Inspection on 25/09/06 for Bluebirds Nursing Home

This inspection was carried out on 25th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bluebirds Nursing Home 31/07/07

Bluebirds Nursing Home 10/11/05

Bluebirds Nursing Home 14/07/05

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 Barbara Mulligan Unannounced Inspection 25 September, 2006 09:30 th DS0000019180.V294784.R01.S.doc Version 5.1 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 DS0000019180.V294784.R01.S.doc Version 5.1 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 Adults 18-65. 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. DS0000019180.V294784.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bluebirds Nursing Home Address Faraday Drive Shenley Lodge Milton Keynes Bucks MK5 7FY 01908 234092 01908 233901 gertie@pjcare.co.uk 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) P J Care Limited Mr Peter Flawn Mrs Agatha Coetzee Care Home 22 Category(ies) of Dementia (22) registration, with number of places DS0000019180.V294784.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mental Health Nursing Care - 40 years plus Date of last inspection 10th November 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. All twenty-two of the rooms are single accommodation and 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 service users social activities. The home is situated in a residential area of Milton Keynes which has all the facilities that a modern city can provide. Fees range from £900 to £1500 DS0000019180.V294784.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken on Monday 25th September at 09:30am. The visit consisted of discussions with the Registered Manager, Responsible Individual, care staff, service users and relatives, a tour of the premises and an examination of the homes records, policies and procedures. The inspection officer was Barbara Mulligan. The Registered Manager is Gertie Coetzee. Twenty-six of the National Minimum Standards were assessed during this visit. Twenty-one of these are fully met, and five were almost met. As a result of the inspection the home has received five requirements. Five comment cards were received from service users relatives and/or representatives and two were received from visiting healthcare specialists. Comments received, both from people interviewed and those who responded to the survey, expressed a high level of satisfaction with the care received from support staff. Some positive comments received include “I cannot praise the owners and the staff enough, it is excellent” and “The care is excellent and the staff are very informative” and “There are regular consultations with the manager and consultant”. Visiting relatives spoken to on the day of the day of inspection conveyed their satisfaction with the care and the environment. The evidence seen and comments received indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. The inspector would like to thank the registered manager and the responsible individual, the staff team and service users and relatives for their cooperation and assistance during this inspection. What the service does well: The home is a nice and comfortable place to live. DS0000019180.V294784.R01.S.doc Version 5.1 Page 6 There are enough staff to support the people who live in the home to have interesting lives. Meals are tasty and there is a choice of food. Staff have good training to help support the people living in the home. What has improved since the last inspection? The home now safely looks after the money and belongings of the people who live there. The home now looks after the medicines safely, for the people who live there. The care plans now tell the staff how to care for the people living in the home. DS0000019180.V294784.R01.S.doc Version 5.1 Page 7 What they could do better: This inspection at the home has shown 5 things need to be done to make it okay. The home must make sure that the people who live in the home are safe when they go out and take part in activities. The home must make sure that all the people living in the home are weighed regularly. The home must keep all the important information and photos of all staff working in the home. The home must support the people who live in the home, and their friends and family, to make their views known. The home must test the fire alarm is tested every week DS0000019180.V294784.R01.S.doc Version 5.1 Page 8 and this is written down. 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. DS0000019180.V294784.R01.S.doc Version 5.1 Page 9 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 Outcomes Statutory Requirements Identified During the Inspection DS0000019180.V294784.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 2 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Potential service users receive a needs assessment undertaken by staff trained to do so, ensuring that the home can meet the care needs requirements of service users. EVIDENCE: The home use an RCN (Royal College of Nursing) assessment tool to complete the initial assessment of needs for a potential service user. Following the completion of this, the assessor will then write up a written report of the assessment. The assessment tool covers all areas as detailed in Standard 2 of the Care Homes Regulations for Younger Adults. Five completed needs assessments were examined, including those most newly admitted to the home. Pre-admission assessments for recent admissions to the home were assessed; these are fully completed to a high standard, dated and signed by the author. Service Users admitted from an out of county placement are only accepted to the Home with a full Social Services report and where necessary hospital discharge summaries. These are received by the home prior to any decision for admission being made. In addition the home will gain information from relatives or significant others prior to admission. Evidence was seen of this. DS0000019180.V294784.R01.S.doc Version 5.1 Page 11 The assessment demonstrates that prospective service users, family members or representatives are included in the assessment process if this is appropriate. This was confirmed during a discussion held with a visiting relative during the visit. DS0000019180.V294784.