Inspection on 05/06/07 for Blackdown Nursing Home

This inspection was carried out on 5th June 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

Blackdown Nursing Home 16/12/08

Blackdown Nursing Home 10/05/06

Blackdown Nursing Home 26/01/06

Blackdown Nursing Home 14/09/05

Blackdown Nursing Home 19/10/04

Blackdown Nursing Home 28/04/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Blackdown Nursing Home Blackdown Mary Tavy Nr Tavistock Devon PL19 9QB Lead Inspector Doug Endean Unannounced Inspection 5th June 2007 10:45 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 Blackdown Nursing Home DS0000029072.V338556.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. Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blackdown Nursing Home Address Blackdown Mary Tavy Nr Tavistock Devon PL19 9QB 01822 810249 01822 810279 paulconnieluke@btinternet.com www.carehomessw.co.uk Whitchurch Care Ltd. 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) Marjorie Hoyle Care Home 33 Category(ies) of Dementia - over 65 years of age (19), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (19), Old age, not falling within any other category (3), Physical disability over 65 years of age (33) Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Registered for max 3 OP Registered for Max 33 PD(E) Service users 65 years and over Registered for max 19 DE(E) service users 65 years and over Registered for max 19 MD(E) service users 65 years and over Date of last inspection Brief Description of the Service: Blackdown Nursing Home is a care home that is registered to provide nursing care to a maximum of 33 people of either sex, over the age of 65. A maximum of 26 beds may be provided to people who have been assessed as having general nursing needs, and a maximum of 19 people who have been assessed as having mental health nursing needs. It is also registered for up to 3 Service Users who have personal care needs only. The Registered Manager is a level one trained nurse and she leads a team of other registered nurses, Social Care staff and ancillary staff. Collectively they are able to deal with the various care needs of the current Service User group. Blackdown Nursing Home is arranged on two floors with access to the first floor via a shaft lift. There is also a stair lift available. The home has a newly established lounge at the front of the building, and a new lounge and dining area in the centre of the home. The unit designed for the 19 elderly Service Users with mental health needs (Sunflower) is secured for the protection of the Service Users and benefits from a lounge/dining room and extensive views over mainly rural land to Dartmoor. There are also refurbished bathrooms with ceiling track hoists and refurbished disabled toilet facilities. There are large, accessible gardens surrounding the home with some paved areas provided with seating. The home is situated on the edge of Dartmoor in the village of Mary Tavy where there are a number of local amenities. As the building work at the home has come to an end the grounds surrounding the home are being improved to provide greater access for people living at the home. The homes present fee structure begins at £481 for nursing care and does not Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 5 include extras such as papers, hairdressing and chiropody the cost of which are invoiced to the appropriate person. Fees are negotiated based on the level of care that is to be provided. Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 5th June 2007 beginning at 10:45 hours and lasted 4.5 hours. The Registered Manager was not on duty but chose to give up her free time to attend the inspection when she was informed that it was taking place. She cooperated fully during the inspection and provided the inspector with all the documentation and information that was requested. We had received the homes completed “Annual Quality Assurance Assessment” immediately prior to the inspection that provided a good self-assessment and useful data for the inspection. During the inspection 4 service users files and five staff files were read. The information was verified when the inspector spoke to the service users, two relatives and three of the staff whose files were read. We received seven completed service users questionnaires and two completed relatives questionnaires. We also made a full tour of the home looking particularly at the areas that had been refurbished or newly built. What the service does well: What has improved since the last inspection? The environment has benefited from the new communal spaces that are now complete and in use. The new carpets in the corridors and communal space are of good quality and attractive to the eye. The shaft lift is fully operational and allows easy access to the new communal spaces for all the people living in the home whatever their disability. Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 7 The bathrooms have been refurbished and have a high standard of finish and include ceiling track hoists. The ground floor toilet has also had its refurbishment completed and includes a wash hand basin and handrails. The Registered Manager has a fully refurbished office at the entrance to the home. She has recently completed the fit person process by the Commission for Social Care Inspection and is registered by the commission for her post of Registered Manager. The Statement of purpose has been reviewed and is up to date. The home is introducing a new system to record all the information about a person receiving care at the home. This is bringing together the information on residents into a file that has a good structure to it enabling information to be easily accessed. It also, when completed, provides a greater amount of information about individuals. 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. Blackdown Nursing Home DS0000029072.V338556.