Inspection on 19/06/07 for Bendigo Nursing Home

This inspection was carried out on 19th June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bendigo Nursing Home 19/05/06

Bendigo Nursing Home 06/10/05

Similar services:

Springfield House

The Shelley

Thorndene

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Bendigo Nursing Home 22 Arundel Road Eastbourne East Sussex BN21 2EL Lead Inspector Debbie Calveley Unannounced Inspection 19th June 2007 08:30 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 Bendigo Nursing Home DS0000065151.V338748.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. Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bendigo Nursing Home Address 22 Arundel Road Eastbourne East Sussex BN21 2EL 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) 01323 642599 01323 431080 Kindcare (UK) Ltd Mariana Ivanova Philipova Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability (25) of places Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the maximum number of service users to be accommodated will be twenty-five (25). Service users must be aged sixty-five (65) years and over on admission. Service users may also have a physical disability. Date of last inspection Brief Description of the Service: Bendigo Nursing Home is registered to provide nursing care for up to 25 older people, over 65 years, or individuals with physical disabilities. Situated in a residential area of Eastbourne it is approximately 20 minutes walk from the town centre with its variety of shops and public transport facilities, with a library, GP surgeries and dental practices accessible. The home is a converted detached property, the kitchen, the staff room and storage facilities are in the basement with a further three floors containing a lounge, resident’s individual bedrooms, 19 single rooms and three double rooms, assisted bathrooms and toilets. There is a small passenger lift, which has been recently improved and can now be used by wheelchair users and staff. There is a large garden to the rear with an access slope at the side of the home for wheelchairs and is used when weather permits. Fees charged as from 1 April 2007 range from £500 to £800, which includes basic toiletries. Additional charges are made for hairdressing, chiropody, newspapers and outside activities such as visits to the theatre. Intermediate care is not provided Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Bendigo care home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. This unannounced inspection was carried out over 6.5 hours on the 19 June 2007. There were twenty-two residents living in the home on the day, of which five were case tracked and spoken with. During the tour of the premises eight other residents both male and female were also spoken with. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including the Service Users Guide, Statement of Purpose, care plans, medication records and recruitment files. Four members of care staff and the cook were spoken with in addition to discussion with the Registered Manager. Telephone contact was made with visiting professionals following the visit and two relatives were spoken with during the inspection visit. The information received verbally has been incorporated into this report. An Annual Quality Assurance Assessment was received from the Manager completed in full prior to this key inspection. What the service does well: There is a combined Statement of Purpose and Service Users Guide that gives prospective residents the information required to enable them to make an informed choice about where they live. Residents confirmed that they were visited by the Manager prior to admission to the home and two stated they had been invited to visit the home to see if they liked it enough to live there. The menus evidence a well thought out balanced diet with a varied choice of food in line with resident’s preferences. Quality assurance systems are in place, which enables the service to monitor and improve their service. There is an open-house policy, which welcomes visitors at all reasonable times. Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 6 Satisfactory arrangements are in place to safeguard residents’ finances. Staff provision is well maintained with a robust recruitment practice being followed and appropriate numbers of suitably qualified staff working in the home. The atmosphere of the home is pleasant with good interaction seen between residents and staff. The Comments received from residents and families regarding the care received included: ‘ Staff efficient and polite ’ ‘ there has to be a bit of give and take on both sides’ ‘ She receives excellent nursing care and care workers are kind, considerate and supportive of her every need’ There is a robust recruitment process in place to protect the residents. Bendigo provides a clean, safe and well-maintained environment, which is appreciated by the residents and their relatives. Comments regarding Bendigo were generally positive and included: ‘I have been here for a long time and like it’ ‘ I haven’t been here long, but its quiet and peaceful, I am comfortable’. What has improved since the last inspection? The manager of the home was registered in February 2007. The staff team, residents and relatives feel that the home has improved over the past year and a half and feel supported by an efficient and competent manager. The requirements made at the previous key inspection 19 May 2006 have been met. The care plans continue to improve and are reviewed and updated on a regular basis, there is more evidence of resident and family involvement in the care planning process. Staff are being enrolled on an induction programme in line with the Skills for Care. There is a rolling plan of redecoration and upgrading of the property. The improvements to the home environment have been considerable and appreciated by the residents and their families. ‘ its always clean and smells fresh’ ‘ the decoration of the home has really improved the atmosphere’ ‘ its really nice home, comfortable and clean’. Quality monitoring systems have been introduced and the results have been analysed by the management team. The response from the surveys was very positive and 16 of 19 were returned and the results indicated where improvements could be made - Choice of lifestyle has been identified by the Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 7 surveys as a point of improvement, as was communication regarding suggestions and comments. Supervision has been commenced and a plan of supervision was seen for the year. Staff are receiving moving and handling training with appropriate updates. 