Inspection on 28/05/09 for Benedict House Nursing Home

This inspection was carried out on 28th May 2009.

CQC 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 CQC judgement.

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

Other inspections for this house

Benedict House Nursing Home 19/06/08

Benedict House Nursing Home 20/02/08

Benedict House Nursing Home 26/06/07

Benedict House Nursing Home 17/08/06

Benedict House Nursing Home 21/02/06

Benedict House Nursing Home 25/10/05

Benedict House Nursing Home 16/06/05

Benedict House Nursing Home 16/11/04

Benedict House Nursing Home 14/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Benedict House Nursing Home 63 Copers Cope Road Beckenham Kent BR3 1NJ Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 28th May 2009 10:00 DS0000010127.V375422.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Benedict House Nursing Home Address 63 Copers Cope Road Beckenham Kent BR3 1NJ 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) 020 8663 3954 020 8658 1337 Sunglade Care Ltd Vacant Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 48 19th June 2008 Date of last inspection Brief Description of the Service: Benedict House is a large detached building situated in a residential area of Beckenham. It is near to local town facilities, and can be reached by public transport. The home is an older building, and is adapted to provide nursing care of older people. The home’s owner lives in the vicinity, but he does not oversee the day-to-day control of the home. Management is carried out by andmedia care, who have done so for over five years. Accommodation is on four floors (lower ground, ground, first and second floors), there are bedrooms situated on each floor. Access to all floors is facilitated by two passenger lifts. There is a mixture of single and shared rooms, and some have en-suite toilet facilities. The home is in the process of reviewing some shared bedrooms to large single accommodation. There are communal areas situated throughout the home, with a large lounge and a separate dining area on the ground floor. Smaller quiet areas are on the first and second floors. The activities room on the lower ground floor leads out through doors to a small garden, which is enhanced by a patio area and tubs of flowers. Parking is provided to the front of the building. The fees in this home range between £601.00 to £850.00. Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 5 Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of the service is 1 star. This means the people who use this service experience adequate. Prior to the inspection the Manager had completed the AQAA and forwarded this to the CSCI. Six comment cards were provided and returned during the inspection. All the comment cards were from residents. During the visit the inspector met with two relatives, several residents and observed staff interaction and engagement with residents. Staff were interviewed as part of the site visit. A tour of the premises was undertaken including bedrooms and communal areas. All of the information obtained from the sources identified above has been incorporated into this report. A selection of documents were inspected including care plans staff personnel files as well as health and safety records. Feedback was provided to the person in charge at the end of the inspection. Other information which has been considered when producing this report and rating, is the information supplied and obtained throughout the year including Regulation 37 reports and complaints. What the service does well: The building has been vastly improved in recent years and continues to be well maintained to a good standard by the current Responsible Individual, Andrea Barden. There is a full time Maintenance Manager, who works hard with the support of Andrea Barden to continually improve and maintain a good standard in the home. The home was clean fresh and odour free in all areas that we visited. Bedrooms are personalised and individually decorated. Equipment is provided for the individual residents needs The home has retained a number of its staff including the qualified nurse team for a number of years. This provides residents with staff who understand the workings of the home and provides consistency in care. What has improved since the last inspection? Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 7 Since the last key inspection several of the previous requirements have been addressed including improvement on records of complaints and residents finances. It was evident that an open supportive ethos prevailed throughout the home particularly within the management. The manager has promoted two qualified staff in to the position of senior RGN’s to manage the clinical issues and generally take on more responsibility. This would provide staff with advice and support, and maximise the management cover, as they will be working at times opposite one another. Occupancy has improved over the last year. The number of beds has reduced with all shared bedrooms now used as single accommodation. The number of beds is due to go down to 41. We were advised that currently there are no staff vacancies. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Benedict House Nursing Home DS0000010127.V375422.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 Benedict House Nursing Home DS0000010127.V375422.