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning documentation has improved and most care plans adequately provide staff with the information they need to satisfactorily meet service users needs. However, further development of the care plans needs to be undertaken to ensure continuous improvement. Service users make some decisions about their lives, with assistance and communication support, that allows them to influence their lifestyle and how the home is run. Risk assessments are not in place that outline individual vulnerabilities and which contain control measures. This does not enable service users to live their lives as independently as possible. EVIDENCE: Following the previous inspection, undertaken in November 2005, a requirement was issued for all service users identified needs to be supported by a care plan. Instructions must be followed through and supported by DS0000019180.V294784.R01.S.doc Version 5.1 Page 13 regular assessments. Five care plans were examined during this inspection, including those most newly admitted to the home. On the whole the care plans looked at are detailed and informative and reflect the changing needs of the individual. Care needs are identified with an action plan detailing how staff will meet those needs. However, there were some areas that need to be further developed. For example one entry in a care plan records “she is at risk of under nutrition, dehydration” and “ she needs support to make choices about food and food preferences”. However, the care plan does not detail how to achieve this. Another two examples seen include nutritional assessments that record the service users at “ high risk” and these state “to be seen by dietician”. However the last recorded weight is July 2006 and there is no evidence of regular monitoring and review. It is pleasing to see the improvements made to the care planning documentation but it is recommended that these continue to be further developed. Many entries in the daily notes are difficult to read because of poor handwriting and this needs to be addressed by the Registered Manager. Staff respect service users rights to make decisions and individuals are provided with some assistance and communication support to make decisions about their lives. The registered manager said that the home will seek information and assistance from relatives and will use advocates if it is requested or felt to be necessary. However the manager was unable to find any information regarding advocacy groups and it is recommended that this information is made accessible to service users and their relatives. There are no advocates supporting service users at the time of the inspection. There are six weekly relative meetings and this was confirmed in a discussion held with a relative during the visit. The manager said that service users are invited to these meetings, however, the home does not hold separate meetings for service users and this is recommended. Risk assessments were observed in regard to moving and handling needs of service users, tissue viability and nutrition. The inspector was unable to find risk assessments in place for other areas of care or activities. The organisation as a whole have already identified this as an area that needs further development and have produced a risk management strategy and policy. It is a requirement of the report that risks assessments are in place for all activities undertaken by services users where there are associated risks involved. DS0000019180.V294784.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to access a wide range of amenities which meet their social, leisure and spiritual needs. Individuals are presented with ample opportunities for social inclusion and benefit from good staff support to do so. Staff support service users to maintain family links and friendships inside and outside the home. Service users rights are respected and the daily routines of the home promote individual choice and freedom of movement. Residents are encouraged to develop the menus in consultation with the chef which should promote independence and choice. EVIDENCE: Service users are given opportunities to maintain and develop social, emotional, communication and independent living skills and there is evidence of this in service user plans. However, due to the physical disability and cognitive impairment of the service users living in the home these can be small DS0000019180.V294784.R01.S.doc Version 5.1 Page 15 steps. The registered manager stated that service users are supported to attend church services if requested. There are activity plans in place for each service users and the home employs four activity staff from 8am to 5pm. Service users take part in varied leisure activities and use local community facilities regularly. Examples seen were visits to the local theatre, park, cinema, shops and local pubs and restaurants. The home has its own transport and service users were being taken out on the day of the inspection and this was noted to have a positive effect on service users. Service users are able to receive visitors in the privacy of their own rooms, and are able to choose whom they see and do not see. There are no restrictions on visiting, and this is documented in the Service Users Guide. During a discussion held with a visiting relative she confirmed that she is encouraged to visit the home and is involved in the care of her relative. She stated that the home is welcoming and has flexible visiting times. Staff were observed knocking on bedroom, toilet and bathroom doors ensuring the privacy of individuals. If service users express a wish to have a key to their own bedrooms then this will be facilitated. Staff open mail with the service users, if they are unable to do so themselves and the mail is read to them. Preferred term of address are used for service users and this is recorded in the care plans. Care staff were seen interacting with service users and did so with respect and in a manner that is appropriate to the individual. Service users are offered three meals a day. The menu is rotated on a four weekly cycle. The inspector had the opportunity to observe a lunchtime meal. This was relaxed, unrushed and well organised. All meals seen are attractively presented. Observed practice