Inspection on 14/07/05 for Bluebirds Nursing Home

This inspection was carried out on 14th July 2005.

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

Bluebirds Nursing Home 31/07/07

Bluebirds Nursing Home 25/09/06

Bluebirds Nursing Home 10/11/05

Bluebirds Nursing Home 25/01/05

Bluebirds Nursing Home 23/08/04

Bluebirds Nursing Home 05/01/04

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

CARE HOME ADULTS 18-65 Bluebirds Nursing Home Faraday Drive Shenley Lodge Milton Keynes Bucks, MK5 7FY Lead Inspector Gill Wooldridge Unannounced 14 July 2005 09:30 a.m. 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bluebirds Nursing Home Address Faraday Drive, Shenley Lodge, Milton Keynes, Bucks, MK5 7FY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01908 234092 01908 233901 P J Care Limited Mr Peter Flawn Ms Deborah Cank Care Home 22 Category(ies) of Dementia (22) registration, with number of places Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 Mental Health Nursing Care - 40 years plus Date of last inspection 25 January 2005 Brief Description of the Service: Bluebirds is a small nursing home opened in May 2001 by the present owner. The home provides 22 beds, for younger and older people with complex physical and mental health needs brought about by cognitive impairment, eighteen of the rooms are single bedrooms and two are shared rooms, all bedrooms have en-suite facilities. The garden is designed to meet the needs of residents. The home is close to public transport links and has its own transport to facilitate residents social activities. the home is situated in a residential area of Milton Keynes which has all the facilities that a modern city can provide. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place at 9.30am until 2.30 pm on 14th July 2005. The inspection was carried out by two inspectors, Joan Browne and Gill Wooldridge, and consisted of a tour of the home, although most bedrooms were observed from the corridors. Three care plans were studied and the care of residents tracked. Residents and staff were spoken to and lunch was observed. The manager, responsible individual and newly appointed clinical nurse made contributions to the process of inspection. The requirements set at the last inspection were discussed and on the whole these issues were met or are in the process of being met. It is noted that the home has met many of the standards assessed with some shortfalls in a small number of areas. The care observed and described by staff and residents was of a high standard, this is supported by a well trained work force. The home has an established staff team which has a range of skills to support residents. What the service does well: The manager stated that residents and staff have developed positive relationships and staff are trained and supported to ensure that the care of each is tailored to meet their needs. There is a holistic approach to care with an emphasis on affection. Residents are given the best possible care, this was supported by relatives spoken to, observations noted and the detail seen in some care records. There is an emphasis on training and personal development for all staff. The home promotes staff development through internal promotion. Staff are supported through supervision and mentoring. The care observed and described by staff and residents was of a high standard this is supported by a well trained work force. The home has an established staff team who have a range of skills to support residents. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: The manager described the home as always striving to improve the care delivery and that she wishes to improve her time management skills. The manager stated that communication between the two homes in this group of homes, could be improved. The home must develop further its quality audit for medication practice and remind staff of their accountability. Blank prescriptions must be returned to the General Practitioner. The manager has agreed to further explore ways in protecting residents finances. The manager must develop a quality audit tool to ensure there is an overall standard of care plans for the home. This must be supported by ongoing training in care planning and good recording practice. The manager is reminded that she must inform the Commission of any event that effects the well being of a resident under Regulation 37 of the Care Homes Regulations 2001. Since this inspection the Commission has received an action plan to identify how the requirements and recommendations set in this report have been met or are in the process of being met. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 7 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. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Residents’ needs are thoroughly assessed which should ensure that the staff have a clear understanding of how to meet their needs. EVIDENCE: One new admission assessment was studied which had been carried out in recent months. This document clearly outlined a picture of the resident’s needs. Further occupational therapy and physiotherapist reports supported the process of assessment. This is good practice which supported the residents and staff in the delivery of good care. Senior staff described ongoing support from a range of professionals with assessment of needs discussed regularly with referring authorities and relatives. The home uses a recognised tool for assessment and supports this by gaining relevant information from referring authorities. The staff also complete a detailed assessment which supports the recognised assessment tool. At this visit relatives spoken to confirmed that the standards of care are good and that residents needs are met. This was confirmed by observations and some good recording in care plans. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Care plans are in place which on the whole enable staff to appropriately support residents in line with their assessed needs and personal goals. There are forums which invite relatives and residents’ comments so that they can participate in the decision making process of the home. Risk assessments are on the whole in place, which should enable residents to access the wider community as they wish. EVIDENCE: Three care plans were studied and the residents’ care was tracked. Care plans covered areas such as personal care, nutrition, incontinence, diabetes, peg feeds and social activity. The care plans studied were on the whole clear documents, however, the quality of the care plans was noted to be dependent on the authors. It is recommended that the manager ensure that care plans are consistently written with a positive slant in recording practice and that ‘staff’s approach’ is included Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 11 in the documentation. Staffs approach was identified, for example, in the moving and handling section, staff had written ‘may need two nurses for personal care re anxiety and pacing’. This information did not correlate with the care plan and the care plan did not detail how to support this resident, for example, with his anxiety or indicate that two nurses were needed to provide personal care. In a further care plan it stated that a resident’s preference was for a bath. In the evaluation section staff had indicated that a regular shower was now the norm. This may indicate that staff had made the decision for the resident to shower, or that this was easier for staff. It is recommended that residents suffering with diabetes should have their blood pressure taken and recorded monthly. Further to this all temperatures, pulses and respiration (TPR’s) should be recorded regularly. It was noted, from the records seen that this practice varies. Care plans did not always confirm all residents likes and dislikes. However, the manager stated that the chef is aware of resident’s food preferences, this was confirmed by the chef. Good practice examples noted included clearly described approaches to service users and step by step instructions which would facilitate good care if the reader was a newly appointed member of staff or an agency staff members. For example, a care plan relating to a peg feed described clearly the care needed; this included; ‘is situated at a 45 degree semi prone position before administrating feed or medication’, ‘use a slow soft but clear tone’ and staff to talk all the time to: whilst carrying out nursing tasks’. All care plans studied had been reviewed and the recent admission care plan had been reviewed weekly during the resident’s trial period. This is good practice. The daily log showed some good detail in some care plans. The manager stated that training and support in care planning for staff is ongoing and an audit system is in place to ensure an overall standard for the home. The manager described one resident’s recent admission to hospital. She is reminded to inform the Commission of any event that effects the well being of a resident under Regulation 37 of the Care Homes Regulations 2001. As described earlier the risk assessments are supported by ongoing support from the occupational therapist, physiotherapist and dietician. Records seen supported the staff statement of detailed assessments being carried out. One risk assessment was not completed, the manager confirmed that this was an oversight. Staff confirmed that residents had been involved in the recruitment of a new chef, this is noted as good practice which will encourage a sense of responsibility and ownership in providing the food residents would choose. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 12 Residents and relatives are invited to regular forums which ensure that they can participate in the decision making of the home. Where systems are in place to support residents’ paper work is signed by them or their relatives to support the home’s practice. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 15 & 17 Residents are presented with opportunities to access leisure activities both inhouse and in the wider community. Bluebirds promotes flexible visiting which enables residents to maintain contract with family and friends. Residents are encouraged to develop the menus in consultation with the chef which should promote independence and choice. The process of disposing of food distracted from an otherwise social occasion. EVIDENCE: Activities described by residents included small group activities, in house, and individually based ones. Music was playing in the lounge. It was noted that a number of residents went out during the day supported by the activity team. The home has its own transport which facilitates activities. Staff described planning a trip to Blackpool illuminations hoping to stay overnight, other recent visits included a trip to the theatre ,shops, local parks and lakes. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 14 Relatives spoken to confirmed that they are encouraged to visit the home and are involved in the care of their relatives, they confirmed that the home is welcoming and has flexible visiting times. The lunchtime meal was relaxed with two choices of main course, all portions were large. Observed practice at lunchtime was sensitive and discreet and staff were seen to be sat next to residents and taking time and encouraging residents to respond, this included picking up on residents body language, and lots of positive reinforcement. The responses from residents included smiles and positive eye contact. Residents and staff interactions showed mutual respect and good humour. Observations of staff indicated their awareness of other residents’ needs in close proximity to them. Lunch was presented attractively. However, residents’ relatives had concerns relating to the consistency of the soft diet, staff actioned this immediately and the manager has arranged to follow this up. Unfortunately it was noted that staff were using two bowls one to dispose of food and a further bowl to place used cutlery in. This distracted from the overall ambience created by the home during the meal. The responsible individual has since written to the Commission stating that ‘ A full assessment of serving food at meals times has been completed.’ Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 Staff training and support for residents is good this should ensure that residents’ physical and emotional needs are met. Medication procedures are in place however, good recording practice and a further quality audit system needs be in place to protect residents. EVIDENCE: It was noted that all personal care was carried out in bathrooms and bedrooms which helped to maintain residents’ privacy and dignity. There was no evidence of residents’ being distressed during the inspection which indicates that residents physical and emotional needs are being met. This was further supported in some care plan documentation viewed. Staff practice of administering medication was observed; this appeared to reflect the home’s policy and procedure. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 16 The manager confirmed that she has developed individual PRN management plans for residents. This is noted as good practice.The Medication Administration Records sheets studied showed some inconsistencies with gaps noted, staff had also written over entries. A number of gaps were noted for creams. A review of staff practice should ensure inconsistencies are not the norm. These inconsistencies must cease and trained nurses must be reminded of their accountability relating to the Nursing and Midwives Council (NMC) Code of Conduct. Records must be kept of these discussions and maintained of for inspection purposes. A more frequent quality audit of Medication Administration Records sheets should ensure that errors are kept to a minimum. The inspectors acknowledge that the home audits the medication process and is supported by an audit from the local pharmacist. It is strongly recommended that where staff handwritten entries on MAR sheets these should be checked, signed and dated by two staff. It was noted that blank prescriptions, FP10, are kept in the home. During the inspection these were not locked away and it is required that the home requests that the GP keeps these documents, so there can be no danger of abuse of this system. It is acknowledged that since the inspection the responsible individual has written to the Commission stating that ‘our GP has removed the blank prescriptions’ Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The manager is open and receptive which should ensure that complaints are handled objectively. This should also ensure that resident’s views are listened to and actioned. There are a range of policies and procedures in place which should ensure that residents are protected from abuse. Residents’ money is on the whole well managed to protect residents’ best interests. EVIDENCE: The home clearly advertises its complaints procedure in the entrance hall. It is noted that the home has a friendly, open environment where concerns are addressed and actioned. Relatives confirmed that where any small concern is raised this would be handled appropriately. It is recommended that staff record all verbal concerns from residents and relatives in the complaints folder. Two recent situations indicate that the manager is supported by the responsible individual and the home’s policy and procedure relating to any adult protection issue. These issues have been reported to Social Services and the Commission. The manager must ensure that residents and staff are protected by thorough consultation with Social Services relating to the holding of residents ‘pin’ numbers. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 18 Two residents’ personal records of money were studied which tallied with the small amounts of money held in the home. The manager confirmed that staff do not loan money to residents. The home has developed a clear procedure relating to residents’ money and there appears to be a good audit system in place. However, it is of concern that staff hold residents PIN numbers, the manager and responsible individual need to explore this further with Social Services to protect residents and staff. The proprietor has written to the Commission stating the inspectors that the home has approached an advocacy service to support the process. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The environment including the garden has been designed to ensure that residents reside in an environment that meets their care and comfort needs. Standards of cleanliness in the home are good which should ensure that residents live in a clean home protecting their health and safety and welfare. EVIDENCE: The home was purpose built in 2001 with 20 bedrooms, 18 single and 2 shared. All bedrooms have en-suite facilities. There are bathrooms and shower rooms at each end of the building. The gardens are well maintained and landscaped with clear pathways to support residents. A tour of the building took place with bedrooms viewed from the corridor. Furniture and fittings are of a high standard with some furniture being recently recovered. Pictures add to the ambience. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 20 The standard of housekeeping was high and there was no odour of incontinence, the housekeeping staff are to be commended for the cleanliness of the home. It is noted that the home has a warm friendly atmosphere, which is facilitated by the residents and staff. A number of aids and adaptations were noted which have been detailed in previous reports. The hot water in the staff toilet was recorded at 56 degrees centigrade. It is strongly recommended that the manager fixes and displays a hazardous warning sign to warn staff that the water is very hot. The responsible individual has written to the Commission stating that ‘A hot water sign has been placed in the staff toilet.’ To aid infection control the manager must replace the waste bin in the staff toilet with a pedal bin. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 34 Recruitment procedures at the home appear robust and along with the implementation of the requirement should ensure that residents are appropriately protected. Staffing levels as indicated on the rota should benefit residents’ care ensuring that residents care needs are met. EVIDENCE: From observing staff practice and their interactions with residents it was noted that staff have a clear understanding of their roles and responsibilities. Throughout the inspection staff were observed smiling, this was noted as having a positive effect on residents. From observing staff practice throughout the inspection it was clear that staff were not phased by the inspection process. It was noted that there is an emphasis on individual care and it appeared that needs are being met. It was noted that the staff team appeared to be sufficient in number, skills and experience to meet the needs of residents. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 22 Two staff personnel files were sampled, one file showed that the manager has a record of staffs’ recent CRB disclosure. Prospective employers fill in an application form and the home requests two references. Both staff files contained two references. It is strongly recommended that all references from a previous employer are accompanied by a letterhead or company stamp or compliment slip to ensure authenticity. The manager and responsible individual were informed that all employees recently employed from abroad must undergo a CRB disclosure which must include a POVA First check this is a requirement of this report. This may appear contrary to the advice given to the responsible individual recently but is guidance received from the Commission’s legal department in recent weeks. The manager confirmed that these staff are at present supernumerary until these checks are carried out. The responsible individual has since written to the Commission stating ‘we have now completed checks on three South African Nurses at Bluebirds.’ The acting manager confirmed that these checks are being carried out by the home for those staff employed already working in the UK. Work permits were in place where appropriate along with health declarations and job offers with terms and conditions. The manager stated that the personnel files are being reviewed to ensure that training records are kept separately and that there is a clear audit trail, this is good practice. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39 & 42 Quality audit systems are in place which confirm that the service delivery is good which ultimately benefits residents. Systems are in place which indicate that residents’ safety is protected and promoted. EVIDENCE: The manager was present during this inspection, this was her first inspection and it was noted that she was accepting of ideas and proactive in addressing any issues relating to requirements and recommendations set at the previous inspection. It is noted that the manager and senior staff create an inclusive and open atmosphere. Fire records were studied which appeared to be in order. It is recommended that staff record more fully the detail of any evacuation. A recent accident/ incident form was studied which appeared satisfactory. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 24 The responsible individual recently sent to the Commission the format of the home’s Regulation 26 visits which was comprehensive. Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 2 Standard No 11 12 13 14 15 16 17 x x 3 3 3 x 2 Standard No 31 32 33 34 35 36 Score 3 x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bluebirds Nursing Home Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x 3 3 x x 3 x Version 1.40 Page 26 H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Are there any outstanding requirements from the last inspection? 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 6 Regulation 37 Requirement The manager must inform the Commission of any event that effects the well being of a resident under Regulation 37 of the Care Homes Regulations 2001. The manager must ensure that she develops further the audit systems to ensure staff inconsistencies on MAR sheets do not occur. Records must be maintained relating to addressing these issues with staff. The manager must request that the GP does not store blank prescriptions in the home. The manager and responsible individual need to explore further with Social Services systems to protect residents finanaces. To aid infection control the manager must replace the waste bin in the staff toilet with a pedal bin. The manager must ensure that all newly appointed staff appointed from overseas have a CRB and POVA First check to ensure residents are protected Timescale for action 31/8/05 2. 20 13 (2) 31/10/05 3. 4. 20 23 13 (2) 13 (6) 31/8/05. 31/10/05 5. 30 16 (20 (k) 31/8/05 6. 35 19 (1) 31/10/05 Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 27 from harm. 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 6 Good Practice Recommendations It is strongly recommended that the manager develops a quality audit system and suports staff practice with ongoing support and training to ensure an overall standard for the home and that documentation contained within the care plan interelates. It is recommended that the manager ensures that residents suffering with diabetes should have their blood pressure taken and recorded monthly. Further to this all temperatures, pulses and respiration (TPR’s) should be recorded regularly. It is strongly recommended that the responsible individual and manager should review the process of disposing of food at meal times to give the home a less institutional feel. It is strongly recommended that where staff handwrite entries on MAR sheets this should be checked, signed and dated by two staff. It is strongly recommended that the manager fix a sign hazardous warning sign in the staff cloackroom so that staff are aware that the water is very hot. It is strongly recommended that the manager ensures that all references from a previous employer are accompanied by a letterhead or company stamp or compliment slip to ensure authenticity. It is strongly recommended that the manager should ensure that staff record more fully the detail of any evacuation regarding the fire drills. 2. 6 3. 17 4. 5. 6. 20 29 35 7. 42 Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 Page 28 Commission for Social Care Inspection Cambridge House, 8 Bell Business Park, Smeaton Close Aylesbury Bucks, HP19 8JR 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 Bluebirds Nursing Home H53_H02_S19180_Bluebirds_V238797_AI_140705_Stage 4_GW_ces.doc Version 1.40 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. 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