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 Blackdown Nursing Home DS0000029072.V338556.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against standards 1 and 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose is up to date and satisfactory. The pre-admission assessment is good as it draws a suitable amount of information together for a decision to be made about the appropriateness of an admission. With the introduction, and use of the new recording system, it will be better. EVIDENCE: The home have recently updated the statement of purpose to include the name of the Registered Manager and information about the now completed refurbishment of the interior of the home. The document is informative and Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 10 has all the information required by the regulations. It should provide anyone reading it with information that will enable them to make an informed choice about moving to the home. The home invites people to visit the home before making a decision to stay. A copy of this document as well as the complaints/compliments procedure, Commission for Social Care Inspection survey forms, information on Funded Nursing care, etc, are at the entrance to the home by the signing in book. There is also a website for the home and others in the group. It is now in need of some updating, as the photographs do not show the new entrance and completed building work that has taken place. People who are referred to the home are assessed by a registered nurse before any decision to offer a place is made. This may take place at there home or place of abode or at the nursing home if they are able to visit. The inspector saw completed copies of the homes pre-admission assessment form in the sample group of four sets of notes that were read. The information gathered included a diagnosis, information about what the care needs are and how they should be addressed. Such things as nutrition, medication, manual handling and also information about the service users mental state especially where the referral is for the dementia care unit was recorded. The need for special equipment such as an air loss mattress and hoists are assessed also. In addition to this information the home also has a document that is completed that informs the staff about the service users personal likes and dislikes called a “comforts guide”. A social history is also taken at an early stage to assist the care planning process. Where a referral has come from a health or social services department there was referral forms and discharge summaries to enhance the information gathered by the home. The Registered Manager is presently establishing a completely new recording system for all the records about people living at the home. This system is more comprehensive then the present on used by the home. The home will provide care to any person regardless of their nationality or religion as long as they meet the criteria for admission and they are able to meet their needs. Blackdown Nursing Home DS0000029072.V338556.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against standards 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. The staff team plan care well for each individual person living at the home and provide it in a professional, dignified and respectful way. EVIDENCE: The records of 4 people living at the home were read and the information verified during the course of the inspection. The process included talking to staff, the person the notes were about and where possible their relatives. The care planning arrangements are good. The recording of information remains the same as during previous inspections for the majority of people’s records. The care plans were in a style that the home has designed and they provide a suitable format for care to be planned and delivered from. The plans were drawn up initially from the information gathered in the pre-assessment process then updated regularly as the person’s needs change. The changes were supported by risk assessments such as manual handling, use of bed guards, Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 12 and tissue viability. There were also assessments made for nutrition and the activities of daily living such as communication and personal hygiene. There is also a “comforts form” that records the likes and dislikes of the individual people and helps to inform staff about them as a person. The home is introducing a new system for recording information about people they provide care for. The inspector saw two files that are the beginning of the homes use of the new system and felt that this was an improvement on the present system. There are good arrangements for other health care professionals to attend the home and meet the needs of the residents and patients. The registered nurses make referrals to the appropriate person and act as advocate for the people living in the home in obtaining the services of the National Health Service. The home records on separate sheets information from visiting professionals and the inspector saw notes from the chiropodist and those made following a General Practitioner visit. The inspector looked at the homes storage and administration arrangements for medication. It remains the same as at the last inspection. The medication management arrangements are good with suitable storage, administration and disposal facilities meeting current guidelines. The administration of medication is the responsibility of the registered nurses. The inspector spoke to four people who live at the home, or watched the interaction between them and the staff. He also spoke to two relatives during the course of the inspection. The people who live at the home are treated with dignity and respect. Personal care was provided in the privacy of the client’s own room or in an appropriate area such as the bathroom or toilet. The staff talked to the residents in a respectful way having established an acceptable way to address them. Blackdown Nursing Home DS0000029072.V338556.