the report. What the service does well: The home is well maintained and offers residents a clean environment to live in. Plans are in place to make the environment more suitable for people with dementia. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 6 There is a good staff team who are knowledgeable about individual needs and this helps them to support residents in the best way. The home encourages residents to follow their own lifestyles where possible and help them to plan holidays outside of the home. A good range of meals are available in the home and the staff consult residents about the food provided. Regular residents meetings are held and staff welcome residents views on the services being provided. Staff will act upon resident’s ideas and use these to develop the services. The homes external management act quickly to deal with any shortfalls in the service and have responded promptly and positively to advice from the inspector during the inspection. The company is ensuring that in the absence of the manager, appropriate support is available to the deputy manager in order to maintain a good standard within the home. Active steps are being taken to recruit more staff so that in times of sickness and holidays there is no disruption to the staffing levels in the home. What has improved since the last inspection? As this represents the first inspection since the change in registration in February 2007 the comments below show improvements made since this date. The home has been awarded a grant from the local authority and they are using this to develop a sensory garden that can be used by the residents. Developments have taken place to enhance the facilities and new laminated flooring has been provided in the dining rooms. The first floor activities room has been decorated and furnished to a good standard. The ground floor quiet room has new furniture and furnishings and plans are in place for new furniture and carpets to be provided in lounges and dining rooms. The home is also developing a sensory garden for use of the residents and this will ensure making it secure so that residents who have dementia can use the garden without being at risk. Lighting is also being improved throughout the home and some of this will be touch sensitive and will link in with plans to make the home more suitable for people with dementia. The first floor has been fitted with memory boards, doorbells and doorknockers, all of which are items that are helping with orientation. A sweet shop window is under development and when complete will look like sweet shop from “bygone years”. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 7 The home, as well as taking residents out to the shop have a small shop trolley that is taken around the home by staff. Residents can purchase items from the trolley and stated that they liked this, as there were times when they would prefer not to go out to the shops. What they could do better: In the Annual Quality Assurance Assessment the home have identified a number of things they could do better in order to provide information about the services provided in the home. These include keeping the service users guide and statement of purpose up to date so that accurate and detailed information is always available to prospective residents. Records that show how resident’s needs are assessed and kept up to date and then how staff will meet these needs with a written plan of care, must improve. Similarly when staff are recording on a daily basis how residents spend their day, they must do this in a way which accurately records events in the home. Life history documentation that is used to record residents likes/dislikes and previous life before moving into the home must be completed and updated. As this offers staff valuable information which helps them when supporting residents with their care. Practices around the storage and administration of medicines must be carried out in line with current guidance. A regular programme of activities must be developed which reflects resident’s interests and with a view to providing activities that are stimulating for those residents who have dementia. The mealtime practices must be reviewed with better use being made of staff during these times. Fire safety in the home must not be compromised. Staffing numbers must be kept under review so that at no time are staffing numbers reduced as a result of sickness and holidays. And in the absence of any management staff being in the home, one of the senior staff must be designated as the person in charge so that they take responsibility for the general management of the home. When using agency staff, records must be available to confirm that they have received appropriate fire induction training while they are working in the home. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 8 Consideration needs to be given as to how better use of the homes minibus can take place in order that residents can benefit from trips outside the home. For those residents who have requested the home to manage their person allowances, arrangements need to be in place so that if they wish they can access this money at weekends. 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. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 9 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 Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 10 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, 2, 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. The Home has a range of relevant information which assists people to make an informed choice about whether to move in; confirms the fees to be paid and what services can be expected. No one is admitted to the home without a full assessment of need being completed. This helps to ensure that residents are offered the right type of care and no one is admitted inappropriately Prospective service users, their relatives and friends can visit the home prior to making any decision to move in. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 11 EVIDENCE: At the time of the inspection there were 50 people living in the home. Residents and staff confirmed that before moving into the home prospective residents can visit, have a meal and also have a good look around the building. They are then given a folder and brochure that contains information about the services provided. Admission is dependent upon an assessment of needs, which are carried out by the placing authority (social services) or the home if the placement is privately funded. Pre admission assessments are available in resident’s files and these are used to develop individual care plans, which are discussed more fully in section 7 – 11 of this report. The home can also use an independent advocacy service, to which they can refer prospective residents should they need support with making a decision to move into the home. Once a resident moves into the home they are issued with a statement of the terms and conditions of residence copies of these were seen in resident’s individual files. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 12 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 & 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual residents care plans do not provide sufficient information about a person’s care needs to ensure independence is maintained and support is given to continue a full and valued lifestyle. Furthermore, assessments are part completed or not up to date, therefore individual needs are not always being met. Residents have good regular access to health professionals to ensure healthcare is promoted. However, records of medication administration are not managed appropriately to promote the health and well being of residents. Residents are treated with respect and privacy and this goes some way to ensuring that they are able to have a valued lifestyle within the home. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 13 EVIDENCE: The care plans, which are developed following an assessment of individual resident’s needs, do not contain sufficient information. This is due to assessments not being kept up to date and also by using terms, which are vague, for example “keep his independence” & “ requires prompting” and “to promote dignity”. It was clear from observations of staff practices and from discussion with staff, that they are very clear about what individual help and support resident’s need. This is not recorded in the care plans. The life story forms that staff can complete in order to have a range of information about a resident’s previous lifestyle is incomplete. And daily reports that are kept on a daily basis to report on life in the home, do not include enough information to demonstrate how residents spend their day and whether there are any changes in their needs. Comments such as “slept well” and “been fine” are not helpful in monitoring resident’s care. Some good practices are taking place, with one resident being supported to fly to France on a religious pilgrimage, though no reference of this is made in the care plan. This has ensured that this resident can fulfil and follow their religious pursuits. Discussion with this resident confirmed that they were looking forward to this trip and stated that it was great that “one of the carers” was accompanying them to France. Another resident who likes to go outside to smoke, is able to go in and out of the home independent of staff and has the access codes to the front door. This too is not supported by the written care plan. Staff have a good knowledge of residents and speak with confidence about the work they are doing but again this valuable information is not included in the care plans. Good arrangements are in place for health needs to be met by health professionals. Records are kept of visits by the community nurse and the G.P and also any other appointments related to health, such as chiropody and the optician. Staff responds quickly to any change in residents health needs by contacting the most appropriate professional. Though some residents have been identified as being at risk from falls, the risk assessment process that is in place has not been fully implemented in order to demonstrate the measures that will be taken by staff to reduce the risk of falling. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 14 Similarly a person who has identified needs related to continence management, has not had an assessment and care plan put in place to demonstrate how staff will offer support. Records of medication administration and storage were examined and it was noted that there are some shortfalls with how this is being dealt with by staff. None of the residents administer their own medication but there is insufficient information to confirm how this has been assessed. Consent forms, which agree to staff administering their medicines and which are kept in residents care files have not been signed or completed. There are no records of the names of staff authorised to issue medicines, in the administration of medicines record. A monitored dosage system is in place for administration of medicines and there were gaps in the records, which made it difficult to determine if some medicines had been issued or not. The written instructions for one cream in use were difficult to follow and discussion with staff confirmed that they were unsure of how and where to apply this cream. A number of creams were on open display in the medication room and were not being stored in a cupboard. Fridge temperatures are not being checked daily and the list on display was out of date. A number of these shortfalls in relation to medication had been picked up by the companies external audit system and as such the company was carrying out remedial action. The company’s clinical nurse is carrying out weekly visits to the home and is currently carrying out a full audit of medication and the systems in use. All senior staff have completed training in the safe handling of medicines and are also completing an in house drugs assessment, to assess their competency. Staff respect the privacy of residents. Staff knock on doors and wait for instructions to enter. There is good rapport between staff and residents and the residents stated “ there are a good bunch of lasses working in the home”. Residents preferred term of address is used but this is not always recorded in the care file. However residents confirmed that they tell staff how they like to be called. Staff are respectful in their work with residents and carry out their work in a professional and at times discrete way, especially when dealing with personal care. Personal and intimate care tasks are carried out in the privacy of bedrooms. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 15 Some practice issues were discussed with the deputy manager and these related to the upstairs unit, where a number of residents have dementia type needs. For example at one stage the television in the main lounge was switched on but with no sound, while in the hallway outside, the radio was playing quite loud. This kind of practice is inappropriate and does not follow best practice guidelines when supporting residents with dementia. The company, as part of the admission procedure, have forms that are used to record a range of resident’s personal information. These are not fully completed and staff had not completed the section that refers to any preferred wishes, in relation to funeral arrangements. It was difficult to confirm that residents would be assured that their wishes would be respected without this information being recorded. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to follow their own daily routines, which satisfy their social, cultural and religious needs. There are no restrictions on visiting the home and friendships with people outside and inside the home are encouraged, this helps to maintain contact with friends and family. Staff encourages residents to take control and make choice in their lives, which helps to promote independence. Residents are offered a variety of wholesome and nutritious meals in comfortable surroundings, which promotes their health and well-being. EVIDENCE: Residents are satisfied with the services offered in the home. One resident confirmed how she was being supported and accompanied by a carer on a religious pilgrimage to Lourdes in France. She stated that this was very important to her and was pleased that staff were able to support her. Other Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 17 residents spoke of how they could attend religious services within the home, with representatives of the various religious denominations visiting the home. Residents confirmed that they were able to follow their own lifestyle within the home and if they wanted to, could spend time in their bedrooms. Many of the residents have personalised their rooms and have access to their own telephones. A number of residents are supported to manage their individual finances, so that they can maintain independence in this area. When asked for comments about the home residents stated the following: “it’s bloody champion here, the staff cannot do enough for you” “ we have had some canny trips out, but there’s not enough outings at the moment” Residents also stated that at the moment there was little use made of the homes minibus due to a shortage of drivers. The residents spoke about the “residents meetings”, that are held in the home and where they are able to discuss anything they want about the home. Minutes available for the last meeting in June confirmed that 13 residents attended and discussed activities, general health and safety issues and changes to the meals. The deputy manager confirmed that the home was trying to get relatives involved more with the meetings, as well as involving them in activities and functions. There are no restrictions in visiting the home and families and friends are free to come and go and this was evident throughout the inspection. The inspector had a meal with residents on both days of the inspection and in different dining rooms. On some tables there were no condiments or serviettes, and some containers, which contained salt and pepper, could not be distinguished, due to their design and colour. This caused some confusion for those residents who have dementia needs. The meals were well presented, hot and tasty and a choice was available. However the meals provided did not match what was on the menu. Similarly the dessert offered was different from the choices on display on the menu. Menus are on display on the wall outside of the dining room and also in the main entrance lobby but not in the dining room. This makes it difficult to know what is available at each meal. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 18 Staff confirmed that residents are always informed on a daily basis of what is available and they are asked what they want for each meal. Discussion with residents about the meals resulted in a number of comments which are as follows, “The food could be better, to much use made of corn beef” “The food is good, always plenty of choice” “There is to much to eat” Information contained in the homes Annual Quality Assurance Assessment confirmed that meals were under review and they had identified, as an improvement plan how they could improve on the variety of meals provided. Some residents required assistance with their meal but there were not enough staff on one occasion to sit with them. On other occasions staff offered verbal support to residents but it evident this would have been more effective if staff had sat at the table with them. The mealtime practices were discussed with the deputy manager who was advised of the actions that needed to be taken to make improvements to the service. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 19 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, 17 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives have information about how to make a complaint and are confident that any complaints will be acted upon immediately. All Staff are aware of the Safeguarding Adults procedure and most staff have received training in this. More training is arranged and this willfurther ensure that all staff are aware of how residents must be protected from abuse. EVIDENCE: The home has a comprehensive complaints policy and procedure, which ensures that any complaint is recorded. This record also confirms the action taken and whom the complaint was investigated by, with an outcome also recorded. Complaints records were available for inspection and these confirmed that the home responded quickly and within their timescales. Staff take all necessary steps to resolve any complaints or concerns. External management support is available in responding to complaints, with the operations manager at times dealing with complaints independently from the home. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 20 Polices and procedures that deal with protection of vulnerable adults and whistle blowing are in place to effectively deal with any suspicions of abuse. Staff receive training in these procedures and this ensures that they follow best practice guidelines when dealing with vulnerable adults. Residents continue to exercise their legal right to take part in the voting process with elections. Residents can use a range of options to vote either by post or attending their local ballot station. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 21 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, 22, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well-maintained, clean, safe and warm, offering residents a homely and safe environment in which to live. However residents wedging their bedroom doors open sometimes compromise fire safety. There are sufficient toilets and bathrooms to ensure that residents personal hygiene needs are met. Residents are encouraged to bring personal possessions into the home in order to ensure that they live in a comfortable environment. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 22 EVIDENCE: A number of bedrooms, all bathrooms and communal area were viewed as part of the inspection. The home is well maintained, however at the time of the inspection, some of the residents were wedging their doors open. This compromises fire safety and was discussed with the deputy manager. The home is inspected by the fire authority and meets all of their safety requirements, however in order to enhance safety for residents, a self closing device is being fitted to all bedroom doors. This closure means that when leaving the room the door will close automatically. However if residents continue to wedge doors open, this renders the self-closing device ineffective against a potential fire. The building was clean and tidy, with evidence that improvements are being made to the first floor, to assist with orientation for those residents who have dementia. Sensory and visual aids are place and a lifelike sweet shop front is under development. An activities room is available, though at the time of the inspection no use was being made of this room. Most of the residents have brought personal effects into the home and this has made their bedroom distinctly different form others. Items such as settees, easy chairs, small pieces of furniture and televisions and other equipment make the rooms look like small flats. Residents confirmed that they see this room as their home and they stated that having their personal effects around them made the room comfortable. All bedrooms have an en suite toilet facility and communal toilets and bathrooms are evenly distributed throughout the home. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 23 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. At times there are insufficient staff on duty to effectively meet the needs of residents. Residents are protected by the home’s recruitment procedures, which are implemented to a good standard. This helps ensure that unsuitable candidates do not gain employment in the home. Staff receive regular training to ensure residents are appropriately supported and protected. EVIDENCE: The registered manager is on long-term sick leave and the deputy manager carries out the day-to-day management of the home. Following an audit carried out by the company the deputy manager has been allocated management support by managers from two of the company’s homes. This is to ensure that developments continue to be made in addressing some of the issues regarding staffing and record keeping. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 24 Examination of the rotas confirmed that there are 2 senior care staff on sick leave and this has caused shortages. Extra shifts have been picked up by staff, as well the home using agency staff. The company does have a bank system whereby they can use staff working in other homes. However annual leave and sickness all have impacted on the current rota and on occasions there has been no senior member of staff on duty on nights. In discussion with the company representatives, they confirmed that they are in the process of recruiting more staff in order to provide cover on rotas for holidays and sickness. Changes have also been made, increasing numbers of staff on night duty following a recommendation from social services. Examination of files for staff newly appointed in the home confirm that rigorous checks are carried out before they are employed to work in the home. This includes receiving appropriate references and completing the necessary criminal record check. Staff files contain employment history, records of training and any training certificates. Once staff commence work in the home they receive induction appropriate to the work. Training records confirmed that all staff has achieved NVQ Level 2,with 2 staff ready to commence on NVQ Level 3. Mandatory training that covers health and safety was achieved in the last month. Other training such as Protection of Vulnerable Adults, fire training, dementia and challenging behaviour, moving and handling and food hygiene has been covered recently or are being arranged. The training file confirmed that there are good training opportunities for the staff team. However for agency staff the records did not confirm whether they had received suitable induction training in fire safety while working in the home. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 25 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, 32, 33, 34, 35, 36, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The deputy manager is experienced in her role and in the absence of the manager is ensuring that staff are appropriately supervised. Thiscombined with the quality assurance systems ensures that the home is run in the best interests of the residents. Good procedures are in place to ensure that residents’ financial interests are safeguarded. The health, safety and welfare of residents is promoted and protected. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 26 EVIDENCE: As previously stated in this report, the manager is on long term sick leave, so the day to day management of the home is carried out by the deputy manager. External support is available from a manager of another home and this will continue while the manager remains on sick leave. The deputy manager has good experience in this work, has achieved NVQ Level 3 and is due to commence the Registered Managers Award. There have been occasions when the deputy manager has been off or attending meetings and no dedicated senior person has been left in charge of the home. This makes it difficult to ensure consistency of the management of the service. Quality assurance systems are in place to ensure that standards are continually improved and the company audits these on an annual basis. Consultations take place with residents and their families and the home takes note of what is said to them and uses this to develop the services. Good records are maintained of fire drills and instruction which confirms that staff receive the necessary regular training to promote the health and safety of residents. However as previously stated in this report, it was not clear from the written records whether agency staff receive similar fire safety training. Discussion with the deputy manager confirmed that they do but it was not being recorded. Hot water temperatures are checked and a record is maintained. Accidents are recorded but some further detail is required when making an entry in the accident book. Accidents are audited monthly with a view to reducing accidents in the home. Appropriate notices are on display throughout the home and where oxygen is in use this is being managed well. The administrator has responsibility for managing the safekeeping of resident’s personal finances. Good records and secure facilities are in place but discussion took place about residents being able to access their money at weekends when the administrator is not at work. As noted in the staffing section of this report staff receives the required mandatory training to ensure the safety and well being of residents. The only time this is compromised is when staffing levels fall below the minimum numbers due to sickness and holidays. However this is currently being addressed by the company. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 27 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 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 3 3 2 Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 28 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 OP3 Regulation 14 (2) (a) (b) Requirement Individual assessments of residents needs must be updated and kept under review. When updating the assessment information relating to previous life history must be obtained. Individual resident care plans must be updated to include the actions being carried out by staff to meet residents assessed needs. Daily records that confirm how residents spend their day must include additional information to confirm how staff is meeting their needs. (Immediate) The arrangements for recording, handling and safe keeping of medicines must be carried out in accordance with the guidance as issued by the Royal Pharmaceutical Society. (Immediate) Staff must ensure that each resident or their representative signs a consent form agreeing to staff being responsible for issuing their medicines. (Immediate) DS0000069205.V337987.R02.S.doc Timescale for action 28/02/08 2. OP7 15 (2) (b) 28/02/08 3. OP7 17 (1) (a) 02/08/07 4. OP9 13 (2) 02/08/07 5. OP9 13 (2) 02/08/07 Bedewell Grange Version 5.2 Page 29 6. OP12 16 (2) (m) 12 (1) (a) 23 (4) 18 (1) (b) 7. 8. 9. OP15 OP19 OP27 10. OP38 18 (2) 11. OP38 12 (1) (a) 12. OP38 18 (1) (c) A programme of stimulating activities must be developed and introduced following consultation with the residents. The mealtime practices must be reviewed as discussed within this report. Fire safety must not be compromised at any time. (Immediate). At all times suitably qualified, competent and experienced staff are working numbers that are appropriate to meet the needs of residents. The registered provider must continue to provide external management support to the home while the registered manager is on sick leave. (Immediate) At all times in the absence of management staff a designated senior member of staff must be designated as being in charge of the home. (Immediate) Records must be available that confirm that agency/bank staff receive fire induction training when commencing work in the home. (Immediate) 31/12/07 30/11/07 02/08/07 30/11/07 02/08/07 02/08/07 02/08/07 Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 30 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 OP12 OP35 Good Practice Recommendations Consideration should be given to developing a system whereby better use can be made of the minibus to provide more regular outings for residents. Consideration should be given to implementing a system that ensures service users if they wish can access money to spend at weekends. Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Bedewell Grange DS0000069205.V337987.R02.S.doc Version 5.2 Page 32 - 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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