Inspection on 09/01/06 for Bedwardine House

This inspection was carried out on 9th January 2006.

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

The inspector 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 27/11/06

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 9th January 2006 09:25 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.V276874.R01.S.doc Version 5.1 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.V276874.R01.S.doc Version 5.1 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.V276874.R01.S.doc Version 5.1 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 26th April 2005 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 ramped access at the front entrance. 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. Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine inspection that took place over the course of one day. Service users’ records, staff records and other relevant policies and procedures were inspected. Parts of the premises were also inspected. Individual discussions were held with five service users and two members of staff. Time was also spent with the registered manager assessing the progress made by the home in implementing the requirements and recommendations arising from the previous inspection. The service users with whom discussions were held were asked about the standard of food. They described the food as ‘good’ and ‘very good’. One service user said, ‘No grumbles, the food is generally very good but some days it’s better than others. I’m quite happy, we’re fed well’. The service users all spoke positively about the staff and the care that they received. They said ‘The staff are very kind’, ‘The staff don’t take advantage of you’, ‘The staff are very understanding, I can’t find any fault there at all’ and ‘The staff treat me well’. The service users also expressed their confidence about raising any concerns or complaints if necessary. They also said that they felt sure that any complaints would be dealt with quickly and appropriately. Four of the service users confirmed that the staff always knocked the door before entering their bedrooms. One service user said that visitors were always made welcome. The service users said that they enjoyed knitting, reading books and the newspaper and watching television. One service user said that the hairdresser visited the home every week. Three of the service users commented on how much they had enjoyed Christmas. Two service users felt that more social activities could be provided. Two service users said, ‘I’m quite happy here’ and one service user said, ‘I wouldn’t change anything’. The two members of staff with whom discussions were held had worked at the home for a number of years. They both felt that the new conservatory had enhanced the facilities provided by the home. However, it was acknowledged that the heating and the air conditioning in the conservatory needed to be improved. One member of staff commented in particular on the friendly atmosphere in the home and said that the staff worked well together as a team. Reference was also made to the caring attitude of the registered provider and the staff. The other staff member said that the service users were well looked after ‘in terms of their personal care’ and that the food was good. The social and recreational activities provided for the service users were discussed. It was stated that ‘sunshine girls’ had visited the home on two occasions before Christmas to sell items from a mobile shop. A similar event was planned for Easter. A visit to the Evesham Wildlife Centre had taken place in the autumn. A New Year’s party had been held and reference was made to the woollen squares that the service users were knitting. One member of staff stated that she had been given specific responsibility for organising activities Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 6 for the service users for two hours every Tuesday and Thursday. She said that she took some of the service users for short walks and that they all enjoyed having manicures. Both members of staff acknowledged that the range of social activities could be improved by having a planned programme. One member of staff confirmed that the CSCI inspection reports on the home were discussed with the staff. It was also stated that the home received good verbal feedback from outside agencies about the service provided. One member of staff said that the staffing levels were adequate. The other member of staff said that she would welcome more time to talk individually to the service users. The home continues to make steady progress towards meeting the National Minimum Standards. During this inspection the home was inspected against fifteen of the National Minimum Standards. One of the fifteen Standards was exceeded, eight of the Standards were met, five Standards were nearly met and one Standard was not met. It was pleasing to note that the number of requirements had fallen since the last inspection from 21 to 9. However, the number of recommendations had risen from 6 to 12. What the service does well: What has improved since the last inspection? What they could do better: Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 7 The home’s statement of purpose and service users’ guide and the service users’ care plans were in need of improvement. The range of social and recreational activities should be increased and the home’s risk assessments needed to be reviewed at least every twelve months. The registered manager felt that the home could provide a clearer annual development plan, better quality assurance monitoring and more frequent staff meetings and service user meetings. 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. Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 8 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.V276874.