Inspection on 22/01/08 for Bishopsmead Lodge

This inspection was carried out on 22nd January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bishopsmead Lodge 12/07/07

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 Unannounced Inspection 22nd and 23rd January 2008 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.V357313.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.V357313.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.V357313.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 12th July 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 people who live in the home and their visitors, can sit outside in the warmer weather. Fees for placement at the home currently range from between £486 - £600, (from £359 for a ‘personal care or residential’ only basis), and are determined on an individual basis. Hairdressing, newspapers and chiropody costs incur additional charges. Prospective people who enquire about the home can be provided with information by the home manager ( the Service Users Guide) and this will detail the services and facilities available at the home. Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key inspection was unannounced and took place over two days. A total of 13 hours were spent in the home. Evidence to form the report has also been gathered from a number of other sources:• Talking with the Home Manager • 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 one person that lives at the home and one relative in CSCI survey forms (30 of each had been supplied prior to the visit) • Information supplied by two GP comments cards • Information that has been received by CSCI since the last inspection, from Healthcare professionals, members of the public and anonymous callers. What the service does well: Information that is available about the home, and the pre- admission assessment processes will ensure that placement is only offered to those people whose needs can be met. The care planning processes will ensure that staff always knows what is expected of them. Healthcare monitoring processes and management of medications are satisfactory meaning the people who live here will receive the medical care they need. The people who live in this home can choose how they spend their time and can participate in a variety of activities. Many people are unable to because of their high care needs. Bishopsmead Lodge is a purpose built home. It is nicely decorated and is well equipped to meet the needs of older and disabled people. Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bishopsmead Lodge DS0000066339.V357313.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.V357313.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 that is available about the home, and the pre- admission assessment processes will ensure that placement is only offered to those people whose needs can be met. EVIDENCE: The Statement of Purpose and Service Users Guide (Welcome Pack) accurately reflects the service provision, and contains all the necessary information to enable any person looking for a care home, to make an informed choice about whether this home is the right place for them. The manager’ name, qualifications and experience needs to be updated to reflect management changes. Both the person and the relative who completed CSCI survey forms said that they had been provided with enough information about the home. Copies of the welcome pack were seen in some bedrooms. A sample of files were looked at, as part of this inspection, to see whether a copy of the terms and conditions or residency is provided for each person. All Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 9 was in order but the home was waiting the return of the signed copy of the most recently admitted person. A pre-admission assessment is undertaken before any person is admitted to the home. This may happen in the persons own home or in the hospital ward. This procedure will ensure that placement is only offered to those people whose needs can be met. Of the people who were case tracked as part of this inspection, three had been admitted in the last couple of months, and each had had a very detailed assessment of their care and support needs. When the adult community care departments are involved in arranging a placement, copies the care plan and health needs assessment are provided as part of the contractual arrangements. Where possible, people who will be living at the home, and/or their relatives are asked to visit and have a look around. One visitor told the inspector during the inspection “I chose this home, because it is near to me and I can visit. I came and had a look and the staff were friendly”. The majority of people who come to live at Bishopsmead Lodge, do so after a stay in hospital. All new admissions to the home are generally reviewed after a four-week trial period, but this can be extended if necessary. Bishopsmead Lodge DS0000066339.V357313.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 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There have been improvements for the people who live here being provided with the right level of care, because care planning processes are now being followed. Healthcare monitoring processes are good but improvements in communication about medications, is needed to ensure that everyone gets the medical care they need. EVIDENCE: Four care plans were looked at in order to determine how the care delivery arrangements are agreed. Care planning documentation had been prepared for each person, based upon the assessment of care needs. On the whole the plans were satisfactory but the responsibility for preparation of the plans must not lie solely with the home manager. The plans covered a range of needs for each resident, and they contained information about the person’s social and family history. There were some good examples of person centred planning, with individualised support detailed but this was not across the board. For one person a ‘challenging behaviour record’ was being kept, but there was no evidence that the staff were thinking about trigger factors. Along side the plans, a number of risk assessments are completed in respects of the likelihood Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 11 of falls and pressure sore formation, nutrition and continence. These assessments are reviewed on a monthly basis evidencing that the home is