Inspection on 12/02/07 for Bosworth

This inspection was carried out on 12th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Bosworth 26/08/09

Bosworth 14/05/09

Bosworth 24/11/08

Bosworth 02/10/07

Bosworth 01/11/05

Bosworth 23/05/05

Bosworth 07/03/05

Bosworth 18/05/04

Bosworth 24/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Bosworth 6 Southdown Avenue Preston Weymouth Dorset DT3 6HR Lead Inspector Sally Wernick Unannounced Inspection 12th February 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bosworth Address 6 Southdown Avenue Preston Weymouth Dorset DT3 6HR 01305 833100 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) Mrs Christine Wells Mr Derek Edwin Luckhurst, Mrs Meryl Susan Hodder Mr Peter Geoffrey White Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user (as known to the CSCI) within the category of LD (E) may be accommodated to receive care. 1st November 2005 Date of last inspection Brief Description of the Service: Bosworth Residential Care Home is located in a quiet residential area of Preston, about 2 miles from the centre of Weymouth. The home looks out over a wildlife reserve and has fine views of the sea and Portland. The home is registered to accommodate a maximum of 22 older persons over the age of 65 years, and also currently accommodates one person who has a learning disability, by arrangement with CSCI. Bosworth offers 18 single and two double sized bedrooms, spread over two floors; as the house is set on hill, a number of 1st floor bedrooms have direct access to the garden. The home has a passenger lift which gives level access to the main area of the 1st floor; six bedrooms on this floor have access via 3 steps on the landing. On the ground floor there are communal lounges and a dining area, together with a bathroom and WC. The registered manager advises that the weekly fee range within the home is: £375.00-£435.00. See the following website for further guidance on fees and contracts. http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_ choos.aspx Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and began at 11.00am on Monday 12 February 2007. This was a ‘key inspection’ where the homes performance against the key National Minimum Standards was assessed alongside progress in meeting a requirement made at the previous inspection. The registered manager assisted the inspector, as did other members of care staff. Methodology used included a tour of the premises, review of records and discussions with staff. During the inspection the inspector spoke with a group of seven residents in the lounge area and visited a further three in their rooms. The inspector also reviewed the contact sheet and service notes for the home. A Pre-inspection questionnaire was also sent to the manager in order that information could be provided prior to the inspectors site visit. That information where relevant will be included in the main body of this report. Prior to the inspection comment cards were sent out by the home on behalf of the commission. Of those returned eleven were from current service users, two from G.P’s, one from a community professional and ten from relatives and friends. Surveys received from residents indicated that overall they were happy with the care in the home medical support is available when needed, food and hygiene are generally good and staff are seen as kind and supportive. Two of the comments included: “staff work very hard on our behalf”. “I’m very content” Friends and family have written: “We are very happy with the care received by my relative. The staff are always welcoming and we arrive at all times of the day/evening. My relative is well cared for, always clean and well dressed. A pleasant well run and friendly place with excellent staff. “staff very professional and very polite”. “We are always made very welcome on our unplanned visits and are impressed by the staffs kindness and the general ambience”. Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 6 “My relative feels very fortunate that they are being cared for so well” What the service does well: What has improved since the last inspection? What they could do better: Quality of life within the home is generally good and residents told the inspector that they were content and happy. There were however, some aspects of the care which service users would like to see improved and some areas where they would like greater choice. Standards of food within the home are generally acceptable with fruit and vegetables available. Residents however would like to have a choice at meal times and those choices should properly reflect the preferences of those living at the home. In addition menus, which are regularly reviewed would be welcomed and should now be introduced. Activities are arranged at the home however there is not a dedicated activities co-ordinator nor are activities based on individual interests. Some residents have indicated that they would welcome more social activities, which should be individually suited. Training is provided at the home so that staff can meet the assessed needs of residents. However not all staff has received adult protection training and one staff member spoken to had not undertaken the mandatory training in areas such as moving and handling and infection control. Fire training was similarly not up to date for staff. All of this training is necessary to ensure the safety and wellbeing of residents. In some areas the home would benefit from thorough cleaning and the laundry requires upgrading. Residents would be better protected if hot radiators were covered. Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 7 The Registered Manager is currently undertaking NVQ4 registered managers award it would be of benefit to all those at the home if he were also to undertake the award in care. All staff should have the opportunity to undertake person centred training which will build on current good practice and continue to place the emphasis clearly on the needs of the resident. The home is continuing to develop its quality assurance systems and will be extending this to care professionals. It would be good if results could be published in a clear format to demonstrate how the home is meeting positive outcomes for service users. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admissions procedure enables prospective residents and their supporters to make informed decisions about the home and ensure that only service users whose needs can be met by the home are offered places there. However the outcome of pre-admission assessments is not yet confirmed in writing, so prospective residents are not yet fully assured that their care needs will be met. The home does not provide intermediate care standard 6 therefore was not inspected. EVIDENCE: Two files of residents who had come to live at the home since the previous inspection were examined. Both showed that prior to arriving at the home, care needs had been assessed by the home’s manager. However, at present Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 10 the outcome of such assessments is not confirmed in writing, so prospective residents cannot be fully assured that their care needs will be met. Pre-admission assessments contained information for managing healthcare needs and where relevant, files held copies of local authority assessment and care plans. All residents moving into the home received a copy of the terms and conditions and a service user guide. Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a care planning system in place to ensure that staff has the information that they need to meet the needs of residents. The health needs of the residents are well met with evidence of support from a range of community health professionals. The medication at the home is well managed promoting the good health and well being of residents. Residents are treated with respect and their privacy and dignity is promoted. EVIDENCE: Three care plans were examined all were of a good standard. They followed on from the assessments made by the home, were easy to read and were informative about the needs of the resident and of how the home was to meet them. Information in the care plans was up to date with plans being reviewed Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 12 monthly. There was evidence that residents were consulted about their daily plan of care and were involved in the assessment process. Daily care notes support and evidences the delivery of care to residents and gives a picture of the care provided as well as visits by community health professionals. Records demonstrate that residents have access to GP’s, district nurses, dentists, opticians and attend for appointments as necessary. Risk assessments are carried out for each resident and appropriate steps taken to minimise any risks identified. A system for the ordering, administering and recording of medication is in place at the home and only staff members that have completed a course in “medication” are able to carry out this task. Medicines were safely stored and countersigned where necessary. Some residents at the home do choose to self medicate and lockable storage is provided. Staff was observed throughout the inspection to be treating residents with courtesy, patience, kindness and respect. Residents spoken to during the course of the inspection spoke very highly of the staff describing them as “very caring” and “excellent”. Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Entertainment and some recreational activities are provided that enable residents to enjoy some of their leisure time. Residents are supported in maintaining contact with their friends, family and the community and they are helped to exercise choice and control over their lives promoting independence. Food is provided that meets some resident’s tastes although a choice of meals is not currently available. Menus are not provided. EVIDENCE: At the current time the home does not employ specific staff for the organisation and provision of activities but relies upon care staff. There is no planned programme of activities although one member of the staff team does have an identified role without the dedicated time to develop that further. Staff do take time when possible to arrange games with residents and there are visiting musicians that call at the home twice monthly although two residents that were asked could not recall seeing them. The deputy manager informed Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 14 the inspector that staff in their own time would often take residents out for walks. One resident has purchased a number of DVD’s, there are games and books available and each week a representative from extend (music to exercise) visits. A number of residents visit their families who live locally and staff and residents told the inspector that some of the residents regularly enjoy a game of cards together. The hairdresser calls weekly and staff often introduce hair and nail sessions. The key worker system means that some staff will often try and visit residents in their rooms. Each month a priest visits from a local church. Residents who are visually impaired pay for and receive audio books from the RNIB. Care plans examined did record some detail of individual preferences regarding religious, cultural and recreational activities but did not identify how the home could support residents or how these could be met. This needs to be expanded and social care plans formulated for all service users including those who may be visually or hearing impaired and/or who may be experiencing short term memory loss. Visitors were at the home on the day of the inspection and residents confirmed that they are able to visit at times that are flexible and suited to the resident. Residents said that they have a choice in daily living deciding who they want to see and when. Bedrooms were personalised with door locks and for some telephones. Residents manage their own financial affairs or are supported by friends and relatives. Residents generally expressed satisfaction with the food although many spoken to would welcome a choice at meal times and would value the introduction of a menu. On the day of the inspection no choice was offered other than pork steaks for lunch with tinned grapefruit as an appetiser and tinned fruit/ice cream for dessert. At the current time individual’s food preferences are not actively sought although where there is a known allergy this is taken into account. A record of the food provided at the home revealed that breakfast is a choice of cereals, toast or crackers. It would be good for the residents if a cooked breakfast or choice of eggs were offered occasionally and at teatime finger foods or as one resident stated a choice of options on toast. Requirements have been made as a result of this inspection and the home is required to provide to menus for residents with a range of food choices. These menus are also to be forwarded to the commission for review by the inspector. Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a formal complaints procedure allowing residents and visitors to express their concerns. To ensure that service users rights are met and they are protected by staff actions the adult protection policy and procedures must be updated. In addition the absence of adult protection training for care staff means that insufficient measures are in place to respond to suspicion or evidence of abuse. EVIDENCE: The home has a clear and up to date complaints procedure, which is provided to residents and their supporters on admission to the home. No complaints have been received by the home since the last inspection. An adult protection policy is in place but requires updating and revising to provide clear advice to staff. The training matrix provided by the registered manager indicated that few of the care staff has undertaken adult protection training. To ensure a proper response to any suspicion or allegation of abuse all staff should undertake upto-date adult protection training with an accredited trainer. Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home generally provides a comfortable living environment, however residents would benefit from some re-decoration in the home, daily cleaning of communal areas, kitchen and bathroom and upgrading of the laundry area. Hot and unguarded radiators may continue to present a risk to some residents. EVIDENCE: The property is built against the side of a hill and has been extended to the rear to provide additional bedrooms many of which have patio doors, which lead to the garden and have lovely views of the sea and nature reserve. The home is comfortable and bedrooms are clean and personalised to the individual with a good living space. The home does not have a dedicated cleaner and much of the cleaning is shared between care staff and the lunchtime cook. Vacuuming of the communal areas takes place approximately 3 days a week however given the volume of residents and staff this is insufficient to maintain Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 17 cleanliness particularly in the dining area. Some of the communal areas were also dusty and in need of cleaning however there were no adverse odours. The kitchen area would also benefit from further cleaning as food debris was observed around the cooker and on the floor and cabinets were in need of some attention. Inspection of the bathrooms and toilet areas revealed that raised toilet seats were soiled with faeces these should be removed and thoroughly cleaned in line with advice previously given from infection control nurses. During the inspection it was discovered that some of the mattresses on beds were covered with plastic sheeting this is not considered good practice and can cause significant discomfort for residents. The plastic covers were removed during the course of the inspection. Plastic covers over tablecloths are used, as table covering in the dining area it would be good practice if these were removed as such articles are indicative of institutionalised practice. The home would also benefit from re-decoration in some places one or two of the bedrooms and the communal hall are tired in places. Bedroom doors are extremely scuffed and in places damaged. At the previous inspection the registered provider indicated that one of the long term aims of the home was to upgrade the laundry area as the floor is in need of repair and is difficult to clean thoroughly. This has not yet happened. In addition it was the inspectors opinion at the last inspection in November 2005 that the home should plan for the covering of all radiators to minimise the risk of residents getting burnt. The registered provider agreed to plan and budget for the covering of more radiators although, many are still exposed and at high temperatures. Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff are sufficient to ensure that the assessed needs of residents are met. Proper recruitment procedures are in place to ensure the protection of residents living at the home. There is a programme of formal training designed to improve and develop staff knowledge and skills for the benefit of people living at the home although this needs to be expanded further. EVIDENCE: Throughout the inspection it was clear that there were sufficient numbers of care staff on duty and staff rotas confirm this although the home would benefit from a dedicated cleaner to ensure that standards relating to hygiene could be better met. The staff team are stable and some have worked at Bosworth for a number of years. More than 50 of the staff team hold National Vocational Qualifications. Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 19 Proper recruitment procedures are in place and staff files evidenced that. In line with a requirement made at the previous inspection criminal record bureau checks are undertaken on all staff appointed to work at the home. Records are kept of all staff training at the home however on the day of inspection the member of staff responsible for managing training was not on duty and not all records were available. The manager and deputy manager however confirmed that all staff has undertaken they’re mandatory training such as moving and handling throughout the year in addition to studying for and obtaining National Vocational Qualifications. One member of staff who had been recruited following the previous inspection had not received training in moving and handling or infection control her induction file however indicated that training had been received on the principles of care and safe working practices. From discussion with the registered and deputy manager it would be beneficial for residents and good practice for all the staff team to receive training in person centred care. The registered manager was also advised to look at the following website which offers advice and information about induction and training programmes. www.skillsforcare.org.uk Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The registered manager is new to care and is currently undertaking NVQ 4 in Management. The home does review its performance through a programme of consultations, which include seeking the views of residents, staff, relatives and other visitors to Bosworth to ensure the home is run in the best interests of residents however this needs to be further extended. Resident’s financial interests are safeguarded. Arrangements for maintenance and safety must be improved to ensure the protection of service users and staff. Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 21 EVIDENCE: Mr Peter White is the registered manager at Bosworth and has been with the home a little over 12 months. He has no previous experience in a care setting and is in the process of studying for his NVQ 4 Registered Managers award. Once this has been completed it will be necessary for him to undertake his NVQ 4 in care. During his time at the home Mr White has completed the mandatory health and safety training as well as a half-day “No Secrets” course run by the local authority. To understand some of the underlying principles of best practice the manager would also benefit from undertaking training in person centred care, which would help to develop his knowledge and skill base further. Since his appointment the registered manager has distributed quality assurance questionnaires to residents, staff, family and friends and there are plans to further extend this to medical professionals and care managers. Where responses have been received that require immediate action the manager has dealt with those individually. Results of surveys however are not yet fed back formally so the majority of those whose views have been sought are not necessarily aware of what action has been taken. It is recommended therefore that the results of surveys are collated and fed back through the homes annual development plan and in a format, which can be easily accessed and understood by family, supporters and other interested parties. In order to protect residents, it is the policy of the home not to have any involvement in their personal finances. All residents who are unable or do not wish to handle their own affairs, have a relative or other representative to support them in managing their finances. The home pays for services such as chiropody and hairdressing and keeps a record of what is owed. The amount is then invoiced to relatives or representatives for payment each month. At least once a month the registered provider must visit the home to monitor standards. A written report detailing findings must be retained for inspection or forwarded to the Commission. No reports were available for perusal during this inspection nor have any been received for a significant period. As a result the registered provider is failing to meet their statutory obligations. The registered manager confirmed that regular checks are undertaken of electrical equipment within the home. Both the environmental health and fire department have made statutory visits to the home and there are no requirements as a result of the fire inspection. Staff records indicate that formal fire training is undertaken yearly with an external trainer although mandatory fire training within the home was found to be not up to date. The registered manager confirmed that the majority of staff had received mandatory health and safety training although this had not been extended to Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 22 all staff. One staff member spoken to who had been at the home for 7 months had received no training in moving and handling or infection control. The accident and injury book was inspected and it was clear that the home was notifying the Commission for Social Care when there was a major incident within the home. However this must be extended to any incident, which may adversely affect the wellbeing or safety of any service user. Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X 2 1 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 1 2 Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 24 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. 1. Standard OP3 Regulation 14 Requirement The registered person must confirm in writing to the service user that, having regard to the pre-admission assessment, the home is able to meet individual needs in respect of health and welfare. The home must develop and implement an activities programme suitable for the individual needs of the service users. The registered person must ensure that there is a menu offering a choice of meals based on the known preferences of service users. The menu should be reviewed at a minimum of 4 weekly intervals to ensure quality and choice for residents. These should be recorded and the record maintained. Menus should be provided in a format that is easily understood by all residents. The home’s policies on adult protection must be updated to ensure they give accurate advice. All staff must receive DS0000026769.V329059.R01.S.doc Timescale for action 12/03/07 2. OP12 16 12/04/07 3. OP15 16 23/02/07 4. OP18 13 12/04/07 Bosworth Version 5.2 Page 25 5. OP25 OP38 13 6. OP26 23 7. 8. OP31 OP37 18 26 9. OP37 37 10. OP19 OP38 13 11. OP38 13 adult protection training to safeguard service users and to protect them from abuse. Where radiators do not have low temperature surfaces steps must be taken to ensure that each are guarded. This is necessary to ensure that risks to residents are eliminated. The home must be thoroughly cleaned and kept clean and hygienic throughout. Infection control measures must be adhered to. It is required that the manager obtains NVQ level 4 in both management and care. The responsible individual must compile a report of his/her monthly visits on the conduct of the home and provide a copy to the Commission and to the manager. The home must give notice to the Commission of any significant events affecting residents. These must include serious falls and associated injuries. In order to safeguard residents the registered persons must ensure that all staff receive suitable training in fire prevention and that fire drills and practices are undertaken at suitable intervals. Clear and detailed records must be kept in order to fully demonstrate compliance. The registered person must ensure that staff receives appropriate training in moving and handling, infection control and all mandatory health and safety practices. This is to ensure safe practice for service users. DS0000026769.V329059.R01.S.doc 12/05/07 12/04/07 12/12/07 12/03/07 12/03/07 12/03/07 12/04/07 Bosworth Version 5.2 Page 26 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 OP12 Good Practice Recommendations It is recommended that social care plans are formulated that identifies following assessment, how individual, social, recreational, cultural and religious needs can be met for all service users. The floor of the laundry should be replaced and should be impermeable to fluids. The laundry must also be suited to effective cleaning, to minimise risks of infection. To demonstrate good practice and to best meet the needs of service users it would be good if management and staff at the home undertook training in person centred care. The Registered manager must develop quality assurance methods based upon seeking the views of service users and other interested parties, to ensure success in achieving the aims and objectives of the home. An annual development plan must be produced in an accessible format reflecting the outcome of the consultation. 2 3. 4. OP26 OP30 OP33 Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bosworth DS0000026769.V329059.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!