at lunchtime was sensitive and discreet, staff sat next to service users talking in an appropriate manner and encouraging individuals to respond, this included picking up on service users body language, and lots of positive reinforcement. Interaction observed between service users and care staff demonstrates mutual respect and good humour. The inspector was told that service users can take their meals in their rooms if they wish. The home offers drinks and snacks throughout the day in accordance with needs of the service users. The nutritional needs of service users are assessed and there is evidence of regular monitoring in some care plans, but not in others. Care plans seen do not all demonstrate the recording of service users weights on a regular basis. A requirement has been made under Standard 19. DS0000019180.V294784.R01.S.doc Version 5.1 Page 16 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 the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ needs are outlined within their individual plans, ensuring that the manner in which they are supported and cared for by staff is appropriate and promotes their preferences. Overall, healthcare support for service users is good, however, there must be an appropriate plan of care in place for nutritional screening to ensure service users health and wellbeing is promoted and protected. Medication procedures are in place however, good recording practice must continue to be reinforced and supported by the homes quality audit system. These measures must be in place to protect residents. EVIDENCE: Information regarding personal care is recorded in the service users plans. Personal support is provided either in bedrooms or bathrooms. There are risk assessments on file regarding the individual’s preferences about how they wish to be moved, supported and transferred. Individuals choose the times they wish to go to bed, bath, have their meals and take part in other activities. It is evident from information contained in care plans that service users are supported to choose their own clothes, hairstyles and make up. DS0000019180.V294784.R01.S.doc Version 5.1 Page 17 Specialist support and advice is accessed via the Physical Resource Team. Chiropody Services visit the home on a six weekly basis. Additional support is accessed through a team of healthcare proffessionals where service users can access physiotherapists, occupational therapists, speech therapists, community dietician and continence advisor. The registered manager stated the dietician had visited the home on the previous Thursday. She not only advises on diet bit provides risk assessments regarding swallowing difficulties. Visits to the home from healthcare professionals take place in the service users bedrooms. Staff provide support to individuals needing to attend outpatient and other appointments. The registered manager stated that eye screening is being undertaken on an annual basis, however, there was no evidence of this in care plans examined. This is a recommendation of the report. The care plans set out in detail the service users preferred routines, likes and dislikes and partnerships with families, friends and relevant professionals outside of the unit. The nutritional needs of service users are identified and their weight is monitored, however in two files looked at, nutritional assessments score individuals as “high risk” and state “ to be seen by dietician”. However these two individuals have not been weighed since July and there is no evidence of regular monitoring and review. The registered manager is required to ensure that where a nutritional assessment deems a service user to be at risk, that a record of nutritional screening is undertaken on a regular basis, including weight gain or loss and records the appropriate action to be taken. This must be reviewed monthly. None of the service users in the home are able to self-administer their own medication. Following the previous inspection a requirement was issued for the home to develop 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 home has now implemented an audit system and records show these have been completed on 29/03/06, 07/05/06, 22/06/06 and 06/07/06. The audit completed in July showed five omissions on medication records, however, there is no record of any action taken following this audit. This is a recommendation of the report. The inspector examined medication records and it is pleasing to note there were no omissions observed. Records show all medication received, administered and leaving the home, or disposed of. There are no controlled drugs in use at the time of the visit. If a service user became ill, an assessment would be carried out with the involvement of their family, and the service users wishes regarding terminal care and death would be discussed, and carried out. DS0000019180.V294784.R01.S.doc Version 5.1 Page 18 The inspector was informed that service users with deteriorating conditions or dementia would be referred to their G.P. or the Learning Disabilities Community Team for personal support or technical aids. DS0000019180.V294784.R01.S.doc Version 5.1 Page 19 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 the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has effective complaints procedures to ensure that service users or their representatives are listened to. Vulnerable adults are protected through a range of policies and procedures and well-informed staff, which means that their intrinsic human rights are protected. EVIDENCE: There is a complaints procedure and this informs the complainant who to approach with their complaint. Copies of the complaints procedure are included in the Statement of Purpose and the Service Users Guide and this gives guidance about referring a complaint to the Commission for Social Care Inspection. The home has not received any complaints since the previous inspection. There is no specific record of complaints and the home need to maintain a dedicated book/record of all concerns and complaints received by the home. This record must be available for inspection purposes and this is a recommendation of the report. Following the previous inspection the inspector raised concerns that staff still hold service users ‘PIN’ numbers. The manager