Inspection on 03/06/08 for Bournedale House

This inspection was carried out on 3rd June 2008.

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 27/07/07

Bournedale House 25/07/06

Bournedale House 22/03/06

Bournedale House 28/11/05

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Bournedale House 441 Hagley Road Edgbaston Birmingham West Midlands B17 8BL Lead Inspector Brenda O’Neill Unannounced Inspection 3rd June 2008 09:30 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.V364885.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. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 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 Vacant. Care Home 11 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (11) of places Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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), DE(E) (Dementia over 65) and the type of home is care home only. The resident numbers shall remain at 11. Date of last inspection 27th July 2007 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 property 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 people who require ground floor facilities. This room has privacy screens. The first floor facilities consist of single bedrooms with ample storage, some with original Victorian fireplaces. The bathroom and shower room are large enough to allow for staff assistance if required. There are grab rails located in toilets and around the home to aid people living in the home. The service user guide for the home did not include any information on the range of fees charged. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate outcomes. One inspector carried out this key inspection over one day in June 2008. During the course of the inspection the care for two of the people living in the home was tracked. This included sampling their care files, daily records and health care notes, observations of care practice and talking to the people living in the home. We also sampled staff records, health and safety records and other applicable records. A tour of the premises was undertaken. We had lunch with the people living in the home and were able to talk to four of them. We also spoke to the manager, one staff member and one visitor to the home. Prior to the inspection the manager had completed and returned the Annual Quality Assurance Assessment (AQAA) for the home which gave some additional information about the home. Satisfaction surveys were sent to ten of the people living in the home before the inspection. Eight of these were returned and all the comments received were quite positive. No complaints have been lodged with us since the last inspection. The complaints log for the home showed that all complaints no matter how minor were recorded. There have been two adult protection issues at the home since the last inspection. One was raised by the manager with Social Care and Health in relation to an incident between two of the people living in the home. The manager dealt with this appropriately and strategies were put in place to ensure the people living in the home were safe guarded. The other was raised by a relative with Social Care and Health was in relation to a person going missing from the home and the relative not being informed. The manager was not on duty of the time of the incident and staff had not notified her. The manager has now dealt with this issue and the appropriate procedures and risk assessments have been put in place. What the service does well: Throughout the course of the inspection good relationships between the staff and the people living in the home were observed. Staff were friendly and polite at all times. Comments received from the people living in the home included, ‘I’m being looked after well’ and ‘staff are good here, they are very friendly.’ Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 6 The health care needs of the people living in the home were being met. Staff were able to identify any needs and ensure these were followed up by the appropriate health care professionals. Visitors attended the home at various times and the people living in the home were able to go out with them if they wished. We spoke to one relative who visited the home very regularly and he was quite satisfied with the service at the home. The people living in the home were satisfied with the meals being served. Comments received included: ‘Meals are very nice, enjoy them most time and plenty of it to choose from.’ ‘Has got a good appetite and always enjoys her food.’ ‘Not bad I always eat them.’ The complaints log showed that the people living in the home were listened to and any issues they raised were addressed. Staffing levels were appropriate for the needs of the people living in the home at the time. The home was generally well maintained and comfortable. The manager ensured the home was running smoothly. What has improved since the last inspection? The detail in the care files had improved considerably since the last inspection. Throughout the care files the needs of the people living in the home were generally well documented with details of how staff were to meet them. The risk assessments for the people living in the home had improved since the last inspection. Several general risk assessments had been undertaken which detailed how staff were to reduce the risks people were exposed to. As recommended at the last inspection health care visits were being recorded separately from the daily records making them much easier to track. Staff were being more mindful of the dignity of the people living in the home and the instructions for care staff that were up on the walls in the home had been removed. The recording of activities had improved considerably since the last inspection. Some were recorded in the activity records and others on the daily records for individuals. Activities included such things as singing, memory games, nail care, newspaper, massage, progressive mobility, hairdresser, ball games, cards, darts, time in the garden, bingo and walks to the shops. The records also showed that the people living in the home have some one to one time with staff. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 7 Since the last inspection a menu board had been put up in the dining room so that people knew what was going to be served that day. The issues raised at the last inspection in relation to poor practice at meals times had been addressed. The manager had improved the signage around the home for the people living there who had dementia making it easier for them to find their way around. The safety and infection control for the people living in the home had been improved, staff were keeping COSHH substances were locked away, rusting commodes had been replaced, the window on the stairs had been restricted, personal toiletries were being returned to the appropriate bedrooms and so on. Staff recruitment procedures had improved ensuring the people living in the home were safeguarded. The manager was addressing the shortfalls in the staff training to ensure staff had all the necessary skills and knowledge to care for the people living in the home. What they could do better: The information available for people wanting to move into the home should be updated and include the range of fees charged at the home. This will ensure people have all the necessary information to help them decide if the home can meet their needs. The manager was advised she should ensure the pre admission assessments she undertakes are fully documented and records retained to evidence how the decision was made that the home could meet the individual’s needs. To ensure the people living in the home were moved safely the manual handling risk assessments needed to specifically detail any handling methods and equipment to be used. The medication administration system in the home needed to be improved to ensure the people living there received their medication as prescribed. All staff needed to receive training in adult protection issues to ensure the people living in the home were fully safeguarded. To improve the safety of the people living in the home a risk assessment needed to be undertaken on the unguarded radiator in the bathroom and the window opening in the bedroom identified during the inspection needed to be restricted. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 8 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. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 9 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.V364885.R01.S.doc Version 5.2 Page 10 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): 1 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was information available for people wanting to move into the home to help them decide if the home could meet their needs. This needed to be reviewed and updated to ensure people received all the current information about the home. The assessment procedures ensured the needs of the people being admitted to the home were known to staff prior to admission. EVIDENCE: There was a service user guide for the home however this had not been updated for some time. The home had had a change to their registration enabling them to care for people with dementia and this was not reflected in the service user guide. The document did not include any details about the fees charged at the home. It was strongly recommended that the service user guide was reviewed and updated to ensure it gave people wanting to move into the home all the current information. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 11 The files for two people admitted to the home since the last inspection were sampled. One of these individuals had been assessed prior to admission by a social worker. There was a copy of the care plan drawn by the social worker but the manager had not obtained a copy of the assessment undertaken. It was necessary to obtain this prior to admission to ensure the staff had all the necessary information to decide if they could meet the needs of the individual. The other individual had not had any social work involvement in the admission. The manager told us she had visited the individual two or three times at their own home prior to admission and made notes after each visit. She had discarded the notes after drawing up care plans and so on the day of admission. The manager was advised she should ensure assessments she undertakes are fully documented and records retained to evidence how the decision was made that the home could meet the individual’s needs. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 12 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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments had been improved and generally ensured staff knew how to meet all the needs of the people living in the home and minimise any risks. Management of the medication system needed to be improved to ensure the people living in the home received their medication as prescribed. EVIDENCE: Two care files were sampled for people who had been admitted to the home since the last inspection. The detail in the care files had improved considerably since the last inspection. Both files included profiles which gave some very good information about the individuals’ past, their family history, work and so on. The profiles also gave a general over view of the individuals at this time, their likes, dislikes and why they were in residential care. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 13 Both files included quite a few documents that detailed various aspects of the individuals’ lives, their needs and what help they needed from staff. The documents included, assessments of daily living needs, care profiles and care plans. All the required areas were covered throughout the documents and they gave some good detail of how staff were to meet the needs of the individuals. However they were quite difficult to track as there was information about the same areas in different places, for example, oral care and nutrition. The layout of the files was discussed with the manager and it was suggested that once the assessments of daily needs had been undertaken and the needs of the individuals identified the care plans should be drawn up from this and include all the necessary information about the care of the people living in the home. This will ensure staff do not have to look through several documents to see how to meet the needs of the people living in the home. Some of the areas in the care plans could be further developed to give staff more information. For example, one file stated ‘forgets she has eaten’ but there was no detail of how staff were to manage this to ensure the individual did