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The pre-admissions procedures provide residents with some of the information they require prior to any decision regarding placement being made, to establish whether the service is right for them. Gaps in the pre admission assessments mean that some areas are insufficiently assessed and without all of the information it would be difficult for the home to state that they were able to provide all of the care needed. EVIDENCE: At the time of the site visit there were 34 residents on site no one had MRSA. All prospective residents are assessed prior to admission .The manager of this service is not a nurse therefore when new residents are referred then he takes Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 10 a qualified nurse with him to ensure that the clinical areas are assessed. This is an appropriate way to ensure that residents are properly assessed although we have been advised that this means that it depletes the qualified nurse cover in the home. Benedict House uses a standard assessment form, which outlines the activities of daily living. There were gaps evident in the completion of these especially areas such as equipment and social activities. Some of the information was sparse and more detail should have been obtained to ensure that the home has as much information as possible prior to admission. Without comprehensive information it would be difficult to say if they could provide for the resident’s total care needs Initial contact forms are completed for all new enquiries. Community Care Assessments were available in those files selected for inspection. This provided good information on the residents needs. Other information included that received from the discharging hospital in some files. Records of trial visits or visits made to the home by families of prospective residents were not available although during the site visit there were family members in viewing the home. There was some information relayed through the comment cards, about information, which had been provided to the family pre admission documents such as the Statement of Purpose. One comment card indicated no information or contract was provided prior to moving in although all the others completed indicated that they had received information. Once admitted residents are provided with a very friendly welcome letter, which confirms the home’s suitability to meet their presenting needs. The contracts are issued through the funding authority and private contracts are available for those who are self funding. Benedict House Nursing Home DS0000010127.V375422.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some of the health care records are incomplete and omissions have led to some elements of care not being fully addressed. Some of the delays in medication administrations, alongside inconsistent, and omissions in the records, introduce risks and could cause residents harm. EVIDENCE: Care plans and supporting records were selected as part of case tracking. Care plans outlined residents identified needs and had good interventions in place from which staff could address the care. Supporting risk assessments were on file including those for nutrition, skin integrity and manual handling. These were reviewed monthly even when risks were identified and more frequent monitoring may have been required. Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 12 Weight records showed that resident were weighed monthly. In one file the resident’s weight had dropped by 9 kilos over the period of a month yet this was not included in the care plan nor were the frequency of weight checks increased. Another resident weighing 45 kilos had not been weighed since January 09; although the care plan clearly indicated that the weight must be monitored. Such omissions can lead to resident’s health deteriorating; staff must provide interventions in a timely manner. Fluid balance charts for some residents were inspected. One resident was seen; who was bed bound, and their relative was visiting. We were advised that this resident had had previous medical issues including a urinary tract infection and had been admitted to hospital with dehydration. This resident was on a fluid balance chart to ensure the intake was clearly monitored and adequate. On sampling some of the fluid charts the records were incomplete; it was evident from these records that long gaps without fluids were occurring. One day the total intake was only 350 millilitres, yet no further instructions were provided to staff re the need to increase intake to an acceptable level of about 2 litres per day. Another fluid chart was completed similarly except for a period of three days when the entries were comprehensive. Some of the 24 hour totals for fluid balance were not recorded. The relative of this resident was in visiting, and was happy with the care provided and felt that they had no concerns regarding their relatives care. This person advised us that the dietician had been in to see their relative and advised staff on nutritional needs. Male and female staff are employed to address gender care issues. Records relating to visits made by members of the multi disciplinary team were in place. One member of the multi disciplinary team, who spoke to us, felt that there were aspects of health care, which the home was still not getting right. It was things such as fluid balance charts – which in their observations were either incomplete or inaccurate. They gave an example where a resident, who was at the end of their life, and taking very little, had amounts of 200mls intake recorded as taken, although it was actually only sips. It is essential that accurate information be recorded. Another area of concern was the fact that the manager who is not a nurse needs to take a qualified nurse out to assess prospective residents and this in turn depletes the qualified nursing cover in the home. In addition it was stated that on occasions only one qualified nurse was available, this made it difficult for that person to effectively manage the home. These issues need to be actioned. Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 13 The systems for medications were also inspected. Medications are stored in the two clinical areas, the home has two trolleys. The medications were inspected with the RGN. The majority of the medication charts had photographs on for identification purposes. Some of the allergies that individual residents suffered were omitted and in one case, there was conflicting information, one record indicating the resident had no allergies, another indicating an allergy to Penicillin. This introduces a margin of risk to residents and must be rectified. Those medications to be administered “as required “, had full instructions provided including the maximum dose to be administered. Medications, which needed the date of opening recorded, had it written on the bottle, although the Collogen, which also has a short shelf life, had it omitted. The medication records, of one resident who had been included in an adult protection issue, were included in the inspection. It was evident that medications had been out of stock for a period of time, and delays had occurred causing the resident distress. There is also problems with contacting the GP and getting him to visit the residents. This must be investigated. The controlled drugs were checked and found to be correct with accurate supporting records. Medications had been subject to regular auditing by the manager and the supplying pharmacist had also conducted one inspection, March 2009. The medications showed a marked improvement. Benedict House Nursing Home DS0000010127.V375422.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some choices are provided which promotes independence and enhances individuals’ well being. Activities, which are age appropriate, are provided regularly. EVIDENCE: Residents were seen to spend time where they wanted to, the majority in their own bedroom areas. One person, who was seen in their bedroom, spoke to use. They were happy and preferred to stay in their room. They said that they were well cared for by the staff in the home, and their room was warm and comfortable. This person enjoyed his TV and liked the food, particularly the desserts and would like” more rice puddings and the like “. All of those bedrooms seen had either TV’s or radios in them which residents had playing. Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 15 Another resident said, “I’m very happy here. I feel lucky to be here In one resident’s comment card, it indicated that the activities were arranged which you could participate in, and that “excellent entertainment was provided”. Another comment card said that the home “Provides good entertainment- has excellent domestic staff, and the chefs are very considerate”. The AQAA stated that they are looking to employ a music and movement teacher and encourage residents to make more use of the garden. The AQAA also indicated that the home has approached a local church to organise a regular service for residents. The lunch was observed on the site visit. The dining tables were nicely presented with condiments tablecloths and juice was served with the meal. The menu is a four-week cycle offering two choices. The evening meal is mainly soup and sandwiches with the hot meal served midday. The lunch itself was nicely presented the two choices offered that included liver and bacon or macaroni cheese. Staff were seen to assist residents with their meal. Several residents needed supervision with their meals and staff were in the vicinity to provide this. The environmental health officer had given the kitchen a good rating in their last visit. Visiting is open. Visitors were seen to come and go throughout the day of the site visit. They confirmed that they were always made welcome and a cup of tea offered to them. Residents can see their visitors in private or any of the communal areas as they wish. External entertainers are brought in to the home on a monthly basis providing various concerts sing-along etc. Daily activities take place, these are organised by the staff on duty. There is no separate person employed to organise activities and this would be beneficial. Benedict House Nursing Home DS0000010127.V375422.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints information is available for residents to access. The records retained on site reflected complaints received and the action taken. Staff had a working knowledge and understanding of adult protection and whistle blowing, to afford protection to residents. EVIDENCE: The system for recording complaints has improved since the last inspection. Information advising people of how to raise a concern was on display in the hallway. This provided information on how a complaint should be raised internally, as well as contact details of external bodies. There is a complaints’ book and there were two entries of recent complaints. The two complaints had the information recorded with the action taken and the outcome of the investigation documented. Included in this file were many compliment slips received, usually from relatives indicating their satisfaction with the care their family member had received. In addition there is a monthly audit of complaints conducted so that any emerging themes can be quickly picked up and action taken. Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 17 During the staff interviews they were asked about abuse and what action to take should this be suspected or witnessed. All staff including the agency staff member were clear that this should be reported and cited internal avenues for this. In relation to external contact points the CQC were referred to although the single point of contact was less well known. Staff were aware of the different forms that abuse may take and overall demonstrated a working knowledge of the subject There was a copy of the Bromley Interagency Guidelines on site and available to staff. The home has its own policies to deal with matters of abuse. There has been one matter, which has been investigated under Adult Protection. The resident involved with this investigation met with us and outlined the concerns. They are now in the process of moving into another home. The main elements of the concern were around health care and these were identified during the previous section of this report. The individual was reasonably satisfied with the care they received except those circumstances that led to the Adult Protection. Residents and relatives with whom we met felt able to discuss issues with the manager and said they would raise any concerns. Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the service experience good quality outcomes in this area. We made this judgement using a range of evidence, including a visit to this service. The homely environment is maintained to a good standard, clean and hazard free. Sufficient equipment and facilities are provided to meet resident’s needs. The various sitting and communal areas provide choice in residents lives. Specialised equipment bathing and mobility aids all assist to provide residents the care they need. EVIDENCE: The home is located in a residential part of Beckenham. It has parking to the front of the building and a garden to the rear. It is close to an over ground railway station and some buses run along the road although the main buses run on the main road some distance away. Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 19 The environment was particularly clean pleasant and free from hazards. maintenance, cleanliness and presentation to the home are all to be commended. The Improvements include replacement of equipment, re carpeting of areas as well as refurbishment and upgrading of bedrooms. The maintenance person addresses many repairs and all of the general upkeep internally and externally at Benedict House. A well maintained building makes it safe for residents to live in and staff to work in. Clocks and calendars were in several bedrooms and these provide good orientation aids to the residents. Bedrooms were individually decorated with curtains and matching bedding, this demonstrated that great attention to detail had been paid when rooms had been upgraded. Residents with whom we met all commented that their bedroom accommodation was comfortable and they enjoyed spending time in them. Specialist equipment including mobility aids, adapted baths and hoists were available and used. Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28.29 and 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Qualified staffing needs to be reviewed so sufficient numbers are available to meet the resident’s needs. Staff are subject to recruitment procedures, which ensures residents are protected. Staff are provided with some training and induction to enable them to undertake the work they perform and provide residents with the support they need. EVIDENCE: At the time of the site visit there were two Registered Nurses and five care assistants for thirty-four residents. The manager is supernumerary to these numbers. We were advised that the home has no vacancies for staff, although it is in the process of recruiting extra bank staff for annual leave and sickness cover. In addition there were laundry, domestic and maintenance staff. A full time administrator is employed. Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 21 Since the last inspection there has been a senior nurse appointed to deal with the clinical issues. Comment cards included positive comments about the staff and some of these as follows:” pleasant helpful staff”,” staff listen in to you and act on what you say”. Those staff that spoke to us felt that things in the home had improved One resident who was interviewed said they were reasonably happy, although in relation to the staff they said they were variable and gave an example of an inappropriate comment made to them. This was relayed to the manager for investigation. Staff with whom we met gave appropriate answers when asked about clinical issues such as infection control. One area, which currently needs to be addressed, is the supervision of the senior nursing staff in relation to clinical supervision. John Hudson the manager provides supervision on general topics although not on clinical areas. The manager has explored a few avenues however so far they have not proved fruitful. An agency staff spoke with us; it was their second shift, although it had been about a year since their first shift. On their arrival they said that their identity was checked by way of a photo identity card. They confirmed that the agency had instructed them on the mandatory topics. Once in the home they had received a short induction including a tour of the building, although was unsure of where the fire exits were. This needs to be actioned. The manager must ensure that all staff have sufficient induction to work safely in the home, and agency staff should be provided with a condensed version of the longer induction permanent staff have. It had been identified that not all of the staff were up to date with their regular mandatory training the manager had started to action this and organise updates for all staff. The manager has developed a training matrix, which clearly identifies when staff are due for up dating and should prevent staff from missing regular updates. The home has 25 places booked with the Bromley training consortium, which provides training for staff in care homes. Four domestics are due to start the housekeeping NVQ training. The qualified staff said they had attended a Dementia course with the University of York and was due to do an update in diabetes. One resident commented that they felt that staff were insufficiently trained in the specific illnesses that resident’s suffered such as osteoporosis. Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 22 Those staff that were interviewed confirmed that they had been subject to recruitment procedure and this was checked by sampling staff personnel files. The personnel files were well laid out with information easy to access. Application forms were completed evidence of identity checks health declarations and references were on file. Interview notes were retained and those specific questions asked at the interview had the applicant’s responses recorded. Evidence of POVA and CRB checks were retained. Some of the files had the original CRB form attached once these have been checked then they should be disposed of, as the information is confidential. Only those of the recently employed staff should be retained for checking by the CQC. Most references were confirmed by way of a company stamp or headed paper. The staff induction had supporting records indicating what staff had covered during this period. Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. People using the service experience adequate quality outcomes in this area. We made this judgement using a range of evidence, including a visit to this service. The Manager is not a nurse and requires support on clinical issues from trained nurses although is experienced in this type of service. . Health and safety servicing and maintenance are addressed to ensure the home is safe for residents. Quality assurance measures are limited therefore give little information on how the service can be improved upon to benefit residents. EVIDENCE: The manager has been in post for a year yet to date he has not proceeded to apply for registration with the CQC, this must be actioned. The manager has Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 24 worked in a management capacity in other care homes in the area, he is not a nurse and he requires support from trained nurses to ensure clinical issues are correctly addressed. A selection of health and safety service certificates were inspected to ensure that the environment and all equipment in the home was safe. These included checks for the hoists and the lifts, under the LOLER regulations. The gas appliances had been serviced May 09 although the certificate had not been received; this needs to be followed up. Lift servicing and electrical certificates were all current. Those records relating to fire precautions were inspected. The fire risk assessment was dated 2006 and needs updating in light of the changes made in the home. It is recommended that the fire risk assessment be updated whenever a change occurs or annually. The fire alarm had been serviced November 08, and extinguishers within the last twelve months. The smoke detectors had been serviced May 2009. Records relating to fire drills were in place and had staff signature to confirm attendance. The fire drills included those specifically for night staff. Emergency lights tests were also recorded, these are done monthly by the maintenance man and again at the routine service visits. Weekly fire alarm testing indicated different zones were tested. The fire doors and means of escape in the event of a fire are also checked monthly. Two residents’ finances were checked and found to be correct as specified on the balance sheet. Records of resident’s finances showed them to be fully recorded to include details of the transaction, receipts and signatures were available to verify this. An external auditor conducts regular checks on the finances and records evidenced these. In relation to quality assurance measures the records of these were limited. There were few records of audits and meetings to demonstrate monitoring of the care provided. The minutes of a qualified staff meeting held 2009 and a health care assistant meeting held 2008 were the only records available toe evidence staff input into the service. In the main audits of medications were the only ones seen. The manager has conducted a resident’s satisfaction survey within the last twelve months. Seven responses were received and very favourably comments were included in them. The reports arising out of Regulation 26 visits were not available. The Responsible Individual visits the home very frequently although an official record/report is made these were not produced for inspection. There was little evidence of input for all other parties involved in the home, which should be included as part of the annual review of the service. Without Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 25 seeking the views of all of those who use the service it is impossible to identify the areas where improvements are required. Please see requirements. Benedict House Nursing Home DS0000010127.V375422.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 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The Manager must ensure that all health care records are accurately and comprehensively completed and interventions are timely. Supporting documentation must be relevant and completed accurately. Medications must be received and administered without delay to residents. Medication charts must be fully completed with accurate information. Staff must be provided with sufficient training to undertake the work they do. This includes mandatory training and those topics relevant to residents needs. The manager must apply for registration through the CQC so his suitability to undertake the role is verified. More comprehensive systems, for obtaining the views of all DS0000010127.V375422.R01.S.doc Timescale for action 30/09/09 2 OP9 13 30/07/09 3. OP30 18 30/09/09 4 OP31 5. OP33 9 30/09/09 24 30/11/09 Benedict House Nursing Home Version 5.2 Page 28 those involved with the service; need to be place to be included in the annual service review. 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 OP28 Good Practice Recommendations The Manager should ensure that practice is monitored to reflect training provided to staff. 2. OP33 The Manager should ensure that all staff are subject to supervision, which is individual to their needs. Benedict House Nursing Home DS0000010127.V375422.R01.S.doc Version 5.2 Page 29 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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