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Inspection on 03/10/05 for Bluebell Nursing Home

Also see our care home review for Bluebell Nursing Home for more information

This inspection was carried out on 3rd October 2005.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The company is continuing to commit revenue to the upgrading and development of the service, which according to both service users and relatives/visitors is beginning to pay dividends, the improving environmental conditions seen as a major plus for the home. It was also felt that the improving living conditions were contributing to the changing environmental atmosphere, people describing the home/staff as positive and welcoming and commenting on the improved communication between parties, which they attributed to a sense of professionalism that now existed. Evidence of the efforts being made by the company to enhance communication opportunities were demonstrated throughout the visit but were best represented through the revamped Statement of Purpose and Service Users` Guide literature. These documents readily available to both patients and visitors within the main entrance hallway and according to the administrator, replenished on a three to four weekly basis.

What has improved since the last inspection?

As indicated above improvements are continually being made to the premises and the general services and amenities available for the patients. At the last inspection visit the position of activities co-ordinator had only recently been established and whilst appearing to be a promising and positive step, the infancy of the position meant it was difficult to ascertain the potential longer-term benefits for service users. At this visit it was possible to determine, with far more certainty, how well the role of activities co-ordinator was working and how the addition of a specific co-ordinator had impacted on the day-to-day life of the service users.What was perhaps most evident was that by creating the activities co-ordinator position the company had provided a structure and organisation to the planning and development of an entertainments schedule, which had previously been missing. A list of forthcoming events and acts was permanently on display within the main hallway, although the size of the poster and the fact that only one was visible around the home somewhat detracted from the effort put in when arranging the programme. A basic recording system has been developed for documenting daily (routine) activities undertaken, whilst more elaborate entertainments or unusual activities are documented in greater depth. The activities co-ordinator has also begun to develop a stock or store of supplies for providing in house activities with an artistic or creative element, as well as books and games, etc.

What the care home could do better:

The company is making positive efforts to improve the overall quality of the service and has completed significant amounts of work since purchasing the home at the latter end of last year. With this in mind it seems a little unreasonable to be critical of the service, although some issues were identified where the practices of the home could be improved. Firstly the activities co-ordinators should be undertaking a more detailed assessments of the service users` needs, wishes, hobbies and abilities before creating activities programmes. Each person having different likes and dislikes, etc. that should be built into a more general and/or inclusive schedule which would ensure a wider appeal. Secondly the training officer needs to review the current system for documenting the training attended by staff, with a view to creating a record that enables her to monitor the training completed, renewal or update dates and hours of training provided, given the need for employers to ensure 3 days paid training is available to each carer.

CARE HOMES FOR OLDER PEOPLE Bluebell Nursing Home 45 - 53 St Ronan`s Road Southsea Hampshire PO4 0PP Lead Inspector Mark Sims Unannounced Inspection 3rd October 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 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. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bluebell Nursing Home Address 45 - 53 St Ronan`s Road Southsea Hampshire PO4 0PP 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) 023 9282 3104 023 9282 6109 Techscheme Ltd t/a Bluebell Care Home Mrs Jacqueline Mary Hawes Care Home 51 Category(ies) of Dementia (15), Dementia - over 65 years of age registration, with number (15), Old age, not falling within any other of places category (51), Physical disability (51), Physical disability over 65 years of age (51), Terminally ill (51), Terminally ill over 65 years of age (51) Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Staffing levels apply Service users in the category of DE are only to be accommodated age 55 years and above A total of 15 service users only in the categories DE and DE(E) may be accommodated in the home at any one time 21/04/05 Date of last inspection Brief Description of the Service: The Bluebell Nursing Home is registered to accommodate a total of 51 placements under seven different categories: older persons, terminally ill, terminally ill over 65 years of age, dementia, dementia over 65 years of age, physical disability, physical disability over 65 years of age. The home is situated along St Ronan’s Road, Southsea and is a short walk from Southsea pier, a predominant feature of the area, which is well serviced by local bus companies. The nursing home is comprised of five period town houses combined to create a single building, with three separate floors and two mezzanine floors, which could prove a little a confusing when first arriving at the home. Local facilities are sparsely situated, although Southeas maining shopping centre is only a 15 minute walk or 5 minute car journey from the home. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection represents the second statutory inspection of the year for Bluebell Nursing Home, although an additional visit was undertaken in August to follow up on concerns raised in respect of the home’s respite service and the recruitment and selection procedures of the home, all inspection visits conducted on an unannounced basis. What the service does well: What has improved since the last inspection? As indicated above improvements are continually being made to the premises and the general services and amenities available for the patients. At the last inspection visit the position of activities co-ordinator had only recently been established and whilst appearing to be a promising and positive step, the infancy of the position meant it was difficult to ascertain the potential longer-term benefits for service users. At this visit it was possible to determine, with far more certainty, how well the role of activities co-ordinator was working and how the addition of a specific co-ordinator had impacted on the day-to-day life of the service users. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 6 What was perhaps most evident was that by creating the activities co-ordinator position the company had provided a structure and organisation to the planning and development of an entertainments schedule, which had previously been missing. A list of forthcoming events and acts was permanently on display within the main hallway, although the size of the poster and the fact that only one was visible around the home somewhat detracted from the effort put in when arranging the programme. A basic recording system has been developed for documenting daily (routine) activities undertaken, whilst more elaborate entertainments or unusual activities are documented in greater depth. The activities co-ordinator has also begun to develop a stock or store of supplies for providing in house activities with an artistic or creative element, as well as books and games, etc. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 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 Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 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): Standards 1 & 2. The statement of purpose documentation is clearly and readily accessible within the front entrance hall and contains all relevant information and a copy of the most recent Commission inspection report. Prior to admission service users are either provided with details of the home’s terms and conditions of residency or can access information relating to the terms and conditions of residency by picking up a brochure at the home. EVIDENCE: During the tour of the premises the opportunity arose to review the home’s statement of purpose, service users’ guide and terms and conditions documentation, which had all been included within a new brochure style booklet, copies of which were accessible within the front entrance hallway of the home. On reading through the statement of purpose and service users’ guide the inspector could easily identify the areas of the document created in accordance with the national minimum standards and those specific to the home and included by the company for reference purposes. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 10 In conversation with key staff it was established that the intention of the company in creating a single brochure document was to provide access to a far more informative and comprehensive document that was easily and readily available to service users and visitors. In discussions with the home’s administrator it was apparent that she was responsible for ensuring adequate stocks of the brochure documents were maintained within the hallway, the administrator stating that on average she has to replenish the stock every three to four weeks. The review date for the documentation was also clearly visible and advertised within the brochure pack, the last update occurring in April 2005. On meeting with service users and their families the question of access to preadmission information was raised, with the service user confirming that she had been provided with information about the home and the services provided prior to arriving at the home, although she wasn’t sure where the literature was currently. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 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): Standards 10 & 11. Service users and their relatives felt the staff were respectful and conscious of people’s rights to the promotion of dignity and privacy. As part of the assessment and care-planning programmes details of people’s funeral wishes in the event of their deaths whilst resident at the home are gathered and recorded. EVIDENCE: A recurring theme at this visit was the regard the visitors held for the staff and management, many of whom they praised for a far more professional approach to care. Although one or two comments were made about younger staff sometimes rushing tasks and not necessarily listening to what the patient wanted or was asking. However, generally people appeared pleased with the service and the way they were greeted or welcomed to the home, starting from the day of admission, when they commented on being welcomed with a tray of drinks and biscuits and afterwards when they are received with an offer of refreshment, etc. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 12 In talking with both service users and their relatives it was also evident that they appreciated the relaxed and friendly atmosphere being created within the home and were quick to mention that regardless of the situation staff always remained professional and polite. A particular theme that was repeated within comment cards returned to the Commission prior to the last inspection where people describe staff as welcoming and friendly and where they confirmed that they are able to meet with their relatives in private. One specific group of visitors attributed the improved service and attitudes of the staff to the management, who they felt had improved communication pathways between the home and the families and the staff and the service users. Several examples of the open and relaxed way the manager and key staff dealt with families and visitors were observed during the inspection, when seated in the office and people came in looking to discuss aspects of a relative’s care or health, etc. The interactions between the parties being very natural and easy and people seeming confident that what they discussed would be addressed. Another aspect of the home’s practice which underpins their commitment to ensuring service users’ health and personal care needs are met and the continuing drive to a more professional service involves their approach to caring for dying service users. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 13 The manager/matron discussing how she attempts to identify at point of admission or during the pre-admission assessment process if possible any specific funeral arrangements a service user might have in case they die whilst staying at the home and more commonly know if the person has any specific requests for active interventions in the event of becoming ill. This information, if volunteered, is documented on the admissions sheet and care plan if appropriate and is kept under constant review in case of change. The provision of almost exclusively single occupancy bedrooms is of great benefit when considering issues of privacy and dignity when caring for a dying service user and ensures that people can remain in their own bedroom throughout their last days. Within the home’s remaining shared rooms the provision of appropriate screening helps promote dignity, privacy and respect for the service user, although this cannot be delivered with the same level of certainty as within single bedrooms. In discussion with the training officer it was established that some staff have completed study days at a local funeral directors and that plans are in place to facilitate further visits, as staff found this form of experiential learning useful. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 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): Standards 13 & 14 Service users are supported in the maintenance of community contacts and are welcome to receive visitors to the home at anytime. The care planning process and running record are used to evidence that people are supported in exercising and retaining control over their own lives. EVIDENCE: The information or brochure packs accessible within the main hallway provide details of the home’s visiting arrangements and hours of visiting, which are generally very flexible and open and would appear from the service users’ comments be suitable for the purposes of promoting appropriate family contacts. Throughout the inspection and specifically during the tour of the premises a number of visitors to the home were observed arriving and leaving and those whom the inspector spoke with confirmed that the arrangements for visiting the home suited both their needs and schedules, etc. as well as those of their relative/friend. It was also noticed within the care plans inspected that the staff document when a service user has a visitor, although the tick box system employed Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 15 cannot identify who the visitor was or how long the visit lasted, etc. due to its simplistic design. However, as the home does maintain a visitors’ log within the main hallway for the purposes of people signing into and out of the home, it might be possible, if required, to tie the two documents together to provide details of who and how long a visit lasted. The issue of record keeping with regards to activities being provided is something the home or activities co-ordinator should look to address as apart from the brief tick box record and occasional self-reviews undertaken by entertainers, etc. the home records little in the way of useful information on the benefits of activities provided. It would be useful to look to create a system that assesses and establishes what the service user likes to do or used to do prior to admission. This information could then be built into an individualised activities care plan, where it might be possible for the co-ordinator to use the information in delivering suitable leisure activities. A more detailed and perhaps individualised recording system could be developed to document the benefits of the activities and entertainments arranged, recording both positive and negative reactions and choices of the service users. In discussion with several service users the reaction to the entertainments provided were mixed, with some people enjoying the external entertainments, whilst others were less impressed although they were able to choose not to remain and participate in the event. A recent social event that everyone seemed to enjoy and wish to discuss was a barbeque, to which service users, staff and their associated families were invited. The service users described the day as a complete success and praised the management and staff for arranging such a fun and enjoyable event, which would appear to have lasted all day. People also commented on how much their families and visitors had enjoyed the day and efforts made by the home in providing such a wide variety of barbeque foods. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 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): Standard 18. The training officer and management have still not introduced a structured recording system for tracking training attended, training required and training planned. EVIDENCE: At the last inspection it was reported that: ‘Adult protection training was discussed with key members of the staff team and found to be an area of the home’s training programme that required attention, as whilst the home has information in the form of Local Authority guidance leaflets and an in-house policy, it has no specific educational or instructional training tool. Adult protection awareness is an important part of any staff training and development package, as a lack of knowledge around protection issues can directly impact on service users, who are considered a vulnerable and at risk client group. The protection of vulnerable people however extends beyond just training and development strategies, embracing culturally important issues such as openness, trustworthiness and clear pathways of communication and leadership.’ At this inspection it was established that improvements had been made with regards to the training officer being provided with a specific office / training Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 17 room, etc. however, little progress has been made in relation to improving the way the training records are maintained or how training is planned. There continues to be no real structure or organisation to the documenting of courses attended or dates for renewal and it was not clear how training or educational needs are identified, other than through people volunteering to attend advertised events. As one of the fundamental issues noted to be outstanding with regards to adult protection training was the lack of a structured approach to the delivery and/or recording of such training opportunities it is imperative that these issues be addressed. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 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): Standards 20, 23, 24 and 26. The communal facilities both internal and external are well maintained, safe and accessible to service users. The service users met during the visit were happy with their personal space / bedrooms. Bedrooms visited during the inspection had clearly been personalised by the occupant in accordance with their own wishes. The home was found to be clean, tidy and free from any offensive odours. EVIDENCE: The tour of the premises and comments from service users and visitors provided evidence that the home is well maintained and that a good decorative standard is being achieved throughout. A maintenance person is employed to undertake routine repairs and remedial works, as well as tackle larger jobs and oversee work completed by external Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 19 contractors, as evidenced by his involvement in the redecorating of the external aspects of the home and constant liaising with trades persons fitting new wrought iron railings around steps and ramps in the rear garden. In addition to the work ongoing externally efforts to improve the internal environment are also continuing, with several bedrooms redecorated since the last inspection, new en-suite facilities completed in a number rooms and the new first floor sluice due for completion within a short period of time. The communal areas of the home whilst not huge are well presented and furnished and the dining area commissioned shortly after the new company took ownership of the home is continuing to prove popular and is well used. As indicated above work to ensure safe access to the rear gardens is maintained was ongoing, with the wrought iron railings being replaced across the length of the garden. The rear garden, which is the main external recreational area of the home, is quite extensive and provides people with a variety of visual stimuli to detract from the built up area surrounding the home, including water features, an aviary and planted out areas. During the summer people obviously enjoyed getting out into the garden, several bedrooms opening directly onto the grounds and service users commenting about the barbeque which took place. Whilst talking to patients and other people met during the tour of the premises, it was evident that efforts to personalise their private accommodation had been made, with pictures, photos, ornaments and small pieces of furniture used to create a sense of belonging and familiarity. However, even people residing at the home on a short-term basis commented on how well presented and set out the bedrooms were, this type of clientele having to accept the room as it comes, as normally they would not bring items of a personal nature into the home to characterise the room for such short periods. All of the people spoken to, both service users and visitors, seemed to agree that the home’s general environment and the private accommodation provided met their immediate needs and that over time they had been able to individualise their space, making them feel more settled. The tour of the premises also demonstrated for the inspector that the home is now much cleaner and tidier with no noticeable odours or areas of unsightly dust or grime, as had been present at the previous inspection. The home has always employed a specific domestic staff team, who now seem to work alongside the care staff to maintain the hygiene levels of the premises, although they retain responsible for overseeing the cleanliness of all major Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 20 areas of the home, such as the communal and staff toileting facilities, which were noted to be properly equipped with liquid soaps, sanitising liquids and supplies of paper towels. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 29 & 30. The home’s recruitment and selection procedures are robust and thorough. The training officer needs to concentrate on creating a structured training plan, a way of identifying training needs and a process for identifying renewal dates for training completed. EVIDENCE: Recently an additional visit was undertaken at the home in connection with concerns around the recruitment of two new staff. During this visit the inspector reviewed a number of staffing files and considered the policies and procedures available to the management team when recruiting new staff. It was evident, given the files inspected, that the home’s general approach to the recruitment and selection of new staff was normally robust and consistent, with tracking or monitoring forms used by the administrator and management to ensure each new staff member’s recruitment follows a very similar pattern and that all relevant information is applied for and received prior to admission. All prospective staff are required to complete an application form as part of the process, the application form designed to obtain details of the person’s employment history, educational history, medical history and references, etc. Once the application has been submitted the manager normally arranges to meet with the applicant, for the purposes of interview, and retains information relating to the outcome of the interview on file. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 22 Once an applicant has successfully completed the preliminary stages of the recruitment process they are issued with written confirmation and subject to the successful return of their references and Criminal Records Bureau and POVA check, are invited to attend for induction. Unfortunately on checking the recruitment files of these two individuals at the last visit it was discovered that the home’s normally reliable recruitment system had not been followed appropriately and that appropriate checks had not be carried out on these people prior to their commencing their inductions at the home. This oversight led to service users being placed at unreasonable risk and the Commission was required to take immediate action to ensure the home’s recruitment process was improved, through the serving of a statutory enforcement notice. At this visit it was ascertained that potential new employees are only offered a position at the home once all appropriate checks and balances have been concluded and the management is satisfied that the person is suitable to work within the home. Consequently the requirements of the enforcement notice were deemed to have been met. As already identified it was established at this inspection that some improvements have been made with regards to the training officer role, as evidenced through the provision of an office / training room, although this room is perhaps a little on the small size for the purpose of running effective training events. Elsewhere little progress has been made in relation to improving the way in which training records are maintained, how training is planned or how training once completed is to be updated, the training officer currently uses a system that relies on the collecting of certificate copies, which are retained in order to evidence courses attended alone. This system, however, does not allow for the easy auditing of training completed nor does it readily lend itself to being tracked, which is imperative if renewal dates for qualifications, etc. are going to be kept up together. There continues to be no real structure or organisation to the documenting of courses attended or dates for renewal and it is not clear how training or educational needs are identified, other than through people volunteering to attend advertised events/courses. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 33 & 35. The company is committed to ensuring the best interests of service users are promoted at all times. The financial system adopted by the home ensures that service users’ financial interests are safeguarded. EVIDENCE: At the time of the inspection the manager was preparing to conduct her first service user and family survey, which she stated she hoped to commence on 1 November 2005. The survey will be questionnaire based and is looking for feedback across a wide range of topics pertinent to the home, including environmental issues, catering issues, staffing issues, records and documentation issues. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 24 It is hoped that shortly after the commencement of the survey that useful data will be returned and that this can be used to influence future operational planning and service delivery within the home. In addition to the survey being planned the manager has recently overseen the review of all policies and procedures and the updating of documents such as the statement of purpose and service user guide literature referred to earlier in the report. It is the policy of the home ‘not to become involved in supporting service users with the management of their monies’, which is explained in the ‘Service Users’ Guide’. The manager does ensure where people wish to retain monies within the home that adequate lockable facilities are provided, although most service users appear to opt for external support from family members, professional sources or independent advocates. The manager is happy to arrange and liaise with external sources when assisting service users address financial management issues, or alternatively the company is prepared to purchase items on behalf of service users and invoice them at the end of each month for the items brought. Spreadsheet information and receipts are available for inspection should families require proof of the items purchased prior to settling accounts. Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X 3 X X 3 3 X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 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. 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 Refer to Standard OP14 Good Practice Recommendations The activities co-ordinator should create a documentation system that enables the needs and wishes of the service users to be ascertained and the benefit of activities recorded, etc. The manager must support the training officer in the creating of a structured training format, that records training completed, staff training needs and renewal or update dates. 2 OP30 Bluebell Nursing Home DS0000062757.V249176.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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. 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