not gain too much weight. The care plan also stated ‘can be very demanding of staff’ but there was no indication of what this meant or how staff were to manage this issue. One of the people living in the home had been in hospital. Speaking to the manager and looking at his records it was clear that since his return to the home his needs had changed considerably, for example, his mobility and continence had deteriorated. The care plan had not been updated with the changes. The risk assessments for the people living in the home had improved since the last inspection. Both files sampled included several general risk assessments for areas such as falls, challenging behaviours, the risks associated with illnesses, using the kitchen and people wandering at night. It was recommended that tissue viability and nutritional assessments were also undertaken to identify if the people living in the home were at risk. This would ensure staff were aware of any issues and could be monitoring where necessary. The care files did give details of any issues with skin but these only indicated if skin was in tact. At the last inspection issues were raised about one of the risk assessments putting some restrictions on one of the people living in the home without any prior discussion. None of the risk assessments seen at this inspection restricted the people living in the home. The manual handling risk assessments that were in place needed to be further developed. There was a section on the assessment detailing what to do if people fell and were not injured but this generally stated staff to assist. It needed to specifically detail the handling methods and any equipment to be used to ensure people were moved safely. The files sampled included details that showed that the health care needs of the people living in the home were being highlighted by staff, followed up and monitored. As recommended at the last inspection health care visits were being recorded separately from the daily records making them much easier to Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 14 track. There was evidence that the people living in the home had visits from G.P.s, district nurses, opticians, chiropodists and audiologists. Other health care professionals were consulted when necessary, for example, the continence advisor visited the home on the day of the inspection and the occupational therapist had visited to assess one person for a specific commode. The people living in the home were being weighed on a regular basis wherever possible. This was an improvement since the last inspection. Medication continued to be administered via a 28 day monitored dosage system. There was no controlled medication being administered at the time of this inspection. None of the people living in the home were looking after their own medication. A random audit of the medication system was undertaken. Medication was being booked in on the MAR (medication administration records) charts and any balances held at the end of the 28 cycle were generally being brought forward to the new MAR charts which was an improvement since the last inspection. There were some gaps on the MAR charts. For some of the medication it could be assumed it had been given as it was not in the blister packs but for the boxed medication this could not be assumed. There were discrepancies in all the boxed medication that was audited. The majority had more tablets left than should have been indicating that people were not receiving their medication as prescribed even though staff were signing for it. The manager was advised she needed to investigate these discrepancies and carry out regular staff drug audits to ensure staff were competent to administer medication. As at the last inspection staff interacted well with the people living in the home and friendly relationships were evident. Assistance with personal care was offered discreetly and individuals were addressed by the name of their choice. Bedrooms had locks on the doors so that the occupants had privacy if they wished. The double bedroom had appropriate privacy screening and all bedrooms had been personalised to the occupants’ choosing. The issues raised at the last inspection about instructions for care staff being put on the walls in the home had been addressed. The manager of the home had begun to write monthly reports about the health and well being of the people living in the home and sending them out to relatives to keep them informed about how people were and what activities they had been involved. She had had some very positive comments from the relatives about these. However it was strongly recommended that the sending out of these reports was discussed with the people living in the home to ensure they did not mind this information being passed onto their relatives. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 15 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were activities available in the home for the people living there both on a group basis and individually. There were no restrictions on visitors to the home within reasonable hours. The people living in the home were satisfied with the meals being served. EVIDENCE: The home was calm and relaxed throughout the inspection and the interactions between the staff and the people living in the home were good. The recording of activities had improved considerably since the last inspection. Some were recorded in the activity records and others on the daily records for individuals. Activities included such things as singing, memory games, nail care, newspaper, massage, progressive mobility, hairdresser, ball games, cards, darts, time in the garden, bingo and walks to the shops. The records also showed that the people living in the home have some one to one time with staff. The manager was trying to think of new activities all the time to try and stimulate the people living in the home. She told us how she had spoken Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 16 to a relative about the garden and he was going to be involved in re arranging the garden and involving the people living in the home in this. A lot of evidence was seen throughout the inspection of people with a level of dementia being involved in tasks around the home. For example washing up, clearing and laying tables, helping prepare tea, taking biscuits and cakes round to other people. They were clearly enjoying this as they were tasks they had been used to doing at home. One person stated, ‘I offer to help, I enjoy doing it.’ The manager said this was avoiding people becoming bored and stopped them becoming agitated as their minds were occupied. We were also told if any of the staff go to the local shops they always ask if anyone wants to go with them. We spoke to one relative who visits the home very regularly. He was quite satisfied with the service at the home. When at the home he sits with his relative and does puzzles, number games and so on to keep them stimulated. There was evidence on the daily records that visitors attended the home at various times and that the people living in the home were able to go out with them if they wished. There was evidence that the people living in the home were enabled to make some choices, for example, when to go to bed and get up, being able to take part in or decline activities, personalise their own rooms to their choosing and so on. There were menus in the home but the manager stated they were looking at changing these after discussion with the people living in the home. Since the last inspection a menu board had been put up in the dining room so that people knew what was going to be served that day. The records of food being served to the people living in the home had been restarted after the last inspection. These needed to be further developed to detail what vegetables were being served and what the fillings were on sandwiches so that it could be determined people were getting a variety. It was also recommended that the section on the food records for the amount eaten was completed so staff knew if people were eating adequate amounts. We had lunch with the people living in the home. The meal was well cooked and presented and people seemed to enjoy it. One person stated ‘I always enjoy my dinner but don’t have any pudding’. Comments received on the returned surveys included: ‘Meals are very nice, enjoy them most time and plenty of it to choose from.’ ‘Has got a good appetite and always enjoys her food.’ ‘Not bad I always eat them.’ Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 17 Staff were on hand to help at meal time where needed. The poor practice issues raised at the last inspection had been addressed. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 18 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The views of the people living in the home were listened to and acted on. All staff needed to undertake training in adult protection issues to ensure the people living in the home were safe guarded. EVIDENCE: No complaints had been lodged with the Commission since the last inspection. The complaints log for the home showed that all complaints no matter how minor were recorded. The complaints log also showed that if the people living in the home raised any issues about the staff team these were investigated and the outcome recorded. The people living in the home were issued with a complaints procedure in the service user guide. The completed surveys received prior to the inspection generally indicated that the people living in the home would know how to make a complaint and who to go to if they were unhappy. There have been two adult protection issues at the home since the last inspection. One was raised by the manager with Social Care and Health in relation to an incident between two of the people living in the home. The manager dealt with this appropriately and strategies were put in place to ensure the people living in the home were safe guarded. The other was raised by a relative with Social Care and Health was in relation to a person going Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 19 missing from the home and the relative not being informed. The manager was not on duty of the time of the incident and staff had not notified her. The manager has now dealt with this issue and the appropriate procedures and risk assessments have been put in place. The training matrix forwarded to the Commission after the inspection showed that not all staff had undertaken training in adult protection issues. This issue was also raised at the last inspection. The majority of staff were detailed as having either adult abuse training or protection of vulnerable adults training. Some of this training had taken place this year and other staff were booked to undertake it. The manager needed to ensure she addressed the shortfalls in this training as soon as possible. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 20 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, 20, 21, 22, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided the people living there with a generally well maintained, comfortable and clean environment in which to live. EVIDENCE: A tour of the home was undertaken with the manager. There had been no changes to the layout of the home since the last inspection and it was generally well maintained. The manager had improved the signage around the home for the people living there who had dementia. There were framed pictures of the people living in the home on their bedroom doors and better pictures had been put on toilet and bathroom doors. At the time of the last inspection the window on the stairs was open and it was not restricted and could have been hazardous for the people living in the home. This had been addressed at the time of this inspection. However it was Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 21 noted that one of the bedroom windows had not been restricted and this needed to be addressed. The communal space at the home comprised of a lounge and dining room. Both were comfortable and adequately furnished and decorated. The lounge had had new carpet fitted since the last inspection and a large screen television had been purchased. The home had adequate numbers of toilets, one floor level shower that allowed for assistance from staff and one bathroom that had been refurbished since the last inspection. This now allowed enough space for staff assistance when the people living in the home needed it. It was noted that the radiator in this bathroom had not been guarded. A risk assessment must be undertaken and a cover provided if necessary. Several issues were raised at the last inspection about COSHH substances and personal toiletries being