This inspection was carried out on 12th January 2006.
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.
CARE HOMES FOR OLDER PEOPLE
Bedford Park Care Centre Pearn Road Mannamead Plymouth Devon PL3 5JF Lead Inspector
Mandy Norton Unannounced Inspection 12th January 2006 10:00 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 Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 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. Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bedford Park Care Centre Address Pearn Road Mannamead Plymouth Devon PL3 5JF 01752 770477 01752 785090 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) Ancyra Health Limited Mrs Sally Anne Thornton Care Home 104 Category(ies) of Dementia - over 65 years of age (39), Old age, registration, with number not falling within any other category (65), of places Physical disability over 65 years of age (39) Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. PD(E) Maximum registered 39 service users DE(E) Maximum registered 39 service users OP Maximum registered 65 service users Maximum of 104 service users accommodated at any one time Registered for 65 years and over Date of last inspection 5th October 2005 Brief Description of the Service: Bedford Park Care Centre comprises of three units; all are purpose built and laid out over two floors with wheelchair access via ramps or passenger lifts. The care centre is situated on the outskirts of Plymouth close to local ammenities.The home provides 24 hour nursing care to a maximum of 39 people and personal care to a further 65 people over the age of 65 years of age of either gender with physical frailty, illness or disability 39 of those requiring personal care may also require care for dementia. Maximum number of service users to be resident is 104.Communal rooms are available and the home benefits from large landscaped and accessible gardens and patio areas including a raised fish- pond.The home is owned by Ancyra Health Limited, a national care home provider. Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3 hours and 40 minutes (between 11.05 am and 2.45 pm) and was conducted with the manager. The inspector spoke to 6 patients and 2 relatives during the inspection. One of the purposes of this inspection was to assess the key standards that were not considered during the last inspection. A brief tour of the premises took place and some records were examined. What the service does well: What has improved since the last inspection? What they could do better:
The homes quality assurance system would benefit from being wider ranging to achieve a continuous monitoring of standards and functions within the home. The risk assessments carried out when fitting bed rails could be more robust in light of recent health and safety advice.
Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 6 The manager is still considering how best to ensure the carers have consistent/ongoing training in basic care. 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. Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 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 Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 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): None of these standards were assessed during this inspection. EVIDENCE: Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 9 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): 8&9 The health care needs of the residents are identified and met. EVIDENCE: The optician was seen during a tour of the home carrying out numerous eye tests. The manager discussed the care of a patient who has recently been admitted to the home who needs some specialist care. The nurses involved with the care are visiting the local hospital, when the patient goes back for some treatment to learn/update on some techniques that will be required. The patient and relatives were spoken to during the inspection and had high praise for the staff. Self medication was not discussed during the inspection. The trained nurse carries out medication rounds in the nursing unit and senior carers with appropriate training carry out medication rounds on the 2 residential units. If there are any queries/issues the care staff can ask the trained nurses on duty. The medicines are handled in accordance with laid down legislation and records are kept of all medicines received and administered. Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 10 Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 The staff have a good understanding of the patients cultural, social and recreational needs and the importance of maintaining contact with family and friends and engage the patients in a variety of ways. The meals in the home offer both choice and variety and cater for special dietary needs. EVIDENCE: A tour of the home showed patients involved in a range of activities including reading, chatting with visitors and other patients, assembling for a bingo session and generally enjoying watching/discussing the fish in the aquarium (in the nursing units lounge). Each unit has an aquarium and the garden has a raised pond. They are all very well maintained by a volunteer and are really enjoyed by the patients. Although there are set mealtimes, patients can have their meals at other times if they wish. Details of activities taking place is displayed in the different units. Outings were not discussed during the inspection, although the manager gave examples of how people remain independent and can come and go as they please following a comprehensive risk assessment that allows for this. Patients can see visitors whenever they like and can stay in their room or use the communal spaces or gardens.
Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 12 During the tour of the home it was clear that patients are able to bring personal possessions with them when they move in (space allowing). Information about independent advocates is available within the home and can be arranged as necessary. Patients spoken to had enjoyed their lunch and said the portions were just right and there was variety. Snacks and drinks are available at all times. There are small kitchenettes within the units where drinks and snacks can be made in between the regular meal times. Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 13 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): 18 Staff have a knowledge and understanding of adult protection issues which protects patients from abuse. EVIDENCE: A discussion with the manager and one of the managers of the residential unit about safeguarding patients and sharing of information confirmed that staff are aware of the procedures in place for reporting of actual or suspected abuse. Ancyra policies and procedures around adult protection, whistle-blowing and dealing with aggression are available within the home at all times. Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 14 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): None of these standards were assessed during this inspection EVIDENCE: Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 15 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): 29 and 30 The homes recruitment policy and practice protect the clients EVIDENCE: Ancyra have a policy of having 2 written references and a CRB check on file for all staff. The manager said that since the staff files have been reorganised they are easier to manage and it is clear if anything is not in place on the file. All prospective staff are interviewed in a private office and the manager uses the same interview format for each interview. At the last inspection the manager had decided that following a complaint about basic care issues that she would make sure an in house training package was developed (in addition to induction and ongoing NVQ training by some staff) for all staff to attend and this should be an ongoing process and on a regular basis. This training package is still being developed as the manager is deciding the most effective way to approach the issue. Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 16 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): 33, 35 and parts of 38. The systems in place in the home promote and protect the safety and welfare of the clients and staff. EVIDENCE: The benefits of quality assurance and self assessment were discussed and the manager was encouraged to build on their existing system of quality assurance to ensure the information in their Statement of Purpose can be measured. The current system involves questionnaires sent to patients and their relatives/representatives and an open door policy that invites people to make comments and discuss any issues that arise. Discussion with the manager and one of the managers of the residential unit confirmed that Ancyra prefer not to deal with patients personal allowances if at all possible. When the home does have to mange money for patients then it it
Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 17 stored securely and only relevant people have access to it. All transactions are documented and receipts kept as proof of the transaction. All patients with bed rails in place have an agreement/ consent form signed by the patient or their representative to agree to there use. A discussion about the need to enlarge this process to include a documented and up to date risk assessment that is seen by the person signing the consent form. Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP30 OP33 Good Practice Recommendations The manager should start the training process she is developing to ensure all care staff have ongoing training in basic care issues. Ancyra should build on the existing quality assurance systems used in the home to ensure information contained in the Statement of Purpose can be measured effectively and desired outcomes are achieved. The manager should ensure that risk assessments are carried out and documented when bed rails are to be used for a patient. The risk assessment should then be seen by the person consenting to the use of bed rails for the patient. 3 OP38 Bedford Park Care Centre DS0000003573.V273416.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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