Inspection on 17/10/06 for Bernash

This inspection was carried out on 17th October 2006.

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

Bernash 14/02/06

Bernash 18/10/05

Bernash 12/10/04

Bernash 06/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Bernash 544-546 Wells Road Whitchurch Bristol BS14 9BB Lead Inspector Sandra Jones Key Unannounced Inspection 09:30 17 & 19th October 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bernash DS0000026497.V302678.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. Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bernash Address 544-546 Wells Road Whitchurch Bristol BS14 9BB 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) 01275 833670 01275 545342 bernash@bernash.fsnet.co.uk Ms Beryl Nash Mrs Deborah Williams Mrs Beryl Nash Care Home 23 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (17) of places Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 Brief Description of the Service: Bernash is a detached property that can provide personal care and accommodation for 23 older people. It is arranged over two floors with a passenger and stair lifts to the first floor for less mobile residents. There are two double bedrooms and thirteen bedrooms are en-suite. Shared space is on the ground floor and consists of a lounge, dining area and conservatory. The property is on a main road, with shops, local amenities and bus routes located nearby. Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key visit was conducted unannounced over two days in October 2006 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the residents, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises conducted and feedback sought from residents and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the pre-inspection questionnaire and notified incidences in the home, (Regulation 37’s). “Have your say” surveys were sent to residents in the home prior to the inspection and fourteen were completed and returned. In addition to the surveys, feedback about the standards of care was also sought from visitors, relatives and health care professionals. Information from these sources has been collated and is detailed throughout the report. What the service does well: Surveys were used to seek the views of the residents, relatives and outside agencies about the standards of care at the home. Overall the comments received were positive and indicate the standards of care are good. Fourteen completed surveys were received from residents and thirteen stated that they always receive the care and support they need. Twelve residents indicated that hey know who to speak to if they are not happy and all residents felt that the home was clean and fresh. Eight positive responses were received from people that visit the home and one person commented that the staff are “caring which provides a homely atmosphere”. Bernash is well maintained and domestic in style, with a comfortable and homely atmosphere. Members of staff were observed using a friendly yet respectful approach when they interacted with residents. Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Potential residents are encouraged to visit the home before their admission. A formal assessment format must be developed to evidence that admissions are based on full assessments of need. Intermediate care is not offered at the home EVIDENCE: The Statement of Purpose and Service User Guide states that prospective service users will be assessed before admission to the home. Admission forms were introduced since the last inspection and seek residents background history. Completed admission forms were found in the case records of newly admitted residents and contained background information sought from relatives and the resident. One resident was admitted in April and another in October 2006, their case records contained basic information about their care needs. A record of the structured assessment conducted to determine if the Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 9 home can meet the needs of the person, is not currently in place. The admission procedure must incorporative the assessments to be followed for people that self-fund their placements, with the criteria for admission to the home. Case records of newly admitted residents must then contain copies of the assessments conducted in advance of their admission. The manager reported that potential residents are either assessed in the premises or at their home or current residency. Assessments are conducted over a period of time and the process entails consultations with GP’s, social workers and family members. “Have your say about” surveys were sent to the home in advance of the inspection and thirteen were returned. The responses received indicate that residents received information about the home before their admission. The most recently admitted resident confirmed that the home encourages introductory visits. It was understood that several visits with family members took place before admission to the home. Intermediate care is not offered at the home. Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The care plans are specific and support a person centred approach to meeting residents needs. For residents with little verbal communication, care plans must be specific about the way they make decisions. In terms of meeting residents personal care needs, care plans must be more descriptive to ensure consistency of care. Residents are enabled to access health care services and their health care needs are monitored and promoted at the home. Risk assessments must be completed for residents that have mobility impairments to ensure that the appropriate aids are used. The safe handling of medications procedures safeguard residents. Members of staff ensure that residents rights are respected. EVIDENCE: Since the last inspection, the care planning process was updated to introduce a person centred approach to meeting needs. Care plans lists the individuals assessed need and describe the persons abilities, with the assistance needed by the staff. Daily routines are incorporated along with leisure activities. Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 11 Care plans viewed indicated that staff monitor the care plans monthly, with the resident. Residents sign their care plans to indicate support with the plan of action. For residents with dementia, care plans describe behaviours that the person may present. The support needed to reassure the person and the action to diffuse potentially aggressive situations is clearly stated in the care plan. Care plan for residents that are non-verbal, must be specific about the methods used by the person to make decisions. The assistance needed with personal support is detailed within the individual’s care plan. Information about the person’s abilities is specified, with a brief description of the assistance needed from the staff to meet the identified need. The assistance to be provided by the staff must be more descriptive in order to meet the needs using a person centred approach. Residents have a choice of health centres and on behalf of the CSCI the home, forwarded comment card based on seeking GP’s views about the care home. Two GP practices’ and four GP have responded, their comments about communication, staff’s insight into residents needs and the provision of care were positive. One GP made additional comments about the home providing excellent standards of care. It was understood from the manager that one resident has a history of pressure sores and a pressure mattress is used to prevent reoccurrence. It is evident from the documentation available that a number of residents are at risk of falls and care plans details their abilities with mobility. The aids used to maintain independence with moving around the home are also listed in the care plan. While care plans are clear about the person’s mobility needs, risk assessments must support the equipment, aids and safe handling techniques to be used by the staff. The manager reported that hoists to transfer are used for two residents and members of staff walk with all other residents. The manager stated that the continence advisor visited the home to pass information and advice to the staff. It is the district nurses who currently undertake reviews and assessments for continence aids. Within the care plans, staff’s actions are detailed for people with continence needs. Described are the residents abilities, preferences and aids needed to provide reassurance to the person. Residents access NHS facilities and care plans describe the check-up residents have with dentists, opticians and chiropodists. For residents with hearing impairments, the appointments arranged with audiologist are listed. District nurses visit the home and care plans for residents with district nurse input briefly states the advice to be followed by the staff. Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 12 Members of staff record their observations of residents, outcomes of visits and advise to be followed. In addition to the reports of significant events, records of health care visits are also maintained. Dates of appointments, reasons for the visit and outcomes are kept, for GP’s visits and hospital appointments. Visits from district nurses and other agency’s visits are recorded separately. The medication profiles detail the name of the medication, its purpose and possible side effects. It was understood from the staff and the manager that senior staff have responsibilities for the administration of medications. Members of staff that administer medications must undertake appropriate training as part of their senior role. Medications are administered through a monitored dosage system and the records suggest that immediately after administering the medication, staff sign the records. Homely remedies are administered from a stock supply when required by the residents. Separate records of administration are kept for homely remedies and detail the person’s name, the dosage administered and the running balance. The manager explained that to promote residents health, their weight is monitored periodically and GP’s are contacted for rapid weight losses or gains. One local surgery undertakes annual health checks for their patients. The home maintains a record of accidents and incidents and the majority of accidents relate to falls. The manager analyses the number of incidents and accidents and where appropriate amend the care plans. Residents consulted during the inspection commented about the home maintaining their rights. It was explained that personal care is always conducted in private, staff knock and wait for an invitation to enter bedrooms and staff address residents in their preferred mode. The Statement of Purpose details the intended approach towards respecting residents privacy and dignity. The Privacy and Dignity policy underpins the commitment towards respecting residents rights. Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are opportunities for residents to exercise choice and to maintain their preferred lifestyle. A record of activities undertaken by residents should be recorded in their running reports. Residents are supported to strengthen links with family and friends. Residents are assisted to take control over their lives. Record keeping policies must specify that residents records are kept locked to maximise residents personal autonomy. Residents have a wholesome and varied diet. EVIDENCE: “Have your Say” surveys were sent to the home in advance of the inspection and fourteen responses were received. Eight residents stated that activities are always arranged by the home, three felt the home usually arranged activities and three felt it was sometimes. Some residents qualified their comments by stating that while activities were organised they did not participate. Residents consulted during the inspection, explained how they keep themselves occupied during the day. Reading, watching television and pursing hobbies are activities that residents undertake on their own. Residents confirmed that activities take place at the home and explained that their participation was optional. Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 14 The manager explained that in-house activities are arranged on a daily basis, with armchair exercises taking place each morning. For residents with dementia, members of staff assist with arts, crafts, games and 1:1 to ensure residents are stimulated. Residents meetings take place periodically and suggestions are sought from residents about the activities to be provided. The activities undertaken by the residents should be included within their running reports. Care plans specify residents daily routines, times to rise and retire with preferred daily activities. Maintaining relationships with family and friends is also included in the individuals daily routines profiles. The Statement of Purpose endorses open visiting and residents have the right to see their visitors in private. Relative comment cards were used to gather information about the standards of care at the home. Positive comments were received about the manner in which staff welcome visitors, the levels of staffing observed during their visits and that privacy is respected. Other positive comments indicate that where appropriate relatives are involved in the care planning process and they are kept informed of important matters. One relative made additional comments about their family member having an improved quality of life and being less frightened since moving to the home. There is a visitor’s book, which is generally used by professional visitors. The manager reported that seven residents are subject to Power of Attorney, which families have organised before admission to the home. The resident with their representatives make individual arrangements about their finances. The Record Keeping policy supports residents access to their own records and Data protection guidelines are followed for residents records. The Confidentiality policy also confirms residents right to access their records. The approach towards the safe handling of residents records is not included within the policies. Policies and procedures must specify the security arrangements for the safety of residents records. Residents dietary needs are specified within their care plans, their specific needs, their preferred size of meals, their likes and dislikes are detailed. The record of the meals provided suggests that residents have a choice of meals at all mealtimes. There is a separate record of residents breakfast preferences, which is kept in the kitchen. A record of food provided is maintained for lunch and teatime meals. Residents have a cooked lunch and at teatime they choose from a range of options available. The home was presented with a 5 Star Food Hygiene Award following an inspection of the kitchen. Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents views are sought and action is taken to resolve their complaints. Policies and procedures in place assist staff that work directly with residents, to recognise forms of abuse and take appropriate action. EVIDENCE: Twelve of the fourteen residents that responded through the “Have your say” surveys indicated that they always know who to speak to if they are unhappy and ten know how to complain. Eight comment cards were received from relatives and six indicated their awareness of the complaints procedure. GP’s views were also sought and they reported that they had not received any complaints about the home. The residents consulted during the inspection reported that the manager and/or service provider would be approached with complaints. The Complaints procedure is appended onto the Service User Guide and Statement Purpose. The complaints procedure is specific and details the address and telephone number of the CSCI. The procedure is on display in the foyer of the premises and in terms of accessibility, the current format must be assessed to ensure it can be understood by the people its intended. The Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 16 manager must assess the current format to ensure its accessibility, and consideration must be given to the use of large print, symbols and pictures. There is a Whistleblowing and Vulnerable Adults policy, which sets the approach to safeguarding residents from abuse. The Whislteblowing policy requires updating to include the implications to staff that witness poor practice and do not report it. The forms of abuse are explained in the Vulnerable Adults policy, with the steps to taken for alleged abuse and preventative measures to be taken. Members of staff will be attending external Safeguarding Adults training to ensure that staff can recognise all forms of abuse. Bernash DS0000026497.V302678.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21 &22 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service The property is well maintained and fits its purpose. Residents are able to maintain their chosen lifestyle. There are sufficient public areas for shared activities and for private use. Toilets and bathrooms are within close proximity to bedrooms and shared space, as the ratio is above NMS the home can meet the needs of the residents. Equipment and Aids are provided to ensure that residents with mobility impairments can move around the home independently. The home is clean and free from unpleasant smells. EVIDENCE: Bernash is a detached property offering accommodation over two floors with passenger lifts and stair lift to ensure residents independence. Accommodation is mainly in single occupancy, however, there are two sharing rooms. The home is well furnished and domestic in style, with a comfortable and homely atmosphere. Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 18 Shared facilities consist of a lounge, dining room and conservatory. There is a large lounge at the front of the premises, with seating for 11 people and in the conservatory there is seating for a further 11 people. The dining are leads into the conservatory and there is more seating with sufficient tables and chairs for the residents to sit together and eat their meals. As thirteen rooms are en-suite the ratio of people sharing communal toilets is 2:8. Toilets and bathrooms are in close proximity to bedrooms and shared space. On the first floor there are two assisted bathrooms and an unassisted bathroom on the ground floor. There is a passenger and stair lift to assist residents with mobility impairments to move around the home independently. Grab rails and assisted bathing facilities are installed to maximise residents independence in the home. With the exceptions of two, bedrooms are single. The double bedrooms are en-suite offering privacy with personal care. Bedrooms contain a combination of the home’s furniture and personal belongings and, are furnished and equipped to meet the needs of the individual. Privacy is promoted through lockable doors with additional lockable space in bedrooms. The fourteen residents that responded through the “Have your say “ surveys indicated that the home was clean and fresh. The laundry room is sited away from the kitchen. The floor covering and walls are impermeable making surface readily cleanable. The washing machine has a specific programme for sluicing and there is a tumble dryer. Bernash DS0000026497.V302678.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Feedback from residents, relatives and outside agencies suggests that the staffing levels meet the changing needs of the residents. Vocational qualifications for staff will be better achieved with an alternative external facilitator. The recruitment process must be more robust to ensure the suitability of the staff working at the home. Members of staff attend training that is specific to meet the needs of the residents accommodated. EVIDENCE: The rota in place lists the staff on duty throughout the day and night. There is a senior member of staff rostered, with two care assistants during the day and at night two staff are awake in the premises. Cooking and ancillary staff are employed at the home and rostered until 6:00 pm. Feedback about the standards of care was sought from a variety of sources and their comments indicate that the staffing levels are adequate. Nine residents indicated through the “Have your say” surveys that staff were always available when needed, four felt that the staff were usually available and one felt it was sometimes. Feedback about the staff was also sought from GP’s practice and they indicated that senior staff were always available to discuss Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 20 residents health care needs. Eight responses were received from relatives and all indicated that sufficient staff are on duty whenever they visited. Application forms were recently updated to strengthen the section that relates to disclosures of criminal background. The manager explained that the application form was reviewed to seek specific information about convictions and cautions. While the application form seeks the candidate’s five-year employment history, recent changes in legislation require that employers seek the candidate’s full employment history. Request for reference formats are used at the home and to validate the authenticity of the reference, the manager must request further information. A compliment slip or the use of the office stamp on the reference would authenticate the reference. 