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. Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 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 Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives with a good level of information about the home, its facilities, services and the costs involved. The admission procedures allow for the needs of prospective residents to be assessed by a competent person before admission, however little information is documented thus not ensuring their needs can be met. EVIDENCE: There is a combined Statement of Purpose and Service Users Guide, which contains clear information about the home and the services it provides. The brochures format is bright and colourful and contains recent photographs of the staff and residents. Copies of these are available in the front entrance, and two residents proudly showed their photo that was in the Service Users Guide. A social care professional that had recently visited the home confirmed that relevant information was provided to a prospective resident. Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 10 It was confirmed whilst talking to residents that the contract arrangements were clear and understood. There is a copy of the terms and conditions of residency included in the Service Users Guide. A review of the care documentation confirmed that pre-admission assessments are completed by the manager and a senior nurse. The format of the preadmission document was seen to be thorough and relevant. However the five assessments seen were not completed in full and did not contain all the information required to ensure that new admissions to the home were suitable and that the home have the staff and environment to meet the care needs of their needs. The prospective residents’ are seen either in their home or hospital before admission and the manager confirmed that wherever possible the family or representatives are involved. A recommendation of good practice is that the venue and all the people involved in the assessment are documented. The manager was able to verbally demonstrate her knowledge and awareness of the different specialities required in the home and ensures that the Registered Nurses and carers employed have attended relevant courses to deal with the needs of the elderly and also specialised courses for certain diseases. Trial visits to the home can be arranged. The manager confirmed that selffunding residents are invited to a trial period to ensure suitability of the home; this is clearly stated in the Statement of Purpose and in the statement of terms and conditions. Intermediate or rehabilitative care is not provided at Bendigo Care Home. Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans provide a good framework for the delivery of care, which give clear guidance to care staff on the care needs of all the residents. The home was found to be meeting resident’s health and general needs with accessed additional specialist support when needed. Procedures and practices in the home allow for the safe administration of medicines and on the whole the privacy and dignity of residents to be promoted. EVIDENCE: The care documentation pertaining to five residents was reviewed as part of the inspection process. These were found to include plans of care, nutritional assessments, personal histories and risk assessments. On the whole the care documentation demonstrated that the care was reviewed and evaluated, however it was noted that not all the plans of care highlighted all the needs of residents. For example one resident who has communication problems did not Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 12 have any guidance in the documentation to facilitate this vital need, the staff though were observed communicating very well with the resident. Another did not provide guidance for staff to deal with her depression and recent bereavement; again the staff were knowledgeable and discussed this in detail during the inspection. It was also found that social histories and social care plans are not completed on all residents. These shortfalls however do not impact on the positive outcomes of the residents due to the stable care team and the knowledge they have on individual residents. It does highlight that staff still need to improve their documentation in certain areas and this was discussed in full with the manager who was to review and address the identified shortfalls. Risk assessments for health needs are included in the care planning format used by the home, and all risk assessments were found to be completed, but not all followed through with an appropriate plan of action when identified as required. This was discussed in full with the senior staff. It is acknowledged that a lot of hard work has been undertaken by the staff to improve the records and documentation and that training in care planning is on-going. Staff spoken with confirmed that they received a full report on each resident daily and read the care documentation that is kept in the main nurses station. They felt that their views were taken into account when planning resident’s care. Relatives and residents spoken with were satisfied with the care provided at the home one saying that the home ‘should be congratulated for its care’ ‘my relative receives good nursing care and care workers are kind, considerate and supportive of her every need’ ‘Staff are efficient, courteous and very kind’. Residents spoken to were also satisfied, comments included ‘they look after me very well’ ‘I am have my own room and the staff are kind ’ ‘ It’s my home’. Relative surveys stated ‘ the home have improved, but still room for improvement’ ‘ I have found the standard of care and consideration to be excellent, the staff are all involved with their patient care, well motivated and cheerful’. The clinical room is also the staff office; it is kept locked at all times. There is a small fridge and temperatures of the room and fridge are recorded daily. There are policies and procedures in place for staff to refer to regarding the safe administration, storage, disposal and recording of medication. The systems for recording and checking controlled drugs were found to be thorough. Medication Administration Charts were found to be competently completed. The comparison signatures of staff able to administer medication were not available and are to be produced to provide a clear audit trail. Some areas of good practice were discussed with the senior nurse on duty during the inspection. Staff were seen to be respectful and considerate to all residents and visitors, whilst attending to their needs. However staff were seen entering bedrooms without knocking during the inspection. Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 13 Each of the residents were addressed by their preferred term and dressed appropriately in well-laundered clothing. Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 14 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. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lifestyle experience by residents at this time does not always match their expectations, choice or preferences. Meals remain good in respect of both quality and variety that meets the majority of residents’ tastes and choice. EVIDENCE: Care plans evidence some residents past histories and social preferences, but they are not linked constructively to a formal activity programme. From direct observation, the morning shift did not evidence any activities and when asked it was stated that they were playing ten pin bowling in the afternoon. It was confirmed by staff that the residents are encouraged to attend facilities away from the home; these include shopping trips, church services and visits to a local public house. It was not clear from documentation how often these take place. One resident said that ‘the activities were disappointing, but the staff try’, other comments included ‘ I do not go to the activities, because I prefer to Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 15 stay in my room’ ‘ I get very bored and it can be lonely’. ‘ Due to my poor hearing I get embarrassed so I stay in my room’. ‘ I think the staff try very hard and I enjoy some of the activities’. Relative feedback included ‘ more mental stimulation is required’ Activities should be an important part of life to the residents of Bendigo, as there are some independent people living there and therefore it is identified as an area that requires development to meet all the residents’ social needs. It was discussed in full with the manager during the inspection. Residents are facilitated to maintain their independence for as long as they are able. There are no restrictions on visiting times as long as consideration is shown to all the residents. There are communal areas throughout the home that are available to residents and their visitors for private meetings if required. Many of the residents have individualised their bedroom with items from home and residents and relatives spoken with confirmed that they are encouraged to make it homely. It was observed during the inspection that the routines at the home are flexible, residents spoken with confirmed that they were consulted about all aspects of their lives. The home has an advocacy policy in place and the information regarding this is available to all residents. There is a small dining area but this is not used, residents eat from small tables from their chairs. From direct observation only five residents take their meals in the lounge, whilst the rest eat in their bedrooms. Whether this is their choice or from lack of communal dining space is not clear. There are plans to extend the communal areas, which would be beneficial to all the residents living in the home. The manager has produced menus that are colourful and contain photographs of the main meal. The meals provided for residents were seen to be nutritious and attractively presented, including the pureed meal; fresh fruit and vegetables are readily available. The kitchen has recently been inspected by the Environmental Health Team and the home has acted on their requirements. The residents comments included, ‘the food is very good’, ‘we get a good variety’, ‘its really very good’. Other comments included ‘ not always very hot’ ‘ evening meal is generally sandwiches and yogurt’. The staff keep fluid and food charts in residents bedrooms, however not all were up to date, which then gives an inaccurate picture of their nutritional status. There is no daily record kept of resident’s food consumption. The home staff use a nutritional assessment tool to identify any residents with special dietary needs, including monthly weights, however as previously mentioned an action plan needs to be in place for those whom have been identified as at nutritional risk. Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 16 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. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a formal complaints system with evidence that residents feel that their views are listened to and acted upon. Staff receive training to protect residents from abuse. EVIDENCE: The complaint policy and procedure is clear and uncomplicated and a copy of this is readily available in the home and the Service Users Guide.. A system of recording complaints was demonstrated to the inspector during her visit to the home. The home has not received any complaints since the last inspection. Relatives and residents spoken with confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. The home has relevant guidelines on the protection of vulnerable adults and staff have received appropriate training. The management team has a clear understanding of adult protection guidelines and are aware of how to initiate an investigation if required. Bendigo Nursing Home DS0000065151.V338748.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, 20, 21, 22, 23, 24, 25 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Bendigo provides a comfortable, clean and safe environment for those living there and visiting. Residents and their families are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. EVIDENCE: The home continues to follow an improvement programme that has benefited the residents and visitors to the home and provided a welcoming and comfortable environment. The tour of the home evidenced that a considerable amount of work has been done. The entrance area has been updated, and is attractive and welcoming. The lounge and dining room area are fairly small, but is pleasantly decorated Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 18 and well furnished. The majority of the furniture in the home has been replaced and is modern and of good quality. Residents who expressed an opinion spoke positively about the home, many have decorated their rooms with their own possessions, pictures