and proprietor were asked to explore this further with Social Services to protect residents and staff. When questioned about this the registered manager stated that this has been done and systems within the home have been improved. She informed the inspector that staff no longer hold personal PIN numbers. Two records of service users money were examined and these were reconciled with the monies held in the home. DS0000019180.V294784.R01.S.doc Version 5.1 Page 20 The inspector looked at an Adult Protection Policy and within this there are guidelines for staff about the responsibilities of the staff, types and signs of abuse and what to do if you suspect abuse. Staff spoken to during the visit, including ancillary staff all stated that they have undertaken POVA training. The registered manager said all staff are up to date with POVA training, however the training records looked at do not reflect this. The manager must address this. The inspector requests written confirmation that all staff have undertaken up to date POVA training. DS0000019180.V294784.R01.S.doc Version 5.1 Page 21 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 the following standard(s): 24, 25, 27, 28, 29 and 30 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good, providing service users with an attractive and homely place to live. The overall quality of the furnishings and fittings is good ensuring the safety and comfort of service users. Standards of cleanliness at the home appear to be good meaning that service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. EVIDENCE: The home was purpose built in 2001 with 20 bedrooms, 18 single and 2 shared. The home is divided into two wings. On the day of the visit one double room in one wing was being renovated into two single rooms. The inspector was informed that this is also due to be undertaken on the second double room in the other wing. The lounges are nicely adequately decorated and there are personal touches around the home such as flowers, plants, books and pictures. The furnishings observed in communal areas are of good quality and suitable for the range of interests and activities preferred by service users. DS0000019180.V294784.R01.S.doc Version 5.1 Page 22 Lighting in communal areas is domestic in character and sufficient to facilitate reading and other activities. All bedrooms have en-suite facilities and were observed to be personalised, with service users own furniture and personal belongings. All rooms seen are spacious and comfortable. Storage space is adequate for the storage of service users clothes and personal belongings. All rooms have locks, and this is a facility that service users can choose to use. The kitchen is clean, spacious and well looked after. The home has a pleasant garden that is well maintained and accessible to service users. There are no CCTV cameras in use within the home at the time of the inspection. There are accessible toilets available for service users throughout the home and several are close to the lounges and dining area. Emergency lighting is provided throughout the home. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The laundry floor finishes are impermeable and these and the wall finishes are readily cleanable. The home has an infection control policy and the inspector observed this. Instructions are in place for the washing of soiled linen. DS0000019180.V294784.R01.S.doc Version 5.1 Page 23 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a staff team who are appropriately trained to ensure that service users are cared for by skilled staff at all times. There are effective recruitment procedures in place to ensure service users are protected from harm. However, not all files held in the home contain appropriate evidence to demonstrate that all recruitments checks have been undertaken. There is a staff training and development programme which ensures staff fulfil the aims of the home and meet the changing needs of service users. EVIDENCE: DS0000019180.V294784.R01.S.doc Version 5.1 Page 24 The manager told the inspector that she felt the staff team are aware of, and support the aims and values of the home. Staff are aware of the organisations policies and procedures and understand how their work, and that of other staff, promotes the main aims of the home. This is achieved through staff meetings, and supervision sessions. There is evidence in service users plans of care that individual needs are met, with particular attention to gender, age, culture and personal interests. There were no staff members under the age of eighteen and there are no staff under the age of twenty one left in charge of the home at any time. Staff know their limitations and, when questioned, were able to give examples of how and when to involve someone else, with more specific expertise in the care of service users. At the time of the inspection there are two senior carers who have completed NVQ level 3 training and six health care assistants who have completed NVQ level 2 training. The inspector requested to look at the recruitment files for the most newly appointed staff and four were examined. Following the previous inspection it was recommended that the manager holds photographic identification of each staff member. This has not been completed yet and will be a requirement of this report. Three of the files examined contained two references, however one file contained only one reference. The registered manager said that she had seen the reference but was unsure why it was not in the staff file. It is a requirement of the report that the home maintains all the necessary documentation as detailed in Standard 34 and Schedule of the Care Homes Regulations for Younger Adults. Staff files contain copies of driving licence and certificates of training and a health check. There is evidence that staff have had a criminal records bureau check before they commence work and all staff are checked against the POVA register. Staff spoken to confirmed the process of recruitment. There is an induction programme in place to ensure that new staff members are familiarised with the organisation and their roles and responsibilities and provides the staff member with a personal development portfolio. This includes fire safety, moving and handling