Inspection on 27/11/06 for Bedwardine House

This inspection was carried out on 27th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bedwardine House 09/01/06

Bedwardine House 26/04/05

Bedwardine House 29/12/04

Bedwardine House 24/05/04

Bedwardine House 08/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bedwardine House Upper Wick Lane Rushwick Worcestershire WR2 5SU Lead Inspector N Andrews Unannounced Inspection 09:30 27 and 29 November 2006 th th 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 Bedwardine House DS0000018631.V317799.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. Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bedwardine House Address Upper Wick Lane Rushwick Worcestershire WR2 5SU 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) 01905 425101 01905 749723 Mrs Victoria Lavender Mrs Victoria Lavender Care Home 17 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (17), of places Physical disability over 65 years of age (17) Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There were no conditions of registration other than those referred to on the previous page of this report. Date of last inspection 9 January 2006 Brief Description of the Service: Bedwardine House is a large, Georgian detached building located in a semirural position and set in extensive grounds on the outskirts of Worcester. The home has an attractive front garden and there are car-parking facilities at both the front and rear of the premises. There is also ramped access at the front and at the rear of the premises. The home enjoys pleasant views over the surrounding countryside. The home provides personal care for a maximum of 17 older people who may also have a physical disability. Eight of the places are registered for older people with a dementia illness. The service users are accommodated on the ground and first floors of the building. The home lacked some essential facilities e.g. an office, a staff room and a passenger lift. However, there is a stair lift from the ground to the first floor. The home has 2 double bedrooms and 13 single bedrooms. None of the bedrooms have an en suite facility. The communal space consists of two lounges and a conservatory. The conservatory adjoins one of the lounges situated at the rear of the premises and is used as a dining room. At the time of the inspection the home had one vacant place. The fees ranged from £1340.00 to £1520.00 per month. Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place over the course of two days. The home was inspected against the key National Minimum Standards and time was spent with the registered provider assessing the home’s response to the requirements and recommendations that were made as a result of the previous inspection. Various records and a number of policies and procedures that the home is required to maintain were inspected. A tour of the premises was also made. Individual discussions were held with three service users, the relative of one service user and three members of staff. As part of the inspection Comment Cards were also issued to the relatives/visitors of service users and to visiting professionals. A total of 14 Comment Cards were completed and returned, 10 from relatives/visitors and 4 from visiting professionals. The majority of the comments contained in the Comment Cards were positive and are referred to throughout this report. What the service does well: What has improved since the last inspection? Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 6 The home’s quality assurance system had improved. The registered provider stated that, since the previous inspection, the bathroom on the first floor had been refurbished, bedroom 4 had been redecorated and a new carpet provided. It was also stated that the number of hours per week that the cleaner worked had been increased. 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. Bedwardine House DS0000018631.V317799.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 Bedwardine House DS0000018631.V317799.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 and 5. The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. Prospective service users had the opportunity to visit the home prior to admission and were provided with information to enable them to make a decision. Each prospective service user was assessed and subsequently provided with a written contract. EVIDENCE: A copy of the home’s statement of purpose was made available for inspection. The contents of the statement of purpose were satisfactory and it was pleasing to note that the document included details of the care and support offered to service users with a dementia illness. A requirement was made as a result of the previous inspection that the statement of purpose must be amended. The requirement had been implemented. However, the information outlining the fire precautions should be extended to include details of the associated emergency procedures e.g. the arrangements made for the care and accommodation of the service users in the event of a partial or temporary evacuation/closure of the home. The statement of purpose should be checked for typographical errors. A copy of the home’s service users’ guide was also made available for inspection. The registered provider stated that a copy of Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 9 the service users’ guide had been given to the service users’ and/or their relatives. A record should be kept to show that a copy of the service users’ guide has been given to all the service users and/or their relatives. The contents of the service users’ guide were satisfactory. It was pleasing to note that the document included details of the summary of the ‘Service Users’ Satisfaction Questionnaire’. However, the service users’ guide should include information about how to contact the local social services and health care authorities. The service users’ guide should also be reviewed in the light of the changes contained in the Care Homes Regulations 2001, as amended. It was confirmed that all of the service users had been issued with a statement of their terms and conditions of residence (contract) and that a copy of the contract was maintained in the home in respect of each individual service user. A copy of the contract was made available for inspection. The contents of the contract were satisfactory. The home’s fees were