CARE HOMES FOR OLDER PEOPLE
Bessmount House 1 Rose Hill Kingskerswell Newton Abbot Devon TQ12 3PP Lead Inspector
Andrea East Key Unannounced Inspection 10th and 15th May 2008 18:00 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 Bessmount House DS0000003652.V365102.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. Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Bessmount House Address 1 Rose Hill Kingskerswell Newton Abbot Devon TQ12 3PP 01803 872188 NONE 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) Mr David George Simpson Mrs Jacqueline Sheila Simpson Mr David George Simpson Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12/12/07 Brief Description of the Service: Bessmount House is a care home that is registered to provide accommodation and care for up to eleven people, who need residential care for reasons of old age, not falling within any other category. The home is situated in the village of Kingskerswell and is close to the Health Centre, local shops, church and other amenities. Mr Simpson is also the Registered Manager. Both Mr and Mrs Simpson work full-time at the home, including sharing the waking night duty. The home has seven single bedrooms and two double bedrooms, all except one have en-suite toilet facilities. All the bedrooms are connected to a call bell system and have telephone and television points. There is a quiet sitting room and a lounge-dining room. There is a bathroom/toilet on each floor. A chair lift provides access to the first floor. At the back of the house is an enclosed patio garden. The fees at Bessmount House range from £550 to £750 Additional charges are made for made for chiropody, hairdressing, outings and newspapers. The homes service users guide, which contains a copy of the inspection report, is located in the hallway. Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes.
The inspection visit was carried out over two days. We examined a range of documents including staff and peoples individual files, policies, procedures and the homes service users guide. People were spoken too in the homes lounge and in private rooms and members of staff were also spoken with. The homes owners were present on the second day of the inspection visit. Feedback about the home was also received by post in survey questionnaires provided by the Commission and in discussion with visitors to the home. This report also refers to information obtained at previous inspection visits to the home. What the service does well:
The home had a system of assessment for people planning to come into the home. People had an opportunity to visit the home and discuss their needs before coming into the home. Peoples, needs were also discussed with relatives and advocates, as some people were unable to say how they wished to be cared for. The home provided a good standard of care for people using the service. People said “they really look after me” “I know they will do what ever is best for me”. Medication administration systems in the home were good. Medication was stored safely and administered safely by staff, who knew the medication policy and procedures well. People were encouraged and supported in enjoying activities inside and outside of the home. People joined in an activities afternoon and going out of the home shopping or to church with staff, relatives or friends. Relatives and visitors were welcomed into the home. People enjoyed the meals served in the home and the home offered a choice in meals and snacks served in the home. People were able to raise any concerns with staff and the owners and that those concerns would be listened to and acted upon.
Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 6 People said that the staff and owners provided a “ kind and caring” service and that they treated everyone with the “respect they deserve”. The home had a good recruitment system, to enable them to check that all documents were in place, before starting a new member of staff at the home. This ensured that no new staff employed in the home, were unsuitable to work with vulnerable people. What has improved since the last inspection?
There had been a past history of written assessments not being fully completed for everyone coming into the home or when completed not being stored on the premises. Written initial and ongoing assessments were on the premises and had been more fully completed. The newly appointed acting manager had worked with the owner Mrs Simpson on extending, reviewing and updating assessment records. Assessments and care plans had improved as they now showed peoples care needs and how the homes staff should care for peoples needs The acting manager and the owner Mrs Simspon had been working on a new format for care planning and assessment that had started to take shape for three of the people living at the home. The things people had participated in and enjoyed was more clearly recorded so that it was clearer how people had been offered the choice to enjoy things that interested them. This had been achieved by the introduction of communication books, activities records and more detail in daily ongoing recording. The management system for the safe handling and recording of foods had been obtained and was being newly implemented. This meant that staff were now following health and safety guidance in relation to food handling. Work had started on re-decorating and the home appeared to be cleaner and brighter. For example the upstairs large communal bathroom was much improved and had been thoroughly cleaned. Work had now started on redecorating and the home appeared to be cleaner and brighter The upstairs large communal bathroom was much improved and had been thoroughly cleaned. Staff training and induction into the home had improved. Staff training records had started to be more consistently updated. So that it was clearer to see what staff had received training in key areas such as manual handling, infection control, adult protection.
Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 7 Induction and supervision records for staff had been re- started. Staff had been enrolled on National Vocational Qualification in care, training and had begun training updates in key areas such as food hygiene and manual handling. The employment of an acting manager in the home to support the owners has meant improvements in management systems and safety in the home. The acting manager worked well with inspectors in exploring ways to continue to improve. For example the introduction of management systems for recording peoples care and health and safety issues. What they could do better:
The service users guide and statement of purpose should be updated and fully circulated as planned. Initial assessments of peoples needs should include if their needs match the registration categories of the home and the new initial assessment for people planning to move into the home should be completed as planned. Care plans and assessments should continue to be regularly (minimally monthly) reviewed and updated to reflect peoples changing needs. The new system of recording should be fully implemented. This would ensure that members of staff are made fully aware of peoples needs and how best to meet those needs. The intercom system can also be cancelled away from the point of call and if accidentally left on in a room can act as a listening device, without the person in the room realising. The manager, owner and staff said that the system was not used in this way and the people using the service liked being able to talk to staff straight away. The intercom system should be cancelled away from the point of call. Written guidance should be provided for the people using the service and for staff on the use of this system. People need to be aware that this system is in place and staff, need written guidance on its use so that people’s privacy is always maintained. There was no system in place for recording and reviewing complaints or concerns that people may have raised. Not recording issues and concerns means that the owners are unable to identify patterns or trends that may indicate poor service or poor care. It would also show how the home deal with concerns and the progress the home had made in some areas. A formal system of recording complaints and concerns should be introduced. Bed rails were in use the home and these rails were not covered with a protective bumper to stop the person in bed, from injuring themselves.
Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 8 The use of Bed rails and bumpers for the rails needs to be assessed, recorded and discussed with the person using the bed or their advocates. Systems should be in place to ensure that the home and garden areas are consistently well maintained. For example have a written plan of maintenance, which includes ongoing work, such as improving the rear garden area and fitting locks to doors. Staff skills and experiences gained from previous employment needs to be sustained to maintain good working practices and safe, affective care for the people using the service. The plans to continue with training and induction for staff should be fully and consistently implemented. Fire safety checks and training needs to be consistently carried out. For example, ensuring that the home has up to date risk assessments for fire safety that are available for all staff, that staff are aware of fire procedures and that fire safety equipment such as escape routes are well maintained. This will assist in keeping people safe from harm in the event of a fire. An ongoing quality assurance systems that seeks the views of the people using the service and monitors the quality of care, should be in place. 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. Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 9 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 Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people using the service were confidant that their care needs had been assessed and that their needs could be met, right from the start of their stay in the home. The services provided did not include intermediate care EVIDENCE: The service users guide and statement of purpose had not been updated and fully circulated as planned. These documents need to be updated so that it is clear to prospective people intending to live at the home the kind of services provided and how peoples’ needs could be met. They should make clear the categories of registration for the home and peoples’ needs in the home should match the categories. Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 11 People living at the home, said that they had an opportunity to visit the home and discuss their needs before coming into the home. Some of peoples needs had also been discussed with relatives and advocates, as some people were unable to say how they wished to be cared for. There had been a past history of written assessments not being fully completed for everyone coming into the home or when completed not being stored on the premises. Staff spoken to relied on information recorded in diaries and information passed on in informal discussions between staff, the owners and the people coming into the home. Written initial and ongoing assessments were on the premises and had been more fully completed. Information not recorded in assessments, were recorded in other places such as diaries and communication books. The newly appointed acting manager had worked with the owner Mrs Simpson on extending, reviewing and updating assessment records. The new system had not yet been implemented for every person living at the home. The new system was in place for any one visiting the home or planning to move into the home. Staff spoken with had a good understanding of peoples needs and said that they talked about peoples needs and how best they could meet them, often before the person came in, although this was not recorded. Assessments had been extended to make clearer the mental health needs of those intending to use the service. For example several people had a level of memory loss. This had not always been recorded in the past and was more clearly set out in the new assessment process. Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People using the service had their health, personal and social care needs met and this was set out in an individualised plan of care. Individuals were involved in decisions about their lives, and did play an active role in planning the care and support they received. People were treated with dignity and respect and their privacy was upheld EVIDENCE: On both days of the inspection care plans and assessments were on the premises. This is an important step forward as there had been a history of these documents not being on the premises for inspection. The acting manager and the owner Mrs Simspon had been working on a new format for care planning and assessment that had started to take shape for three of the people living at the home. The acting manager was working through the paper work for people who had lived at the home for some time and was transferring information into the new system.
Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 13 Assessments and care plans showed peoples care needs and how the homes staff should care for peoples needs. Members of staff were able to describe peoples’ individual needs and preferences in detail. Members of Staff were observed assisting people and they asked people what way worked best for them, when caring for them. There had been an increase in recording systems in the home so that, Staff used diaries and communication books to share information about peoples needs. These books also held information on Health Professionals visits and the day- to- day life in the home. Surveys returned to the Commission said that people using the service felt well cared for and, that staff called in Health Professionals when needed. Care plans and assessments had also started to be regularly (minimally monthly) reviewed and updated to reflect peoples changing needs. When fully implemented this would ensure that members of staff are made fully aware of peoples needs and how best to meet those needs. Medication administration systems in the home were good. Medication was stored safely and administered by staff who knew the medication policy and procedures well. People said that staff dealt with their medication safely and reliably. Medication records examined were well maintained. There call system for people to use to call staff for assistance is an old system that has been in place for some time (years). The system operates as an intercom system so that people can talk to the member of staff through the intercom without a member of staff going into their room. The intercom system can also be cancelled away from the point of call and if accidentally left on in a room can act as a listening device, without the person in the room realising. The manager, owner and staff said that the system was not used in this way and the people using the service liked being able to talk to staff straight away. There were no written guidance for the people using the service or for staff on the use of this system. People need to be aware that this system is in place and staff needed written guidance on its use so that people’s privacy is always maintained. Bessmount House DS0000003652.V365102.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): Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. People’ s lifestyle in the home met their expectations and satisfied their needs. People who used the services were able to make choices about their life style, and were supported to develop their life skills. Social, educational, cultural and recreational activities met individual’s expectations. People enjoyed an appealing, varied diet, at a time that suited them, with support from staff. EVIDENCE: Staff said that people were encouraged and supported in enjoying activities inside and outside of the home. This included most people joining in an activities afternoon and going out of the home shopping or to church with staff, relatives or friends. The things people had participated in and enjoyed was more clearly recorded so that it was clearer how people had been offered the choice to enjoy things that interested them. This had been achieved by the introduction of communication books, activities records and more detail in daily ongoing recording.
Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 15 Surveys consistently said that relatives and visitors were welcomed into the home. One person’s relative said that the staff and owners welcomed them at any time. They said that they had an opportunity to share in the events planned in the home such as meals and how care was provided. Members of Staff were observed preparing and serving meals on both days of the inspection. Staff said that the home did not employ one person as a cook, so that care staff were caring and cooking. After the inspection site visits the acting manager contacted us and said that they home now employed a cook, with staff assisting when necessary. Members of staff, spoken with, were able to describe peoples’ preferences, special diets, meal sizes and favourite snacks and drinks. People said that they could eat where they wanted to and although they were not always aware of what was on the menu, felt that they did have a choice in meals and snacks served in the home. Making sure that people are aware of what is on the menu gives them the opportunity to make an informed choice about what they eat. The acting manager said that the management system for the safe handling and recording of foods had been obtained and was being newly implemented. A management system for food handling had been highlighted at the Environmental Health Officers last visit to the home. (see management section of this report). Bessmount House DS0000003652.V365102.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who used the service were able to express their concerns, and complaints and suggestions from those using the service, relatives or other visitors to the home were treated seriously. People were protected from abuse, and had their rights protected. EVIDENCE: People said that they felt able to raise any concerns with staff and the owners and that those concerns would be listened to and acted upon. Surveys said that people were aware of the homes complaints procedure and new who to speak to if they had any concerns. People felt confident that any concerns would be addressed There was no system in place for recording and reviewing complaints or concerns that people may have raised. The owner and acting manager said that concerns were responded to quickly and the lack of recording did not mean concerns were not addressed. Not recording issues and concerns means that the owners are unable to identify patterns or trends that may indicate poor service or poor care. It would also show how the home deal with concerns and the progress the home may have made in some areas.
Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 17 A relative had raised a concern that had not been dealt with as the acting manager was on leave. The concerns had been considered but not recorded or responded to promptly or formally. Bed rails were in use the home and these rails were not covered with a protective bumper to stop the person in bed, from injuring themselves. One bed rail had been covered with a blanket rather than a fitted bumper. Bed rails are a form of restraint. The use of Bed rails and bumpers for the rails had not been assessed, recorded and discussed with the person using the bed or their advocates. The acting manager confirmed that this would be addressed immediately and after the inspection confirmed that action had been taken to fit bumpers to bed rails and that this had been discussed with families. Bessmount House DS0000003652.V365102.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People lived in an adequately maintained house, which offered a range of facilities and was on the whole comfortable, clean and safe. EVIDENCE: People’s individual rooms were personalised with their own possessions such as photographs, items of furniture and ornaments. Surveys said that the home was generally clean and tidy and that the people living and working at the home enjoyed it’s “homely atmosphere”. Parts of the home had been in need of redecoration and cleaning for some time. For example inside the entrance to the home and the doorway needs decorating. This was highlighted at the previous inspection.
Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 19 Work had now started on re-decorating and the home appeared to be cleaner and brighter There were no ongoing written plans of maintenance. Staff said that repairs were completed as and when needed and receipts for work and maintenance checks were stored at the home. This was also raised at the last inspection. The acting manager had compiled an ongoing working list of repairs and improvements that she said they were working through. A written plan for repair shows the progress the home has made in redecorating and maintenance and is way to ensure that areas of the home are continually refreshed and kept in good repair. The upstairs large communal bathroom was much improved and had been thoroughly cleaned. Since the last inspection improvements to door- way entries had been completed after guidance from an environmental health officer. This had reduced the risk of people falling as part of the doorway had been changed to prevent slips and falls. The outside area to the rear of the property continued to be cluttered and had rubbish bags that had not been removed for some time. The owner said that they removed some of the rubbish. There was no process or system for making sure that this rubbish was removed on a routine regular basis. This collection of rubbish gave the outside of the home an unsanitary appearance. This was raised at the previous inspection. In addition clinical waste bags had begun to accumulate posing a possible health risk. The acting manager and owner were aware of the need to address this and said that they would increase collection of clinical waste. The garden area at the back of the property is not as well kept as the front of the building. The front garden offers a patio area with seating and was a pretty area that people said that they enjoyed looking at. The back garden area should be tidied, grass cut and made more accessible for people to use. Peoples individual rooms do not have locks fitted, so that they can lock them for privacy. The owner said that people had been asked if they wanted locks on their doors and this had been recorded. This was only the case for those people living at the home at the time of the last inspection. This practice had not been continued for new people entering the home. People must have the opportunity to have locks fitted to their private rooms to ensure their privacy. Bessmount House DS0000003652.V365102.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people using the service, were supported by Staff, who were trained, skilled and competent. Staff had been subject to rigours recruitment checks EVIDENCE: Surveys said that the staff and owners were kind and caring and that they treated everyone with the “respect they deserve”. Surveys consistently said that staff had the right skills and experience to look after people properly. Staff were observed assisting people around the home and helping with medication and meals. Members of Staff were described as “kind” and did not rush people, explaining what they were doing and sharing information about the days events. One relative said the staff and owners were “wonderful”. We examined staff files, which had a range of documents in, including application forms and contracts of employment, police checks and references for new staff, that had been consistently completed. The owner and acting manager had reviewed and developed clear processes, to enable them to check that all documents were in place, before starting a new member of staff at the home.
Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 21 Staff said that they had received training and induction into the home. Staff training records had started to be more consistently updated. So that it was clearer to see what staff had received training in key areas such as manual handling, infection control, adult protection. Induction and supervision records for staff had been re- started. The acting manger was working alongside an outside agency, a private firm, to reestablish good induction, supervision and on going training for staff. This was in the early stages of introduction and development and needs continued commitment to ensure all staff have regular induction and supervision. Staff had been enrolled on National Vocational Qualification in care, training and had begun training updates in key areas such as food hygiene and manual handling. Staff skills and experiences gained from previous employment needs to be sustained to maintain good working practices and safe, affective care for the people using the service. Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People lived in an adequately managed home, with some management systems in place to keep people safe. The staff team and owners, worked together to respect and protect peoples’ rights. EVIDENCE: Throughout the inspection visit several shortfalls in management that had bee highlighted at previous inspections had been addressed or partly addressed by the time of writing the report. Some of the management issues had been highlighted on several occasions through inspection visits, so that improvements in these issues were important. The management of fire safety was initially poor. Devon and Somerset Fire and rescue service had highlighted in writing, in April 2007, several areas of
Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 23 concern that had been partly addressed. However on the first day of the inspection an immediate requirement notice was issued in relation to Fire Safety. Immediate requirement notices are served when inspectors feel immediate action needs to be taken by the registered person or person to reduce or remove immediate risks to the people living at the home. The immediate requirement notice highlighted that Fire doors were wedged open with devices not approved by the Fire Authority. The fire panel was turned off and care staff in charge in the home, were not sure how the fire panel worked. Staff in charge rang the owner obtain instruction in how to work the panel. Staff said that they had received fire training but could not recall if this included sounding the fire alarm and checking that fire doors closed. The owners responded to the immediate requirement notice addressing the concerns raised. On the second day of the inspection the fire risk assessment for the home was examined. The document has been extended and updated. However it did not make clear the action staff should take in the event of a fire. The acting manager contacted the commission after the inspection to confirm that this had been completed. She also confirmed that work to the fire escapes had been completed. Clear ongoing systems for fire safety need to be in place to maintain good fire safety practices and keep people safe. Management routines for recording information had been improved. The management system for the safe handling and recording of foods had been implemented. A management system for food handling had been highlighted at the Environmental Health Officers last visit to the home. Although, there were no ongoing written plans of maintenance or cleaning for the home had been cleaned and redecoration of the entrance hall had started. Staff training and induction for staff had started to be more consistently monitored and recorded and staff training had improved. The home had did not have an ongoing quality assurance systems that seeks the views of the people using the service and monitors the quality of care. One of the owners was present for part of the inspection feedback. Unfortunately when discussing the progress made in the home and the need to continue to improve in some areas, the owner was unable to remain in the same room as the inspectors.
Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 24 The employment of an acting manager in the home to support the owners has meant improvements in management systems and safety in the home. The acting manager worked well with inspectors in exploring ways to continue to improve. Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x x x 2 Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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. 2 3 4 Refer to Standard OP1 OP3 OP3 OP7 Good Practice Recommendations The service users guide and statement of purpose should be updated and fully circulated as planned Complete as planned the new initial assessment for people planning to move into the home Initial assessments of peoples needs should include if their needs match the registration categories of the home. Care plans and assessments should continue to be regularly (minimally monthly) reviewed and updated to reflect peoples changing needs. The new system of recording should be fully implemented The intercom system should be cancelled away from the point of call. Written guidance should be provided for the people using the service and for staff on the use of this system. People need to be aware that this system is in place and staff should have written guidance on its use so that people’s privacy is always maintained.
DS0000003652.V365102.R01.S.doc Version 5.2 Page 27 5 OP10 Bessmount House 7. 8. OP16 OP18 9. 10. 11. 12. 13. 14. 15. OP19 OP19 OP19 OP19 OP30 OP33 OP38 Develop a system for recording and reviewing complaints or concerns that people may have raised. The use of Bed rails and bumpers for the rails should be assessed, recorded and discussed with the person using the bed or their advocates. Bumpers should be fitted to bed rails. Ongoing written plans of maintenance should be completed. The garden area at the back of the property should be tidied, grass cut and made more accessible for people to use People must have the opportunity to have locks fitted to their private rooms to ensure their privacy The outside area to the rear of the property should be uncluttered and a system should be in place to ensure rubbish bags do not accumulate. The plans to continue with training and induction for staff should be fully and consistently implemented. An ongoing quality assurance systems that seeks the views of the people using the service and monitors the quality of care, should be in place Clear ongoing systems for fire safety need to be in place to maintain good fire safety practices and keep people safe. Such as up to date risk assessments, maintaining fire safety equipment and fire training for staff. Bessmount House DS0000003652.V365102.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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
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