and ornaments. The gardens are accessible and attractive. There are adequate communal bathrooms and shower rooms in the home with specialist equipment, which enables frail residents and those with a physical disability to enjoy the facilities available. However the bathrooms are not attractive and inviting and are in need of redecorating. They are also used as storage areas for zimmer frames, wheelchairs and hoists. This was discussed in full. Specialised equipment to encourage independence is provided e.g. handrails in bathrooms, hoists, wheelchairs and lifts to all areas of the home. Call bells are provided in all areas. The lighting in the home is of domestic quality and there are above bed lights as well as the main ceiling lights. Water temperatures are controlled and monitored monthly and a record kept. Random temperatures were taken and were of the recommended level. There are systems in place for monitoring safety issues such as fire checks, fire drills, PAT testing, electrical tests and gas and boiler checks and all the rooms are routinely checked for safety and maintenance issues. The records in the home confirmed they were up to date. The tour of the home confirmed that staff are aware of the fire safety policies, no doors were found inappropriately wedged open. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. Sluice and laundry areas were found clean and safe. The home provides a good laundry service. Bendigo Nursing Home DS0000065151.V338748.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. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures are in place to protect residents, and staff training ensures that they are aware of their roles and are able to provide the support and care the resident’s require. EVIDENCE: The staffing rota was viewed and the staffing levels were seen to be sufficient to meet the needs of the residents at this time. It was confirmed by the manager that there is a flexibility of the staffing levels and they are adjusted according to the changing needs of the residents. Care staff spoken with said that the levels of staff on duty were sufficient to give the care required; they also said that the trained staff always helped out. Residents also confirmed that they had no complaints regarding the amount of staff. A selection of staff recruitment files were viewed and demonstrate that a robust recruitment process has been maintained to protect residents and contained all the relevant information required. There was evidence of health questionnaires, Criminal Record Bureau checks, two references, a resume of previous employment and work permits where necessary. All the paperwork is kept within a locked room. The induction programme is now in place and has been introduced for all staff. Files seen confirmed this. Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 20 Staff spoken with said that training opportunities at the home are good and they are well supported by the senior staff and the manager. Staff and the training list seen confirmed that compulsory training such as manual handling, adult protection, first aid and fire safety are being undertaken. The manager is introducing a training matrix, which will track the training needs. Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The overall management of this home is good with effective systems in place to protect residents. EVIDENCE: The manager came to Bendigo fifteen months ago as acting manager and was registered by the CSCI as Manager in February 2007. She has completed a management degree course and states that she is due to complete the National Vocational Qualification level 4 in care in the near future. The staff spoken with said that they felt supported by the management structure of the home. Residents were aware of whom the manager is and of her role in the Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 22 home. Relatives and visitors state that the manager has significantly improved the service and that they can approach the management at any time. The ethos of the home is to focus on the residents and staff were observed doing this. The quality assurance systems in the home include questionnaires sent out to residents and relatives following admission to the home. The introduction of this formal quality assurance and quality monitoring systems has enabled the management to objectively evaluate the service and ensure it is run in the residents best interests. The quality assurance results have recently been audited and action taken to address any suggestions of improvement. There are no residents at present who are responsible for their own finances; relatives and solicitors support the majority, while the home does not handle the financial affairs of residents. Staff supervision was discussed and staff supervision has been commenced. Staff spoken with confirmed that they receive supervision and a plan of the year’s supervision sessions seen. At present not all staff have received the mandatory training in moving and handling, health and safety and fire safety. However, there is evidence of a rolling plan of training that will address this. The manager confirmed that all staff are appropriately supervised until they have received the necessary training and induction. It was discussed that expert advice be sought regarding those residents that have recurrent falls. Good practice was observed throughout the inspection in respect of promoting the safety and well being of the residents. Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 3 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14 (1) (a) (b) Requirement That the pre-admission assessment is completed in full to ensure that the home can meet the identified needs of the prospective service user. That activities are provided to suit service users expectations, preferences and capabilities. That service users are supported and enabled to attend activities. That a programme of activities is more formally devised based on residents choices. Timescale for action 19/07/07 2. OP12 16 (2) (m) (n) 19/07/07 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 OP3 Good Practice Recommendations That the venue and all the people involved in the preadmission assessment is documented. DS0000065151.V338748.R01.S.doc Version 5.2 Page 25 Bendigo Nursing Home Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Bendigo Nursing Home DS0000065151.V338748.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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