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Inspection on 26/06/07 for Bedford Park Care Centre

Also see our care home review for Bedford Park Care Centre for more information

This inspection was carried out on 26th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The centre is well maintained and comfortable. The staff are welcoming and approachable. When possible, prior to admission, the manager and / or experienced staff visit the person in their current setting to perform a full needs assessment in addition to receiving care plans from other social and health care professionals. Once admitted to the home peoples needs are set out in a care plan, the plans provide sufficient information for care staff to be able to meet the individuals` health, social and psychological needs. Regular training for the staff, on clinical issues, helps to assure the people living in the home that they are well looked after. People are able to maintain contact with family and friends and exercise some choice and control over their lives.The service offers a comprehensive activities schedule. These are organised by a team of activities co-ordinators 7 days a week who offer activities in and outside of the centre. The centre presented as clean and hygienic.

What has improved since the last inspection?

A training plan has been implemented and in house trainers trained to deliver some of the statutory training. Implementation of some internal rotation of staff to ensure staff have the skills to meet the needs of people living at the centre and to reduce the territorial attitudes that some staff have had in the past. Care plans are reviewed more regularly. The new company have introduced a robust quality assurance system to ensure ongoing quality of the service offered.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Bedford Park Care Centre Pearn Road Mannamead Plymouth Devon PL3 5JF Lead Inspector Mandy Norton Unannounced Inspection 26th June 2007 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.V337015.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. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bedford Park Care Centre Address Pearn Road Mannamead Plymouth Devon PL3 5JF 01752 770477 01752 785090 manager.bedfordpark@aermid.com 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.V337015.R01.S.doc Version 5.2 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 20th September 2006 Brief Description of the Service: Bedford Park Care Centre comprises of three separate units (known as the ‘nursing unit’, ‘Compton Gardens’ and ‘the residential unit’; 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 amenities. 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 in each unit and the home benefits from large landscaped and accessible gardens and patio areas including a raised fish- pond. The home is owned by Aermid Health Care Group PLC a national care home provider (www.aermid.com) who have taken over since the last inspection. The current fees range from £285 to £560 (July 2007)). All people living in the home are issued with a contract breaking down the fees so people can see who is paying what. The last inspection report is on display in the entrance foyer to each unit. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Tuesday 26th June (2 inspectors; 10am to 3.15 pm) and was completed on Thursday 28th June ( 1 inspector; 10.50 am to 2 pm) 2007. It was conducted with the centre manager and assistant managers from the residential unit and Compton Gardens. A tour of the centre was carried out. (Some Service Users seen were not always able to fully express themselves fully or comment on the care they received). This report also contains views from 16 completed care workers surveys and 9 relatives surveys reflected throughout, information taken from the completed Annual Quality Assurance Assessment (submitted prior to the inspection) and discussion with staff and people living in the home on the days of the inspection. We case tracked 8 people (looked at information about how their care needs are to be met and any other information held about them in the home and met with the person to discuss their experience of living in the home. This includes talking to staff who are familiar with caring for them and other health professionals involved in their care if at all possible) in detail. What the service does well: The centre is well maintained and comfortable. The staff are welcoming and approachable. When possible, prior to admission, the manager and / or experienced staff visit the person in their current setting to perform a full needs assessment in addition to receiving care plans from other social and health care professionals. Once admitted to the home peoples needs are set out in a care plan, the plans provide sufficient information for care staff to be able to meet the individuals’ health, social and psychological needs. Regular training for the staff, on clinical issues, helps to assure the people living in the home that they are well looked after. People are able to maintain contact with family and friends and exercise some choice and control over their lives. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 6 The service offers a comprehensive activities schedule. These are organised by a team of activities co-ordinators 7 days a week who offer activities in and outside of the centre. The centre presented as clean and hygienic. What has improved since the last inspection? 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. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 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.V337015.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service or are prospective Service Users have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. The home is not registered to provide intermediate care. EVIDENCE: The care centre is divided into 3 separate units nursing (38 beds), residential, for people requiring personal care who also have dementia, and Compton Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 9 Gardens which is for people requiring personal care who may also have dementia. Each unit is staffed individually and has a unit manager who is responsible to the general manager who is a qualified nurse. Care staff do rotate between the units to ensure people have the skills to care for people with a variety of needs. The most appropriate staff member visits a person in their current situation to carry out an assessment to ensure the care centre can meet their needs. The person and or their representative are encouraged to look around the care centre to decide if it will suit their needs. Contracts are issued for everybody that moves into the home whether they are publicly or privately funded. They contain information about the terms and conditions of residency and the complaints procedure. The last inspection report is displayed in each entrance foyer along with information about local services, upcoming events and a complaints procedure. The up to date Service Users Guide and Statement of Purpose (reviewed June 2007) is given to all people when they enter the home and can be sent o people who enquire about the care centre. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager promotes and maintains peoples health and ensures access to health care services to meet assessed needs. The homes medication systems protect the welfare of Service Users. People are treated with respect and their right to privacy is upheld. EVIDENCE: Care plans examined (8 taken at random from all of the units) had all the required information in them (skin integrity, moving and handling, safety including risk of falls, use of bed rails risk assessments and nutritional screening). Some had been signed by a relative to say that they had discussed Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 11 and agreed the content of the care plan. The Annual Quality Assurance Assessment (self assessment document required to be completed prior to the inspection) states that over the next 12 months the staff plan to’ become more proactive with the involvement of Service Users/family with care plan reviews’. Professional visits from speech and language therapy (SALT) and GP’s for example were documented in the care plans. Some of the care plans examined had some information about lifetime events, hobbies and pastimes included in them. This is something the unit managers are improving as it helps to develop activities and topics for conversation with people living in the care centre. Four (4) of the nine (9) completed relatives surveys indicated that the home usually meets the needs of their relative and five (5) indicated that they always meet their needs. Comments included ‘the staff are always very patient and kind’ and we ‘think highly of the kindness shown to her and feel the care home definitely meet her needs’. The completed Annual Quality Assurance Assessment states that improvements over the last 12 months have included continuing improvement with the administration of medicine and auditing of care plans. Fourteen (14) of the sixteen (16) completed staff surveys indicated that staff are not asked to look after people outside their area of expertise and 2 indicated that they were expected to. The manager is aware that some staff do not have the skills to look after people with dementia so has introduced a system of internal rotation that gives a number of staff chance to work on other units to build up their confidence in working with people with dementia and the assistant manager, who runs the dementia unit, puts on regular study sessions for staff as part of their ongoing training. The medication system is well managed, now that some changes have been put into place following a series of problems. Audits are regularly carried out now to ensure that the staff are regularly checking medicines procedures and management to ensure consistent and safe practice. Disposal of unused/ out of date medication is safe, well recorded and removed by a licensed contractor. Appropriate interactions between staff, people living in the home, and visitors, was heard during the inspection. People were heard knocking on doors before entering rooms. And doors remained closed when staff were attending to people. People spoken to (and/or their relatives) said that they have a choice of where to spend their day and what time they get up. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effort is made by the home to provide an activities programme and social interaction/stimulation for people who live in the home. People are able to maintain contact with family and friends and exercise choice and control over their lives. People receive a wholesome appealing diet and are not rushed at mealtimes. EVIDENCE: The Service Users Guide and the manager said that there is a team of activities organisers employed 7 days a week who organise a variety of activities. They are also responsible for recording who attended what activity and completing the ‘getting to know you forms’ for each person living in the Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 13 home. This helps in tailoring the activities to meet the needs of all of the people. The Service Users Guide also says that if there is ‘an activity of particular interest to you please discuss it with a member of the team who will accommodate your request if at all possible’. They also say that the centre endeavours to provide some sort of entertainment at least twice a month. Notices displayed throughout the centre, advertising upcoming events, show that this does happen. The manager and one of the assistant managers said that the entertainments and activities take place in different parts of the centre so that people who don’t want to or cant move to other parts of the centre can still attend on occasions. A volunteer visits the home once a week to see people who may not have any other visitors (a criminal records bureau check has been carried out). A mini bus has to be hired to take people out. This means that all trips have to be planned and sometimes people do not want to go on the day planned or the weather may not be suitable. It also means that ad hoc trips cannot be taken to take advantage of the weather or a special event. A home of this size would benefit from their own minibus. The manager and assistant manager discussed their wish to provide a sensory room (and /or a mobile sensory unit) to help people with dementia as an alternate to using pharmacological interventions (as recommended in the NICE Guidance November 2006 – ‘Supporting people with dementia and their carers in health and social care’). People spoken to said that they can please themselves where they eat there meals and how they spend their time. Although staff said they do try to encourage people to eat in the dining rooms as it is often a good social occasion for them. The people spoken to said that the meals were of a high standard and they looked forward to them. Extra staff are available at mealtimes to ensure all of those that need assistance are able to have it. The menus have a choice of meals and alternatives are always available. Drinks and snacks are available 24 hours a day. Specialist diets are catered for and some care plans examined had information about specialist feeds in them following instructions form the dietician, with whom the home are in regular contact. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 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. 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. People living in the home and their relatives/friends know how to make a formal complaint. People are safe living in this home. EVIDENCE: There have been 3 concerns raised to the commission since the last inspection. One was about the prolonged time the lift was out of order. The commission were kept fully informed of the situation, which has since been resolved. One was about poor staffing levels, this was from an anonymous source. Staffing levels were discussed during the course of the current inspection and found to be satisfactory for the number and dependency of the people currently living in the centre. The Annual Quality Assurance Assessment states that 6 complaints have been received in the last 12 months One (1) of these complaints were upheld and one (1) is still awaiting an outcome. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 15 The complaints procedure is displayed at all entrances to the units within the centre and is at a level that can be read by people using a wheelchair, and is also in the Service Users Guide. Only one (1) of the nine (9) completed relatives surveys said they did not know how to make a complaint. The manager submits information to the Commission about any incidences where concerns about adult protection are raised and any subsequent actions taken. There are no ongoing adult protection issues at the time of this report. Twelve (12) of the fifteen (15) completed care workers surveys indicate that they are aware of adult protection procedures. The Service Users Guide states that staff are encouraged to attend courses (other than statutory training) this includes protection of vulnerable adults (POVA) training. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 16 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, 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 safe and generally well maintained and clean and hygienic ensuring the people living in the home generally live in a satisfactory environment. EVIDENCE: The care centre is divided into 3 units one nursing, one predominantly for people requiring personal care with dementia (separate units but in the same building) and the other for people requiring personal care some of whom may have dementia (this unit is separate from the main building called Compton Gardens). Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 17 The centre is purpose built and arranged on 2 floors. There are 2 shaft lifts in the main building and 1 in Compton Gardens. The gardens are extensive well laid out and accessible to everyone living at the centre. They are well maintained and attractive. Many of the people living in the residential unit have some form of dementia and during a tour of the unit it was noted that the colours are bland therefore not providing a stimulating environment for the people living there. The assistant manager said they are trying to raise money for a sensory room or mobile unit to help stimulate people with dementia as these are proven to be beneficial (see standard 12 – 15). It was also noted that signage in the residential unit could be better to help people orientate themselves in the unit. A tour of the units showed that peoples rooms have furniture, ornaments and pictures that reflect their personality and interests. Some of the carpets in the corridors in Compton Gardens are in need of replacement. The assistant manager said that some have already been replaced and the budget has been agreed for the rest to be done. Lifting and handling equipment and wheelchairs were stored appropriately when not in use. A variety of equipment examined during a tour of the home had up to date servicing records on them. Due to a lack of storage space in the nursing and residential unit equipment cannot be put away leading to some areas of the units looking cluttered. This does not help people with dementia to become familiar with their environment. Aermid provide people from the estates team to carry out major work and the maintenance team based at Bedford Park carry out the ongoing maintenance, redecoration and gardening. There is a call bell system fitted throughout the home. The laundry is a suitable size for the amount of washing the home produces. Clean laundry was being delivered to peoples’ rooms during the inspection. The Service Users Guide asks that labels are put into clothing before it is bought into the home. One (1) completed relatives survey said that although clothing their relatives clothing is labelled it does not always get returned to the Service User. The residential unit and Compton gardens have flushing sluices. Mechanical sluices are now recommended by the Health Protection Agency (HPA). The home was clean and hygienic. There were a variety of hand washing facilities prominently placed around the home. All ‘work’ trolleys seen around the home had a supply of disposable gloves and aprons on them. One of the assistant managers said that staff wear aprons when serving meals. The Annual Quality Assurance Assessment states that each unit has an allocated infection control link person to ensure good infection control measures are being practised and inform staff of any up dates to infection control advice. On the second day of the inspection there was as small outbreak of diarrhoea. The Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 18 staff were observed to be taking the right precautions and informed the appropriate authorities. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff with generally appropriate skills and knowledge to meet the needs of the people living at the home. The homes recruitment procedures protect people living at the home from being placed at risk of harm or abuse EVIDENCE: Duty rotas supplied with the pre inspection questionnaire indicate that the manager works full time. She is based in the nursing unit, a full time assistant manager based in the residential unit and Compton Gardens has a full time assistant managers post filled by 2 people who job share. They all report directly to the manager who is supported by trained nurses and carers, administration, catering, domestic and maintenance staff. Aermid supply a regional manager who provides support when needed and carries out the regulation 26 visits (the provider is required to make monthly unannounced visits to the home each month to check the quality of the service being provided) a copy of which is supplied to the Commission after each visit. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 20 Staff where a variety of colours of uniforms and so people living in and visiting the home can identify who is who it was suggested that a frame with pictures of staff with names and job titles on them could be displayed near the main entrances. The home is staffed according to the needs of the people living in the home. The assistant manager in Compton gardens showed us the ‘dependency profiles’ that have to be completed monthly. These are used to ensure the correct staffing levels are in place to meet the needs of the people currently living in the home. A variety of training certificates were seen displayed in one of the offices and in staff files and covered subjects such as care for people with dementia, continence care, dementia and dealing with challenging behaviour and some NVQ 4 (National Vocational Qualification) qualifications and infection control. Induction, fire safety and POVA training is provided by an outside agency. All other statutory training is provided in house as part of a structured training programme. New carers are also being asked to work through a ‘basic care booklet’ with an allocated experienced carer to ensure they are aware of basic skills. Eight (8) of the sixteen (16) completed staff surveys indicated that they do have regular meetings. Thirteen (13) stated they have regular meetings with their manager (this includes the assistant managers in the residential unit and Compton Gardens) and twelve (12) stated that they receive formal one to one supervision. Three (3) staff files were examined – they had all of the required documents in them including 2 written references, a criminal records bureau (CRB) check, application form, contract of employment and job description. The staff files are stored securely. In the Annual Quality Assurance Assessment the manager has stated that Aermid intend to implement a personal development plan for all staff. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced Registered Nurse. There is a formal quality assurance system in place. Personal money held by Aermid on behalf of Service Users is managed appropriately. The registered provider shows a responsible attitude toward promoting and protecting the health, safety and welfare of people living in the home. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager is a first level registered nurse with many years of experience. She has achieved a registered managers award. She is supported by assistant managers who are based in the residential unit and Compton gardens. The managers hold formal meetings for residents and relatives periodically to disseminate information about any changes that are taking place and to take any feedback or concerns. The manager said that formal and informal supervision of staff takes place and on the Annual Quality Assurance Assessment she stated that the managers and supervisors have’ attended training which has improved/ maintained their professional development and clinical practice’ and that over the next 12 months the centre intends to continue to develop staff ‘skills and knowledge’. The company has a robust quality assurance system. As part of this system audits are carried out on different areas monthly or weekly to ensure ongoing quality of the service provided. At the time of the inspection there is no regional manager in place but the centre manager is able to contact other people from Aermid if she needs advice or support. A representative from the company carries out monthly regulation 26 visits (monthly unannounced visits that the provider is required to carry out to ensure ongoing quality of the service offered). A copy of the report is sent to the Commission. There was a compliments and comments box seen on each unit during the tour of the centre for use by anybody. The centre has a team of maintenance people who maintain the gardens and carry out some work on the building. They also have responsibility for ongoing maintenance, checking water temperatures, checking fire alarms and fire safety equipment and general health and safety. Health and safety risk assessments/ audits are carried out regularly throughout the centre. The Annual Quality Assurance Assessment and documents examined during the inspection confirm that maintenance of equipment is carried out as required. The administrator manages the Service Users personal allowances, which are stored securely in the centre. The amounts held are checked weekly by her and receipts are kept for cross reference. There is an ongoing audit process to ensure safe management of peoples monies. The fire log - books and accident books examined and were up to date and completed as required. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 2 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 24 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. 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. Refer to Standard OP12 Good Practice Recommendations A centre the size of Bedford Park would benefit from their own mini bus to allow people choice about how often and where they go out instead of relying on a mini bus that has to be booked in advance and therefore planned. The programme of renewal of carpets in the corridors of Compton gardens should continue until all of them have been renewed. In order to provide a more suitable environment for people with dementia the provider should consider, especially in the residential unit: • • • More storage space in order that clutter can be removed from the unit. Better colours and signage to allow for better orientation within the unit. Provision of a sensory room or mobile sensory unit recommended by current guidance that can improve DS0000003573.V337015.R01.S.doc Version 5.2 Page 25 2. 3. OP19 OP22 Bedford Park Care Centre 4. OP26 the quality of life of some people with dementia. The hand flushing sluices in the residential unit and Compton Gardens should be replaced to reduce the risk of cross infection from splashing. Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Bedford Park Care Centre DS0000003573.V337015.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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