left about in bathrooms and toilets. This had been addressed at the time of this inspection. There were some aids and adaptations in the home and these appeared to meet the needs of the people living there. These included stair lift, assisted showering and bathing facilities, emergency call system and free standing hoist. There were also wheelchairs around for the use of the people living in the home. At the time of the last inspection none of the wheelchairs had foot rests in place. This could have been hazardous for the people using the wheelchairs. All the wheelchairs seen at this inspection had footrests fitted. The bedrooms seen were generally comfortable, some had been redecorated and had new carpet since the last inspection. Not all the rooms contained all the furnishings and fittings detailed in the National Minimum Standards, for example, two chairs and a lockable facility. All the bedrooms needed to be audited against the Standards and any shortfalls discussed with the occupants or their representatives to ensure they were satisfied with their rooms. One of the bedrooms had been rearranged to suit the needs of the occupant however this had meant she did not have access to the emergency call point. The manager stated they had given the person an extended lead for the call point but she had said she did not want it. The manager needed to ensure this was recorded in the individuals file and included in the risk assessments. The home was clean and odour free. The issues raised at the last inspection in relation to good infection control had been addressed, for example, rusting commodes had been replaced. The kitchen was clean and tidy. A new large extractor fan had been installed over the cookers. It was noted that staff were freezing some fresh foods but were not dating them when frozen. All the opened foods in the fridge had been dated on opening. The laundry was clean, tidy and appropriately equipped. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 22 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels met the needs of the people living in the home. Staff had generally undertaken the appropriate training to enable them to care safely for the people living in the home. Recruitment procedures had improved and ensured the people living in the home were safeguarded. EVIDENCE: Throughout the course of the inspection good relationships between the staff and the people living in the home were observed. Staff were friendly and polite at all times. Comments received from the people living in the home included, ‘I’m being looked after well’ and ‘staff are good here, they are very friendly.’ The staffing levels were appropriate for the needs of the people living in the home at the time with two care staff on duty throughout the day plus a cook in the morning. The manager’s hours were supernumery to the care rota. There was one waking night care assistant and one person sleeping in every night. However when the need arose this was changed to two waking staff. Some issues were raised at the last inspection in relation to the recruitment of staff. These had been addressed at the time of this inspection. Two staff files were sampled and these included evidence of all the necessary checks being undertaken prior to staff being employed including, POVA first checks, CRBs Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 23 and two written references. The manager was reminded she should have recent photographs of all staff on file. New staff were undertaking induction training. This was a very lengthy checklist of induction/foundation standards. The manager needed to cross reference these to the specifications laid down by Skills for Care to ensure all the required areas were covered. The dated training matrix was forwarded to us the day after the inspection. This showed that the majority of the staff had received training to enable them to care safely for the people living in the home. Topics covered included such things as, fire, manual handling, infection control, food hygiene, dementia care and health and safety. There were some shortfalls however the manager had a rolling programme of training to ensure these were addressed. Staff were also having the opportunity to undertake other training, for example, equality and diversity, care planning, vision awareness and the Mental Capacity Act. The training matrix detailed eleven care staff in the home, seven of whom had undertaken NVQ level 2 giving them above the required 50 . Some staff were also undertaking NVQ level 3. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 24 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 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager ensured the smooth running of the home in a competent manner and that it was run in the best interests of the people living there. The health and safety of the people living in the home and the staff were generally well managed. The home needed to have a development plan in place to show how the service was to be continually improved for the benefit of the people there. EVIDENCE: The home was running smoothly. The manager was clearly trying to improve all aspects and is very much focused on improving the lives of the people living in the home. Several improvements had been made since the last inspection including care plans, risk assessments and activities. The manager had also ensured the environment was safer. The main area for improvement following Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 25 this inspection was the system in place for administering medication. The manager showed a commitment to improving the home and ensuring people living there lead fulfilled lives. She demonstrated a good knowledge of the needs of the people in her care throughout the course of the inspection. The manager had undertaken all the necessary qualifications for a manager. The Commission had not received her application for registration. When this was discussed with her she said she was waiting to see how the inspection went before submitting her application. There was a quality assurance system in place at the home. This included such things as meetings with the people living in the home every three months, satisfaction surveys being sent out two or three times a year, staff meetings and health and safety audits were being carried out. However as