reviewed annually in April and the service users and/or their relatives were informed of the increased charges by letter. Copies of the letters of notification of the increased charges were held on file. The wording of the contracts had not changed fundamentally apart from the amendments that had been made in response to requirements arising from previous inspection reports. It was confirmed that the needs of all prospective service users were assessed prior to admission. The registered provider was normally responsible for carrying out the assessments and these took place in the service users’ home or at hospital, if that was appropriate/necessary. The assessment form contained a reference to all of the aspects of care listed in Standard 3.3. It was confirmed that prospective service users were invited to visit the home prior to admission. However, this did not always operate in practice, depending on the prospective service user’s individual circumstances. The service users with whom discussions were held confirmed that they had visited the home prior to admission. There was a trial period of four weeks following admission. The home did not normally accept emergency admissions. Bedwardine House DS0000018631.V317799.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 and 10. The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The service users felt that they were treated with dignity and respect. However, the care plans, risk assessments and medication procedures did not ensure that the service users’ health care needs were fully safeguarded or met. EVIDENCE: All of the service users had a care plan. The care plans were reviewed every month. A requirement was made as a result of the previous inspection that the care plans must be amended to include a reference to the service users’ religious and cultural needs and to carer and family involvement and other social contacts/relationships. The requirement had been implemented. The registered provider stated that the service users that lacked the mental capacity were not involved in discussions about their care needs. In some cases, the care plans stated what the service users’ needs were rather than how the needs should be met. For example, under ‘Mental State/Cognition’ one care plan stated ‘Can be forgetful at times’, rather than giving directions about the way in which the staff might help the service user to cope with his forgetfulness. The care plans did not always include specific directions or guidance for the staff to follow to ensure that all of the care needs of the service users were met. For example, in one case there was no reference to Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 11 the frequency of when the service user should be taken out for walks, checks on the service user’s skin condition or the application/use of a cream. The care plans did not always include the signature of the service user or their representative. The service users with whom discussions were held felt that their healthcare needs were being met. All of the service users were registered with local GPs surgeries. None of the service users had any pressure sores or required the use of pressure relieving mattresses or cushions at the present time. The district nurse had been appropriately asked to visit one service user who had a discharge on her heel. The continence adviser had visited the home recently to discuss the needs of several service users. The mental health of several service users was being appropriately monitored. It was stated that none of the service users required any special exercises or input from a physiotherapist. The service users were weighed every month and their weight was recorded. The chiropodist visited every six to eight weeks. The optician visited annually or more frequently if necessary. The dentist visited when required. It was noted with concern that risk assessments had not been carried out and recorded in respect of falls, nutrition or, in the case of two service users, the use of bed rails. It was also noted that service users were being transported in wheelchairs by staff without footrests being attached to the wheelchairs or used. An Immediate Requirement Notice was issued to the registered provider at the conclusion of the inspection in regard to these matters. The medication was kept in a lockable cupboard. All the staff knew the combination lock. The controlled drugs were not being kept in a controlled drug cabinet that complied with the Misuse of Drugs (Safe Custody) Regulations 1973. The home used the Nomad monitored dosage system. Two members of staff signed the record of the administration of controlled drugs. Two members of staff were not signing the Medication Administration Record (MAR) charts when the record of the medication is written on to the charts by hand. When the dosage prescribed is for one or two tablets the actual number of tablets that is administered should be recorded. It was noted that the record of administration contained one omission. A copy of the home’s policy and procedure for the administration of medication was made available for inspection. The policy was not as comprehensive or as detailed as it should be. For example, there were no specific details in the policy for the • ordering of prescriptions, • receipt of medication (i.e. where or what is recorded), • administration of medication, • disposal of medication (i.e. how, where and what is disposed), • action to be taken following an error in administration (including informing the CSCI in accordance with Regulation 37), • administration of controlled drugs. In addition, the policy was not dated or signed. It was confirmed that none of the current service users self-administered medication apart from one service Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 12 user that used an inhaler. The staff had undertaken a one-day training session on ‘Handling and Administration of Medication’ on 20 June 2006. However, the training was not accredited. The service users with whom discussions were held stated that they were treated with respect and that their privacy and dignity were upheld. The staff with whom discussions were held understood the importance of respecting the service users’ privacy and dignity. Their responses to the questions that were asked reflected good practice. The service users were able to see their relatives and friends in private. It was also confirmed that visiting professionals saw the service users in private. It was stated that mail was handed to the service users unopened or to their relatives if the service users were not able to manage it for themselves. The home had a cordless phone to enable the service users to make and receive calls in private. Two of the service users had their own telephone. The service users wore their own clothes at all times. However, the home kept a supply of essential items in case of an emergency. Any item used for this purpose automatically became the property of the same service user. The staff induction programme included a reference to respect for the service users’ privacy. The bedroom that was shared by two service users that were unrelated contained fixed screening i.e. curtains. Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 13 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 and 15 The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. The service users were satisfied with the range of social activities provided by the home and were able to maintain their contact with their relatives and friends. The service users were helped to exercise choice and control over their lives and were provided with wholesome food. EVIDENCE: The service users expressed their satisfaction with the range of social and leisure activities provided by the home. They also felt that the home responded in a flexible manner to their individual needs. The two recommendations that were made as a result of the previous inspection regarding the introduction of a written programme of social and recreational activities and quarterly service user meetings had been implemented. A list of proposed activities for the month was displayed on the notice board and service users were also informed verbally of the activities that had been arranged. Three service user meetings had been held since the previous inspection. There were no unnecessary restrictions in regard to visiting. The service users confirmed that their visitors were always offered a drink and made welcome and that they could see their visitors in private. The relative of one of the service users also stated that she was always made welcome when she visited Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 14 and offered a drink. The service users’ guide contained relevant information in regard to visiting. The service users confirmed that they were able to handle their own financial affairs, where possible, and to exercise choice in regard to daily living tasks. They also confirmed that they were able to bring personal possessions with them when they were admitted to the home. There was evidence to show that the service users had brought various items with them to personalise their bedrooms. The service users’ guide contained relevant information n regard to personal possessions. The service users’ guide also stated, ‘Service users have the right of access to their records and the information held about them by the home and the opportunity for them to help maintain their personal records’ and ‘Service users and their relatives and friends will be informed on request how to contact external agencies (e.g. advocates) who will act in their interests. The service users were generally satisfied with the standard of food provided. One service user said, ‘The food is better some days than others but if you don’t like it you can always have something else. The staff put the food up on a board. It’s always served well’. It was confirmed that meals could be eaten in the service users’ bedrooms. However, the service users were encouraged to eat in the dining room. The record of the food that was maintained by the home was balanced and wholesome and the meal that was observed being served during the inspection was attractively presented. The staff were also observed offering help in a discreet manner to the service users that required assistance. Service users that had difficulty with eating were provided with the necessary aids. Mealtimes were evenly spaced throughout the day and drinks were also served mid-morning and mid-afternoon. It was stated that a drink and snack was provided at 7:00 pm and 9:00 pm. The service users were given a choice of food for breakfast and tea. Only one main meal was provided at lunchtime. However, an alternative meal was provided to any service user if they did not like the food that was being offered. One service user was in receipt of a glutton-free diet. The registered provider stated that none of the service users had difficulty swallowing but six service users had their food cut into small pieces. It was confirmed that a member of staff was always present at meal times. The service users confirmed that meal times were unhurried. The conservatory was used as the dining room and provided a pleasant environment in which to eat. Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 15 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 and 18 The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. The service users felt confident about making complaints. However, the lack of relevant training for the registered provider and the absence of evidence to show that all the staff had read and understood the home’s policies on the protection of vulnerable adults from abuse did not fully ensure the safety of the service users. EVIDENCE: The home had a satisfactory complaints procedure. The complaints procedure was referred to in the service users’ guide and in the statement of purpose. A copy of the complaints procedure was also displayed in the main hallway near to the front entrance. A framed notice was also displayed on the table in the main hallway informing visitors of the availability, on request, of various documents including the complaints procedure. No complaints had been received by the home since the previous inspection. The recommendation that was made as a result of the previous inspection regarding an amendment to the complaints procedure had been implemented. The service users said that they felt confident about making a complaint and that, if they did, it would be dealt with quickly and appropriately. However, the comment cards from six of the service users’ relatives/visitors indicated that they were not aware of the home’s complaints procedure. Three of the service users’ relatives/visitors also