Inspection on 23/08/06 for Bethune Court

This inspection was carried out on 23rd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 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

Bethune Court 29/07/09

Bethune Court 12/12/05

Bethune Court 06/06/05

Bethune Court 07/01/05

Bethune Court 05/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Bethune Court 30 Boscobel Road St Leonards-on-sea East Sussex TN38 0LX Lead Inspector Elizabeth Dudley Key Unannounced Inspection 23rd August 2006 10:00 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 Bethune Court DS0000021051.V305366.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. Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bethune Court Address 30 Boscobel Road St Leonards-on-sea East Sussex TN38 0LX 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) 01424 719393 sharon.blackwell@anchor.org Anchor Trust Mrs Olga Blything Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is fortyfive (45) Service users to be over sixty-five (65) years of age Date of last inspection 12th December 2005 Brief Description of the Service: Bethune Court is a purpose built residential home on the outskirts of St Leonard’s on Sea in East Sussex. The home incorporates single flatlets for all residents which are furnished with resident own furniture, however furniture can be provided if required. There are several communal areas within the home, and a small well maintained garden, which is easily accessible to all residents of the home. Residents also run a small shop and library and hold meetings to decide what activities and outings they wish to take part in. The home holds many parties and photographs of these adorn the walls of the home. All residents can receive help with personal care, and local GPs and community nurses visit the home. The fees charged are between £400 and £440 per week, this does not include extra services such as hairdressing and chiropody. Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on the 23rd August 2006 and was facilitated by Mrs O Blything manager and Mrs L Lelliot deputy manager. During the course of the visit a tour of the home was undertaken and documentation which included care plans, catering documents, medication charts, health and safety information and personnel files were examined. Ten care plans were examined and six of these were looked at in depth and the residents to whom they referred spoken with at length to ascertain whether their needs were being met and whether the care given was as documented in the care plans. A further eight residents and six visitors were spoken with. Comments received included: ‘what my husband wants is the way they work — they ask his preference on everything, allow him to choose, even when its not always appropriate, they respect his choice’. ‘Excellent home, if I could have got Dad in here I would have been pleased. I’ve got my name down to come here!’. A parochial visitor stated that ‘This is one of the best homes in Hastings’. Whilst residents stated: ‘This is my second time in the home for respite care, the food and atmosphere are very good, it’s a lovely place’, ‘Everything is good, I know about my care plan, the food is nice and the staff are good’. Ten members of staff were spoken with. They affirmed that they received the required training and that they were encouraged to study for the National Vocational Qualification Level 2 in Care. Over 50 of the current staff have achieved a National Vocational Qualification Level 2 in Care, with some achieving Level 3. Discussion with staff showed that they were proactive in allowing residents choice in activities of daily living and were aware of their duty in regarding the care and protection of those in their care. The home has succeeded in providing a good quality of life for those whom they care for. What the service does well: Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 6 The service provides a good quality of well-documented care for all residents at the home. A good range of activities is arrange, with a residents’ committee (comprised of residents) deciding where they will go for outings and what activities will be arranged. Residents are encouraged to continue belonging to those clubs or societies that they attended prior to being admitted to the home. The food is very good, all residents and visitors spoken with made very positive comments and there was evidence of well thought out menus, fresh fruit and choices being offered to residents. A nice touch was added insomuch that tables in the dining room have the dishes of vegetables at lunch for residents to help themselves and at suppertime have pots of tea which are covered with tea cosies, giving and informal and homely atmosphere. Meals can be taken in the resident’s own room if so wished. All health and safety documentation and the tour of the home showed that the home is safe and well maintained, with staff having attended regular fire training and moving and handling training. Risk assessments in place to allow residents to have kettles or to smoke in their room. Everything is being done to facilitate residents being able to lead a life that is as similar as possible to the life that they would have led in their own homes. Several current residents had been admitted to the home for respite care or had visited friends in the home prior to them making the decision to move there. What has improved since the last inspection? What they could do better: Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 7 The manager must ensure that those residents that self medicate are locking their medications away following administration. The home has provided locked boxes and drawers for this to be done. Frequent checking of this must take place. It is recommended that some senior care staff become competent in the monitoring of blood glucose levels in order to be able to admit insulin dependant diabetic residents to the home. 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. Bethune Court DS0000021051.V305366.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 Bethune Court DS0000021051.V305366.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is good, this is based on the available evidence including a visit to this service. All prospective residents have sufficient information to allow them to be sure that Bethune Court will meet their needs and expectations. EVIDENCE: Bethune Court provides a service user guide and statement of purpose, which meet the standard and the regulations. All residents stated that they have received a copy of the statement of purpose and residents confirmed that they had full information about the home prior to admission. Two residents said ‘The manager came to see me before I came in and gave me the information’ and ‘I had so much information given me and then I came in and had tea and a look around’. All residents spoken with and some visitors to the home said that they were able to come and look around prior to coming into the home. The manager also said that prospective residents could come in for lunch or tea and to look around the home. Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 10 There was evidence that all residents are assessed prior to being considered for admission to the home and this assessment forms the basis of the care plan. All residents receive a copy of the terms and conditions on their admission to the home and a signed copy of these are kept. The manager is aware that residents must have payment details prior to their coming into the home and plans to initiate this with the next person to be admitted. Staff are encouraged to undertake courses in the care of the older person and over 50 of the staff have their National Vocational Qualification in care level 2, with some having level 3. Bethune Court DS0000021051.V305366.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is excellent, this is based on the available evidence including a visit to this service. Residents receive a good, well-documented quality of care and are safeguarded by safe practice in the administration of medication. EVIDENCE: A sample of ten care plans was examined with six of these being part of the indepth case tracking of residents. All care plans identified the physical, social and psychological needs of the residents, showed evidence of resident and involvement and that all parts of the care plan had been reviewed on a monthly basis with any new needs being identified. The instructions for the care required were easy to follow and in sufficient detail for a member of staff unfamiliar with the resident to be able to give the correct care. Daily care records are in place and these included sufficient detail to inform of care given. The monthly review of care plans also includes a six monthly full review of the residents care and every resident has a complete care review 6 weeks following admission to the home and on readmission from hospital. Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 12 There was evidence of district nurse involvement when a resident required nursing care or treatment and residents stated that the GP is always called as required ‘I see the doctor when I want to and do my own tablets’. Ongoing instructions received from GPs and district nurses were seen in the care plan with the plans amended where necessary, to ensure that instructions were followed. Two district nurses were spoken with, both said that the care given by the home was good, although one was concerned that the home did not do Blood glucose monitoring. All residents have on-going nutritional assessments and are weighed on a monthly basis. There was evidence that the nutritional care is changed in relation to the results of residents weight with catering staff being involved in this. All staff maintain the daily record in the care plans. Staff accompany residents on hospital visits when required to do so. Continence advisors visit the home as required. The staff receive medication training from the supplying pharmacist and all members of senior care staff have undertaken this. All medication rounds are conducted with two staff members present at the time and all medication charts have been signed following administration. There was evidence of medicine audits and stock rotation, and all controlled drugs were adequately recorded and accounted for. Staff in the home do not undertake the testing of blood glucose levels and it is recommended that this and the understanding of the meanings of these are included in the next training with competence levels assessed. The ordering and disposal of medications were well documented and there is a range of policies. The self-medication risk assessments have been reformatted and the resident is being reassessed on a regular basis. It was noted that two residents were not keeping their medications in the lockable drawer provided for this purpose and the deputy manager addressed this at the inspection. Photographs of residents are in the process of being put in place on medication records. There was evidence of good interaction between staff and residents and residents spoken with said that they were treated with dignity and respect, and this was seen. Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 13 ‘I have a Key worker her name is… She comes and talks to me often so does the manager’. There was ‘preferred name’ details in the care plans and staff were seen to be adhering to these. Staff were treating residents with empathy and great courtesy and residents and visitors gave assurances that this was the ‘same as always, they are very polite and thoughtful’. The home tries to ensure that whenever possible the dying resident can remain at the home in their own room when this stage is reached. As the home does not provide nursing care, district nurses and the Macmillan nurses provide nursing care for these residents withy district nurses saying that the staff maintain a good standard of personal care and keep the resident comfortable. It was evidenced that staff were aware if someone needed extra pain control and accessed the doctor or the Macmillan nurse when this became apparent. Previous inspections have evidenced a high standard of care with residents being kept comfortable. The home has policies relating to the care of the dying resident and letters from relatives thanking the home for their ‘excellent care’ in these circumstances. Bethune Court DS0000021051.V305366.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is excellent, this is based on the available evidence including a visit to this service. The quality of life afforded to all residents is of a good standard. The residents committee meets regularly to decide outings and activities and all residents are kept informed of what is happening in the home. The standard of catering is high. EVIDENCE: Residents are able to make choices about their times of rising and retiring and how they wish to spend their day. The residents have formed a committee which meets on a regular basis and is used as a forum for them to make decisions over what outings and activities will take place within the home, what parties they wish to have and what entertainment will be brought in. They have an ‘Amenities’ fund to which all residents contribute a very small monthly sum, which helps to pay for their transport for outings and shopping. Any money given to the home is put into this fund and the residents make the decisions over the way the money is used with the balance sheet being given to all residents. Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 15 In house activities taking place include musical evenings and afternoons which recently included a member of staff playing the violin - which took place on the day of the site visit and was well attended, with glasses of wine and other drinks being provided. Other activities may include board games, videos, and entertainers being brought in. These include keep fit sessions, an organ player, a singer, a musical theatre and a storyteller. The manager states that the majority of residents take part in the outings and activities. The home puts on some evening activities which have included a drinks evening and some parties, buffet teas and suppers. Outings over the summer included visits to a fish farm, out to Rye for a cream tea, and cream teas in Eastbourne at Beachy Head. Theatre trips take place about three times a year. Residents are also encouraged to go out to clubs and belong to groups etc that they visited prior to being admitted to the home, and are helped with transport etc. This was evidenced on the day of the inspection. Residents stated ‘They inform me of what activities are on and I go to residents meetings’, ‘We go to the residents meetings and are on the committee’, ‘I am very happy here its probably the best thing I’ve ever done. Wonderful care, good food, own choices of how to spend my day and the staff are lovely’, ‘The entertainment is good and they give you a glass of wine when you want one. I love it here’. ‘I am very happy here, it’s a good home and we can do as we wish, yes very happy, I am allowed to smoke my pipe in my room’. There is a resident’s magazine produced on a regular basis that holds residents contributions in the way of poems, short stories, and a newsletter is sent to all residents informing them of what is happening in the home. The home has an open visitors policy and ministers of religion visit the home, visitors can be entertained in any part of the home and are invited to various functions taking place. All residents bring in their own furniture to furnish their flats, although this can be provided if required. The standard of catering is of a high standard with a variety of meals served and residents being aware of the alternative meals available. Carer staff and catering staff go around and ask residents what they would like for the meals on that day. The meal served on this day was Roast Chicken, stuffing, roast potatoes, carrots and sprouts or savoury pasta bake (a vegetarian meal is an option every day). The supper meal was either savoury pancakes, omelettes, soup Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 16 and a selection of sandwiches. Most cakes and puddings are home made. Wine is always offered with Sunday lunch. Snacks and drinks are available on demand and fresh fruit is offered daily. There is a choice of food for breakfast, which can be either served in resident’s rooms or in the dining room until 10.30. Each dining table has dishes of vegetables for residents to help themselves and at suppertime there are teapots (with tea cosies) on the tables. Staff can cook a variety of special diets and all catering staff have their food hygiene course. The kitchen is clean and all temperatures of fridges, freezers and hot and cold food are recorded on a daily basis. All records required by the CSCI were in place. The kitchen is due a refurbishment and the Environmental Health Authority have made this a recommendation. This is being addressed by the home. Positive comments only were received about the food from residents and visitors, ‘We couldn’t do better, we have a change of menu every day’, ‘The food is very good and I have my own kettle’. Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 17 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): 16,17 and 18 Quality in this outcome area is excellent, this is based on the available evidence including a visit to this service. Residents are protected by the complaints policy and staff awareness of their protection. Minor concerns have been addressed in an open and transparent manner. EVIDENCE: There is a comprehensive complaints policy which is displayed in the home and is included in the service user guide. All residents spoken with were aware of how to make a complaint, either through the manager or through Anchor Trust. No complaints have been made this year, the manager states that she talks to residents about any minor concerns that they may have and residents verified that these are usually ‘very small matters — something going missing in the laundry or suchlike’ and that these are always resolved to their satisfaction immediately. All staff have had training in the protection of the vulnerable adult and were aware of their role in this. This training takes place initially during the induction of new staff and is then updated on a regular basis. There have been no complaints or concerns received by CSCI. Bethune Court DS0000021051.V305366.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is good; this is based on the available evidence including a visit to this service. The standard of decoration, maintenance and cleanliness within the home is good, providing a pleasant home for residents. EVIDENCE: This is a purpose built home with resident’s accommodation spanning three floors. There is a large dining/communal room on the ground floor with access to the garden and lounges and small sitting areas on the other floors. The garden is pleasant and well maintained with seating areas, and is accessible to all residents. The home is pleasantly decorated and well maintained. Residents bring their own furniture into the rooms, but can furniture can be provided if required, every room has a lockable door and a lockable facility for residents possessions. Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 19 Residents stated ‘We can lock our own door’ and ‘lovely home, I can lock my door and its always lovely and clean’. All water to resident’s outlets is thermo regulated and records of the water temperatures showed that these were within recommended parameters. Some curtains are in need of replacement but the manager is in the process of choosing these and curtain samples were seen in the office. All residents’ accommodation has lockable doors, windows with a restricted opening and magnetic door closures for use in the event of fire. All rooms have an ensuite facility consisting of a shower, washbasin and wc. The home has assisted baths in the general bathrooms and raised wc and grab rails. The home has been assessed by a disability living specialist, and has hoists and lifting equipment and handrails in corridors. All areas are in a clean and tidy, sufficient gloves and aprons are provided for staff use, and there are disposable towels and soap dispensers in all bathrooms and wc’s. The home provides a laundry service for residents and the laundry area is clean with impermeable flooring. Most staff have undertaken a course on basic infection control and there are policies and procedures addressing this aspect of care. As the home has no sluice facility, face visors are provided for staff to use when dealing with body fluids. Bethune Court DS0000021051.V305366.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is excellent, this is based on the available evidence including a visit to this service. The number of staff on duty over a twenty-four hour period is sufficient for the numbers and needs of the residents living at the home. Residents are protected by the recruitment policies and the training of the staff to meet their needs. EVIDENCE: Sufficient staff are rostered on the duty rota to meet the assessed needs of the residents. All staff spoken with stated that there were sufficient staff on duty at all periods during a twenty-four hour period, including weekends. A health care professional visiting the home had stated that at weekends staff had said that they were short staffed, but staff refuted this saying that although this may have been said, usually weekends were well covered, Sometimes in the event of sudden staff sickness this may occur but there were still enough staff on duty to ensure that the home was covered and all resident’s needs were met, without the staff feeling unduly pressurised. An extra member of staff is now rostered for night duty, bringing the total to three. All staff undertake an induction training on the commencement of their employment at the home and takes place over a period of six weeks. Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 21 Staff spoken with verified that they had all attended mandatory training including fire training, moving and handling training and first aid, and where applicable, the food hygiene certificate. Other training relevant to the care and various health conditions of the residents is given both in house and externally, a bereavement and care of the terminally ill course was attended by some staff. Further members of staff have just completed their NVQ level 2 bringing the total to 50 of staff having completed this training. Three members of staff have NVQ level 3 and the manager, deputy manager and administrator are NVQ Assessors. There is a good training schedule and the services of ‘Investors in People’ are presently used. All staff personnel files examined (10) contain all documentation as required by the regulations and the National Minimum Standards. All staff have a copy of the GSCC (General Social Care code of Conduct) booklet. Interviews with staff were held and they confirmed that they receive sufficient training, are aware of their responsibilities in the protection of those in their care and were aware of company policies and procedures particularly relating to choice, privacy and dignity. They were enthusiastic about the various training opportunities offered, both in house and externally. Bethune Court DS0000021051.V305366.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 Quality in this outcome area is excellent, this is based on the available evidence including a visit to this service. Management systems within the home support the safety and welfare of the residents and staff. EVIDENCE: Mrs Olga Blything has managed Bethune Court since it opened, fourteen years ago. She is an RGN (Level 1), is on the register of accredited social workers and holds the Registered Managers Award. Some staff have worked with Mrs Blything since the home opened. There is a positive ethos within the home with residents, visitors and staff speaking of the pleasant atmosphere. Staff turnover is low and many of the staff have worked at the home for several years. Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 23 Management practices are transparent, with all residents being kept informed of what is happening in the home and receiving copies of the balance sheets for the amenities fund. Residents meetings, run by the residents, are held on a monthly basis and a newsletter is provided three monthly. There is an process for monitoring quality within the home and recently a national care homes quality audit company completed a quality audit within the home which stated that this puts the home into an ‘elite category of homes surveyed’ by them. Some comments from residents that they included in their report were ‘perhaps the lift signs could be a little clearer’, ‘cannot fault it’, ‘everything is excellent’, ’There is nowhere else I would rather live, the staff are perfect and care for me well’. Of 36 attributes measured, 35 scored above the mean for all homes surveyed by this company. Regulation 26 visits by the responsible individual take place on a monthly basis and staff supervision takes place at intervals as dictated by the standard. Staff meetings are held on a monthly basis and the minutes of these were seen. The business plan for the home was seen for the year 2006/7 and appeared to be satisfactory, and all residents’ finances held by the home for them were in order. All records were kept secure and policies and procedures have been updated on a regular basis. All certificates relating to the servicing of utilities and equipment were in place and in date and all staff have attended mandatory training. Risk assessments are in place. The fire risk assessment is due for renewal and the manager has arranged this. No matters that could adversely affect the safety or welfare of residents or staff were found. Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 3 4 4 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 3 3 3 3 3 Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation Reg 13(2) Requirement That review of those service users who self medicate takes place on a regular basis to ensure that they continue to keep their medication locked in the facility provided for this. Timescale for action 30/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations That some senior staff undertake training for the monitoring of blood glucose levels. Bethune Court DS0000021051.V305366.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Bethune Court DS0000021051.V305366.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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