Inspection on 18/08/06 for Bolealler House

This inspection was carried out on 18th August 2006.

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

Bolealler House 09/09/09

Bolealler House 07/08/07

Bolealler House 11/11/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME ADULTS 18-65 Bolealler House Bolealler House Westcott Cullompton Devon EX15 1RJ Lead Inspector Vivien Stephens Key Unannounced Inspection 18th August 2006 10:00 Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 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 Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bolealler House Address Bolealler House Westcott Cullompton Devon EX15 1RJ 01884 38275 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) Bolealler House Limited Anne Maddox Care Home 20 Category(ies) of Learning disability (20), Learning disability over registration, with number 65 years of age (20), Mental disorder, excluding of places learning disability or dementia (20), Mental Disorder, excluding learning disability or dementia - over 65 years of age (20), Old age, not falling within any other category (20) Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Manager must obtain NVQ level 4 and the Registered Managers’ Award by 1st January 2008 11th November 2005 Date of last inspection Brief Description of the Service: Bolealler House is owned by Bolealler House Ltd, a subsidiary of Allied Care Ltd. The property consists of a large detached country house with a converted stable block and a further extension, called Angels. It is situated in a rural area between Broadclyst and Cullompton. The main property is a period style house retaining many original and interesting features. The recent extension, Angels, is a stylish and modern house that operates separately from the main house, with its own kitchen, lounge, dining room and bedrooms. There are large grounds and lovely views of the surrounding countryside from many of the rooms. The home provides support and personal care for 20 adults with a learning disability or a mental health problem. The home has transport to enable service users to use local facilities. The inspection report is available in the home for anyone who requests to see a copy. The inspection reports are read out in Residents’ Meetings. All staff are given a copy of the report and asked to sign to confirm they have read it. Fees range from £444.55 to £1,302.95 per week Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Approximately 2 months before this inspection took place the home submitted a pre-inspection questionnaire. From the information provided by the home survey forms were sent to residents, care workers, and professionals involved in the home. Replies were received from 16 residents, 12 care workers and 2 professionals. This unannounced inspection began at approximately 11am and finished at 7pm. During the day conversations were held with most of the staff on duty and 10 residents. The inspector sat and had a meal with the residents and staff at lunchtime. A tour of the building was carried out, and records required to be maintained were checked. The storage and administration of medicines were inspected. What the service does well: There have been no admissions to the home since the last inspection. However, through discussion with the manager, staff and residents and through reading the statement of purpose it was clear that the home would take great care to ensure that any prospective new residents would be suitable for the home. Good assessment procedures are in place, and prospective residents would be invited to visit the home and get to know residents and staff before any decision to move in is made. The home is in the process of changing to a new care planning system. Both previous and new care plans are detailed and cover all areas of need. They explain how residents want to be supported and assisted by staff. Risk assessments have been carried out regular activities and show how residents are supported to take responsible risks and make decisions about their lives. The care plans show how residents want to be assisted with personal care tasks. The health care needs of each resident are also covered in the care plans. Comment cards received from GPs indicate that the home has good contact with health professionals and advice and treatment are sought appropriately. There are lots of activities provided by the home. On the day of the inspection residents were out and about in the community. Some attend colleges and clubs, while others enjoy staying at home and helping with daily routines such as cleaning, cooking and shopping. The home has transport facilities and provides regular outings and holidays. Residents expressed complete satisfaction with the activities and individual weekly programmes. Menus are balanced and varied and meet the nutritional needs of the residents. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 6 The home uses a monitored dosage system of medicine administration. Good records of administration have been maintained. All medicines are stored securely. Good procedures are in place to ensure all complaints and concerns are listened to and acted upon to the residents’ satisfaction. Policies and procedures are in place to ensure that staff take appropriate action to reduce or eliminate the risk of abuse or harm. Staff have received training on the protection of vulnerable adults. There are good systems in place to ensure all areas are regularly maintained and kept clean and hygienic. Good systems are in place for checking and maintaining equipment and ensuring all areas are safe. Staff have received regular training in all relevant health and safety topics. Staffing levels are good. Records seen during the inspection showed that the home follows careful procedures for checking and ensuring that prospective new staff are suitable before they are confirmed in post. There are now good induction and ongoing training provisions in place for all staff. Staff are supervised and supported appropriately. All records seen during this inspection were found to be well maintained. The home is developing systems to check on the quality of the services and facilities, and to ensure there is continuous improvement. What has improved since the last inspection? What they could do better: The care plans could be improved by including individual goals, and how these will be met. At the last inspection a recommendation was made that the home seeks professional advice on how to meet dietary needs and ensure all residents have a healthy diet. Two appointments were agreed with a dietician but Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 7 unfortunately both were cancelled due to unforeseen circumstances. They hope to have another appointment in the near future. During this inspection residents indicated that the meals are usually good, but suggested there is still room for improvement. 