Inspection on 27/06/06 for Bishopsmead Lodge

This inspection was carried out on 27th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 12/07/07

Bishopsmead Lodge 02/01/07

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 09:30 27 and 29th June 2006 th 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.V296595.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.V296595.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 None Mimosa Healthcare (No4) Limited Marcia Dawkins Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51) of places Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager must be a RN1 or RNA on the NMC register Date of last inspection 28th February 2006 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 has recently changed ownership and is now under the new management of Mimosa Healthcare, a Nottingham based company who are expanding into the West Country. Along with Bishopsmead Lodge, Mimosa purchased 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 £348 - £550, 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.V296595.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. This inspection is the second visit by CSCI to the home, since it changed ownership to Mimosa Healthcare on 30 January 2006. Evidence was gathered from a number of different sources: - Information taken from the pre-inspection questionnaire - Directly speaking with residents and some visitors during the visit - Case tracking a number of residents - Speaking with care and ancillary staff - Speaking with registered nurses - A tour of the premises - Examination of some of the homes records - Observations of staff practices and interaction with the residents. The home manager was present during the inspection, but was not able to provide all the evidence necessary to show compliance with the Care Homes Regulations and the National Minimum Standards. The home is currently not running to full capacity and during the inspection had only 35 residents (up to 16 vacancies available however a number of shared rooms are used by a single occupant). This inspection has shown that the home has major shortfalls in a number of areas, and is therefore classed as a service of concern. At the time of the inspection, two immediate requirement notices were issued in respect of staff recruitment and safe vetting procedures and fire safety. A number of additional requirements have been issued along with this report and an improvement plan requested with the aim of raising standards and stamping out bad practice. What the service does well: The home does provide clear and detailed information about the service and facilities it has to offer, and this is given to anyone who enquires about the home. Residents who live in the home can expect to be able to participate in a range of meaningful activities and will be provided with good meals. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 6 The home is purpose built and is fully equipped to meet the needs of elderly and disabled people. It is pleasantly decorated and is clean, tidy and free from any malodour. What has improved since the last inspection? What they could do better: Two immediate requirement notices were issued at the time of inspection. The manager was not able to demonstrate that robust recruitment practices, including safe vetting procedures are followed. The other notice was in respect of fire procedures – new staff were not aware of the homes fire procedures and practice drills had not been arranged for them or the rest of the team. The manager did later produce evidence of one recent fire drill however this does not evidence good home management. The assessment and care planning processes must be comprehensive to ensure that all needs are identified and met. The current standard of care planning has the potential to mean that the needs of some residents may not be met. The quality of records kept about each resident is not consistently good and their accuracy cannot always be relied upon. There is the potential that residents may be harmed when being moved by care staff who have not been trained in safe moving and handling techniques. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 7 Improvements must be made in ensuring that the staff team have the necessary skills to care for, and safeguard, the residents. Some staff have not had any Protection of Vulnerable Adult training, and therefore were not aware of their responsibility in safeguarding the residents. New staff are not provided with an induction programme and therefore may not fulfil the aims of the home. A record of qualifications and training sessions attended should be individually maintained for each staff member. 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. Bishopsmead Lodge DS0000066339.V296595.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 Bishopsmead Lodge DS0000066339.V296595.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 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information written about the home will inform prospective residents about the services available, however improvements must be made with the preadmission assessment processes. EVIDENCE: The homes Statement of Purpose and Service Users Guide, (Welcome Pack) accurately reflects the current service provision. A copy had been issued to each of the five residents who completed their survey forms. The documents provide a detailed outline of the home and what services can be expected Also issued to each resident is a Residency Agreement – a sample copy is included in the welcome pack but signed copies were not on file for all of the residents who had been admitted since the last inspection. The manager must have systems in place to ensure that residents, relatives or representatives, receive and return this document. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 10 The home’s admission procedure states that prospective residents will have been fully assessed prior to being offered placement. This will ensure that the home is suitable for the purpose of meeting their needs. Two pre-admission assessments were looked at – neither has been signed or dated to verify they were completed prior to admission. One assessment contained information that had not been followed through into care planning documentation. This shortfall has the potential to mean that a residents needs may not be fully met. Both residents had been admitted directly from hospital – the relatives of one had chosen the home on the resident’s behalf. Bishopsmead Lodge DS0000066339.V296595.