at the last inspection there needed to be a system in place for analysing all the information gathered and then producing a yearly development plan for the home based on the views of the people living in the home. The home continued to manage some money on behalf of the people living there. The records for this were sampled and found to be generally adequate. The manager was getting two signatures for expenditure wherever possible. There was still no evidence that two staff were auditing the system in place. The manager stated that the issue raised at the last inspection about people being consulted about paying for activities such as progressive mobility had been addressed. No documentation was seen to support this. The AQAA received prior to the inspection showed that the equipment used in the home was being serviced regularly. The in house checks on the fire system were sampled and found to be up to date. The frequency of the emergency lighting checks had improved since the last inspection. The manager stated that a fire drill had taken place in February however no record of this could be found. She was advised that records of fire drills must be kept to comply with the requirements of the fire service. The premises risk assessments had been improved since the last inspection and included all the necessary areas. Accident and incidents were being recorded appropriately and notifications to the Commission had been greatly improved. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 26 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 2 X 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 13(5) Requirement Manual handling risk assessments must specifically detail any handling methods and equipment to be used. This will ensure the people living in the home are moved safely. There should be no gaps on MAR charts unless for PRN medication to ensure a full audit trail. Any discrepancies in the amounts of medication received into the home, what has been administered and what remains must be fully investigated. The manager must carry out regular staff drug audits before and after drug rounds to ensure staff are competent to administer medication. This will ensure the people living in the home are receiving their medication as prescribed. The Responsible Person must ensure that the short falls identified on the training matrix in relation to adult protection DS0000016740.V364885.R01.S.doc Timescale for action 31/07/08 2 OP9 13(2) 31/07/08 3 OP18 13(6) 30/09/08 Bournedale House Version 5.2 Page 28 training are addressed. (Outstanding since 01/06/06) This will ensure the people living in the home are safeguarded. The window opening in the bedroom identified during the inspection of the home must be appropriately restricted. This will ensure the people living in the home are not exposed to any unnecessary risk. A risk assessment must be undertaken on the bathroom radiator and a cover fitted if necessary. This will ensure the people living in the home are not put at risk. 4 OP19 13(4)(c) 08/07/08 5. OP21 13(4)(c) 08/07/08 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 OP1 Good Practice Recommendations The information available for people wanting to move into the home should be updated and include the range of fees charged at the home. This will ensure people have all the necessary information to help them decide if the home can meet their needs. The manager was advised she should ensure the pre admission assessments she undertakes are fully documented and records retained to evidence how the decision was made that the home could meet the individual’s needs. It is strongly recommended that the information for care plans is streamlined and all the necessary information included in one care plan to avoid any confusion when consulting care plans. Care plans should be updated when the needs of the people living in the home change and further developed DS0000016740.V364885.R01.S.doc Version 5.2 Page 29 2. OP3 3. OP7 4. OP7 Bournedale House 5. OP8 6. OP10 7. OP15 11. OP24 12. 13. OP26 OP30 14. OP33 15. OP35 16. OP38 where necessary to ensure staff have all the necessary information to enable them to meet the needs of the people living in the home. It is recommended that tissue viability and nutritional assessments are undertaken to identify if the people living in the home may be at risk. This will ensure staff are aware of any issues and can be monitoring where necessary. To ensure the privacy of the people living in the home it was strongly recommended that the sending out of the monthly reports was discussed with the people living in the home to ensure they did not mind this information being passed onto their relatives. Food records should be further improved to detail all foods served to the people living in the home and the amounts eaten. This will show they are having a varied diet and enable staff to monitor that people are eating adequate amounts. The bedrooms should be audited for furnishings and fittings against the National Minimum Standards and any shortfalls discussed with the occupants to ascertain if they are happy with their rooms. To ensure good infection control in the home all fresh foods that are frozen should be dated on the day of freezing. The manager should cross reference the induction training in the home to the specifications laid down by Skills for Care to ensure all areas are covered. This will ensure new staff have all the necessary skills and knowledge to care for the people living in the home. The home should have in place a development plan based on seeking the views of the people living in the home and the outcomes of the quality audits. This will ensure there are plans in place to continually improve the service offered to the people living in the home. It is strongly recommended that the system in place for managing the money for people living in the home is regularly audited and records are kept. This will ensure people are safeguarded and any errors are noted in a timely manner. Records of fire drills must be kept to comply with the requirements of the fire service and to evidence that the people living in the home are being fully safeguarded. Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Bournedale House DS0000016740.V364885.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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