CARE HOMES FOR OLDER PEOPLE
Bevan House Stackwood Avenue Barrow in Furness Cumbria LA13 9HQ Lead Inspector
Marian Whittam Unannounced Inspection 25th July 2006 09:00 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 Bevan House DS0000035555.V297848.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. Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Bevan House Address Stackwood Avenue Barrow in Furness Cumbria LA13 9HQ 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) 01229 894547 01229 894550 www.cumbriacare.org.uk Cumbria Care Post Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (40) of places Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 40 service users to include: up to 40 service users in the category of OP (Old age, not falling within any other category) up to 9 service users in the category of DE(E) (Dementia over 65 years of age) When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing Wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available. 28th October 2005 3. Date of last inspection Brief Description of the Service: Bevan House is a care home registered to care for 40 older people, 9 of whom may have dementia. The home is in a residential area of Barrow in Furness, close to a local bus route into Barrow, and to surrounding areas. The home has a car park to the rear of the building and there are patio areas for residents to use. All of the home’s 40 bedrooms are single rooms and the home is divided into five units for residents. On the first floor are Langdale, Abbey and Furness units and on the ground floor are Piel and Ramsden units. Piel cares for up to 9 people with dementia and Ramsden offers respite care for up to 6 people. Each unit has a non- smoking lounge and dining area with a small kitchen attached, a bathroom and 2 separate toilets. The home has a main kitchen and a large ground floor lounge for communal activities. Information is available to prospective residents in the combined Statement of purpose and service users guide; this is available and displayed in the home. A copy of the last inspection report is on display. The fees charged by the home range from £363.00 to £422.00 per week as at the date of the inspection and an additional charge is made for personal toiletries, newspapers, magazines, also hairdressing and chiropody services and any personal travel expenses, according to information provided during the inspection. Bevan House DS0000035555.V297848.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 visit took place on 17th July 2006. Pre inspection information on residents, fees, staffing and services provided requested in advance of inspection by CSCI was not returned by the providers before the inspection. No resident surveys were returned before the inspection. Therefore before the site visit information was gathered on the service from records of previous visits, notifications, regulatory activities and complaints, concerns and allegations received. The morning was spent looking around the home talking with residents in the lounges and in their own bedrooms. Speaking with the manager, with care and supervisory staff, the cook and observing activities on the units and work practices, and looking at care plans. Ten residents were happy to talk about their experiences of living in the home. An inspection of medication handling and records was carried during this visit out by the pharmacy inspector. A full report is available from the Penrith office of CSCI. The afternoon was spent examining policies and procedures, menus, systems for recording complaints and quality assurance, activities programmes, financial, personnel and training records as well as other records required by regulation. What the service does well:
Residents and visitors spoken with praised the staff, liked the staff team and one resident said they felt that staff are, “ very helpful”. Staff have a good rapport with residents and their approaches to residents are friendly and informal. Throughout the day the inspector saw that staff and residents got on well together and that residents individuality is respected. Care staff do their best to support residents in their interests where they can during the working day. The home provides a comfortable and homely atmosphere. Residents spoken with felt staff worked hard for them and gave them time as they could and listened to what they had to say. Staff show an interest in the residents and in supporting them in daily life and in small details such as getting small items of shopping for them. Care plans in the home are well kept and up to date to reflect resident’s needs. The service has worked hard and shown commitment to improving areas of the service where requirements have been made and to try and improve the service for residents from this. The home ensures that residents are able to take their own medicines if they want to and are assessed as safe to do so. Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 6 This promoted independence that is also important for those receiving respite care who may return to their own homes. What has improved since the last inspection? What they could do better:
Staff on the individual units provide residents with some opportunities for recreation during the day as workload allows. However these can lack variety and suitability for individual abilities and expectations, as in the case of trips outside the home. An overall programme of social and cultural activities reflecting resident’s expectations needs to be developed. This should be in consultation with them and in light of different capabilities and preferences and with particular attention to residents with dementia and other cognitive impairments. The programme should be easily accessible to residents and in a format to suit and so improve what is available according to the individual expectation and preference. An identified individual should take responsibility for organising and making sure planned activities take place The home has some areas of good practice in handling medication but must improve the ordering procedures for medicines to ensure that they are always in stock so that residents have the medicines they need at the time they need them and that medication changes are put into practice straight away. Some
Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 7 medicine administration records need to improve to avoid the risk of error and confusion and the location for storage before disposal of medication must be reviewed to reduce risks to residents from accidental access to these medicines. The morning medicines rounds are lengthy and would benefit from extra staff being made available to enable residents to get their medicines at the right rime. Although records generally were in good order the home must make sure that all events that may have an adverse effect on the well being or safety of any resident is notified to the CSCI without delay. Similarly the manager in post at present must apply to register with the CSCI promptly, as they have been in post since January. The home manager is dealing with occasional staff shortages as well as he can and as resources allow but should consider addressing the current method of moving staff around the home during the course of the day as shifts change to promote better continuity and more effective use of management time. The manager is making progress in working to fully implement a formal staff training and development programme and this should continue until fully implemented and also individual training assessments and profiles for staff. The home provides information for residents and prospective residents but to promote good practice should consider making its statement of purpose/service user guide available in different formats also the complaints procedure should be available in different formats to suit resident’s needs. The statement of purpose and service user guide should also be updated to reflect changes. 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. Bevan House DS0000035555.V297848.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 Bevan House DS0000035555.V297848.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 judgement has been made using available evidence including a visit to this service. The home’s Statement of Purpose, Service User Guide and terms and conditions of residency provide information for prospective residents to make informed choices about moving to the home. An assessment process, care planning system and relevant information is in place to provide the staff with the information to meet resident’s needs. EVIDENCE: The home has a combined statement of purpose and service user guide, including resident views and the most recent inspection report on display in the entrance hall. This needs only minor updating on the management arrangements. These documents are however not available in alternate formats, such as audio or large print for those with sight problems. Individual care plans show that the residents have their personal health and social needs assessed before and following admission to the home and their individual care plans have been developed from this. The home manager or senior staff do an individual assessment of needs if needed in addition to social
Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 10 services care management plans to try to ensure that the home can meet individual needs before residents come to live there. The home has an introductory period that varies in length depending on the individual situation and this is followed by a review to make sure needs are being met and the resident is happy to stay. Residents are provided with terms and conditions of residency so they are aware of their rights and responsibilities. Bevan House DS0000035555.V297848.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 adequate. This judgement has been made using available evidence including a visit to this service. An effective care planning and review system is in place and the personal, social and health needs of residents are being met and privacy respected. However, some aspects of medicine administration and recording must improve to fully safeguard residents. EVIDENCE: All residents have an individual care plan that states objectives and is based on initial assessments and risk assessments, setting out assessed health, social and personal care needs. Equipment to prevent pressure sores is in use and nutritional screening. These are reviewed and updated as needs change. Specific healthcare needs are being identified at assessment and residents said they are asked about their care by staff and staff give them information they ask for. Staff spoken with are aware of residents care needs and their preferences and demonstrated a familiarity and understanding of their needs and preferences. Individual choices and decisions by residents are recorded, for example one resident has definite preferences about a footrest on their wheelchair, which they find helps their mobility.
Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 12 The recording of receipt and disposal of medicines is good and audits of medicines use showed that residents’ medicines are handled properly. The administration records must however be more accurate to reduce risks to resident’s health. The home demonstrated some areas of good practice in handling medicines such as getting written confirmation from resident’s doctors of dosage changes so that the right dose is given. However, the systems for ordering medicines must be reviewed to ensure that they are available at all times to reduce risk to residents health if they do not get the medicines they need. Storage for medicines awaiting disposal needs review to reduce risks to residents from accidental access to these medicines. The morning medicines rounds are lengthy and would benefit from extra staff being made available to enable residents to get their medicines at the right rime. Observing staff going about their duties and talking with residents during the day indicated they are approachable, polite and respect individual’s wishes and privacy. Residents confirmed that staff explained what they were doing when helping them and one resident said they had “ I cannot fault the carers, they’re helpful and come when I ring”. Another resident commented that they felt safe in the home and had only to ring the bell and that night staff are “very good” and check on them during the night. Staff observed attended to residents needs promptly Residents confirmed they saw relatives, other visitors and doctors and nurses in private. Policies and procedures are in place on aging, death and dying including spiritual needs. The district nurse and GPs manage the care of any dying residents alongside the home. Bevan House DS0000035555.V297848.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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides some social and leisure activities within the home and outside but this is not always consistent, the staff support residents individually to maintain their own affairs, outside contacts and interests. There is variety and choice in the food on offer and special dietary needs are catered for. EVIDENCE: On the individual units staff do support residents, as their work allows, in recreational activities and listen to what they want to do, on one unit dominoes are a regular activity with one resident coming to play from another unit. Cards are also played in the evening. Other units do impromptu activities, sing a longs, chat with residents and the atmosphere is friendly and informal. One resident said they had enjoyed the bingo but that has now stopped. There have been some organised musical events from time to time and there are regular multi denominational religious services each month. However some residents spoken with say that they would like to have some organised trips out locally and have raised this at residents meeting “but nothing happens”. One resident said they sat outside sometimes but wished there was “a bit more to do beside watch TV”. Minutes of the meetings show the topic of activities has been raised with residents asking for more. Although the statement of
Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 14 purpose has an activities programme there is no evidence of that being displayed and followed in the home and no one person has responsibility for making sure activities are planned with residents and take place. Interests and preferences are recorded in care plans. The manager is aware of the need to improve the provision of activities and make sure they are planned and varied to suit residents expectations and capacities. Some additional equipment has been bought to try and improve the activities available. The manager has an understanding of the reasons why activities development has so far been unable to proceed. An overall programme of social and cultural activities reflecting resident’s expectations must be developed in consultation with residents and information about activities made available to residents in formats suited to their capabilities. An identified individual should take responsibility for organising and making sure planned activities take place. Menus have been discussed at the residents meetings and these have been taken forward. More than one resident said the food was “ good” and that they enjoyed it and always had a choice of meals. The lunchtime meal observed offered a choice, was well presented, unhurried and sociable. Staff were helpful and offered assistance sensitively. The menus provided showed a nutritious and varied diet that catered for special diets, one vegetarian. The cook was spoken with and confirmed the feedback from residents meetings that have been put into practice. Records are kept of the food served to residents. Bevan House DS0000035555.V297848.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure available within the home and a system in place for logging and responding to complaints. There are satisfactory adult protection processes in place to help protect vulnerable adults and these and appropriate training is available for staff in the home. EVIDENCE: Since the last inspection the home has completed one adult protection investigation and one is still in progress following an allegation of abuse. The correct procedures are followed using multi agency guidance and it is being addressed by the home with other relevant agencies. The home has a complaints procedure and a system for logging complaints for investigation and the procedure is displayed in the foyer and in the service user guide. However it is not available in alternative formats in the home for residents with disabilities such as large print or audio. One resident spoken with has a visual impairment and so could only read large print. No complaints had been recorded since the last inspection. Residents spoken to said that they knew who they would speak to if they were not happy, usually their carers. Residents say the manager goes round each morning and spoke to everyone so they could tell him then if they were not happy. Those spoken with felt confident the manager and staff would listen and take action if they were unhappy. Advocacy services are available to residents if they want someone to act on their behalf and information on this is displayed.
Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 16 Multi agency guidance is in use with adult protection procedures. Staff spoken with confirmed they had received training and were clear on what they would do, in the first instance, if they thought someone was being abused in the home. The home did not deal with any resident’s personal finances only small amounts of spending money for safekeeping and practices and procedures are in place to protect resident’s financial interests. Bevan House DS0000035555.V297848.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, 22, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, tidy, homely and adequately maintained for residents and has the equipment they need to promote mobility and independence although some areas of the grounds are not easily accessible for all residents. EVIDENCE: There is a programme of maintenance and improvement for the home planned and agreed annually within the organisation. The grounds are well cared for and some residents sit out on the patio. However, some residents with poor mobility and dementia have reduced safe access to the grounds, this was particularly evident with the hot weather. The manager is aware of this limitation for some due to a lack of ramps and security for dementia residents using the grounds. The manager recognises the difficulty, discussed his approach to managing this at present and ideas for future improvement. The manager should take these ideas to improve facilities for residents forward as part of the homes long term improvement strategy and maintenance planning to improve access to and use of the grounds for the residents affected.
Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 18 The dining and lounge areas on the units are clean, homely and well decorated and used for daily activities, and some residents were sitting in them reading their papers, chatting and watching television. There are telephone facilities available for residents to use and call bells in all areas used by residents. The new smoking room is an improvement for residents. It gives smokers a designated place to go and does not intrude on others. The windows were open to allow smoke out but an extraction system is planned for the smoke. Resident’s bedrooms seen by the inspector had locks for privacy, satisfactory decoration and suitable lighting, ventilation and furnishings. Many residents have brought in their own possessions and pictures and this made their rooms more personal and homely. Some rooms had been redecorated and carpeted as part of the ongoing maintenance The home has policies and procedures for infection control in place supported by staff training. The laundry facilities are clean and tidy and systems in place to minimise risks from Legionella and test water temperatures are being done to minimise risks from scalds. A schedule of shower -head cleaning is also in place. Sluices are tidy and kept locked, as cleaning substances are stored there. There is a range of mobility equipment, some provided by the occupational therapist to suit individuals, and adaptations to help residents make the most of their independence and to get about inside the home. Bevan House DS0000035555.V297848.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing numbers are adequate with care staff who have training relevant to the resident groups but are at capacity and stretched to meet residents needs at some times of the day. There are satisfactory recruitment procedures being followed to safeguard resident and appropriately trained staff offering care to residents. EVIDENCE: The rotas indicate the home has experienced periods of staff shortages when staff levels have been below a minimum level and is having to use agency staff on occasion to maintain minimum staff cover. The rotas indicate that staff levels are at capacity with little room for any sickness or holiday cover. The manager is covering shifts by moving staff around the home in the course of a day to fill in when shifts go off and there are not staff coming on until later. There are periods of the day when units would not have staff at minimum levels if this were not being done. The home manager has to re deploy staff throughout the day to achieve this. For good practice the home should address this reactive method of staff deployment to promote better continuity and more effective use of management time. It also depends very much on close monitoring by senior staff daily rather than an organised system known in advance. The number of staff with NVQ Level 2 in care is just below the 50 level required but some are yet to complete. Staff spoken with felt supported in
Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 20 achieving this qualification and are well motivated to take on training and to progress in their NVQ and in other training. The homes recruitment practices are in good order and appropriate procedures and checks are being carried out. An overall training programme and staff development profiles need to be put in place. Assessing individual training is difficult as the records are not all on file and there is no record of updates and identified needs. Staff in the home are also being involved in this and working on their development plans themselves. Records of induction training are on file. Appraisals have been done for staff so learning needs have been identified. The manager is aware of the need to formalise training and development profiles and develop a programme for all staff and is working towards this and should continue to do so until fully implemented. Residents spoke well of staff approaches and how hard they work to care for them. Bevan House DS0000035555.V297848.