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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements must continue with the care planning processes, so that residents can be assured that their needs are identified and met as described in their plan of care. EVIDENCE: Four care plans were examined, including those of two of the residents who were newly admitted. The care plans were drawn up from information recorded on a ‘Physical and Social Care Assessment’. This document however, does not cover the full range of personal, health and social care needs– for example a person’s mobility needs or personal care needs. The manager had been unaware of this omission and thought “pages were missing”. This evidences that the staff do not have the necessary skills to undertake detailed assessments of the residents. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 12 The care plans in general were poorly written. One person, who had lived in the home for three weeks, had only one plan about mobility, however those needs identified at pre-admission, in respects of requiring help with dressing, choosing clothing and with cutting up their food, had not been planned for. The resident was able to confirm that they got the help they needed. For one other resident, their plan about “risk of developing pressure sores” was confusing in the context in which it was written. The plan referred to the “potential” for developing a pressure sore, despite them having a large pressure sore. On the other hand, there was a plan about the persons personal hygiene needs – this was written in a very person centred style, with reference to what they liked to be washed with and a need to look out for “gritty eyes”. This was a good example of individualised care planning but sadly is not usual practice. The manager stated that all care plans are audited 7 days after admission; therefore it is concerning that these things are not being picked up. Care plans are reviewed on a monthly basis. For one such review the amendments that were discussed with the relatives had not been transferred in to the care plan despite a period of 8 days having passed by. Risk assessments in respect of pressure sore development are completed and reviewed on a monthly basis. Where necessary, pressure-relieving equipment was in place. The manual handling assessments were meaningless and did not result in a safe system of work being devised. A care assistant knew that one resident needed to use the bath hoist, but this was not on their care plan. Recording of resident’s bowel function is variable, one person’s records showing that they had a not had a bowel action for 18 days. The records were unlikely to be accurate and this is not acceptable practice. The home must ensure that all forms are completed correctly and include the day and the month of recording. A number of residents have “ pop-in charts” where staff record dietary intake, fluid intake/output, and any positional changes. One visitor complained that often the charts are not completed correctly and that their relative is frequently left sitting for long periods of time and their pad is not changed frequently enough. Through observations during the inspection, the practice of completing these charts at the end of a workers shift remains common practice. This is not good practice and is likely to be open to “guess work”. One wound care plan evidenced improved practice from previous visits. There was evidence that registered nurses were consulting with the GP and seeking advice from a specialist wound care nurse. The wound had been photographed on many occasions to monitor progress. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 13 Records evidence that the residents have access to other healthcare professionals, examples include GP’s, foot care specialists, and PEG feed nurses. All residents are registered with one GP, but could retain their family GP if local to the home. The GP visits the home each Tuesday, and at any other time upon request. One resident said they were not feeling well and were seeing the GP that afternoon. The homes medication systems have not changed since the last inspection. The registered nurse was observed during part of a drugs round and followed safe administration guidelines. A number of the residents appeared to be on large amounts of different medications. The manager explained that the pharmacist has recently completed an audit and liaises with the surgery. There were some positive comments received from residents and their visitors about how they are treated by the staff. Two people were being shown around the home and said that they had had a very warm welcome. One resident said “they never give me my bell”- this was referred to in that persons recent care plan review and yet, the bell continues to be placed out of reach. Care staff must ensure that they are vigilant and do not leave residents without the means of summoning help. Personal care is given in private. Friendly and appropriate interaction was noted between residents and care staff, but they must ensure that they respect the residents and do not leave them “vulnerable”. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality of the resident’s lives has been enhanced due to them being able to participate in a range of meaningful activities. The residents are well fed. EVIDENCE: An Activities Organiser, previously employed at the home, has returned to the post providing 25 hours per week support. She works from 10am – 3pm each weekday and is enthusiastic about her role. She has formed a weekly plan of activities. She likes to meet with residents on a one to one basis in the morning and provide group activities 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. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 15 Plans are currently being made for a trip to the seaside – one resident said they would not go as “the day was too long and they preferred a quiet life”. They had enjoyed the recent music session though. Relatives and staff are encouraged to join in arrangements with the trips. The Activities Organiser is hoping to arrange visits from the church, as this has been requested by one of the residents. 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 visited the home on the day of the inspection and were welcomed by staff. It was obvious that a good rapport has developed. Residents are able to choose where they would like to spend their day and where they take their meals. “I sometimes have my meal in my room and I sometimes go to the dining room”. One person said they liked to spend their time in the smaller lounge, as it was a more peaceful atmosphere. One resident chose to spend their time in bed and would always return to bed after being attended to. In the comment cards from residents and relatives there were positive comments regarding the meals, with one person commenting that breakfast is served too late and the others saying that the meals were usually very good. The home has a four-week menu plan and there is a choice of two main midday meals. A choice of steak and mushroom pie or a pork chop, were on offer on the day of inspection, and this corresponded with the menu plan. These meals were served along with vegetables, and followed by fruit flan or creamed rice pudding. One resident was being helped to choose what they needed for the next day – they added, “the food is very good here”. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be assured that any concerns or complaints they have will be listened to and acted upon. Improvements are necessary with the knowledge of some staff about adult protection issues, to ensure that residents are fully safeguarded from any harm. EVIDENCE: The home’s complaints procedure is well advertised displayed in the main reception area and included in the home’s new statement of purpose and welcome pack. The manager undertakes a monthly audit of any complaints received and looks for common traits. A record is made of the outcome of the complaint. The information was logically maintained and organised. Residents spoken with during the course of the inspection, felt confident to raise concerns with the staff. One resident said that they would “shout out” if things were wrong. Another said that they felt able to raise any concerns if need be. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 17 Since the last inspection in February CSCI have not received any complaints. The home have received a small number but these have been handled correctly by the home manager The home has a Protection of Vulnerable Adults (POVA) policy. The staff training matrix shows that 8 staff have attended POVA training in recent months. Further staff will be attending the training in the near future. Whilst this is good, it is concerning that two staff spoken to during the course of the inspection were not fully aware of their responsibility to protect the residents from harm, and the actions they should take if any bad practice was witnessed. For these two workers, this should have been covered during their induction-training package. This shortfall does have the potential to mean that some residents may not be protected from harm. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This 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. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 19 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. Currently the home has only 35 residents, spread between the two floors. One of the bathrooms on the ground floor is currently being converted into a level access shower room. The home is well decorated throughout. Improvements have been made in the upstairs lounge with the removal of the kitchenette area. At the last inspection staff expressed difficulties in working routines with the sluice room door being locked, however during this inspection the room was unlocked. Whilst there were no cleaning products stored in the room, it would be best if the room were secured. Alternative options for securing the door should be explored. The home has equipment to assist the care staff with moving and transferring residents with impaired mobility. The equipment was last serviced in February. A number of profiling beds have been purchased and there will be a rolling programme of replacement of the others. Each bedroom had ensuite facilities of a toilet and wash hand basin. There are four shared rooms each with privacy screening in place. Two single occupants currently reside in two of the shared rooms. 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 clean tidy and free from any offensive smells. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Improvements must be made in meeting the training needs of staff to ensure that the residents are cared for by staff who are skilled and competent. EVIDENCE: The home has a full compliment of staff to meet the needs of the current residents but recognises that additional staff will need to be recruited as occupancy levels increase. On the day of inspection there was one registered nurse, one senior care assistant and three junior care assistants on duty plus the home manager. There are dedicated housekeeping, laundry, maintenance and catering staff in addition, to ensure that the resident’s daily living needs are met. Residents stated in the survey forms that there was usually staff available when they needed them, but on occasions have to wait for assistance. A number of staff are on extended leave. Records show that the home covers a significant number of shifts with bank or agency workers. Two workers have been placed by a recruitment agency for a 12-week period, prior to being confirmed as permanent members of the staff team. One resident commented, “there are always new faces”. The home currently has seven members of care staff who have achieved the NVQ level 2 in care, and two have just been enrolled onto the course. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 21 One of the senior carers, a qualified nurse in their own country can be considered as having equivalent qualifications. Three staff have been enrolled onto NVQ Level 3. 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 NVQ Assessors visited the home on the day of inspection. The home will achieve the requirement for a minimum ration of 50 trained members of staff, when this group complete their qualifications. This will ensure that residents are cared for by staff who are skilled and competent. Staff files of the most recently recruited members of staff were examined. All the necessary checks were not carried out prior to the start of their employment, thereby not ensuring that workers suitability for care work. One person had only one written reference on file, whilst for three staff there was no evidence that POVAfirst checks had been obtained prior to their start date – there CRB disclosures were not received until after this date. The home has failed to consistently follow safe recruitment and vetting procedures. The manager must ensure that when staff are supplied by a recruitment agency, that full vetting procedures have been followed and they must retain evidence in the home that this has been achieved. It is the manager’s responsibility that this has been done. An Immediate Requirement Notice was issued regarding the homes recruitment practices. Two new staff members had not received a satisfactory induction programme when they started at the home and therefore were unaware of safe working practices (for example the homes fire procedures and moving and handling policies). It is concerning that new staff employed at the home are not instructed in safe manual handling and transferring techniques, prior to working with the residents. This has the potential to mean that residents may be harmed by unsafe working practices. One care assistant said they watched what others did whilst the other said “they were told what to do and how to do it”. Neither worker was allocated a mentor who supervised their work practice. No further workers should commence at the home without a robust induction training programme, and records should be available for examination at future inspections. The staff training matrix evidenced that staff are undertaking training course in Infection Control, First Aid and Food Hygiene, under “distance learning” arrangements. A number of staff have recently attended a POVA training session and this was confirmed by the registered nurse. The majority of the staff team have had fire prevention training. Mimosa have recognised that the majority of staff need to receive training in all mandatory subjects (food hygiene, health & safety, POVA, fire, first aid and basic life support for example), and are introducing a “Red Crier” package of training for all staff. The progress of the home will feature in ongoing monitoring of the home. The manager must ensure that individual staff training records are maintained for each staff member and these are available for future inspections. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Improvements must be made in the management of the home to ensure that residents live in a home that is safe and run in their best interests. EVIDENCE: The manager has been in post since September 2005. This is her first home manager post, having previously worked within the NHS. She is a registered nurse and has commenced an NVQ Level 4 in Management qualification. The home has a deputy manager who is also doing a registered managers award. Whilst the manager has the necessary skills and qualifications to be the registered manager, during the inspection she did not demonstrate that she had control of what was going on in the home. At times she had a very ‘casual’ attitude. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 23 Although the home undertakes a number of audits on a regular basis, and all the homes policies and procedures have been updated, there are no other quality assurance mechanisms in place to capture the views of the residents, relatives and stakeholders. The manager said that a full quality review survey will be undertaken by the owners after “6 months”. It will be expected that the home will formulate a development plan from the results of the survey, and that this plan will result in improved outcomes for the residents and staff. The home looks after monies for some of the residents and maintains good administration systems of all transactions to and from the accounts. Three sample accounts were checked and each tallied. Staff said that they have not had supervision with a senior member of staff on a regular basis, and the matrix showing those sessions held, supplied by the manager verified this. Observations made during the inspection, were that the staff worked unsupervised for much of their shifts. At one point a “minor situation” developed and the two very junior care assistants were unsure of what action to take. This has the potential to place the residents at risk from receiving an unsafe service. The manager does not ensure that all staff safe use working practices, therefore staff may not have the necessary skills to safely care for the residents. New staff are not routinely instructed in safe moving and handling techniques, and are not instructed in fire systems and the homes fire procedures. Both these issues should be covered at the start of each workers employment. In addition to this the home do not complete a manual handling assessment for each resident that results in a safe system of work being devised. This has the potential to mean that staff may use incorrect methods of moving a resident, causing both them and themselves harm. There was no evidence that staff have participated in recent fire drills. The last fire drill that some of the night staff took part in was dated October 2005. An Immediate Requirement Notice was issued. The fire officer states that night staff should take part in fire practices every three months and day staff every six months. The records concerning fire safety checks and hot/cold water checks are complete and the home is well maintained. Bishopsmead Lodge DS0000066339.V296595.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 2 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 2 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 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 1 X 1 Bishopsmead Lodge DS0000066339.V296595.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 OP3 Regulation 14(1) Requirement Evidence that pre-admission assessments are undertaken prior to placement. Care planning documentation must accurately reflect resident’s needs, be comprehensive, and be kept up to date. (the previous timescales of 20/11/05 and 28/04/06 have not been met). An enforcement notice will be issued. Timescale for action 27/07/06 2. OP7 15(1) 27/07/06 3. OP8 12 The records made to assist in monitoring residents health care needs should be accurately kept and clearly evidence the care given. Staff must ensure that residents are treated respectfully and they are not left feeling vulnerable, without the means for summoning assistance. All staff must receive POVA training. New staff must receive instruction as part of their induction programme. 27/07/06 4. OP10 12(4)a 27/07/06 5. OP18 13(6) 27/07/06 Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 26 6. OP29 19 Robust recruitment procedures must be followed for all new staff. The home have been issued with An Immediate Requirement Notice. All new staff must complete an induction training programme that meets national training organisation targets and fulfils the aims of the home. Quality Assurance systems must be in place to ensure that the home is run in the best interests of the residents. 27/06/06 7. OP30 18(1)c 27/07/06 8. OP33 24 27/12/06 9. OP36 18(2) Staff must be appropriately 27/08/06 supervised and their work monitored, on a day-to-day basis and also a formally basis. A comprehensive manual handling risk assessment must be completed for each resident that results in a safe system of work being devised. All staff must receive Manual Handling Training before assisting residents, and have updates on an annual basis. All staff must participate in regular fire practice sessions, night staff 3 monthly and day staff 6 monthly. Records must be maintained and available for inspection. An Immediate Requirement Notice was issued 27/07/06 10. OP38 13(5) 11. OP38 13(5) 27/09/06 12. OP38 23(4) 27/06/06 Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP28 OP36 Good Practice Recommendations All care planning documentation should be written in a person centred manner. The home should continue to work towards achieving a 50 ratio of trained members of care staff. All staff should receive supervision at least six times per year and records should be kept. Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bishopsmead Lodge DS0000066339.V296595.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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