monitoring each resident’s health status. Wound care planning documentation was very clear and contained specific 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. Photographs are also taken at regular intervals to monitor what is happening. GP’s have previously been concerned about the standards of care given to some of their patients, however working relationships have improved, with agreed communication methods being set up. One GP wrote in a CSCI survey form “I am now satisfied with the overall care provided to service users within the home, I wasn’t in the past” and also “the new manager is very organised and on the ball”. Whilst the other GP reported the same satisfaction, they commented that “the home communicate clearly most of the time, and we have not received any complaints in recent months”. Other healthcare professionals have raised concerns in the past regarding the care of two individuals and nursing care practices – strategies were put in place to address the issues but the registered nurses must ensure that staff always undertakes tasks safely and properly. There have been no recent issues, inferring that the strategies have been effective. The four sets of care plans and other records evidenced that each persons healthcare is monitored, that the GP is consulted when necessary and all appropriate measures are taken to meet healthcare needs. One good practice recommendation is that monitoring of each persons bowel movements (on the personal hygiene record) must be properly and accurately recorded. Both CSCI survey forms said that medical care was available when needed. Medication procedures were discussed with the manager and one registered nurse. It is evident that safe working procedures are followed for the ordering, receipt, storage, administration and disposal of medications. Controlled drugs were checked and correct, and medication administration sheets were all in order. One concern was that for two people one of their medications had been marked as ‘out-of-stock’ for several days. There was no evidence that anyone had done anything about re-ordering them, but the registered nurse had already picked up on this and was taking the appropriate action. All registered nurses must ensure they communicate appropriately when new prescriptions are need. During the course of the inspection most staff were observed carrying out their duties in a calm and friendly manner. The conduct of one care assistant was reported to the home manager who took the appropriate management action. The people who live in the home and any visitors were responded to with a familiar style. Care staff were observed knocking on doors before entering a Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 12 room and communicating respectfully. Staff were attentive to the needs of the people being looked after. One person said, “the staff are kind and polite”. Bishopsmead Lodge DS0000066339.V357313.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. 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 people who live in this home can choose how they spend their time and can participate in a variety of activities. Improvements are needed with mealtime arrangements and ensuring each person receives a well balanced diet. EVIDENCE: An Activities Organiser works each weekday and arranges a range of different activities. One person said “ I take part in some activities depending on what is going on”. The people 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. Outside entertainers visit the home sometimes. The activities organiser was observed to be working with individual people and doing group activities. One person was taken out for a walk during the course of the inspection as a means of engaging them in meaningful activity, whilst another person went out to attend the stroke club. The televisions were on in both lounges for both days, but nobody appeared to be watching them. Many of the people were just sitting and dozing for most of the time. Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 14 The home has an open visiting policy and visitors are asked to sign in at the front door, to comply with fire regulations. 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. The people who live in this home are able to choose where they would like to spend their day and where they take their meals. Some choose to get up later in the morning than others, and the homes routines do their best to accommodate each resident’s preference. One person and their visitor commented “sometimes staff are very busy I have to wait some time for call bells to be answered. I am very unhappy with staffing levels”. This has been referred to again in the staffing section. The home has a four-week menu plan. The menus are usually displayed in the main foyer, but according to the cook, they can be out of date. A varied, well balanced and nutritious diet is offered, but sometimes this can be altered at last minute because of problems with supplies. In general there was a positive response from people when asked if they like the meals, but one person was very unhappy because meals are served that are overcooked and at the wrong temperature. The manager has been asked to see this person following their complaints procedure. The chef who previously worked at the home has returned to post – they were not on duty both days of the inspection. A choice between two meals were served on both days of the inspection. A number of people complained that only cold drinks were provided at meal times, and that hot drinks were not made available at times other than when the tea trolley goes round. A member of staff was observed to be asking everybody what they wanted for the following midday meal, whilst that days meal was being served up. This caused a great deal of confusion for some people. A number of improvements regarding meals and mealtimes need to be made to make this a more pleasurable experience for people. Bishopsmead Lodge DS0000066339.V357313.