techniques and core skills training. Training records do not reflect that staff are up to date with mandatory courses and this is a recommendation of the report. Staff confirmed that there are regular staff meetings. Further training for staff includes dementia care, skin care and simple wounds, swallowing difficulties, challenging behaviour and dyspraxia workshop. DS0000019180.V294784.R01.S.doc Version 5.1 Page 25 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is supported well by the staff team in providing clear leadership and demonstrating an awareness of their roles and responsibilities to the benefit of service users. The home has in the past implemented a quality assurance system but this needs to be strengthened and delivered more consistently to ensure the home is being proactive in identifying issues that may effect the well being of services users. Overall the health and safety procedures are in place, however the home must test the fire alarm on a weekly basis. EVIDENCE: The manager is a registered general nurse and mental health nurse. She has achieved a nurse management degree in 1980. Examples of further training undertaken by the registered manager include health and safety training, mentorship workshop and managing challenging behaviour. Staff spoken to understand and can relate to the aims and purposes of the home. This is usually achieved through regular staff meetings, staff supervision and annual DS0000019180.V294784.R01.S.doc Version 5.1 Page 26 appraisals. There is a communications book, handover meetings, service user plans and training. The home has a complaints procedure in place and a whistle blowing policy, which enable staff and service users to voice concerns and affect the way in which the service is delivered. The responsible individual said that a service satisfaction questionnaire has been sent out in the past but that no questionnaires were returned. The home must ensure that they continue to explore more effective ways to provide effective quality assurance and quality monitoring systems, based on seeking the views of service users, relatives and/or representatives and is a requirement of the report. Following the previous inspection a requirement was issued for the responsible individual to ensure that Regulation 26 reports were available for inspection and sent to the Commission on a monthly basis. It is pleasing to see that this has been complied with. Records were seen for fire safety. These are comprehensive and up to date. Fire equipment was last serviced on 31/05/06 and the most recent fire inspection was carried out on 05/06/06. However, testing of the fire alarm needs to be undertaken weekly and is requirement of the report. A fire manual covers the homes fire procedures, practice fire drills, fire prevention, maintenance of escape routes, fire alarm testing, emergency lighting testing and door maintenance. A generic fire risk assessment for the home is in place. Following the previous inspection a requirement was issued for all records pertaining to health and safety be available in the home for inspection purposes. It is pleasing to see that this has been complied with. Service reports are in place for the maintenance of the lifts and hoists, and these were dated 21/08/06. PAT testing certificates are in place dated 08/06/06, gas boiler certificate is dated 17/08/05 and is now due another service. The registered manager must ensure this is completed. There is a water chlorination certificate dated 21/04/06. COSHH sheets are up to date and accurate. Risk assessments for the use of cot sides are in place. The inspector looked at Infection Control guidelines that are available for all staff. DS0000019180.V294784.R01.S.doc Version 5.1 Page 27 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 Standard No Score 1 X 2 3 3 X 4 X 5 X X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 X 2 X X 3 x DS0000019180.V294784.R01.S.doc Version 5.1 Page 28 No 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 YA9 Regulation 13(4) Requirement The registered manager is required to ensure that risks assessments are in place for all activities undertaken by services users where there are associated risks involved. Timescale for action 30/12/06 2. YA19 14(1) 3 YA34 Schedule 2 4 YA39 26 The registered manager is 30/11/06 required to ensure that where a nutritional assessment deems a service user to be at risk, a record of nutritional screening is undertaken on a regular basis, including weight gain or loss and records the appropriate action to be taken. This must be reviewed monthly. The registered manager is 30/12/06 required to ensure that all the necessary documentation as detailed in Standard 34 and Schedule 2 of the Care Homes Regulations for Younger Adults is maintained and this must include photographic identification of each staff member. The registered manager is 30/06/07 required to ensure that the home implements an effective method to provide effective quality DS0000019180.V294784.R01.S.doc Version 5.1 Page 29 5 YA42 23(4) assurance and quality monitoring systems, based on seeking the views of service users, relatives and/or representatives. The registered manager is 30/10/06 required to ensure that the fire alarm is tested weekly and is recorded. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 5 Refer to Standard YA6 YA7 YA7 YA20 YA22 Good Practice Recommendations It is recommended that the care plans are further developed to ensure continuous improvement. It is recommended that information regarding advocacy groups is made accessible to service users. It is recommended that the home carry out service users meetings. It is recommended that a record of any action taken following the medication audits is recoded. It is recommended that the home maintain a dedicated book/record of all concerns and complaints received by the home. This record must be available for inspection purposes. The registered manager is required to ensure that training records reflect the training undertaken by staff. 6 YA35 DS0000019180.V294784.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 DS0000019180.V294784.R01.S.doc Version 5.1 Page 31 - 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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