Inspection on 12/07/07 for Bishopsmead Lodge

This inspection was carried out on 12th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Bishopsmead Lodge 22/01/08

Bishopsmead Lodge 02/01/07

Bishopsmead Lodge 27/06/06

Bishopsmead Lodge 28/02/06

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

CARE HOMES FOR OLDER PEOPLE Bishopsmead Lodge Vicarage Road Bishopsworth Bristol BS13 8ES Lead Inspector Vanessa Carter Key Unannounced Inspection 12th – 13th July 2007 09:30 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 Bishopsmead Lodge DS0000066339.V337665.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. Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bishopsmead Lodge Address Vicarage Road Bishopsworth Bristol BS13 8ES 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) 0117 935 9414 0117 935 9424 viviennec@mimosahealthcare.com None Mimosa Healthcare (No4) Limited Post Vacant Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51) of places Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Registered Manager must be a RN1 or RNA on the NMC register May accommodate 4 persons aged 51 years or over who have a physical disability and require nursing and personal care 2nd January 2007 Date of last inspection Brief Description of the Service: Bishopsmead Lodge Nursing Home is a purpose built care home, designed to accommodate up to 51 persons over the age of 65 years. The home is a twostorey building with lift access to the first floor. There are 43 bedrooms for single occupancy and four shared rooms. All rooms have ensuite facilities including a toilet and wash hand basin. The home is owned and run by Mimosa Healthcare Ltd, a Nottingham based company that expanded into the West Country in 2006. Along with Bishopsmead Lodge, there are three other care homes in the Bristol area Honeymead Care Home in Bedminster, Sunnymead Manor in Southmead and Kingsmead Lodge in Shirehampton. This home is located in the residential area of Bishopsworth on the south side of Bristol close to local shops and the library. Car parking is provided to the front of the property, and to the rear is a small paved area where the residents can sit outside in the warmer weather. Fees for placement at the home currently range from between £472 - £487, (from £400 for a residential basis only), and are determined on an individual basis. Hairdressing, newspapers and chiropody costs incur additional charges. Prospective residents can be provided with information about the home (Service Users Guide) and this will detail the services and facilities available at the home. Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection was unannounced and took place over two days. A combined total of 13 hours were spent in the home. Evidence to form the report has also been gathered from a number of other sources:• Information provided by the Home Manager in the Annual Quality Assurance Assessment (AQAA) • Talking with the home manager during the inspection • Talking with some of the registered nurses, care staff and ancillary staff • Observations of staff practices and their interaction with the residents • A tour of the home • Case Tracking the care of a number of residents • Talking with a number of the residents • Talking with a number of visitors to the home • Looking at some of the homes records • Information supplied by residents and relatives in CSCI survey forms • Information supplied by one GP surgery The home has markedly improved since the last inspection. The requirements made from the last inspection have been met showing compliance with the relevant regulations. Of the nine good practice recommendations, five have been met. Following the last inspection, four statutory enforcement notices were issued – each were met within the given timescales. What the service does well: Information available about the home, and the admission processes ensure that placement is only offered to those whose care needs can be met. Residents can choose how they spend their time, are able to participate in a variety of activities and are provided with a well balanced diet. Residents can be assured that any complaints they may have will be properly handled and that they would be safeguarded from coming to any harm. Residents live in a comfortable, well maintained, clean and tidy home which is free from any unpleasant odours. Positive changes in the staff team and the measures for meeting the training needs of staff will ensure that the residents are cared for by staff who are competent and have the necessary skills. Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 6 Improvements in the management of the home ensures that residents live in a safe home that is run in their best interests, where their views are valued and acted upon. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. 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. Information available about the home, and the admission processes ensure that placement is only offered to those whose care needs can be met. EVIDENCE: The home’s Statement of Purpose and Service Users Guide, (Welcome Pack) accurately reflects the current service provision, and contains all the necessary information to enable any prospective resident to make an informed decision about moving to the home. Copies of the welcome pack were seen in some bedrooms. One resident who had only recently moved to the home said she had been given information about the home. All of the relatives and about half of the residents who completed CSCI survey forms said that they had been provided with information about the home, enabling them to make a decision that the home was the right place for them or their relative. For all the residents who were care tracked as part of the inspection process, a copy of the terms and conditions of residency had been completed. A Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 9 requirement notice was issued to the home after the last inspection and the home are now complying with the relevant regulation. The home follows good admission procedures to ensure that placement is only offered to those whose needs can be met. Prospective residents will have been fully assessed prior to being offered placement. Four assessments were looked at and each provided a comprehensive picture of the resident and their care needs, were signed and dated therefore verifying that they had been completed prior to admission. Information is