indicated that they did not have access to a copy of the inspection reports on the home. The home had a satisfactory policy and procedure for the protection of vulnerable adults. The registered provider stated that she had issued a copy of the booklet ‘Reporting abuse or mistreatment of vulnerable adults – guidance Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 16 for staff’ produced by the Worcestershire Vulnerable Adults Protection Committee to all members of staff. The registered provider confirmed that no incidents of alleged or suspected abuse had occurred within the home or had otherwise come to her attention since the previous inspection. The registered manager also confirmed that she had had no reason to refer any member or former member of staff for consideration for inclusion on the POVA register. It was stated that all of the staff had undertaken training on abuse awareness during 2005. The deputy manager and the senior care assistant had undertaken training in the protection of vulnerable adults from abuse on 1 February 2006. The registered provider must also undertake similar training at this higher level. The home had a whistle blowing policy that was amended during the inspection in order to include a correct reference to the CSCI and a reference to the Public Interest Disclosure Act 1998. The home also had a policy regarding the service users’ money and financial affairs and a policy to help staff deal appropriately with service users’ aggression. However, the policies on the protection of service users had not been signed or dated by the registered provider and there was no evidence to show that the staff had read and understood the policies. Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 17 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 and 26. The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The service users lived in clean, comfortable and homely surroundings. However, some aspects of the environment required attention in order to ensure the wellbeing of the service users. EVIDENCE: The location of the home was suitable for its stated purpose. The home was on a level site with ramped access at both the front and rear of the premises. The home was safe, well maintained and comfortably furnished. The grounds were tidy and attractive. A record was kept of the work that was carried out in each room to maintain the fabric and decoration of the premises. This record should include the items of work that the registered provider plans to undertake to improve the premises in the future. However, the home did not have a passenger lift, an office or adequate staff facilities. In addition, none of the bedrooms had en suite facilities. The registered provider was aware of these deficiencies and intended to address them by the provision of a proposed extension within the next twelve months. A letter from the Fire Safety Officer dated 16 June 2006 confirmed that all of the issues relating to the fire Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 18 precautions for the newly built conservatory had been satisfactorily addressed. The home had undergone a food hygiene and health and safety inspection by Malvern Hills District Council on 8 June 2006. As a result of the inspection the home had received a Food Guard Award that was valid for one year. It was noted that one new member of food handling staff would benefit from training. The registered manager subsequently confirmed that the member of staff had undertaken training in food hygiene and handling on a ‘Skills for Care Foundation’ course on 12 April 2006. It was also confirmed that the member of staff had been placed on an appropriate course to be held on 23 January 2007. It was noted that a cleaning schedule should be provided. Standard 20 was not fully assessed during this inspection. However, it was pleasing to note that the requirement that was made as a result of the previous inspection that the portable heater in the conservatory must be removed and replaced with a fixed heater and air conditioning system had been implemented. Standard 22 was not fully assessed during this inspection. However, the home’s response to the requirement and recommendation that were made as a result of the previous inspection was assessed. The requirement concerned the provision of suitable handrails on the outside wall on both sides of the door at the rear of the premises. The recommendation was that the advice of a qualified occupational therapist should be sought to ensure that the home provides all of the recommended disability equipment and environmental adaptations to meet the needs of the service users. It was pleasing to note that both the requirement and recommendation had been implemented. The home was clean and tidy and there were no unpleasant odours. The bedrooms were well maintained and personalised. However, the doors of the vanity unit in bedroom 13 were damaged and in need of replacement. The registered manager subsequently confirmed that this item of work had been placed on the programme of routine maintenance and renewal and would be addressed in February 2007. The home had a satisfactory policy and procedure on infection control. It was confirmed that the recommendation that was made as a result of the previous inspection to amend the policy on infection control had been implemented. The laundry was appropriately sited and contained a wash hand basin, two tumble dryers and two washing machines, one of which had a sluice facility. However, it was noted that one of the laundry walls was affected by damp and the plaster and paintwork were in need of attention. It was also noted that one shower room and toilet and a separate toilet facility on the first floor did not have a liquid soap and paper towel dispenser. The service users with whom discussions were held stated that the home was kept clean. They said that they were pleased with the standard of cleanliness of their bedrooms and their personal clothing. The relative of one service user stated that the home was always clean and that the service users ‘always looked well groomed’. Bedwardine House DS0000018631.V317799.