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Inspection on 05/10/05 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 5th October 2005.

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 individual units meet the needs of their client group but still work with manager to strive for a consistent approach to the service delivered. The environment in the units is homely and welcoming.

What has improved since the last inspection?

A housekeeper has been appointed to oversee the domestic activity within the centre. She is able to co-ordinate the work and carry out ongoing quality audits to ensure the centre is clean, tidy and hygienic at all times. A new care planning system has been introduced. It contains relevant information and is well presented. Many of the requirements and recommendations made following the last inspection have been met or are in the process of being achieved.

What the care home could do better:

Attention to detail when providing personal care to a resident. (Training in basic care issues is to be implemented in the near future). There are areas in all of the units where the carpets are worn and in need of replacement.

CARE HOMES FOR OLDER PEOPLE Bedford Park Care Centre Pearn Road Mannamead Plymouth PL3 5JF Lead Inspector Mandy Norton Unannounced 5 October 2005 th 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 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 D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bedford Park Care Centre Address Pearn Road, Mannamead, Plymouth, Devon, PL3 5JF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 770477 01752 785090 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 D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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 01.05.2005 Brief Description of the Service: Bedford Park Care Centre is comprised of three units; all are purpose built and comprise of two floors with wheelchair access via ramps or passenger lifts. The care centre is situated in the city of Plymouth.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 fishpond.The home is owned by Ancyra Health Limited, a national care home provider. Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. It took place over 3 hours ( 12midday – 3pm) and was conducted with the manager. The focus of the inspection was to look at the environment the clients live in and to assess if the requirements and recommendations from the previous inspection have been met. What the service does well: What has improved since the last inspection? What they could do better: Attention to detail when providing personal care to a resident. (Training in basic care issues is to be implemented in the near future). There are areas in all of the units where the carpets are worn and in need of replacement. Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 6 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 D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 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 standard(s) 3 and 4. Clear information and opportunities to visit the home are given to people to help them to decide if they want to live at Bedford Park Care Centre. EVIDENCE: The Service Users Guide states that a pre admission assessment, carried out by the matron/manager will be carried out prior to admission. The guide and the Statement of Purpose includes a lot of detail about the home and what people should expect if they move in. They are well presented and written in plain English. Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 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 standard(s) 7,8 and 10. The health care needs of the residents are generally identified and met. Interactions between staff and residents promotes and protects patients privacy and dignity. EVIDENCE: The care plans examined were all well presented (the home is using a new format), had generally been reviewed, contained appropriate risk assessments and set out in sufficient detail the actions to be taken by staff to ensure the needs of the patients are met. The staff try to encourage the residents to help draw up their care plans where this is possible. Following a recent complaint about poor attention to detail in one of the residential units all care staff are to undergo training/ retraining in basic care. The patients are all registered with a GP and have eye tests and dental checks as necessary. A tour of the home confirmed that equipment necessary for the promotion of tissue viability and prevention or treatment of pressure sores is available throughout the home and is in good condition. Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 10 A tour of the home confirmed that staff treat the residents with respect and dignity and interact with them appropriately. Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 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 standard(s) None of these standards were assessed during this inspection EVIDENCE: Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 12 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 standard(s) 16. The home has a satisfactory complaints system. EVIDENCE: The complaints procedure is clearly displayed within each unit of the centre and a copy is in the Service users Guide plus a sample complaints form. Discussing recent complaints with the matron/manager it is clear she follows the laid down procedures and will ensure any changes are implemented as a result of a substantiated complaint if necessary. Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19, 20,21,23, 24 25 and 26. The standard of the environment within the home and the grounds is good providing clients with attractive and homely place to live. The overall quality of the furniture and fittings is good providing a safe environment. The home is clean and hygienic. EVIDENCE: A tour of the home confirmed that all of the communal facilities and the gardens are accessible to clients. There is plenty of communal space within the units. The furniture and decoration in the communal areas is of good quality and domestic in character. The grounds are extensive and very well maintained. The patio area has a raised fish pond and flower beds. Individual rooms were decorated to make them look light and airy. Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 14 Clients rooms seen looked comfortable were clean and contained many of their own possessions. There are a variety of bathrooms and toilets throughout the units adapted to meet the needs of the clients. All rooms have en-suite facilities. Domestic staff were seen cleaning the units during the inspection. The home was clean and tidy. The housekeeper does the duty rota for the domestic staff (2 permanent and one relief for each unit) and allocates the work to be done on a daily basis. She is able to carry out internal quality assurance as she knows who has been responsible for which job during the day. Compton Unit - (residential unit for 26 people) - The 1st floor carpet is in need of replacement and some areas of the unit need repainting. The office was being decorated at the time of the inspection. The unit has 2 hoists, one on each floor. The bathroom carpet needs to be replaced (the manager said that this has already been requested as part of capital expenditure). There are 2 showers in the unit which are not used very often. Residential Unit – (this unit can take up to 39 clients with a degree of dementia) – The garden area is secured to ensure that the residents cannot wander away from the homes grounds. Some of the divan beds are being replaced in this unit in order that they are accessible to a hoist if required. The carpet on the 1st floor also needs to be replaced (this has also been requested by the manager). Nursing Unit – ( this unit can take up to 39 clients who have been assessed as requiring nursing care) – The unit also needs some carpeting replacing. This unit has the equipment required to deliver nursing care, but remains homely and comfortable. Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 and 30. Clients needs are met by a satisfactory mix of nurses, carers and ancillary staff who are trained and competent to do their job. EVIDENCE: The centre is managed by a matron /manager based in the nursing unit who is supported by 9 registered nurses and care staff. The residential units each have their own assistant manager who have a team of carers. Each unit does its own duty rota, this is overseen by the matron/ manager. Care staff can work in any unit depending on the level of need. The matron/manager is a level 1 nurse, has a registered managers award and has managed the home for 3 years. The Service User Guide has details of the staff and the qualifications they have or are working towards. The care staff are to undergo training / retraining in basic care to remind them to pay attention to detail which was an issue bought up in a recent complaint. The centre has a full time activities co-ordinator, 3 maintenance personnel, 1 part time and 1 full time administrator and catering staff employed to support the care staff in meeting the needs of the residents. The Service user Guide details all of the checks made on staff prior to employment. The matron / manager said that all of the staff files are being improved and will include all of the information required by the regulations plus a back to work interview form and a sickness record form. Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 16 Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32, 37 and 38. There is good leadership and guidance for staff to ensure residents receive consistent quality care. The systems in place in the home generally promote and protect the health and safety and welfare of the clients and staff. EVIDENCE: The registered manager is a first level nurse and has 3 years experience of managing the care centre. She has a registered managers award. She demonstrated a clear leadership style during the inspection and there are clear lines of accountability within the home. She works with the assistant managers to ensure clear communication and staff development are ongoing. Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 18 All records seen during the inspection were accurate, up to date and stored appropriately. All staff have statutory training in fire safety, first aid, health and safety and moving and handling, this is also detailed in the Service Users Guide. All of the units have their own accident book, the nursing unit one was examined during the inspection and information was recorded appropriately. Risk assessments are completed individually and reviewed regularly. A tour of the home confirmed that hazardous chemicals were stored correctly. Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 x x x x 3 3 Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 20 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. 1. 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 8 Good Practice Recommendations To implement, as planned, the basic care training for all care assisstants Bedford Park Care Centre D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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 © 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 D52-D04 S3573 Bedford Park V231756 051005 Stage 4.doc Version 1.40 Page 22 - 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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