gathered from social workers and other healthcare professionals where appropriate. Upon admission, the home then complete a further ‘Physical and Social Assessment’. This is only a “tick box” and is used to follow through into the care planning documentation. The document does not allow the staff to record any specific information about the resident, and a recommendation was made after the last inspection that this form be reviewed. This form does not encourage the staff to then prepare person centred care plans. Where possible, prospective residents or their representatives are encouraged to visit the home prior to making a decision about moving there. They would be shown around, told what the home has to deliver, and given an explanation of how their needs are going to be met. The majority of residents are admitted in to the home following a hospital stay. Comments that residents wrote on CSCI survey forms included “I came up for dinner”, “my family brought me to the home to have a look around”, and “I have been here before as my brother in law used to live here”. All new admissions are generally reviewed after a four-week ‘trial period’ but this can be dependent on individual circumstances. Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six care plans were looked at, three from each floor. Despite the home showing at the last inspection that improvements had been made with care planning documentation, those improvements have started to slip back to old ways. Each of the six plans had areas where minor improvements were necessary. In general the plans were satisfactory but nurses must ensure that when they prepare plans, they are individualised for that resident. The planned actions they record must be specific to that individual, be appropriate to a care home setting, and then acted upon in the way that has been agreed. Examples where amendments were needed were discussed with both the home manager and the deputy manager. Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 11 The plans covered a range of needs for each resident, and they contained information about the person’s social and family history. The plans followed on from the information contained on pre-admission assessment documentation. Along side these plans, the home have completed a number of risk assessments in respects of falls, nutrition, continence and pressure sore formation. These assessments are reviewed on a monthly basis evidencing that the home is monitoring each resident’s health status. Wound care planning documentation was good and contained clear instructions for staff to follow about how often dressings were needed and what products should be used. A record of when the dressing is attended to and how the wound is progressing is kept, thereby monitoring progress or deterioration. Monitoring is also checked via photography at regular intervals. One GP has recently raised concerns about the standards of care given to some of their patients. Some of the concerns were historic however the home manager gave assurances that the other issues raised will be investigated and addressed, and measures will be taken to improve the working relationship between the surgery and the home. From examination of the six care documentation, it was evident that the home do monitor each residents healthcare, they do consult with the GP’s when necessary and they do take all appropriate measures to meet the residents healthcare needs. Of the 16 residents who returned CSCI survey forms, 13 said that they always get the medical support they needed. One relative commented “the GP is always called when my sister is poorly, and I am informed too”. A CSCI pharmacy inspector visited the home prior to the last inspection in December 2006. A requirement was issued in respects of some of the homes medication procedures. Only a brief examination of the home systems were made on this visit- the five areas of concern, detailed in the last inspection report have been addressed. From discussions with two qualified nurses it is evident that the home follows safe working procedures for the ordering, receipt, storage, administration and disposal of medications. During the course of the inspection the staff were observed carrying out their duties in a calm and friendly manner, responding to residents with a familiar style. Care staff were observed knocking on doors before entering a room and speaking to residents respectfully. Staff appeared to be more attentive to the residents than on previous visits, even when they did not know they were observed. In one such situation, a staff member was reassuring a resident at great lengths and later explained that this resident gets anxious each morning in the same manner. There was a lot of friendliness shown towards both residents and visitors to the home. One resident said, “the girls are all great, they are respectful and polite”. Another said “It is great to be back home after being in hospital, everyone is looking after me so well”. One relative who has been a visitor to the home for many years said that great improvements had been made in the last six months and “the home is a nicer place to visit”. Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can choose how they spend their time, are able to participate in a variety of activities and are provided with a well balanced diet. EVIDENCE: The home employs an Activities Organiser who works each weekday. There is a weekly plan of activities, but this is often altered dependent upon what the residents want to do that day. The small lounge on the ground floor is used as a “The Club”. Generally the organiser does group activities in the morning, and 1-to-1 sessions in the afternoons. Residents are able to choose whether to participate or not and a record of each resident’s involvement in the activities is maintained – these records were not examined on this inspection however they have previously been shared with the inspector. Sixteen CSCI resident survey forms were returned with residents in general saying that there was usually or sometimes activities arranged that they wanted to take part in. Comments included “I join in most of the activities”, “I only have oneto-one”, and “I don’t like to mix”. Residents comments received during the course of the inspection included “the TV in the lounge is too loud and the residents are all asleep, so I like to stay in my room”, “I like to have my hair done every week and the hairdresser is good to chat too”. Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 13 On the second day of the inspection a number of residents and staff went on a trip to Weston-super-Mare. They were collected from the home by taxi but were travelling to Weston by train. The previous day one resident had said they were looking forward to the train journey. A second similar outing is being made in August for other residents, and some residents said they were going on this trip. In the main reception area, photographs of other recent events and celebrations are displayed. A music man visits the home on a monthly basis, several residents and relatives commented about these visits on the CSCI survey forms, “the music man is good but only comes once a month. Perhaps sing-a-long music could be played instead of the TV more often”. Since the last inspection, and at the suggestion of residents, a ‘Mobile Shop’ has been set up from which residents can purchase confectionery and toiletries. The manager explained that although it was set up at the request of some of the residents, it is a facility that is not well used as yet. Also regular visits from a local vicar have been arranged – up to 20 residents have attended the ‘church service’ and although these are directed at those with a Christian faith, the home manager gave assurances that arrangements would be made to meet other religious needs should the need arise. These are good examples that the home listens to what the residents want and values their opinions. The home has an open visiting policy and visitors are asked to sign in at the front door, to comply with fire regulations. CSCI survey forms were returned from 13 relatives – “the home is warm and welcoming”, “the staff make you feel welcome when you visit” and “there is a friendly atmosphere “ were some of the comments made by relative. Relatives said they were kept informed of any important matters “I was contacted promptly when my relative was unwell and admitted to hospital”. A number of visitors were in the home during the course of the inspection and had a good rapport with the manager and the staff team. Residents are able to choose where they would like to spend their day and where they take their meals. Some residents choose to get up later in the morning than others, and the homes routines do their best to accommodate each resident’s preference. One resident commented on a CSCI survey form “sometimes staff are very busy and may not be there at the moment”. One resident spoken with about the recent smoking ban, was not happy about being “forced to give up” however was feeling the benefits and said their clothing smelt nicer. The home has a four-week menu plan – these are displayed in the main foyer. A varied, well balanced and nutritious diet is offered. In general there was a positive response from residents when asked if they like the meals. Since the last inspection the chef who had worked at the home for many years has left, but the home has recently recruited a new cook. A roast meal of beef, Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 14 yorkshire pudding, roast potatoes and cabbage was served on day one of the inspection. It was well presented, hot and tasty. One resident said “they don’t know how to cook cabbage properly” however all other residents spoken with and the inspector, found it to be very good. There is a choice of two main midday meals, cooked breakfasts are available twice a week and there is a choice of hot or cold teatime meal. Birthdays are always celebrated with a cake at afternoon tea. Bishopsmead Lodge DS0000066339.V337665.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. 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. Residents can be assured that any complaints they may have will be properly handled and that they would be safeguarded from coming to any harm. EVIDENCE: The home’s complaints procedure is displayed in the main foyer and also included in the home’s statement of purpose and the welcome pack that is provided to each resident and their family. All relatives who completed a CSCI survey form said that they were aware of the complaint procedure. One also wrote “Clear instructions are posted on the notice board”. Other comments from residents included “ I have been told to go to the managers office anytime and she is willing to help”. The home has received two complaints since the last inspection, one only most recently and has yet to be actioned. This one was copied into CSCI who will be overseeing how the home address the issues raised. Residents spoken with during the course of the inspection said “ the staff listen to me and do as I ask”, “any concerns I have had have been dealt with as soon as possible” and “I would ask my relative to speak to someone”. The home has improved the management of complaints, ensuring that the concerns of residents and their families are listened to, taken seriously and acted upon. The home has a Protection of Vulnerable Adults (POVA) policy. Those staff spoken with during the course of the inspection showed good basic awareness of adult protection issues and of the responsibilities they have towards safe guarding the residents from harm. Some were unsure about whistle blowing Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 16 procedures, with an expectation that only the home manager would report any concerns of bad practice to the appropriate agencies. The home are recommended again to make sure that each staff member is aware of the company’s whistle blowing policy. Some staff have attended POVA training – there is further adult protection training arranged at the home later this month for staff. No one from the home has attended the local authority training that is run by the Safeguarding Adults Coordinator – this would ensure that they have up to date knowledge of local protocols and procedures. This recommendation is being made again. Bishopsmead Lodge DS0000066339.V337665.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. 