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Sufficient information was available to enable prospective service users to make an informed choice about admission to the home. However, both the statement of purpose and the service users’ guide needed to be amended. EVIDENCE: The home’s response to the requirement that was made in regard to Standard 1 as a result of the previous inspection was assessed. The requirement was that the statement of purpose must be amended so that it includes the size of all the communal rooms i.e. shared space, and the number and location of all the toilets, baths and assisted showers. A copy of the home’s statement of purpose was made available for inspection. The requirement had been implemented. However, it was noted that the number of service users for which the home was registered referred to in the statement of purpose was 16. The statement of purpose also referred to the number of service users with a dementia illness for which the home was registered as 6. Following the changes to the premises that had taken place since the previous inspection and the variation in the conditions of registration these details were out of date. The numbers should be amended to 17 and 8 respectively. A copy of the home’s service users’ guide was also made available for inspection. Some of the information contained in the service users’ guide also Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 10 needed to be updated. For example, the service users’ guide referred to the number of staff that would have achieved NVQ level 2and 3 by ‘the end of 2004’. There was also a reference to the registered provider ‘working towards NVQ level 4’ and an incorrect reference to the number of service users for which the home was registered (as already referred to above in regard to the statement of purpose). The service users’ guide also contained part of the previous CSCI inspection report. The service users’ guide should either contain a copy of the whole of the previous report or a statement to the effect that a copy of the most recent CSCI inspection report is available for perusal on request to the registered provider. The attention of the registered provider is drawn to the statement regarding copyright that is printed on page two of the inspection report. The statement of purpose and service users’ guide must be reviewed and amended, where necessary, in accordance with the above guidance. The home’s response to the requirement that was made in regard to Standard 3 as a result of the previous inspection was assessed. The requirement was that a risk assessment must be carried out and recorded in respect of each service user in order to identify and, so far as possible, eliminate any risk of falls. The registered provider confirmed that a risk assessment had been carried out in respect of all the service users using a form headed ‘A Resident Handling Assessment’. Copies of the risk assessment forms were made available for inspection. The requirement had been implemented. Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10 All of the service users had a care plan. However, the care plans needed to be amended. The service users felt that they were treated with respect and that their right to privacy was upheld. EVIDENCE: The home’s response to the two requirements that were made in regard to Standard 7 as a result of the previous inspection was assessed. The first requirement was that all service user plans must contain clear, specific and detailed guidance to staff for the safe delivery of care. Copies of the service users’ care plans were made available for inspection. It was noted that the care plans still contained descriptions of the service users’ care needs. However, they also included more specific instructions for the staff. The requirement had, therefore, been implemented. Nevertheless, the registered provider must continue to set out in detail in the care plans the action which needs to be taken by the staff in order to ensure that all of the service users’ care needs are met. The second requirement was that the home’s care plan must include a specific reference to dietary preferences in accordance with the requirements of Regulation 14 and Standards 3 and 7. The care plans of three service users were inspected. The care plans contained information regarding food and dietary preferences and a referral to the ‘food request list’ that was kept in the kitchen. The ‘food request list’ contained a record of all the service Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 12 users’ dietary preferences. The requirement had been implemented. During the examination of the care plans it was also noted that the service users were weighed at the end of every month and that a separate record of their weight was maintained. A separate record of the service users’ medication was also kept. However, there was no section in the care plans to enable any instructions to be recorded regarding the action to be taken by staff to ensure that the service users’ religious and cultural needs were met. Similarly, there was no section that would enable any instructions to be recorded of the action to be taken by the staff to ensure that the service users were supported in regard to carer and family involvement and other social contacts/relationships. The care plans must be amended to include these two important aspects of care. The home’s response to the two requirements that were made in regard to Standard 8 as a result of the previous inspection was assessed. The first requirement was that the service users’ physical and psychological health must be monitored, recorded in their care plan and preventive and restorative care provided. Evidence was made available