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): The homes performance was assessed against standards 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 home provides care, services and activities that satisfy the needs of the service users who can exercise their choice in how they are received. The food prepared for the people living at the home is well prepared and nutritionally balanced. EVIDENCE: The home does offer a variety of activities, formal and informal for the people who live in the home. There are televisions in the bedrooms and each person can choose to provide their own videos, DVD’s, and freeview TV if they wish. The notice board in the entrance gives details of entertainment that is planned such as music from visiting musicians, move to music fortnightly arts and crafts and reminiscence. They also have a hairdressing salon in the home that is open weekly with very reasonable rates. The staff also provide activities most afternoons such as bingo, massage and aromatherapy. If the people living at the home are a member of a club in the community the home will help to maintain there attendance. One person attends a stroke club fortnightly. Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 14 When the home provides an activity relatives may join in if they wish. Records of attendances to activities were seen in the individual persons files. The home shares a mini bus with a sister home and this is used occasionally for trips around the area. The home has no set visiting hours allowing visitors to arrive at any reasonable hour. Visiting can take place either in the privacy of a person’s room or in one of the communal areas that are now available. The one complaint received within the last year did relate to communication between the home and a relative. One relative has commented in a response in the survey questionnaire that the home was very good at keeping her family informed everyday with a progress report after a relative had suffered a fall at the home. They also wrote that the staff were “always helpful and friendly” and they were “generally satisfied with the care given”. Another relative wrote that the staff are “attentive, cheerfully interacting with all the residents even at difficult times”. The inspector made a tour of the home and saw that the bedrooms are personalised using pictures and items of furniture. Some people choose to spend much of their time in the privacy of their own room whilst others choose to use the lounge space. The home has a large kitchen that it well equipped to provide all the meals to the people who live at the home. Nutritional assessments help the cook to prepare meals that are of good quality and meet individual needs such as diabetic, soft or pureed. The eight service users survey responses generally agreed that the food is usually or always good with one saying that it is sometimes good. The relatives who were spoken to also agreed that the food is of a good standard. The cook provided the inspector with records that showed how the kitchen and the food is managed using “Safer Food, Better Business” documentation. Menus are on display at the front entrance of the home and the likes and dislikes of the people living in the home are obtained and recorded in the comforts form. Alternative food is prepared when the food on offer does not meet with the wishes of an individual. Also the home will provide meals that meet cultural and religious needs of residents. Meals are served either in the privacy of a persons room or in one of the two dining areas. Where assistance is needed or supervision required the staff provide this in a way that maintains the dignity of the resident. The home does not manage the financial affairs of any of the service users. Where a charge is made for a service, such as chiropody or hairdressing, an invoice is produced and sent to the person handling the financial affairs of a person receiving care. Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 15 Blackdown Nursing Home DS0000029072.V338556.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for handling complaints and providing protection of client’s from abuse, plus recording and reporting of abuse, are satisfactory. EVIDENCE: The complaints procedure was displayed on the notice board in the front entrance and is also in the homes Statement of Purpose. It had all the information clients or visitor to the home would need should they wish to raise an issue including the contact details of the Commission for Social Care Inspection. The service users that were spoken to did know how to make a complaint if they felt it necessary. The home does have a complaints/compliments book with the signing in book at the front door. The inspector looked at the book during this inspection. It held information about one complaint raised and the action taken by the home to resolve it. The inspector has managed one complaint in the last year that led to an improvement in the way information on care plans is recorded. The care plans lacked detail with regard to manual handling, tissue viability, pressure area care and the choice of pressure relief to be used as her needs changed. The new Registered Manager has resolved this problem. Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 17 At the signing in book is a notice inviting anyone to bring any complaints or concerns they may have to the Registered Manager, or nurse in charge’s attention, before leaving the home. The home training booklets on open display in the manager’s office for staff to read. One is “Your introduction to Work in Adult Social Care” and another is “A practical guide to POVA”. The Devon County Council Alerters Guide is also available and staff are required to watch the “No Secrets” video as part of the adult protection training. All new staff are shown this video during their induction period. The inspector saw evidence that staff have signed that they have seen this video. The Registered Manager told the inspector that further adult protection training by an external provider is planned for October 2007. The homes recruitment policy and procedure provides a measure of protection by screening people who wish to be employed in the home. See the portion of this report headed “Staffing”. Blackdown Nursing Home DS0000029072.V338556.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against standards 19, 20, 21 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The amount, and standard finish of the communal space and the bathing facilities is excellent. The general appearance of the home has improved a great deal as the building work has been completed. The laundry facilities and infection control arrangements are good. EVIDENCE: The home is located in the village of Mary Tavy on the main road from Tavistock to Oakhampton on the edge of the Dartmoor National Park. The village shop has a small post office but most other facilities such as the Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 19 pharmacy are found in Tavistock that is a few miles away. The home is within its own grounds up shared a driveway with several parking spaces at the front entrance of the home. There is level access from the car park into the home through its new front entrance. The home is on two levels and there is a new shaft lift providing easy access to each floor. There is also a stair lift and staircase between the two floors. It is registered for 33 people with physical disabilities or dementia the care being provided in two separate units. The home has had extensive upgrading over the last few years that has almost come to an end. There are now two new lounge areas and a dining area in the physical disability area and the dementia care wing has its own lounge/dining area. The bathrooms have been refurbished and now provide wet rooms and modern disable bathing facilities with ceiling track hoists. The ground floor toilet has been refurbished and fully tiled to a good standard of finish with handrails also being in place. There has been new high quality carpeting to the lounges and also through all the passageways and staircases where new tread edging has been fitted to meet the needs of the visually impaired. Some of the windows have also had new curtains. The people spoken to by the inspector who have lived at the home for some time are very pleased with the changes to the appearance of the home and the provision of more communal space. The home now has a warm, comfortable appearance and the facilities, bathing and toilets are excellent. In addition the infection control arrangements have improved with the provision of a mechanical disinfecting sluice on each floor, hand gels and disposable gloves and aprons placed for staff at intervals throughout the home. The grounds can be accessed directly from the lounge of the dementia care unit and also from around the side of the new lounge at the front of the building when the path is complete. The second lounge is having a patio area developed and ramping to join the other paths around the grounds. The views from the home extend for several miles across Dartmoor National Park from different vantage points in and around the home. The home has a large modern laundry that has a large commercial dryer and two large capacity washing machines with sluicing cycles. The floors and walls are washable and not permeable to water. There are policies and procedures in place that deal with hand washing and other infection control issues. Staff are employed in this area, which is located at the end of a corridor separate from the kitchen. The home asks that personal clothing is marked to assist in it being sent to the correct bedroom. One person did remark that well marked cloths do sometimes go to the wrong room. Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 20 Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 21 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): The homes performance was assessed against standards 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. The home is adequately staffed and has suitably trained and experienced individuals who have been properly prepared for the work that they undertake. EVIDENCE: The home is registered to provide nursing care and therefore employs registered nurses who have a current pin number. The home is always in the control of a registered nurse 24 hours a day supported by care staff that have a variety of skills through training. The overall management of the home is the responsibility of the Registered Manager who has been recently registered in this role by the Commission for Social Care Inspection. The inspector looked at current and past duty sheets and verified that the staffing arrangements that have occurred were suitable. In addition to the care staff the home also has catering staff, domestic and laundry staff who work along side of the carers to meet the homes aims and objectives. The recruitment process was studied and the inspector read five staff files. Each file was complete having a completed application form, photograph, and interview checklist, various forms of identification including passport, driver’s licence and utility bills. The files had a Criminal Records Bureau check and Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 22 POVA first result. There were two references in each file. The inspector saw evidence that the staff had gone through induction training that included seeing the adult protection “No Secrets” video. There was some evidence that staff had attended supervision with the manager and this had been recorded. The manager told the inspector