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. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 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 the following standard(s): 1, 2, 3, 5 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” The home has good admission and assessment procedures in place, ensuring that residents are able to make an informed choice about where they want to live. EVIDENCE: Many of the residents have lived at the home for a number of years. There have been no new residents admitted in the last year. Allied Care has detailed admission procedures in place to ensure any prospective new residents will be carefully assessed before they move in, and that they receive good information and plenty of opportunities to visit and get to know the home before any decision to move in permanently is made. All of the residents who completed survey forms said they had received enough information about the home before they moved in. In the last year one resident moved on to supportive accommodation and Anne Maddox talked about the time and care taken by the home to support the resident in this move and to ensure he settled in well. Since the last inspection the Statement of Purpose has been updated. The residents were consulted about the information to make sure it is accurate. This document gives a wide range of information about all aspects of the home and its management. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 10 Out of 16 residents who completed survey forms for this inspection 7 confirmed that they have received a contract of residence. 9 said either no, they hadn’t received a contract, or that they couldn’t remember. Most added a comment such as ”I cannot remember, it was a long time ago.” Many are funded by Social Services, and in these cases it is the responsibility of Social Services to issue a contract. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 11 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, 9 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” The home has good care planning systems in place that show how residents want to be supported and assisted by staff. Residents are supported to take responsible risks and make decisions about their lives. EVIDENCE: Since the last inspection the home has started to change to a new format of care planning. A number of the residents still have the old style of care plans, while others have been changed to the new style. The home is still in the process of getting used to the way information is presented in the new care plans. Overall the plans (both old and new style) contain a very good level of information about the resident and how they want to be cared for. They demonstrate a very clear understanding of the needs of each resident. The manager and many of the staff are especially skilled at helping residents to overcome problems and help them reach goals. After discussion about the care needs of one resident it was clear from reading the care plan that some of the special techniques used by more experienced staff have not been Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 12 documented and agreed in the care plans. Such information would ensure that all staff follow a consistent approach, and would encourage open discussion about good practice and how to help the resident reach their desired goals. 14 residents who responded to the inspection by surveys said they always receive the care and support they need. 2 said they usually receive the care they need. Comments include “I always feel that I am well looked after and the care is always caring and loving – more so when I have had an attack (fit)” 10 residents who responded to the inspection by survey said the staff always listen and act on what the resident says. 6 said they sometimes listen and act on what they say. Comments included – “I feel that they could come and ask me more”. This indicates that the home is generally good at listening and consulting with residents, but there is room for improvement. The above findings were confirmed through discussion with residents during the inspection. There was evidence of close friendships between residents and staff, with staff working in a supportive and encouraging manner. Residents lead active lives. Many like to go out and about on their own. Care plan files contain risk assessments that demonstrate how residents will be supported to remain independent whilst minimising any possible risks to their safety. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 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 the following standard(s): 11, 12, 13, 14, 15, 16, 17 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents lead interesting and varied lives to suit their individual interests and preferences. Menus are balanced and varied and meet the nutritional needs of the residents. EVIDENCE: On the day of this inspection many of the residents were out during the morning, either shopping, going for a walk, or at organised activities. The home provides transport to enable residents to access local services and leisure facilities. All of the residents have recently been helped to obtain Disability Living Allowance (mobility allowance), and they all have bus passes. Residents have been supported to attend college courses, take up jobs, and to participate in clubs and sporting activities in which they can learn new skills and work towards greater independence. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 14 The home has good links with the local community. Friends and neighbours are always welcomed into the home. Residents enjoy shopping trips, pub outings, and eating out at local restaurants. Some attend church services. Some of the most popular activities enjoyed by residents are currently swimming, horse riding, gardening, cooking, walking, outings and games. The home has recently bought new garden furniture, barbeque and outdoor games. Paths and patios have been laid and there are attractive areas where residents can sit and relax in the garden. Residents have decided they want to play Bingo every week – several said how much they enjoy these evenings. They have also chosen to have a regular skittles evening at a local pub. During the inspection residents and staff talked about the holidays that residents have been on this year. On the evening before this inspection the home held a Residents’ Meeting. These are held regularly and during the meetings residents are consulted on many of the day-to-day routines within the home. Activities and menus are regularly discussed. Half of the residents who completed survey forms said there are always activities arranged by the home they can take part in. The other half said there are sometimes activities they can take part in. One person commented “I would like to do more painting and play cards more often”. The overall findings during the inspection showed that although the home offers a good range of activities there may be room for improvement. The inspector joined the residents for lunch. It was a Friday, and there was an option of fish, fish fingers, or sausage with peas and chips. The meal was tasty and well cooked. A selection of fresh fruit was offered to each resident after the meal. Seven residents said they always like the meals and nine said they usually enjoy the meals offered. The staff gave assurances that they know the likes and dislikes of each resident and will always cook an alternative meal if the resident does not like what is on the menu. Menus for the current week are on display in each of the three units. During the residents’ meeting the previous evening the residents decided to change the main meal of the day to the evening. They had found that daily activities often meant that some of them couldn’t sit down with the others for a cooked meal, and they decided that if they all have a cooked evening meal, they can have the meal freshly cooked rather than re-heated, and they can all sit down together if they wish. At the last inspection it was recommended that professional advice is sought on healthy eating. A dietician has made 2 appointments to visit the home but unfortunately due to various circumstances the appointments have been cancelled. They are hoping another appointment will be made in the near future. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 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 the following standard(s): 18, 19, 20 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents receive good support from well-trained staff to meet their personal and health care needs. Medicines are stored and administered safely. EVIDENCE: During the inspection residents and staff talked about how personal care is provided. The staff have a very good understanding of how individuals want to be supported in order to maintain their privacy and dignity. There is a balance of male and female support staff to ensure residents are supported by someone of the same gender where required. The care plans set out how residents want to be helped with personal care tasks. They show what times the residents like to get up/go to bed, and how often they like to have a bath or shower. Residents choose their own clothes and hairstyles. GPs who responded by comment card to this inspection indicated that they are satisfied with the way the home ensures the healthcare needs of the residents are met. All of the residents who completed questionnaires said they always Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 16 receive the medical support they need. This was also confirmed through discussions with the manager, staff and residents during the inspection. The home uses a monitored dosage system of medicine administration. The pharmacist visits the home regularly to check the storage and administration procedures and to provide advice and support. The medicines are held in a secure cupboard. There is a locked fridge for medicines that have to be kept cool. The medicines cupboard is tidy and well organised, and the system is easy to follow. Good records have been maintained of all medicines received, administered and any unwanted medicines that are returned to the pharmacist. Staff have received training on the safe administration of medicines. Staff were seen administering the lunchtime medicines, and their practice was entirely satisfactory. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 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 the following standard(s): 22, 23 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents are safeguarded from abuse, neglect or self-harm. Good procedures are in place to ensure all complaints and concerns are listened to and acted upon to the residents’ satisfaction. EVIDENCE: No complaints have been received by the home or by the Commission since the last inspection. The home has a good complaints procedure in place. Twelve of the residents who responded to the inspection by survey form said that they always know how to make a complaint. Their comments included “Yes, it tells me on the wall”, “I always go to the manager Anne Maddox” and “Staff and Anne and that piece of paper on the wall”. Four residents were less certain about the process (it is possible they may have misinterpreted the question). Anne Maddox said she has read out and explained the complaints procedure to all of the residents. All staff have received training on safeguarding adults. There are policies and procedures in place to ensure residents are safeguarded from abuse. These procedures have been followed correctly where necessary and the home has ensured that any issues or concerns raised have been investigated thoroughly. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 18 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, 30 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” The accommodation is comfortable and homely throughout. Improvements are currently being made that will bring the home up to a high standard of decoration and furnishings when completed. There are good systems in place to ensure all areas are regularly maintained and kept clean and hygienic. EVIDENCE: Since the last inspection a considerable amount of work has been carried out on all areas of the home. The entrance driveway has been gravelled and now gives a smart appearance to the front of the house. Paths and patio areas have been re-laid to provide pleasant sitting areas to the side of the house. New garden furniture and a barbeque have been purchased. An unused building in the grounds is in the process of being converted to provide two supported living bungalows. New windows in the stable block are due to be installed during September 2006. Two maintenance men are employed at the home. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 19 Inside the home a number of areas have been redecorated and other areas are either in the process, or will be redecorated in the near future. New carpets have been purchased and will be laid throughout the home. Residents have been consulted on colour schemes and new furnishings. The dining room in the main house has been refurbished and is now a bright and comfortable room. There is a programme of upgrading the bathrooms and toilets. One bathroom has recently been completely renewed and now looks attractive, bright and homely. The office has been moved to a ‘portakabin’ in the grounds and the room previously used as the office is being converted into an activities room and designated smoking area. Al residents are accommodated in single bedrooms that are of a good size. The bedrooms have been individually decorated and furnished to reflect the preferences and tastes of each resident. There are plans for all of the bedrooms to be redecorated on a rolling programme when the communal areas have been completed. All areas of the home were found to be clean and hygienic. Staff assist residents with daily cleaning tasks and laundry routines. Residents who responded to the inspection by survey forms said the home is always kept fresh and clean. Comments include “Yes, all the staff keep it clean like Mrs Doubtfire – and I keep the kitchen clean always”, and “I like to be independent and do jobs around the house”. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 20 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, 35, 36 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents are supported by competent and trained staff. Staffing levels are sufficient numbers to meet the needs of the residents. Good recruitment procedures are followed to ensure residents are in safe hands. EVIDENCE: The home employs 18 care workers. Of these, 8 already hold an NVQ qualification at level 2 or above (this is a nationally recognised qualification for care workers). Four more staff are in the process of doing NVQ level 2 and 2 are currently doing NVQ level 3. 2 senior staff are in the process of obtaining the Registered Managers’ Award. When these staff have completed their qualifications it will bring the home well above the recommended level of 50 of staff with a recognised qualification. In addition staff have received training in all required health and safety topics, and also Challenging Behaviour and the Protection of Vulnerable Adults. Residents and staff confirmed that the staffing levels are satisfactory. There is a low turnover of staff. The morale within the staff team is good. Comments from staff include “ The care home is well managed” and “As far as possible the service user is treated as an individual”. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 21 The files of 3 staff recruited since the last inspection were seen. These showed that all required checks and references have been taken up before the staff have been confirmed in post. Anne Maddox talked about how the residents are involved in the recruitment of staff by meeting the applicants and giving their views on the suitability of the applicants. 12 staff responded to this inspection by completing a questionnaire. Of these, 9 staff said they had not received adequate induction training when they started work. These staff were employed by the previous owner. Anne Maddox said that staff recruited in the last year have received a thorough induction to meet the standards laid down by Skills For Care (these are nationally recognised minimum standards for the induction of new staff). She confirmed that some staff recruited under the previous ownership have since attended an induction course to ensure they have all of the basic knowledge required for all staff. She said she will check with the remaining staff to see if there are any gaps in their knowledge that could be addressed by induction or foundation training. Staff confirmed that they have received regular supervision and support. They also confirmed that they have regular group meetings. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 22 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, 42 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service”. The home is well managed. Records have been well maintained. The home has taken all possible steps to ensure the health and safety of residents and staff. EVIDENCE: The residents and staff interviewed during this inspection were full of praise for the new owners and managers of the home. They talked about how much they enjoy the regular visits by the owner of Allied Care and the Regional Manager, and how they have involved themselves in the day-today running of the home. Comments from 11 staff who responded to the inspection by survey form were very positive about the management of the home. These included “Manager Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 23 Anne Maddox always works hard to be here at all times, for one and all” and “The home is well managed – very different from when it was previously owned”. Another member of staff responded to the question about what the home does really well by saying “Everything”. However, one member of staff was less satisfied with the management and senior staff and indicated that they were unhappy about the balance of cleaning and care tasks. There are systems in the home for staff to raise concerns and talk about matters that concern them, and for these to be addressed where possible. Anne Maddox is in the process of gaining NVQ level 4 and the Registered Managers’ Award. She has a number of years of relevant experience. Records checked during this inspection included – Administration of medicines Care planning systems Staff recruitment files Staff training records Staff rotas Menus Policies and procedures Fire log book Accident and incident reports These were found to be well maintained. The current certificate of insurance was displayed in the office. Evidence of maintenance of equipment and health and safety checks were seen during the inspection. Electricity and water systems have been checked by qualified professionals. Risk assessments have been carried out on the environment and regular checks have been carried out to ensure the home is kept safe. Staff have received training and instruction on all relevant health and safety topics. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 2 3 3 3 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA17 Good Practice Recommendations Care plans should be developed to show individual goals and set out clearly how these will be achieved. The home should seek further advice on how to promote healthy eating. Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 Bolealler House DS0000064992.V300102.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!