to show that this requirement had been implemented. The second requirement was that opportunities must be provided for service users to receive appropriate exercise and physical activity. The registered manager confirmed that one of the staff had been placed on the duty roster twice a week (every Tuesday and Thursday) specifically to encourage the service users to take part in physical exercises. The activity included taking some of the service users for walks outside. The requirement was, therefore, regarded as having been implemented. The registered manager confirmed that the practices outlined in Standard 10 to ensure that the service users’ privacy and dignity were respected at all times were adhered to by the home. Three service users, including a married couple, had their own telephone. A telephone with large numbers was available for use in the main hall. A mobile handset was also available for service users to make and receive calls in private. The home had two double bedrooms one of which was shared by a married couple. The other double bedroom had fixed screening. Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14 The service users were provided with different social and recreational activities. However, the range of activities needed to be increased. The service users were enabled to maintain contact with their relatives and friends and to exercise choice over their own lives. EVIDENCE: The registered manager stated that a mobile library visited the home. The service users enjoyed listening to music, watching television, knitting, crosswords, and playing cards and Bingo. An organist visited the home once a month. It was also stated that the service users enjoyed playing croquet on the front lawn in the warmer weather. Some of the service users had been on an outing to Evesham in 2005 that was organised by young people. The service users said that they had enjoyed a Christmas lunch in a local pub. A visit to the theatre in Malvern was planned for January 2006. The registered manager stated that a record of activities was kept by the home but the practice of maintaining it had lapsed. Two of the service users with whom discussions were held felt that the range of social and recreational activities provided by the home could be increased. The registered manager was advised to develop, perhaps as part of the annual development plan, a programme that included a range of activities for the coming year. The programme could include activities linked to special occasions e.g. Easter and Christmas, and also weekly activities as well as outings for pub lunches and to garden centres and other places of interest, reminiscence, art and craft, Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 14 shopping trips etc. A record of the activities should be kept with the dates and names of those who participated. The service users were provided with a choice of food. The service users could eat their meals in their bedrooms if they so wished. The local vicar visited the home once a month to hold a Communion service for approximately seven service users. One of the service users received a visit from members of the local Roman Catholic Church every month. Two of the service users visited Worcester Cathedral occasionally. No specialised activities were provided for the service users with a dementia illness. The registered manager said that they were encouraged to take part in drawing and painting activities at times. Information regarding the activities that were provided was placed on the notice board. In addition, it was stated that any activities that were planned were discussed with the service users in their meetings and that they were also informed individually. The service users’ meetings were held approximately every six months i.e. the last two meetings were held on 27 May and 2 November 2005, respectively. Service user meetings should be held more frequently i.e. at least once a quarter. There were no unnecessary restrictions on visiting. The service users’ relatives and friends were able to visit at any reasonable time. The service users were able to receive their visitors in private and to exercise their choice in regard to the people they saw and did not see. The service users’ guide stated, ‘Friends and relatives are welcome to visit at any time on any day’ and ‘Visitors will be welcomed at all reasonable times’. The service users’ guide also stated, ‘Service users’ family, relatives and friends are encouraged to visit the service users regularly and maintain contact by letter or telephone when visiting is not possible. In these cases, staff will offer to assist the service user to respond where help may be needed’. The service users’ guide also stated, ‘The service user has the right to refuse to see any visitor and this right will be respected’. The service users were helped to exercise choice over their own lives. None of the staff and no one connected with the running of the home acted as an agent or appointee on behalf of any of the service users. However, the home handled the personal allowances in respect of fourteen service users whose money was given to the home for safekeeping. Service users were entitled to bring personal possessions, including small items of furniture, with them when they were admitted to the home. There was an appropriate reference to this issue and to the service users’ right of access to the records held about them by the home and to the local advocacy service in the service users’ guide. Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/A It was not possible to form an overall judgement as none of the Standards in this section of the report were full assessed. EVIDENCE: It was noted that the home’s complaints procedure still referred to the former NCSC. The reference to the NCSC is now out of date and should be deleted and replaced by a reference to the CSCI. The home’s response to the requirement that was made in regard to Standard 18 as a result of the previous inspection was assessed. The requirement was that all the staff must undertake training in the protection of vulnerable adults from abuse. The registered provider confirmed that most of the staff had undertaken training on 6 July 2005 arranged by Abacus Care called ‘Abuse and Challenging Behaviour’. Two members of staff i.e. the deputy manager and senior care assistant, who were unable to undertake the training will undertake adult protection training on 1 February 2006 arranged by ACT. The registered manager stated that she had undertaken the above training and ‘Abuse Awareness’ training organised by Age Care Training on 4 March 2005. The requirement was regarded as having been implemented. Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The service users lived in a clean and pleasant environment. EVIDENCE: The home’s response to the five requirements that were made in regard to Standard 20 as a result of the previous inspection was assessed. The first requirement was that written evidence must be provided to show that the new conservatory meets with the approval of the Fire Safety Officer. The requirement had been implemented. The second requirement was that the portable heater must be removed from the conservatory and fixed heaters/radiators and an air conditioning system provided that meet with the approval of the Fire Safety Officer. The requirement had not been implemented and still stands. The registered provider stated that the current heater would be removed and replaced by a wall-mounted heater/air conditioning system by the end of March 2006. The third requirement was that a suitable ramp with fixed handrails leading from the door of the conservatory to the rear patio must be provided. The requirement had been implemented. The fourth requirement was that written confirmation must be provided to show that the conservatory meets all of the Council’s Building Control Regulations appropriate to the conservatory’s proposed use as a dining Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 17 room. The requirement had been implemented. The fifth requirement was that an amended copy of the home’s fire risk assessment that takes account of the provision of the conservatory and evidence to show that the revised fire risk assessment meets with the approval of the Fire Safety Officer must be provided. The requirement had been implemented. The home’s response to the two requirements and one recommendation that were made in regard to Standard 22 as a result of the previous inspection was assessed. The first requirement was that egress from the home to the outdoor space must be made safe for the service users in wheelchairs and those with mobility problems by the provision of a ramp at the rear of the premises in accordance with Regulation 23 and Standard 22. This requirement had not been implemented. However, the provision of a ramp leading from the conservatory (as outlined above) was considered to be sufficient to provide a safe means of egress from the home at the rear of the premises for service users in wheelchairs and those with mobility problems. This requirement, therefore, has been deleted. The second requirement was that suitable handrails must be fitted to the outside wall on either side of the door at the rear of the premises for the safety of the service users. A handrail had been fitted to the outside wall on one side of the door only. Therefore, the requirement had not been fully implemented and still stands. The recommendation was that the advice of a qualified occupational therapist should be sought in order to ensure that the home provides all of the recommended disability equipment and environmental adaptations to meet the needs of the service users. The recommendation had not been implemented and still stands. The registered provider was subsequently provided with information to enable her to implement this recommendation. The premises were clean and free from unpleasant odours. The laundry facilities were appropriately sited on the first floor. The laundry contained hand-washing facilities. The laundry floor was impermeable and the floor and wall finishes were readily cleanable. The registered provider confirmed that the washing machine had a sluicing facility and that soiled items were washed at appropriate temperatures. The home had a policy and procedure on infection control. However, the home did not have a copy of the ‘Guidelines for Infection Control in Care Homes (2003) produced by Herefordshire and Worcestershire Local Health Protection Unit. A copy of the Guidelines was subsequently sent to the registered provider to enable her to review the home’s policy and procedure on infection control. Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 The staffing levels were adequate. The level of NVQ training exceeded the National Minimum Standard and other training opportunities in core areas were provided to ensure that the staff were competent to do their jobs. EVIDENCE: The level of staff turnover since the previous inspection had been minimal. One member of staff had left and a new member of staff had been appointed. In addition to the registered provider, who was also the manager, the home employed a deputy manager who worked 37 hours per week, a senior care assistant who worked 36 hours per week and seven care assistants who worked a total of 187.5 hours per week. Two of the care assistants also worked as night care assistants together with another member of staff who was employed specifically as a night care assistant. A cook was employed for 30 hours per week. One of the care assistants, in