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 and 30. The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The service users’ needs were being met by staff that were competent and in receipt of appropriate training. However, the staff recruitment procedures did not fully protect the service users. EVIDENCE: A copy of the staff rota for a two-week period was made available for inspection. The rota indicated that the home was adequately staffed. However, it was noted with concern that one member of staff had had only one day off in fourteen days. In addition to the registered provider, the home employed a deputy manager for 38 hours per week, a senior care assistant for 36 hours per week and seven care assistants for a total of 206 hours per week (days). Two cooks were employed, one of whom also carried out caring and cleaning duties. At night there was one member of staff on waking duty, supported by a member of staff, usually the registered provider, on sleeping-in duty in the premises at the rear of the care home. The registered provider was aware that, in the event of the number of service users for which the home is registered being increased as a result of the proposed extension, the staffing levels would have to increase proportionately. The increase in staff would have to include the provision of two waking staff on duty at night. The husband of the registered provider carried out maintenance work and gardening and was also involved in social activities and in chairing the service users’ meetings and staff meetings. The service users with whom discussions were held expressed mainly positive comments about the staff. One service user stated, ‘On the whole they’re excellent’. One service user felt that Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 20 sometimes there were not always enough staff on duty but said, ‘They seem to get through the work alright’. The relative of one service user said that she had formed a positive impression of the attitude of the staff. The relative stated, ‘I’ve never seen anyone needing help and not being attended to’. The comment card from one visiting professional included the statement, ‘The standard of care and accommodation has always been first class. There has always been a good level of communication with the manager’. The comment cards from relatives/visitors included the following comments, ‘The standard of care is universally excellent and consistent, friendly yet professional’, ‘I consider Bedwardine House to be a very good home. My relative is well looked after and is pleased to be a resident there’. ‘Bedwardine House provides excellent care’. ‘The manager and staff are always very pleasant and my friends are extremely happy in Bedwardine House. They are always clean and well cared for and seem to receive the best attention. I’m very impressed with the care they receive’. ‘The residents speak very highly of the staff and the care they receive and everyone is made very welcome, a lovely clean and caring place’. ‘The staff seem approachable’. ‘Since being at the home my father’s health and general contentment has improved noticeably. I put this down to the very personal care and attention he is given’. ‘I am very pleased with the care my mother receives and she is very happy there’. The home employed a total of twelve permanent day and night staff, including the deputy manager and senior care assistant, all of whom were involved in the provision of personal care. The deputy manager had undertaken NVQ level 3 training and six of the other staff had undertaken NVQ level 2 training. Therefore, a total of seven of the twelve members of staff currently employed by the home had completed the NVQ level 2 training or above. This exceeds the target of 50 of the number of care staff with NVQ level 2 as laid down in the National Minimum Standards. The files of the two most recently appointed members of staff were inspected. The file in respect of one member of staff contained all of the information that was required. However, it was noted with concern that the file in respect of the second member of staff did not contain a POVAfirst check or a valid CRB disclosure. An Immediate Requirement Notice was issued to the registered provider at the conclusion of the inspection in regard to this matter. In addition, a reference had not been sought from the person’s most recent employer. A reference from the person’s most recent employer would have been particularly relevant as it was a registered care home provider. The registered manager subsequently confirmed that references from other sources had already been obtained in respect of the employee. There was evidence to show that one member of staff had undertaken the induction and foundation training provided by Abacus. The registered provider was advised that, if any member of staff that is employed to carry out cleaning duties subsequently transfers to working as a care assistant, s/he must undertake formal induction training. There was evidence to show that the staff Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 21 received a minimum of three paid days training per year. A requirement was made a s a result of the previous inspection that all staff must have individual training and development assessments and profiles. It was confirmed that individual lists of all the training that was undertaken by all the staff was maintained including the dates of completion. It was also confirmed that staff training needs were discussed in supervision. The requirement was regarded as having been implemented. Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 22 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, 33, 35 and 38. The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The home had a competent and experienced manager and was being run in the best interests of the service users. However, the systems for monitoring and maintaining the quality of the service did not fully promote the service users’ safety and welfare. EVIDENCE: The registered provider, who was also the manager of the home, was both competent and experienced. She had obtained the NVQ level 4 Registered Managers (Adults) certificate dated May 2006. She had also undertaken training in a number of core areas. Since the previous inspection the registered provider had completed training in dementia awareness on 14 March 2006, handling and administration of medication and infection control on 20 June 2006, moving and handling on 24 July 2006 and fire awareness on 31 October 2006. A requirement and recommendation were made as a result of the previous inspection. The requirement was that all