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 judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, well maintained, clean and tidy home which is free from any unpleasant odours. EVIDENCE: The home is a purpose built two-storey building, with lift access from the ground to first floor. Car parking is available to the front of the building, and although there is an incline of the path up to the front door, there is level access into the home. The front entrance is secured with a key padded system, so the home is safe and protected. To the rear of the home there is a very small paved area, and the downstairs lounge opens out on to this area. As part of the homes improvement and development plan, this garden area will be redesigned to include raised planters and a larger seating area. These works are expected to start at the end of the summer, so as not to prevent the residents using the area during the warmer weather. The home is well decorated throughout. Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 18 The home meets all the standards required and has sufficient communal areas (lounges and dining rooms), bathrooms and toilets, to meet the needs of 51 residents. One bathroom on the ground floor has been converted into a level access shower room and one on the first floor has been changed into a hair saloon. There are three bathrooms per floor, but one is in the process of being refurbished with a specialist parker bath. The home has an adequate supply of equipment to assist the care staff with moving and transferring residents with impaired mobility. The equipment has been regularly serviced in line with guidelines. Other items of disability equipment were located throughout the home to aid the residents and care staff in meeting personal care needs. A number of specialist nursing beds have already been purchased and there is a rolling programme to increase the numbers of specialist nursing beds. The majority of bedrooms were seen during the inspection, were each comfortable furnished and had been personalised to reflect personal taste. Rooms are generally redecorated in between residents. Each bedroom had en suite facilities of a toilet and wash hand basin. There are four shared rooms each with privacy screening in place. Residents are encouraged to bring in as much of their own furniture and belongings as they wish – the home will make an inventory of each resident’s personal belongings. The home is centrally heated and well lit with domestic style light fittings. Each bedroom has an opening window, fitted with width restrictors for safety. Emergency lighting is installed throughout the home and this is checked on a regular basis. The home was spotlessly clean, tidy and free from any offensive smells. The housekeeping staff were seen going about their duties effectively and interacting well with the residents and visitors to the home. Bishopsmead Lodge DS0000066339.V337665.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Positive changes in the staff team and the measures for meeting the training needs of staff will ensure that the residents are cared for by staff who are competent and have the necessary skills. EVIDENCE: The home has recruited a number of new care staff and the home is now fully staffed and has almost full occupation (at the time of the inspection there were 46 residents). One relative commented on a CSCI survey form “things would be better if the home could keep staff longer”. The home has appointed a deputy manager however is again without an administrator. Previously the home has struggled without an administrator and the impact upon other personnel caused immense difficulties in providing a satisfactory service. During the course of the inspection, the manager was frequently called away to deal with administrative tasks, answer the telephone and deal with visitors to the home. A team of housekeeping, laundry, maintenance and catering staff support the registered nurses and care staff in meeting the resident’s daily living needs. On both days of the inspection there was one registered nurse plus a team of carers on each floor. Staffing levels appeared to appropriate. 16 residents completed CSCI survey forms and 14 said “I receive the care and support I need” whilst there were other comments about there being periods of time Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 20 throughout the day when staff were very busy and it can appear to be “shortstaffed”. The home currently has four members of care staff who have achieved the NVQ level 2 in care (16 ), but three others are working towards the award. When these workers have achieved this, the home will have 33 of trained members of staff. In addition two senior care staff who have already achieved level 2 are working towards Level 3. The manager explained that a further cohort of staff will be starting their NVQ training soon. It is an expectation that all new staff recruited to work at the home will start the NVQ Level 2 after a period of time. The home must continue to work towards achieving a 50 ratio of trained members of care staff. The staff files of five recently recruited staff members were examined. All new staff will have been through a robust recruitment procedure, which includes a written application, two satisfactory written references and CRB checks. POVAfirst checks had been obtained on all the new staff prior to their start date, and had been followed up with the CRB disclosures. This evidences that the home follow good recruitment procedures. New staff members have an induction programme to follow when they start employment. A number of programmes were seen where these had been completed and one new member of staff spoken to during the inspection said they were working through theirs. The home now ensures that all new staff undertakes manual handling training and fire procedure awareness at the start of their employment. The homes training matrix has been kept up to date by the new home manager and this provides an overview of what training each staff member has received. A training log is maintained for each staff member, and examination of a sample of these evidenced a wide range of relevant training. Examples include food hygiene, health & safety, POVA, fire, first aid and basic life support. Since the last inspection Mimosa have contracted a new training provider. The home has a training plan but the manager explained that it is operational impossible to ensure that all staff attend and that some staff are reluctant to attend training at all. A number of the registered nurses and care staff are due to attend specific training courses in the near future – dementia care, infection control, catheterisation and pressure sore care. The home must ensure that all persons employed receive training appropriate to the work they are to perform, and must address the shortfall with the small number of staff who do not turn up to the training they have been allocated. Bishopsmead Lodge DS0000066339.V337665.