that not all staff have begun having supervision yet but it is being implemented. One of the staff files was for a new recruit who has not yet started work at the home. This file was also complete except for the Criminal Records Bureau check that has not yet been returned. The home does not discriminate on the grounds race, colour or religion when recruiting staff and it does have a staff group of mixed nationality. The staff turnover is low with several staff having worked at the home for several years. The manager supplied information that showed all the care and catering staff in the home have had at least the basic food hygiene training. There was evidence of other training in staff files that included working with people with dementia, moving and handling, first aid, Fire training, adult protection, care of older people and continence assessment. There is 87.5 of the care staff that have a National Vocational Qualification at level 2 or above. At present two staff are working toward level 3 and one more is soon to commence the level 2 training. The Registered Provider takes an active part in arranging the training staff undertake. The main corridor provides evidence of some of the certificated training staff have undertaken as many certificates are on display. The two relatives that were spoken to comment said that the staff are very caring and one resident stated that the Registered Manager was excellent. This person and his relative said that they have been very demanding of the service and it has responded very well. Three staff were interviewed during the course of the inspection. Each have several years experience at the home, and each were able to verify the information that had been read in their staff files, such as training that had been undertaken. They made positive comments about the caring approach that is used by the staff and the direction the home is taking under the management team. Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 23 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): The homes performance was assessed against standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed well by an experienced Registered Manager, and the Registered Providers who are involved in the running of the home on a daily basis. Collectively they are meeting the care needs of the people under their care in a safe environment. EVIDENCE: The Registered Manager has recently completed the vetting process by the Commission for Social Care Inspection for this role. She has, however, several years experience as a Registered Manager in the independent Health Care Sector. She is an experience registered nurse and provides good leadership Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 24 within the home. She also has the Registered Managers Award having successfully completed the course in October 2005.There has been a gradual change to the way the home operates, partially as a result of the building work being completed, but also as a result of the manager’s approach to her role and the introduction of new ways of doing things, such as the service users records. There are clear lines of accountability both in the home and with the external management. Meetings are held, an agenda produced, and minute taken between the levels of management. The meetings include the Registered Manager and Providers, Registered Nurses and representatives from the Care Assistants from day and night shifts. The inspector has seen copies of these minutes. There was some evidence that staff had attended supervision with the manager and this had been recorded. The manager told the inspector that not all staff had begun having supervision yet but it is being implemented. This was also recorded in the AQAA form completed by the home immediately prior to this inspection. There was evidence that the home seeks the views of client’s and their advocates regarding their levels of satisfaction with the services offered by the home. The Registered Provider is looking at ways of increasing the scope of quality assurance to include various processes that are undertaken in the home that will further show how they have met their aims and objectives. The Registered Manager and the Registered Providers have provided a safe environment for the people who live and work in the home through attention to staff training and good maintenance of the building and equipment. All staff had a suitable period of induction training and supervision. Staff are provided with infection control training and equipment to prevent the spread of infection. All staff had food hygiene training. The care staff have had moving and handling training and have modern equipment such as stand aids and ceiling track hoists in the refurbished bathrooms. The inspector saw evidence of good maintenance of equipment, such as hoists and the fire equipment, by competent people under contract to the home. Fire training and drills are up to date also. Accidents are recorded and reported to relatives, and health care professionals such as the General Practitioner if their skills are required. Blackdown Nursing Home DS0000029072.V338556.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 4 4 X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 OP35 OP33 Good Practice Recommendations The Registered Manager should continue to implement staff supervision and record the sessions. The Registered Person should increase the scope of the quality assurance system to include processes that are undertaken in the home and will further show how they have met their aims and objectives. Blackdown Nursing Home DS0000029072.V338556.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Blackdown Nursing Home DS0000029072.V338556.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. 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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