the staff, including the Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 23 registered provider, must undertake appropriate training in the care of people with a dementia illness. The recommendation was that a copy of the registered provider’s job description should be kept in the home and made available for inspection at all times. It was pleasing to note that both the requirement and the recommendation had been implemented. The service users with whom discussions were held spoke highly of the registered provider and described her as ‘very kind’. The relative of one service user also felt that the registered provider was approachable. Standard 32 was not fully assessed during this inspection. However, the home’s response to the two recommendations that were made in regard to Standard 32 as a result of the previous inspection was assessed. The first recommendation was that staff meetings should be held at least every three months. It was noted that, since the previous inspection, two staff meetings had been held on 21 April and 31 July 2006, respectively. A third staff meeting was due to be held the first week in December 2006. The first recommendation was, therefore, regarded as having been implemented. The second recommendation was that evidence should be provided to show that management planning and practice encourage innovation, creativity and development. The two practical examples provided by the registered provider were not sufficient to demonstrate that the second recommendation had been implemented. Two requirements and two recommendations were made in regard to Standard 33 as a result of the previous inspection. The first requirement concerned the introduction of an annual development plan for the home, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. A copy of the home’s annual development plan was made available for inspection. It was pleasing to note the positive efforts that had been made by the home to maintain and improve the quality of the service. The plan included details of the social activities for service users, staff training and proposed improvements to the accommodation. However, the format of the plan should provide more information about the outcomes for service users. The second requirement was that a quality assurance system must be introduced. The registered provider produced a file that contained a number of letters of thanks and commendation mainly from relatives of service users expressing their gratitude for the care provided by the home. A quality assurance audit form covering catering, housekeeping, care, administration and activities was also made available for inspection. The registered provider, deputy manager and senior care assistant had used the form to carry out audits in January, February and April 2006. However, these documents were not sufficient evidence to show that the requirement had been fully implemented. The first recommendation was that the results of service user surveys should be made available to current and prospective service users, their representatives and other interested parties including the CSCI. It was pleasing to note that the home had issued questionnaires to the service users’ visitors and to the service users in May and September 2006, respectively. Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 24 The responses to the questionnaires had been collated and a summary of the results produced in a clear and simple format. The results of the visitors’ questionnaires had been placed in a folder on the table in the main hallway. The results of the service users’ questionnaires had been referred to indirectly in a framed notice on the same table and, more specifically, in the service users’ guide. The registered provider was advised to make the results of the questionnaires more widely known. The second recommendation that the home should be able to demonstrate a commitment to lifelong learning and development for each service user linked to the implementation of their individual care plans had not been implemented. Standard 34 was not fully assessed during this inspection. However, the home’s response to the recommendation that was made in regard to Standard 34 as a result of the previous inspection was assessed. The recommendation was that a business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. The registered provider made various documents that were associated with the home’s finances available for inspection. However, these did not constitute a business and financial plan. Therefore, the recommendation had not been implemented and still stands. It was confirmed that money was held in safekeeping on behalf of fourteen service users. The service users’ money was kept separately in individual plastic wallets in a lockable box in a lockable cupboard. All of the members of staff had access to the cupboard. The registered provider did not feel that there was any need to improve security by restricting access. A separate account of the money held on behalf of each service user was maintained. A check was carried out of the money that was held in respect of two service users. The money and the accounts agreed. It was confirmed that no one connected with the running of the home acted as an agent or appointee on behalf of any of the service users. The registered provider confirmed that no valuables or other personal possessions were kept on behalf of any of the service users. One requirement and one recommendation were made in regard to Standard 38 as a result of the previous inspection. The requirement was that all of the risk assessments that have been carried out and recorded for all the safe working practice topics covered in Standard 38.2 and 38.3 must be reviewed at least every twelve months. The risk assessments had been reviewed on 10 January 2006. The requirement had been implemented. The recommendation was that the service users that have had an accident should be asked to sign and date the accident report in the Accident Book, wherever possible. The registered provider stated that the recommendation had been implemented wherever possible but that it had been difficult to implement the recommendation in the majority of cases. The fire safety records were checked and these were up to date. Since the previous inspection the CSCI had not been notified of any serious incidents or events in accordance with Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 25 Regulation 37. This was despite the fact that two service users had died and a number of service users had had falls, at least one of which had resulted in a visit to hospital. A copy of an appropriate form for reporting incidents to the CSCI in accordance with Regulation 37 was forwarded to the home following the inspection. It was noted that one member of staff had not undertaken any training in the care of people with a dementia illness or abuse awareness. Another member of staff had not undertaken any training in infection control or food hygiene. Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 26 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 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 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 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The care plans must set out in detail the action that should be taken by the staff to ensure that all aspects of the service users’ needs are met. Risk assessments must be carried out and recorded for all service users in respect of falls and nutrition. Risk assessments must be carried out and recorded for two service users regarding the use of bed rails. Footrests must be used whenever service users are transported in wheelchairs by staff. When the medication prescribed is for one or two tablets the actual number of tablets that is administered must be recorded. An accurate record of all the medication that is administered must be maintained at all times. The policy and procedure for the administration of medication must be amended in accordance with ‘The Administration and Control of Medicines in Care DS0000018631.V317799.R01.S.doc Timescale for action 31/01/07 2 OP8 13 29/11/06 3 OP8 13 29/11/06 4 OP8 13 29/11/06 5 OP9 13 15/12/06 6 7 OP9 OP9 13 13 15/12/06 31/01/07 Bedwardine House Version 5.2 Page 28 8 OP9 13 9 OP18 10 10 OP18 17 11 OP18 18 12 13 14 OP26 OP26 OP26 23 23 12,13 15 OP29 19 16 OP29 19 Homes and Children’s Services’ published by the Royal Pharmaceutical Society of Great Britain in June 2003 and the guidance given in this report. All staff that are involved in the administration of medication must undertake accredited training that includes basic knowledge of how medicines are used and how to recognise and deal with problems in use and the principles behind all aspects of the home’s policy on medicines handling and records. The registered provider must undertake training at an appropriate level in the protection of vulnerable adults from abuse. All of the home’s policies and procedures, including those on the protection of vulnerable adults from abuse, must be signed and dated by the registered provider and reviewed at least once a year. Written confirmation must be provided to show that all of the staff have read and understood all of the home’s policies and procedures. The vanity unit doors in bedroom 13 must be replaced. The wall in the laundry affected by damp must be made good. Liquid soap and paper towel dispensers must be provided in close proximity to all communal wash hand facilities. A POVAfirst check and an application for an enhanced CRB check must be carried out in respect of one member of staff. Disclosure checks from the Criminal Records Bureau must be obtained for all new staff before their appointments are DS0000018631.V317799.R01.S.doc 28/02/07 28/02/07 28/02/07 28/02/07 28/02/07 31/01/07 31/12/06 29/11/06 15/12/06 Bedwardine House Version 5.2 Page 29 17 OP29 19 18 OP33 19 19 OP38 37 20 OP38 18 confirmed. Two relevant written references must be obtained before appointing any member of staff and any gaps in employment records must be explored. A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 28/02/06 not met). Any serious incident or event that occurs in the home must be reported to the CSCI without delay in accordance with Regulation 37. Arrangements must be made for staff to receive training in all of the core areas as outlined in this report. 15/12/06 28/02/07 15/12/06 28/02/07 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 OP1 Good Practice Recommendations The information in the statement of purpose regarding the home’s fire precautions should include details of the associated emergency procedures in accordance with the guidance given in this report. Evidence should be maintained on each service user’s file to show that they have been issued with a service users’ guide. The service users’ guide should include information about how to contact the local social services and health care authorities and be revised, where necessary, in the light of the changes contained in the Care Homes Regulations 2001, as amended. A metal cabinet that complies with the Misuse of Drugs (Safe Custody) Regulations 1973 should be provided for the storage and safekeeping of controlled drugs. DS0000018631.V317799.R01.S.doc Version 5.2 Page 30 2 3 OP1 OP1 4 OP9 Bedwardine House 5 6 7 OP9 OP19 OP31 8 9 10 OP32 OP33 OP33 11 12 13 OP33 OP34 OP35 When medication is written on to the MAR charts by hand it should be checked and signed for as being correct by two members of staff. A cleaning schedule should be provided for the kitchen. The registered manager should ensure that the training that she undertakes is at a level appropriate to the role of a registered manager and extends beyond a basic awareness. Evidence should be provided to show that management planning and practice encourage innovation, creativity and development. The format of the home’s annual development plan should be reviewed in order to provide a clear reflection of the aims and outcomes for service users. Current and prospective service users, their representatives and other interested parties should be informed of the results of service user surveys and visitor surveys. The home should be able to demonstrate a commitment to lifelong learning and development for each service user linked to implementation of their individual care plans. A business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. The registered provider should give consideration to improving the arrangements for ensuring the security of the service users’ money. Bedwardine House DS0000018631.V317799.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Bedwardine House DS0000018631.V317799.R01.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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