Inspection on 28/11/05 for Bournedale House

This inspection was carried out on 28th November 2005.

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

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

Other inspections for this house

Bournedale House 27/05/09

Bournedale House 03/06/08

Bournedale House 27/07/07

Bournedale House 25/07/06

Bournedale House 22/03/06

Bournedale House 21/03/05

Bournedale House 23/09/04

Bournedale House 27/02/04

Bournedale House 13/10/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bournedale House 441 Hagley Road Edgbaston Birmingham West Midlands B17 8BL Lead Inspector Monica Heaselgrave Unannounced Inspection 28th November 2005 09:20 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 Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bournedale House Address 441 Hagley Road Edgbaston Birmingham West Midlands B17 8BL 0121 420 4580 0121 420 4580 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) Mr David Pangbourne Leah Robertson Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The resident numbers shall remain at 11. That Ms Leah Robertson provides evidence of completion of a management qualification at NVQ level 4 or equivalent at the earliest opportunity or before April 2005. The category of registration is OP (older people, over 65) and the type of home is care home only. 21st March 2005 3. Date of last inspection Brief Description of the Service: Bournedale House is located approximately 3 miles from Birmingham city centre, and within walking distance of Bearwood shopping centre. Facilities such as churches, public houses, restaurants, library and parks are close to the home. Bournedale House is a large Victorian house providing accommodation to 11 older adults. Care is provided on the ground and first floors, a chair lift provides access to the first floor facilities. On the ground floor there is a main lounge, dining area and kitchen, with toilet and shower facilities within easy reach. The lounge is to the rear of the property, is spacious and provides nice views of the rear garden. There is a shared double room to the ground front of the property that provides accommodation for two service users who require ground floor facilities. This room has privacy screens. The first floor facilities consist of spacious single bedrooms with ample storage, some with original Victorian fireplaces. The bathroom has a bath hoist to assist persons into the bath; there is also a shower. There are grab rails located in toilets and around the home to aid service users. There has recently been an assessment of the environment and service users needs. This has led to the provision of aids and equipment suited to the needs of people who require assistance. Raised chairs, pressure cushions for chairs, and handrails at the top of the stairs have been provided. Individual service users have been provided with zimmer frames to enhance their mobility and independence. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place on a Monday, between 9.20 a.m. and 12.30. The inspector met the manager, senior care staff, one care staff, and the cook. Ten service users were in the home. The district nurse and a relative were also spoken with. Two service users actively contributed to the inspection process. The majority of service users had limited involvement as a result of confusion or dementia. Observation of the care delivered to them was undertaken intermittently and on an individual one to one basis. A number of records were sampled to include, service users daily notes, care files, risk assessments, the complaints records, staff files, staff rotas and certificates for the testing and maintenance of fire equipment, gas and electric appliances. Records and practices relating to the safety of service users were also examined, these included, the testing of water temperatures, menus, and the storage of substances hazardous to health. A tour of the building was undertaken. What the service does well: What has improved since the last inspection? Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 6 There has been a lot of progress in developing the care records since the last inspection. These now clearly identify the needs service users have, and state how they should be met. The management of medication has improved and is now stored, dispensed and recorded safely. All staff has undertaken accredited medicine training that assists them in doing this aspect of their job safely. The complaints procedure has been updated which ensures service users and their relatives know how to contact other agencies for support if needed. Improvements to the building to make it safe and comfortable for Service Users are evident. These have included the fitting of appropriate locks to the rear doors that are compatible with fire regulations. Bedroom doors have been adjusted and gaps in the fire doors have been repaired to improve overall fire safety. A window has been replaced in bedroom ten. A bath hoist has been fitted in the bathroom in order to assist service users to use this facility in comfort and safety. An assessment of service users abilities and the aids they require has been undertaken. This has led to fitting handrails at the top of the stairs, three bedrooms now have chair raisers, which make it easier for service users to use their chairs, and pressure cushions have been provided for those at risk of pressure sores. One service user has had a bedrail fitted to ease getting in and out of bed. Some service users have been provided with Zimmer frames to promote their mobility and independence. Three bedrooms have been decorated to the satisfaction of the service users. Fire precautions and records have greatly improved, with regular testing and recording of alarms and emergency lighting. Hot water temperatures are also now tested and recorded on a regular basis. In a short amount of time, a good deal of work has been undertaken, to try and meet the requirements made at the last inspection. A significant number of these have now been addressed. What they could do better: The activities on offer to service users, needs to be communicated to them, whilst being linked to their Care Plan. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 7 In relation to the choice of meals provided for service users, there was room for further improvement. The manager should seek to improve the choices on offer to service users, currently only one set meal is provided. Consultation with service users regarding their choices must be recorded. The manager should seek assistance from the dietician in order to ensure that menus are planned in a manner that ensures service users are receiving a wholesome and nutritionally balanced diet. Menus must be regularly reviewed in order to ensure Service Users are eating well. Any difficulties in managing someone’s diet must be specified in their Care Plan. The manager must ensure that outstanding requirements are met in relation to fire safety, the storage of substances hazardous to health, staff training, and staff supervision. One condition of registration relating to the qualifications of the manager remains outstanding and must be addressed. Progress in these areas would lead to an increased opportunity to build on some of the more positive features of this home. 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. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4 A detailed assessment of service users current needs, gives assurance that care needs will be met, and risks diminished. Staff training does not adequately reflect that they can deliver the services and care that the home offers to provide. EVIDENCE: At this inspection one standard outstanding from the last inspection was assessed. Assessment of service users current needs has been addressed. Each now has an up to date assessment, care plan and risk assessment. An assessment undertaken by the Occupational therapist and Physiotherapist has ensured service users now have appropriate aids suited to their needs. Detailed records are now available to ensure that needs are identified, acted upon and recorded. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 10 The occupancy has remained stable with no residential vacancies. Five requirements were made at the last inspection, 1) The Statement of Purpose requires further development to include all the information and documentation in Schedule 1. 2) The Service User Guide requires development to include all the information and documentation in Regulation 5. 3) Service users must only be admitted to the home following a detailed assessment. 4) The manager must undertake a detailed assessment of service users current needs, and if necessary involve other professionals. 5) Accurate and detailed records must be maintained to evidence what action was taken in the care plans to meet the needs of service users. The manager should submit to the Commission copies of the Statement of Purpose, Service User Guide and Assessment format, in order that progress in this area can be determined. Assessment of requirements 4 and 5 show that these are met. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 There are very good systems in place, which ensure Service Users health and social care needs are met. Service Users are cared for in a manner that protects their dignity and privacy. EVIDENCE: Care Plans have been completely revamped since the last inspection, and meet with requirements made at that time. They are current, and contain good descriptions of Service Users needs, and how these will be met. This ensures needs are met in a consistent and planned way. Review dates are set and take place on a monthly basis to ensure any changing needs are highlighted and acted upon. Daily records have significantly improved. A new format is in use, which specifies the specific requirements an individual has. This included how many carers were needed for tasks, which equipment to use, such as a hoist, whether a wheelchair is used, and any particular care to be given such as skin care for delicate skin, or pressure area care. These more detailed entries enable staff to be consistent in their care giving, and promptly identify any change in a person’s health, and act upon it. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 12 Risk assessments were evident for all service users at risk of falling. There were excellent preventative measures in place for the management of fluid intake, diet, weight loss, and pressure sore care. These were detailed in care plans, and monitored in daily records. On the day of inspection the visiting District Nurse spoke very positively of the staff team and manager, stating that they always report any concerns to her for follow up, and follow the advice given. Two services users commented favourably on how staff supported them. One said “The staff are very good, they look after me, today I’m going to hospital because I told them the plaster on my arm is sore, and they will sort it out.” The majority of service users were not able to verbally contribute their experiences of the care they receive, however their care plans and daily records confirmed that their care is planned and structured around their needs, which ensures the needs of particularly vulnerable people are met in a caring manner. Staff had very good knowledge of Service Users needs, characters or idiosyncrasies, and observation of their interaction with service users, showed they used this well in supporting them with their care and preferred routines. This is particularly important where service users are confused. It was nice to see staff being so perceptive. Unfortunately there was no up to date staff training records that showed whether staff had received training and guidance in these areas. However the manager stated all staff had undertaken training in manual handling and food hygiene since the last inspection. There has been a significant improvement in recording the medical services service users use. Records confirmed that Service Users have access to health care services, to include; a G.P of their choice, dental, chiropody, hearing and optical services. It was also evident that advice had been sought regarding the management of continence. This information is now easily accessed, easy to track and enables staff to act upon any concerns promptly. The arrangements for personal care ensure that the privacy and dignity of Service Users are protected. Care Plans provide a good insight into previous lifestyles and routines, so that the service users expectations are known. Service users use the communal bathroom, which is equipped to assist people who have difficulties, whilst maintaining their dignity. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 13 The shared double room has privacy screens, and the service users sharing this facility had access to a phone line. The management of medicines has improved. Requirements made at the last inspection visit have now been met. Medication is now dispensed from its original container, minimising the risk of mistakes. The original prescriptions are now photocopied before being sent to the pharmacist, in this way when medication is delivered, this can be checked against the original prescription and medication administration records. The keys to the medicine cupboard are now held securely. All staff have received accredited medicine training and old creams found in service users bedrooms, have been removed. Currently no service user self manages medication. The manager is intending to implement a protocol for the use of ‘As required medication’. This will ensure that there is clear information stating when someone may need this medication, the criteria will be recorded and will ensure it is only administered in those circumstances. The manager stated that currently no one requires Controlled drugs, but should this be necessary, a secure controlled drugs cabinet and separate recording system would be provided. Care plans now contain personal details regarding service users preferences and choices in respect of illness or death. The inspector had no reason to believe that staff would not handle this aspect of care with compassion and sensitivity. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Service users benefit from some stimulating activities, which they enjoy. However the variety and frequency of activities must be recorded and kept under review to ensure these support the social needs of service users. The food provided is home cooked, and enjoyed by service users. There needs to be further development of a menu that offers meal choices that match the preferences and expectations of Service Users. Advice from the dietician in providing a nutritionally balanced diet will ensure the maintenance of service users appetite and nutrition. EVIDENCE: Care plans have been updated since the last inspection, and now incorporate the social interests service users have, and their preferred daily care routines. One service user was able to describe flexible routines in relation to getting up and retiring to bed. She also confirmed her personal care routine which reflected flexibility in the frequency of bathing. The personal care of service users was observed to be of a good standard. All were dressed appropriately, and hair was nicely styled. The care of clothing Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 15 was seen to be good, nicely laundered and ironed. It was evident that staff do support service users with their general appearance. A visiting relative confirmed that her mother is well cared for, always well presented, and that the staff and manager are very caring towards service users. Service users have access to a weekly progressive mobility activity. Informal activities take place on a daily basis such as bingo, and sing-alongs. The hairdresser visits weekly and the catholic priest visits occasionally. A visiting relative said that there had been three choir concerts this year, which service users particularly enjoyed. Another concert was planned for the following week. The care plans viewed showed the activities that individuals enjoyed and engaged in. Whilst there are examples of activities taking place, the manager needs to develop a means of communicating these to service users, possibly via a weekly poster. This could then be used to monitor the variety and frequency of activities to ensure service users have the opportunity to engage in stimulating and interesting activities of their choice. Contact with family and visitors is known and respected. Contact arrangements are detailed in service users care plans. Meals featured positively in the estimations of those who could voice an opinion. Two service users commented very favourably, upon the quality of food. The manager said that service users used to be given two choices at the main meal, but that this had not worked well, and had caused confusion. Service users made a choice then changed their mind. Currently one main meal is provided. The inspector is concerned that there is no means of identifying how meal choices are arrived at. This was discussed with the manager who said there is informal daily consultation with service users regarding their meals. There needs to be a more structured means of consultation and this must be recorded to show how choices have been made. The inspector has also required the manager to seek advice from the dietician with a view to menu planning. This will ensure that service users are receiving a nutritionally balanced diet. Service Users have appropriate support to eat their meals, and food and fluid intake is monitored where concerns are evident. This support is well documented in daily reports. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 There are systems in place to enable any concerns or complaints to be identified and resolved. There is minimal information available to judge how effectively this is managed. However, concerns have been listened to and acted upon to the satisfaction of the individual. EVIDENCE: Since the last inspection the manager has updated the complaints procedure to include details for contacting the Commission. This now meets with requirements. A complaints logbook has been implemented since the last inspection. This is to record all complaints made including details of the investigation and any action taken. There were no entries made in the logbook at this inspection. From discussions with service users it is evident that they would require a great deal of support to utilise this procedure, or an advocate to act on their behalf. The experiences of a visiting relative have been that their concerns have been listened to and acted upon. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 26 There has been continued progress in the maintenance and redecoration of the home. This has led to improvements for service users in the comfort and safety of their environment. There are still some outstanding requirements from the Commission and the Fire officer, which must be addressed. Failure to do so could potentially place service users at risk. EVIDENCE: Since the last inspection the proprietor and manager have continued with their maintenance and redecoration programme. This has ensured that service users continue to live in a safe and well-maintained environment. A new window has been fitted to room 10. Bedrooms 3,6, and 8 have been redecorated to the satisfaction of the occupants. The bathroom has been upgraded to include a hoist. This now meets the assessed needs of the service users. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 18 The Proprietor has addressed many of the requirements made in the Fire Officers report of 08 March 2005. These have included fitting appropriate locks to the two back doors. Bedroom doors have been re-adjusted to ensure proper closure in the event of a fire, and gaps in the fire doors have been repaired. As per the requirements of the fire officer’s report, ‘cold smoke seals’ are to be fitted to those doors identified in the report. The proprietor was also advised that this type of premises should be covered by smoke detectors. The proprietor was advised to check this and if necessary, extend the existing fire alarm system to comply with the relevant fire safety standard. This remains outstanding at the time of this inspection. The Commission must be informed as to when these checks are to be carried out, and the outcome of the check. Delays in this area potentially place service users at risk. The manager must ensure that confirmation of completion of these works is submitted to the Commission. Test certificates for all fire equipment were in place. Fire training for all staff is proposed for January 2006. Fire Drills must be undertaken on a six monthly basis, with records of this training being maintained. A plan of training dates must be submitted to the Commission. Service Users are positive about their surroundings, and said they are comfortable. Many have their own possessions around them. Service Users said they were happy with the décor and furnishings in their rooms, one lady in particular is pleased with the colour of her room, which she chose. No service user currently uses a key for their bedroom. The manager must ensure that service users can lock their doors, unless their assessment identifies specific risks. Decisions must be recorded in the service users care plan. Facilities are suited to the assessed needs of service users. Occupational therapists and Physiotherapists have undertaken a recent assessment of the premises and equipment. This has ensured that specific aids or equipment is available to service users, which has increased their mobility and independence. The communal bathroom is fitted with aids and equipment to assist those with difficulties. Corridors and communal areas are fitted with grab rails to assist Service Users. A call system is installed which enables Service Users to Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 19 determine when they need help. Chairs have been fitted with leg raisers to ensure they are at the right height for individuals to use safely. The lighting is domestic and creates a soft homely atmosphere. Radiators are covered to prevent burns, and window catches are evident to prevent injury from falls. The environment is comfortable and well maintained. All areas of the home were found to be clean, and odour free. A visiting relative, and some service users stated that the level of cleanliness in the home is good. A certificate confirming that the water supply is free from the risk of Legionella, was not available. This was a requirement from the last inspection. The COSHH cupboard was unlocked at the time of inspection. This has been noted at the previous two inspections. This could potentially place service users at risk. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 30 Staff numbers are sufficient to meet the care needs of service users. Staff are not adequately trained in all aspects of their work. This potentially compromises their ability to meet the needs of people accommodated. EVIDENCE: Staff rotas showed that there is normally one carer and a senior on each shift, with the manager working supernumerary. At the time of inspection the rota matched the numbers of staff on duty. There is currently a full compliment of staff. A cook is employed who has worked in the home for a number of years; she prepares all the meals for service users. A visiting relative stated staffing numbers had improved. From the general appearance and demeanour of service users, the standard of physical care is good, and emotional needs are responded to well. The District nurse spoke positively of the care service users had, ‘always good care, follow up and reporting of any concerns, one of the better homes I visit.’ A relative said; ‘The staff team and manager are very caring and the food is lovely, and home cooked’. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 21 The manager said that just fewer than 50 of staff is trained to NVQ level 2. At the time of this inspection, there has been no further progress in providing a training matrix to determine what training has been completed. This needs to be undertaken to establish the immediate statutory and mandatory training needs of staff. Training identified as outstanding from the previous inspection includes; First Aid, Fire safety, and Health and safety. Training for staff in caring for people with Dementia and Altziemer is also identified as outstanding from the previous inspection. The manager stated that a training plan for all staff is proposed for January 2006. A copy of this must be submitted to the Commission. The manager has yet to implement a training programme in line with ‘Skills for Care’. (The National Training Organisation for Social Care.) There has been little progress in ensuring training targets fulfil the aims of the home and meet the changing needs of service users. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 36, 37, 38 Out comes for service users regarding their care and health are good. The manager has successfully met the majority of requirements outstanding from the previous two inspections; this has had benefits for service users in structuring their care. Some areas continue to compromise the health and safety of service users and must be addressed with urgency. There has been little progress in ensuring training targets fulfil the aims of the home, and meet the changing needs of service users. This could potentially compromise what is otherwise a good caring home, with caring staff whom service users clearly like. EVIDENCE: The manager has NVQ level 4 in care. She is waiting completion of her NVQ level 4 in management. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 23 She has experience in meeting the needs of older people. Observations made of the care practices demonstrate that the manager and her staff team are caring and supportive to service users. It is evident from comments made by service users, visiting professionals and a relative, that the manager is respected and well liked. There has been a significant improvement in addressing the majority of previous requirements made, some of which had been outstanding for the last two inspections. The manager said that a new quality assurance system is being implemented, and that this will address many of the requirements. Staff meetings and formal supervision are not established. Informal arrangements currently exist to provide a sense of direction for staff in undertaking their role and responsibilities. The maintenance of statutory records has improved, these were well organised, and up to date. The management of safe working practices has improved in some areas, fire requirements have been addressed and fire records are now being maintained more consistently, however other areas continue to compromise the health and safety of service users and must be addressed with urgency. These are: Fire drills are not routinely carried out or recorded. Out standing requirements from the fire officer’s report must be addressed, the existing fire alarm system may need to be extended following assessment of the roof void. Cold smoke seals are needed on fire doors. A certificate confirming that the water supply is free from the risk of Legionella was not available. This was a requirement from the last inspection. The COSHH cupboard was unlocked at the time of inspection. This has been noted at the previous two inspections. This could potentially place service users at risk. Statutory training for all staff needs to be planned. First aid, fire safety and health and safety training are outstanding. The manager has yet to implement a training programme in line with TOPPS. (The National Training Organisation for Social Care.) There has been little progress in ensuring training targets fulfil the aims of the home and meet the changing needs of service users. Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 24 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 X 1 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 3 3 X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 1 3 2 Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4(1)(a-c) Sch 1 Requirement Timescale for action 01/02/06 2 OP1 5(1)(2) 3 3 OP3 14(1)(a) The Registered manager must ensure that the Statement Of Purpose is further developed to include all the information and documentation required in Schedule 1. A copy of this must be forwarded to the Commission. This requirement is outstanding from the previous two inspections and must be addressed with urgency. The Registered Manager must 01/02/06 ensure that the Service User Guide includes all the information and documentation required in Regulation 5. A copy of this must be forwarded to the Commission. This requirement is outstanding from the previous two inspections and must be addressed with urgency. The Registered Manager must 01/02/06 ensure that service users are only admitted after completion of a detailed assessment. A copy of the assessment format must be forwarded to the Commission. DS0000016740.V254840.R01.S.doc Version 5.0 Bournedale House Page 26 4 OP12 16(2)(m) 5 OP15 16(2)(i) This requirement is outstanding and must be addressed with urgency. The Registered Manager must ensure that a programme of activities suited to the needs of service users, is displayed. The Registered Manager must ensure that alternative choices to the daily meal are available, and included on the menu. Service users must be consulted as to their daily preferences and documentation to support their choices, maintained. Advice from the dietician should be sought to ensure menus are planned in a manner that provides wholesome and nutritious food, which is varied. The Registered manager must ensure that service users are provided with keys to their bedrooms unless the risk assessment states otherwise. The Registered Manager must inform the Commission of the outcome of the roof void assessment. 01/01/06 01/02/06 6 OP24 12(2) 01/01/06 7 OP19 23(4)(a) 20/01/06 8 OP26 13(3) 9 OP28 18(1) Progress on fitting cold smoke seals to fire doors must be clarified. The Registered Manager must 14/02/06 ensure that checks for Legionella are undertaken in line with Health and Safety requirements. This is an outstanding requirement and must be addressed with urgency. The Registered Manager must 14/02/06 provide a training matrix to show how it is proposed to meet the requirements of 50 staff trained to NVQ Level 2. This requirement is outstanding DS0000016740.V254840.R01.S.doc Version 5.0 Page 27 Bournedale House 10 OP30 11 OP30 from the previous inspection. The Registered Manager must submit a training plan with dates to show when all staff are to receive mandatory training in first aid, health and safety and fire safety. This is an outstanding requirement. 18(1)(c, i) The Registered Manager must ensure staff have access to specialist training in Dementia to meet the identified needs of service users. 19(5)(b) This is an outstanding requirement from the previous inspection. A proposed training plan with dates must be submitted to the Commission. The Registered Manager must complete their NVQ Level 4 in management and care. The date of completion must be submitted to the Commission. A training plan to address the Registered Manager’s training needs in First aid higher level, Staff supervision and appraisal, must be submitted to the Commission. These are outstanding requirements from the previous inspection, and must be addressed with urgency. The Registered Manager must ensure that all staff receive formal supervision at least 6 times a year. 14/02/06 14/02/06 12 OP31 9(2)(b)(i) 14/02/06 13 OP36 18(1)(2) 14/01/06 14 OP38 13(4)(a) (c) This is an outstanding requirement from the previous inspection. The Registered Manager must 28/11/05 ensure that the COSHH cupboard DS0000016740.V254840.R01.S.doc Version 5.0 Page 28 Bournedale House 15 OP38 23(4)(d) is kept locked at all times. The Registered Manager must forward to the Commission a copy of the updated fire procedure, which should include those amendments required at the previous inspection. 14/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Bournedale House DS0000016740.V254840.R01.S.doc Version 5.0 Page 30 - 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!