addition to carrying out her day and night care assistant duties, also worked in the capacity of a cook for one day a week. The home had a part-time i.e. two days a week, vacancy for a cook. A cleaner was employed for 33 hours a week. The husband of the registered provider undertook maintenance duties. The number of staff hours per week provided was the minimum acceptable level for a home of this size. The registered provider must ensure that the staffing hours do not fall below the present level. The home maintained a staff rota that recorded the names and position of all the staff and the hours per week that they worked. There was one member of staff on waking duty at night and one member of staff on sleeping-in duty, usually the registered provider, in the registered provider’s private accommodation at the rear of the premises. None of the staff were below the age of 21 years. The registered provider confirmed that agency staff Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 19 were used on occasions e.g. a cleaner was employed during the Christmas period. There were no trainees. The home employed ten members of staff, including the deputy manager and senior care assistant, who were involved in the provision of personal care. The deputy manager had undertaken the NVQ level 3 training and one of the care assistants who had completed the NVQ level 2 training had embarked on the NVQ level 3 training. Another four members of staff had completed the NVQ level 2 training. Therefore, six members of staff out of a total of ten staff members had been trained to at least NVQ level 2. The home’s response to the two recommendations that were made in regard to Standard 29 as a result of the previous inspection was assessed. The first recommendation was that all prospective staff should sign a form giving their permission for the registered provider to obtain a medical reference from their GP in appropriate circumstances. The recommendation had been implemented. The second recommendation was that all of the staff should complete the home’s medical questionnaire. The recommendation had been implemented. Since the previous inspection the home had provided a range of training opportunities for the staff on six separate days. The home’s response to the three requirements that were made in regard to Standard 30 as a result of the previous inspection was assessed. The first requirement was that all staff must have individual training and development assessments and profiles. The registered provider maintained a record of the training that the staff had undertaken. However, there was no evidence to show that the training needs of the staff had been fully assessed and there were no details of the training that had been identified as being appropriate to meet their ongoing developmental needs. The requirement had not been fully implemented and still stands. The second requirement was that all staff must receive up to date training in moving and handling, food hygiene, health and safety, infection control and fire safety. The registered manager confirmed that patient handling and risk assessment training had been provided for all the staff on 26 July 2005, food hygiene training had been provided for all the staff on 30 June 2005, health and safety training, including fire safety awareness had been provided for all the staff on 29 April 2005, infection control training had been provided for all the staff, except two on 11 May 2004 and that fire safety training had been provided for all the staff on 13 May 2005. In addition, first aid training had been provided for all the staff on 17 May 2005. Therefore, two members of staff had not undertaken all the relevant training. The registered provider stated that she would make the necessary arrangements to ensure that the two members of staff would undertake the relevant training. On the basis of this assurance, the requirement was regarded as having been implemented. The third requirement was that all new members of staff must receive induction and foundation training to National Training Organisation specification within 6 weeks and 6 months of appointment to their posts, Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 20 respectively. The registered provider confirmed that one member of staff had undertaken induction training and would undertake a two-day foundation training course provided by Abacus in January 2006. Since the previous inspection one member of staff had left the home and only one new member of staff, a cleaner, had been appointed. Therefore, the requirement was regarded as having been implemented. Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 The manager was competent and experienced. However, the arrangements for planning and monitoring the quality of the service needed to be improved. Appropriate procedures and practices were in place for safeguarding the service users’ money. The arrangements for providing staff with individual supervision were satisfactory. The home’s risk assessments for safe working practices needed to be reviewed. EVIDENCE: The registered provider was also the manager of the home. She was competent and had relevant experience. The registered provider confirmed that she had completed the NVQ level 4 and Registered Managers’ Award training on 9 December 2005 but she was still awaiting her certificate. The registered provider was not responsible for or involved in any other home. The registered provider confirmed that she had undertaken the same core training as the other staff (see details above). However, the registered provider stated that neither she nor any of the other staff had undertaken any recent training in the care of people with a dementia illness. The registered provider stated Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 