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements in the management of the home ensures that residents live in a safe home that is run in their best interests, where their views are valued and acted upon. EVIDENCE: The home manager has been in post since the end of January and has made application to CSCI to be the registered manager. She is a registered nurse and has previously been a manager in another care home setting. The manager started when there were serious concerns about the standards of care. In the six months she has been in post, she has demonstrated her leadership skills and management ability and has raised the standards of care and has changed the way in which the home is run home. The residents have benefited because the home that is run in their best interests. Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 22 Relatives meetings are going to be held on a three monthly basis. The last meeting was held on a Sunday afternoon in May – the recent quality assurance survey results were discussed the forthcoming smoking ban. Staff meetings are held on a regular basis. The manager needs to address with certain members of staff their non-attendance at these meetings. In April 2007, the manager arranged for a Customer Satisfaction Survey to be undertaken. A copy of the survey results was forwarded to CSCI, together with an action plan to address any issues raised. The home also developed an improvement and development plan, as they had been requested to do. Some parts of this plan have already been actioned whilst others have still to be achieved. The home completes a number of different audits on a monthly or quarterly basis. Examples of such audits are maintenance, health& safety, domestic services, catering and care planning processes. A senior person from Mimosa visits the home on a regular basis and provides CSCI with a written report. All of this evidences that the home are now monitoring the quality of their service, are listening to residents. Relatives and staff, and are making decisions based upon the views and opinions expressed. The home looks after monies for some of the residents and maintains good administration systems of all transactions to and from the accounts. Five sample accounts were checked and each tallied. A cascade system of staff supervision has been set up since the last inspection. The manager will supervise the registered nurses, who will supervise senior care staff. Senior care staff will supervise care staff and have been provided with relevant training before taking on this role. Staff spoken with during the inspection, confirmed that they receive formal 1:1 supervision although some said that there is no regularity to the arrangements. These improvements will ensure that all staff work as a team and that any bad working practices are dealt with. The homes records are well organised and are kept secure. The home is well maintained, and in good decorative order. All maintenance contracts and utility servicing is up to date. The manager “walks the floors” each day and checks that the environment is safe. Staff are expected to record all maintenance requests in a log –0 a check of this showed that all tasks are dealt with promptly. Housekeeping staff had access to the COSHH sheets for all the cleaning products they use. Staff are expected to follow safe working practices at all times, and refresher training in safe moving and handling techniques is arranged for all staff on at least an annual basis. Manual Handling risk assessments are completed for each resident and a safe system of work is devised. Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 23 The records concerning fire safety checks are complete. Records are now maintained of when each staff member participated in a fire practice session. The home now has two fire wardens who have delegated responsibility for staff training and maintenance checks of fire fighting equipment. Improvements have been made in the way that the home monitors the falls or any accidents that occur. An accident form is completed after any event, but follow up monitoring is still only recorded in the daily records. The manager maintains an overall picture of accidents in the home and ensures that any trends are identified and preventative measures are taken. All these measures ensure that the residents live in a safe and comfortable home Bishopsmead Lodge DS0000066339.V337665.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Bishopsmead Lodge DS0000066339.V337665.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 OP7 Regulation 15(1-2) Requirement A written plan should be prepared for each resident, that details how their health and welfare needs are to be met: • This plan must be kept under review and updated as necessary. • Where weight loss is to be reported to the GP. guidelines must be stated • Diabetic monitoring should state the boundaries for ideal blood-sugar levels. • Any new needs identified should be included in the care planning process. The home must ensure that all persons who work at the home receive training appropriate to the work they are to perform: • Registered Nurses must meet NMC PREP requirements to ensure that their clinical skills are kept up to date. Timescale for action 13/09/07 2. OP28 18(1)c 13/12/07 Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 26 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 OP3 Good Practice Recommendations The provider should consider reviewing the ‘physical and social assessment’ form, to ensure it captures a full assessment of needs. The home must make sure that each staff member is aware of the company’s whistle blowing policy. Representatives from the home should attend the local authority adult protection training. The home should continue to work towards achieving a 50 ratio of trained members of care staff. The home should ensure that all staff have formal supervision at least six times per year. 2. 3. 4. 5. OP18 OP18 OP28 OP36 Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 © 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 Bishopsmead Lodge DS0000066339.V337665.R01.S.doc Version 5.2 Page 28 - 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. 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