50 of the staff files were examined during this inspection to assess the robustness of the recruitment process at the home. Staff personnel files were found to contain their completed application forms, POVA first and Criminal Records Bureau (CRB) checks obtained along with written references. The procedure for poor references and declared convictions were discussed with the manager. It was understood that separate discussions take place and decisions about their employment are made following the meeting. The manager does not currently keep formal records of these discussions, and to ensure the robustness of the recruitment process, formal records of the discussion must be maintained. Members of staff on duty were consulted about training attended and the responsibilities of their role. Members of staff confirmed that new staff undertake the home’s induction programme, which incorporates Manual Handling, Safeguarding Adults, Health and Safety training. It was understood from the staff that they had previous experience of working with older people and had attended other courses to meet the needs of the residents. Dementia training and where appropriate medication training was provided. Vocational qualifications for care assistants were discussed with the manager. It was understood that alternative training facilitators are being sought for the staff already undertaking NVQ level 2. Dementia training was provided by the NHS Trust for the staff, which ensures that staff have the skills to meet the needs of the residents with dementia. Medication training is provided for staff that administer medication and new staff undertake induction training. Bernash DS0000026497.V302678.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35&38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The manager is qualified and competent to undertake the day-to-day management of the home. For residents views to be reflected into the future planning and reviews of the home, a Quality Assurance system must be introduced. Residents are encouraged to maintain control of their finances and procedures are in place to safeguard their finance. The manager ensures compliance with associated legislation to promote a safe environment for residents and staff EVIDENCE: Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 22 The managers’ feedback was sought about the future direction of the home. It was understood from the manager that the intention is to improve the home’s rating from good to excellent. Regarding personal development, the manager said that the Registered Managers Award (RMA) was being consideration to develop the home. The sources used to seek feedback about the standards of care, were positive about the style of management used at the home. The members of staff stated that the manager was approachable and their suggestions are taken on board. As it’s the manger’s intention to improve the home’s rating, a Quality Assurance system must be introduced. Quality Assurance systems are used to measure the success of the home and formalise the planning, actions and reviewing processes. It ensures that residents comments reflect the future planning and reviewing of the home. The manager explained the arrangements in place for safeguarding residents finances. Fees are paid either by cheque or direct debit into the homes account. It was understood that the manager does not act, as appointee for the current residents and facilities exist at the home for the safekeeping of cash and valuables. The records of cash were examined and generally deposits for safekeeping of cash are from family members on behalf of the person. Records are up to date and accurate. There are three boilers at the home, which are serviced annually by a competent contractor. Arrangements are in place for annual PAP testing of electrical equipment and appliances at the home. The local pharmacist visits the home to check storage and ordering of medications and to offer advice on safe handling of medicines. A company registered to manage the collection of waste removes clinical waste from the home. The records that relate to fire safety checks and practices were examined. Records suggest that checks and practices take place at the stipulated frequencies. Call bells, passenger lifts, stair lifts, hoists are serviced annually to ensure the safety of residents and staff. Chemicals are kept in a locked cupboard in the laundry, and notices are displayed to maintain staff safety when using these chemicals. Data sheets and risk assessments for each chemical used at the home are available. Bernash DS0000026497.V302678.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 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 3 3 3 x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12(3) Timescale for action Care plans a) must specific about 30/03/07 how residents that have no verbal communications make decisions incorporate residents preferred routines. b) Personal care needs must be specific for staff to consistently meet the identified need. Formal assessments must be developed to ensure that residents needs can be met at the home. Risk assessments must be completed for residents with mobility impairments to ensure safe systems of moving and handling are in place A Quality Assurance system must be introduces to evaluate the quality of care The manager must request that referees authenticate the reference. Full employment history must be sought through the application forms for all candidates. The Complaints procedure must be assessed to ensure that it is DS0000026497.V302678.R01.S.doc Requirement 2. OP3 14 (1) (a) 30/01/07 3. OP8 13 (5) 30/01/07 4. 5. 6. 7. OP33 OP29 OP29 OP16 24 19 (1) (C) 7,9 & 19 Sch. 2.6 22 (2) 30/10/07 30/12/06 30/12/06 30/03/07 Bernash Version 5.2 Page 25 8 OP10 4(1)(C) Sch1.18 accessible to the residents. Record keeping policies must specify the arrangement in place for the safekeeping of residents records. 30/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bernash DS0000026497.V302678.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Bernash DS0000026497.V302678.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. 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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