22 that she had a job description that was in her NVQ file. Unfortunately, the file was not available and, therefore, the job description was not available for inspection. The home’s response to the two recommendations that were made in regard to Standard 32 as a result of previous inspections was assessed. The first recommendation was that staff meetings should be held at least every three months. The registered provider stated that the last staff meeting had been held on 4 May 2005 and that the next staff meeting would be held on 8 January 2006. The recommendation had not been implemented and still stands. The second recommendation was that evidence should be provided to show that management planning and practice encourage innovation, creativity and development. The registered provider stated that the service users were involved in knitting woollen squares that would be made into blankets and donated to charitable causes. It was also stated that the service users had been helped recently to participate in making Christmas cards to send to their relatives. It was pleasing to note that these activities had taken place. Nevertheless, there was very little evidence available to show that the recommendation had been fully implemented. Therefore, the recommendation still stands. The home’s response to the two requirements that were made in regard to Standard 33 as a result of previous inspections was assessed. The first requirement was that an annual development plan for the home, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users, must be introduced in accordance with the requirements of Regulation 24 and Standard 33. A copy of the home’s annual development plan was made available for inspection. It was noted that most of the issues referred to in the plan were dated 2005 and did not include matters relating to the proposed developments in the home for 2006. It was also noted that most of the issues had not been reviewed to reflect the aims and outcomes for the service users. It was pleasing to note that the home had introduced a development plan. However, further work was needed to ensure that the plan was an effective tool for developing the home’s service. The requirement had not been fully implemented and still stands. The second requirement was that a quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. The registered provider confirmed that the home had issued service user satisfaction questionnaires between 19 and 26 February 2005. In addition, on 6 November 2005 the service users had been consulted and their responses had been analysed. The registered provider stated that she had made the results known to both the staff and service users but not to their relatives. Service user questionnaires can be an important part of a quality assurance system. However, a complete and effective quality assurance system had not been introduced. The requirement, therefore, had not been fully implemented and still stands. There was very little evidence available to demonstrate the home’s commitment to lifelong learning and development for each service user. The procedure for Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 23 obtaining feedback from both staff and service users was informal and unsystematic. For example, staff meetings were held infrequently e.g. only one staff meeting had been held during 2005. Some of the home’s policies, procedures and practices had been reviewed in the recent past as a result of the requirements and recommendations contained in inspection reports. Some of the requirements and recommendations in inspection reports had not been progressed within agreed timescales. The home’s response to the recommendation that was made in regard to Standard 34 as a result of previous inspections 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 provided details of the home’s accounts for the year ended 31 March 2005 and outline costs for the proposed extension i.e. quotes for the work to be carried out. However, the recommendation had not been implemented and still stands. The home handled the personal allowances for the majority of the service users. The money was kept in individual wallets in a lockable tin within a lockable storage facility. Individual records of the service users’ money were maintained. The records were checked against the amounts held. The records were accurate and up to date. The registered provider confirmed that neither she nor any other person connected with the running of the home acted as an agent or appointee on behalf of the service users. The registered provider stated that the home did not hold any personal possessions or valuables in safekeeping on behalf of the service users. The home’s response to the requirement that was made in regard to Standard 36 as a result of the previous inspection was assessed. The requirement was that care staff must receive formal supervision at least six times a year that includes all aspects of practice, philosophy of care in the home and career development needs. The supervision forms must include clear, relevant details of the issues that are discussed. Copies of the forms that were used for recording staff supervision were made available for inspection. The forms contained headings that reflected all of the issues referred to in Standard 36. The comments that were recorded in the supervision forms were still very brief. The registered provider was requested to ensure that the comments were written in greater detail in order to accurately reflect all of the relevant points that were discussed. The supervision records in respect of three staff members were inspected. It was pleasing to note that, in each case, the staff supervision meetings during the past year had been held at the required frequency. The requirement