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 adequate. This judgement has been made using available evidence including a visit to this service. The people who live in this home must be assured that any complaints they have will be properly handled. Recruitment procedures must be improved in order to safeguarded people from coming to any harm because of unsuitable workers. EVIDENCE: The Mimosa 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 person and their family. The relative who completed a CSCI survey form said that they were aware of the complaint procedure – “I have no complaints”. The person who lives at the home who completed a survey form was also aware of what to do if they were unhappy about anything. During the course of the inspection, the home manager was observed to be having a conversation with a visitor who was raising concerns regarding the care of their relative – at the end of the inspection the outcome of this complaint was not known. One person spoken with during the course of the inspection, expressed dissatisfaction regarding their dietary choices being met and meals being served cold or lukewarm. This information was passed to the manager who must deal with this under the complaints procedures. Three further complaints have been dealt with by the new home manager, with two of these also having been raised with CSCI. Whilst the home manager and the area support team took the appropriate action, issues were raised that the Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 16 care team should have been aware of and addressing. Issues were raised around manual handling procedures, nursing care issues, staffing levels and management of one persons ‘behaviour’. Staff must always use safe moving and handling procedures, and should ensure that when helping people to feed, the person is sat in the correct position. These issues have been referred to in the appropriate sections of this report. There needs to be a greater emphasis by the home staff in dealing with the issues that affect the quality of the service that is provided. This will reduce the need for others to raise concerns on behalf of the people who live in the home. Mimosa 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. Staff also spoke about reporting bad practice to the manager. The manager will be attending the Bristol City Council abuse training in the near future to ensure she is fully aware of the responsibilities that go with the manager’s job. An external training provider arranges POVA training on a regular basis and all staff are expected to attend. Whilst this is good practice, the recruitment procedures must be improved. The home must always ensure that they have checked that a potential employee is not barred from care work (POVAfirst checks), and that references are always obtained from previous employers. These shortfalls have the potential to mean that people who live in this home, could be cared for by unsuitable workers. In this instance this referred to one worker who now no longer works in the home. Bishopsmead Lodge DS0000066339.V357313.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. Bishopsmead Lodge is a comfortable and well-maintained home. It is not currently as clean and tidy as it has been in the past, and must be improved to ensure that the people who live here, are cared for in pleasant surroundings. 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. Work is due to start very shortly in developing this garden area. It will be redesigned to include raised planters, bushes and a larger seating area. The plans for the area are currently displayed in the main reception area. Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 18 The home is well decorated throughout, and in general bedrooms are redecorated in between occupants. Each floor has its own lounge area and quiet room plus dining room. One person who lives at the home said “I don’t like the upstairs dining room, so I have my meals in my room”. The communal areas are furnished with domestic style furniture, however there is a range of different style seating to suit different needs. The home was warm, well lit and well ventilated. The home has a sufficient numbers of bathrooms and toilets, to meet the needs of the 51 people who live in the home. One room on the first floor has been changed into a hair saloon. The home has an adequate supply of equipment (hoists and stand aids) to assist the care staff with moving and transferring people who have impaired mobility or are completely immobile. The equipment has been regularly serviced in line with guidelines and was last done in July 2007. Other items of disability equipment were located throughout the home, for example grab rails, slide sheets, walking frames and wheelchairs, to aid people and care staff in meeting personal care needs. The home currently has a total of 12 specialist nursing beds. At the last inspection the manager reported that there was a rolling programme of bed replacement, to increase the numbers of specialist nursing beds. Some people have ordinary divan beds but those with high dependency nursing needs have the specialist beds. The home currently have a large number of people who do not require nursing care and therefore the numbers of specialist beds is adequate. The majority of bedrooms were seen during the inspection, were each comfortable furnished and had been personalised to reflect personal taste. Each bedroom had en suite facilities of a toilet and wash hand basin. There are four shared rooms each with privacy screening in place. Just one person each is currently using two of these shared rooms. The people who live here are encouraged to bring in as much of their own furniture and belongings as they wish. The home has previously always been spotlessly clean and tidy, however was not so for this inspection. The senior housekeeper who has always maintained the home to a high standard has been working in the kitchens, and the absence of her role in overseeing the work of the team is obvious. Whilst the housekeeping staff were seen working on both floors, parts of the home were in need of a really good clean. Carpet edging was noted to be very dusty as were furniture surfaces. There was a bad smell in one of the bathroom. The relative who completed a CSCI survey form said “ very often there is a strong smell of urine in the corridors”. Improvements must be made to the cleanliness of the home to ensure that it is a pleasant place in which to live and work. Bishopsmead Lodge DS0000066339.V357313.