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, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has quality systems to see if it is meeting its aims and promoting residents best interests and maintains records required for regulation. The manager has yet to register with CSCI for the post. There are health and safety procedures in place to safeguard resident’s welfare. EVIDENCE: The manager has yet to begin the process for registration and fitness as manager with CSCI, although they have been in post since January 2006 and must do this quickly. There are quality monitoring systems and procedures in place in the home. Regular staff meetings allow staff feedback, there are internal reviews of policies and procedures and staff appraisals are being done. Residents
Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 22 meetings are being held and topics recorded and some acted upon. Residents say that the manager comes around daily and they can speak with him then, raise issues with him or their key worker. The home is doing satisfaction surveys for residents, families and health care professionals. Staff spoken with found that the manager was approachable and supported them in their role. There is a development plan for the home within the overall organisational plan for 2006-7, setting targets and objectives and a strategic action plan. The manager shares targets with staff and what the home wants to achieve and this promotes staff involvement. Policies and procedures are produced and reviewed centrally across the organisation. Formal staff supervision is being done and records kept. The standard of record keeping and organisation of information is generally satisfactory. Policies and procedures are in place to protect resident’s financial interests and to safeguard spending money given to the homes for safekeeping. There are health and safety procedures in place to promote the interests and safety of residents and records of fire and other mandatory training, fire drills, equipment testing and the servicing of equipment and appliances. However trailing wires and the awkward positioning of furniture in one room identified at inspection could pose a hazard to staff and the resident and must so far as possible be eliminated. There have been occasions when the home has not notified CSCI of events in the home that may adversely affect the well being or safety of a resident, as required by regulation, and the manager must consistently do this. Bevan House DS0000035555.V297848.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 2 2 Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement The reason why a medication is not given must always be recorded on the MAR chart. This was to have been met by 30/11/06 The person administering the medication must sign the record immediately after giving it. This was to have been met by 30/11/05 A continuous supply of medication must be provided for residents. This was to have been met by 30/11/06 The registered person must ensure that medication administration records are maintained: • They must be accurate for form, dose and strength of medication where they are hand written, and must be signed, checked and dated
DS0000035555.V297848.R01.S.doc Timescale for action 01/09/06 2. OP9 13 (2) 01/09/06 3. OP9 13 (2) 01/09/06 4. OP9 13(2), 17(1)(a) Schedule 3(3)(i) 01/09/06 Bevan House Version 5.2 Page 25 5. OP9 13 (2) 6. OP9 13 (2) 7. OP12 16 (2) (m) (n) 8. 9. OP31 OP38 9 (1) (2) 13 (4) 10. OP37 37(1) (e) All administrations must be signed for • Duplicate administration records must be avoided and this must be discussed with the pharmacy The registered person must ensure that there is a system in place so that all medication changes are implemented accurately and without delay. The registered person must ensure that medicines that are awaiting disposal are stored securely. An overall programme of social and cultural activities reflecting resident’s expectations must be developed in consultation with them and available in formats suited to their capabilities. The acting manager must apply to register for the post with CSCI without delay. Trailing wires and the layout of furniture in one residents room, identified at inspection, must be attended to make sure unnecessary risks to health and safety are, so far as possible, eliminated. The home must notify CSCI of any event, which adversely affects the well being, or safety of a resident. • 01/10/06 01/10/06 30/09/06 25/08/06 31/08/06 07/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 26 1 2. 3. 4. 5. 6. OP1 OP1 OP9 OP12 OP16 OP27 The home should consider making its statement of purpose/service user guide available in different formats. The statement of purpose and service user guide should be updated to reflect management changes. It is recommended that more staff are available to assist with medicines administration during large medicines rounds. An identified individual should take responsibility for organising and making sure planned activities take place. The complaints procedure should be available in different formats. The home should address its current method of staff deployment to promote better continuity and more effective use of management time. The work to fully implement a formal staff training and development programme should continue until fully implemented and also individual training assessments and profiles for staff. 7. OP30 Bevan House DS0000035555.V297848.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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