was regarded as having been implemented. The home’s response to the requirement that was made in regard to Standard 37 as a result of the previous inspection was assessed. The requirement was that all of the staff files must include a recent photograph of the respective Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 24 staff member. The registered provider confirmed that the requirement had been implemented. Risk assessments had been carried out in respect of safe working practice topics in June 2004. However, the risk assessments had not been reviewed, signed or dated since that date apart from the fire risk assessment that was reviewed on 30 May 2005. The food safety risk assessment was dated 27 June 2005. All of the home’s risk assessments must be reviewed, signed and dated at least every twelve months and more frequently, if necessary. A Notice of Immediate Requirement was issued to the registered provider in regard to risk assessments at the conclusion of the inspection. The home had a health and safety policy. All of the home’s portable electrical appliances had been tested on 14 November 2005. Evidence was made available to show that safety checks had been carried out on the home’s electrical installations on 10 June 2002. Accidents were recorded in the Accident Book. The Accident Book complied with the Data Protection Act. It was noted that the service users who had had the accidents did not always sign or date the accident report. Safety notices were displayed in the kitchen and on the notice board in the main corridor. Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 25 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 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 3 X 2 Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 26 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 OP1 Regulation 4 Requirement The statement of purpose and service users’ guide must be reviewed and, where necessary, amended in accordance with the guidance given in this report. The care plans must include a reference to the service users’ religious and cultural needs and to carer and family involvement and other social contacts/relationships in accordance with Regulation 15 and Standards 7 and 3.3. The portable heater must be removed from the conservatory and fixed heaters/radiators and an air conditioning system provided that meet with the approval of the Fire Safety Officer. (Previous timescale of 30/06/05 not met). Suitable handrails must be fitted to the outside wall on either side of the door at the rear of the premises for the safety of the service users. (Previous timescale of 30/06/05 not met). All staff must have individual training and development DS0000018631.V276874.R01.S.doc Timescale for action 28/02/06 2 OP7 15 28/02/06 3 OP20 13,23 31/03/06 4 OP22 23 28/02/06 5 OP30 18 28/02/06 Bedwardine House Version 5.1 Page 27 6 OP31 18 7 OP33 24 8 OP33 19 9 OP38 13 assessments and profiles. (Previous timescale of 30/06/05 not met). All the staff including the registered provider must undertake appropriate training in the care of people with a dementia illness. An annual development plan for the home, based on a systematic cycle of planning - action review, reflecting aims and outcomes for service users, must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 30/06/05 not met). A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 30/06/05 not met). All of the risk assessments that have been carried out and recorded for all the safe working practice topics covered in Standards 38.2 and 38.3 must be reviewed at least every twelve months. 31/03/06 28/02/06 28/02/06 13/01/06 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 programme of social and recreational activities should be introduced with details of the planned activities for the coming year appropriate to the service users’ needs and wishes (including those with a dementia illness) with records kept in accordance with the guidance given in this report. DS0000018631.V276874.R01.S.doc Version 5.1 Page 28 Bedwardine House 2 OP12 3 4 OP16 OP22 5 OP26 6 7 8 9 OP31 OP32 OP32 OP33 10 11 12 OP33 OP34 OP38 Service user meetings should be held at least once a quarter in order to seek the service users’ views on issues that affect their care and to discuss social and recreational activities. The out of date reference to the now former NCSC in the complaints procedure should be deleted and replaced with a reference to the CSCI. The advice of a qualified occupational therapist should be sought in order to ensure that the home provides all of the recommended disability equipment and environmental adaptations to meet the needs of the service users. The home’s policy and procedure on infection control should be reviewed and, where necessary, amended using the ‘Guidelines for Infection Control in Care Homes (2003)’ produced by Herefordshire and Worcestershire Local Health Protection Unit. A copy of the registered provider’s job description should be kept in the home and made available for inspection at all times. Staff meetings should be held at least every three months. Evidence should be provided to show that management planning and practice encourage innovation, creativity and development 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. 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 service users that have had an accident should be asked to sign and date the accident report in the Accident Book, wherever capable. Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 29 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: 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 Bedwardine House DS0000018631.V276874.R01.S.doc Version 5.1 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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