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 poor. This judgement has been made using available evidence including a visit to this service. Staffing levels do not always reflect the needs of the people who live in this home and recruitment procedures are unsafe. These shortfalls have the potential to mean that people will not always have their needs met and they could be looked after by unsuitable workers. EVIDENCE: There has been a significant staff turnover since the last inspection and there remains a number of staff vacancies. There is currently only one registered nurse covering the night duties but recruitment to fill this and other posts is in progress. One registered nurse is moving across from another Mimosa care home to take up one of the lead nurse posts. A number of new care staff have been recruited. The home currently has only 42 people in residence, of which 14 are in receipt of personal care only. The manager stated that day shifts are covered with eight staff – two registered nurses and six care staff, and night shifts are covered with one registered nurse and four care staff. During day one of the inspection, the day shift was working one staff member short because of last minute sickness. CSCI have received concerns that the home is being run with low staff levels, and that this is happening consistently at the weekends because of staff sickness. A random inspection by CSCI was undertaken in October 2007, and evidenced that the home is on occasions being run with inadequate staffing levels, and staff reported that this significantly impacted upon their ability to meet all the peoples needs. Staff spoken with during the course of the inspection confirmed that the home often Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 20 has low staffing levels at the weekends. At all times, suitably qualified, competent and experienced staff must be on duty to meet the care needs of the people who live in the home. The manager and area manager explained that sickness management procedures are in place to deal with those staff who are persistently letting the team down. The relative who completed the CSCI survey form wrote “weekends are very short staffed”. Further non-compliance in providing adequate staffing levels may lead to enforcement action being taken. In addition to the registered nurses and care staff, a team of housekeeping, laundry, maintenance and catering staff are employed to meet the daily living needs of the people who live in the home. The difficulties with staff sickness include the kitchen staff and therefore staff are deployed from other teams to cover kitchen duties. An administrator has been employed who covers weekdays only, deals with administrative tasks, answer the telephone and welcomes visitors to the home. There are currently only four members of care staff who have achieved the NVQ level 2 in care (16 ), but seven others are working towards the award. When these workers have achieved this, the home will have 52 of trained members of staff. Nine other staff will be signed up for NVQ 2 in the next cohort. A number of staff who have already achieved level 2 are working towards Level 3. There is an expectation that all new staff recruited to work at the home will start the NVQ Level 2 after their probationary period. The staff files of six recently recruited staff members were examined. Robust and safe recruitment and vetting procedures are not always followed meaning there is the potential to place the people who live in this home, at risk from being cared for by unsuitable workers. For one recruit there were no references on file although these were marked as having been received by the home. For another worker there was no evidence that POVAfirst checks or a CRB disclosure had been received, and no references had been obtained. All new staff must be recruited properly and this must include at least a written application, two satisfactory written references and CRB checks. If workers are employed prior to the return of a CRB disclosure but after a clear POVAfirst check, they must be appropriately supervised at all times, until the CRB is obtained. No new worker must be allowed to work in the home without a POVAfirst check. New staff member are expected to complete an induction programme after they start their employment at the home. As part of this programme they will be expected to undertake manual handling training and fire awareness training. Only one such programme was seen during the inspection and despite there being evidence that the worker had completed many of the sections of the programme, the book was not ‘signed off’. Another worker was unsure who their mentor was but thought it might be the manager. New Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 21 workers should be allocated a mentor who is responsible for ensuring that the induction programme is completed. The staff-training matrix is kept up to date by the manager and provides an overview of what training each staff member has received. Mandatory training includes health & safety, moving and handling, fire, first aid, food hygiene, COSHH and POVA. The new training plan for the home has just been provided - the only additional training sessions arranged are infection control and dementia awareness. A training file is maintained for each staff member, and examination of a sample of these evidenced a wide range of relevant training – pressure area care, continence care, peg feeding and wound care management for example. Staff spoken with during the course of the inspection said that they felt they were given the opportunity to attend regular training. Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live in this home benefit from it being well run but staff must follow safe working procedures to ensure they do not harm themselves or the person they are caring for. EVIDENCE: Since the last inspection there has been a change in manager. The home manager was appointed in October 2007 and was previously a deputy manager in another Mimosa care home. Application to CSCI to be the registered manager has not yet been made and must be addressed as soon as possible. She is a qualified nurse and will be signing up to complete the Registered Managers Award management training. During the inspection process, she demonstrated an enthusiasm for the job and “getting the home right” but is aware that there is plenty to learn about staff management. Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 23 Those staff that were spoken with during the inspection, were complimentary about the new manager and felt that they were listened to and their views were valued. Staff meetings will be held on a regular basis – the minutes of the last meetings were seen, only seven care staff had attended. The manager will need to ensure that all staff attend these meetings so that they can be involved in the running of the home. Relatives meetings will be held on a monthly basis and will alternate between a weekday and a weekend day. The last meeting was poorly attended and ways of making these more productive will be explored by the manager. Customer Satisfaction Survey are undertaken every six months, the last having been undertaken in June/July 2007. A copy of the survey results were sent to CSCI, together with an action plan to address the issues raised. The questionnaires have just been sent out and it is expected that the results will be analysed at the end of February. CSCI sent 30 survey forms for ‘service users’ and 30 for relatives, prior to this inspection but only one of each were returned – the manager must ensure that their quality assurance methods captures the views and opinions of all interested parties. A senior person from Mimosa visits the home on a regular basis and provides CSCI with a written report – these now result in a plan being formulated for the manager to action. A number of other audits are completed on a monthly or quarterly basis. Examples of such audits are maintenance, health& safety, domestic services, catering and care planning processes. This evidences that the quality of the service is monitored and takes account of the views of others, however the manager needs to look at those issues raised during recent complaints. 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. The home is well maintained, and in good decorative order. All maintenance contracts and utility servicing is up to date. A tour of the home evidenced there were no health and safety issues. The manager likes to go out on to the floor each day and will check that the environment is safe. Staff are expected to record all maintenance requests. Housekeeping staff have access to the COSHH sheets for all the cleaning products they use, and the laundry assistant referred to the new washing products that were now being used. 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. Visiting healthcare professionals raised concerns when they observed staff using unsafe manual handling procedures, and the staff involved have received additional training. The manager has introduced a manual handling audit in order to monitor how the staff are performing. There is no longer a Manual Handling trainer employed at Bishopsmead therefore other Mimosa homes and staff are used to provide practical training for new staff and offer advice where needed. Manual Handling risk assessments are Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 24 completed for each resident and a safe system of work is devised. Some of the safe systems of work do not contain sufficient information. They should always provide clear instructions for the staff on what equipment is needed and how many staff are required The maintenance person undertakes all fire safety checks. At the start of day two of the inspection an unplanned fire drill took place because the fire alarm system was activated. Staff responded appropriately. Records are kept of which staff members participate in each fire drill. The number of accidents, falls and incidents are monitored weekly and monthly and statistics supplied to senior management. Records are also maintained of wound progress or deterioration, and body weights of a number of people, on a weekly basis. The manager is therefore able to have an overview of the healthcare needs of the people who live in the home. Where bed rails are used as a means of maintaining the safety and welfare of a person whilst they are in bed, a risk assessment should have been carried out first to make sure this is the appropriate method and does not pose further risks. Written consent for the use of bed rails must be obtained prior to their use and this information must be incorporated into the plan of care. Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 1 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 X X 2 Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 26 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 OP18 Regulation 12(1) (4) Requirement The registered provider must ensure that people are safeguarded from harm at all times and that staff actions do not place them at risk. Staff must always use safe moving and handling procedures, and should ensure that when helping people to feed, the person is sat in the correct position. The home must be kept clean, hygienic and free from odours throughout. The odour in one bathroom must be resolved. The registered provider must ensure at all times there are enough staff on duty to meet the care needs of the people who live in the home. The previous timescale set was 07/10/07 following a random inspection visit. Further noncompliance may lead to enforcement action. Timescale for action 22/02/08 2. OP26 23(2)d, 16(2)k 22/03/08 3. OP27 18(1)a 22/02/08 Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 27 4. OP29 19 The registered provider must 22/02/08 ensure at all times, robust recruitment procedures are followed. Written references POVAfirst and CRB’s must always be obtained. The manager must make application to CSCI for registration Safe systems of work in respects of manual handling procedures must be devised for all people and staff must always follow these safe working practices. Where bed rails are used as a means of maintaining a persons safety in bed, written consent must be obtained. 22/03/08 22/02/08 5. 6. OP31 OP38 9 13(5) 7 OP38 13(7) 22/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP7 Good Practice Recommendations The Statement of Purpose must be updated to reflect the management changes. Where challenging behaviour records are maintained, any triggers should be recorded. This will enable a strategy plan to be put in place. Bowel monitoring records should be accurate. A review to be made of meal time arrangements including the presentation of meals, drink availability and choices, and how individual choices for meals are obtained. 3. 4. OP8 OP15 Bishopsmead Lodge DS0000066339.V357313.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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