Inspection on 25/06/08 for Brandon Park Nursing Home

This inspection was carried out on 25th June 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Brandon Park Nursing Home 26/06/07

Brandon Park Nursing Home 23/05/06

Brandon Park Nursing Home 03/01/06

Brandon Park Nursing Home 14/10/05

Brandon Park Nursing Home 25/02/05

Brandon Park Nursing Home 27/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

CARE HOMES FOR OLDER PEOPLE Brandon Park Nursing Home Brandon Country Park, Bury Road Brandon Suffolk IP27 0SU Lead Inspector Mrs Jan Sheppard Unannounced Inspection 25th June 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000024341.V367160.R03.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. DS0000024341.V367160.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brandon Park Nursing Home Address Brandon Country Park, Bury Road Brandon Suffolk IP27 0SU 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) 01842 812400 01842 813213 elmyl@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd Ms Lisa Elmy Care Home 55 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (55) of places DS0000024341.V367160.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th June 2007 Brief Description of the Service: Brandon Park Nursing Home is set within Brandon Country Park, which is an area of Thetford Forest. The home is a short drive from Brandon village, which has a Post Office, library, café, shops, a health centre and rail and bus links. The care home with nursing is registered to provide care for 55 older people 5 of who may have a diagnosis of dementia. The Grade II listed building has been converted and extended to provide suitable accommodation. Bedrooms and lounges are located on both floors, which can be accessed using the passenger lift or stairs. The 2 main dining rooms are located on the ground floor. There are 39 single and 8 shared bedrooms, all of which have en-suite facilities (some also include a bath). There are also bathrooms located close to residents’ bedrooms. The homes own mature gardens lead onto the Country park and tourist centre. There is ample parking at the front of the home. It should be noted that Brandon Park is located close to the military bases of Mildenhall and Lakenheath so there are periods when aircraft noise is evident during the daytime. The current fees range from £ 520 to £ 850 per week. The fees do not cover the cost of hairdressing, toiletries, chiropody and newspapers. DS0000024341.V367160.R03.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 2 *. This means the people who use the service experience good quality outcomes. This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven and a half hours on a weekday. This was a key inspection which focused on the key standards of the Care Standards Act 2000 relating to older people. The report was written using accumulated evidence gathered prior to the inspection, including information contained in the AQAA, (Annual Quality Assurance Assessment) completed by the Manager, information given in the pre inspection questionnaires completed by residents, staff, relatives, health professionals; and also takes account of statutory notifications sent periodically to the CSCI by the home. During this inspection the inspector made a tour of the building, had in depth discussions with the homes Manager met and spoke with a number of staff and visitors and also with residents. Spot checks were made on a number of the homes records. Although the inspection was completed by just one inspector the wording used in the report will refer to “we” as the report is written on behalf of the Commission. What the service does well: The home continues to provide good quality personal and health care support to meet the individually assessed needs of each resident. Residents consulted all confirmed that they were well cared for with comments such as “my needs are fully met here I have nothing at all to complain about”; “ Staff are very kind and understanding”. The environment is of a high standard and is well maintained. Being a listed period building it is very spacious but still provides a homely environment with a noticeable happy and relaxed atmosphere. Furnishings and fittings are of a high standard and the décor and furnishings suit the architecture of the building and are appropriate for the client group. DS0000024341.V367160.R03.S.doc Version 5.2 Page 6 Staffing levels are good and on the day of this inspection staff were observed spending time with residents talking and undertaking activities. The atmosphere was calm and unhurried. Recruitment procedures for new staff members are thorough with evidence of all the required checks having been made before staff commence duties. There are clear management arrangements in place and staff reported that they were well supported. What has improved since the last inspection? The range of activities has increased since the last inspection and more activity organisers are now available. Residents activity needs are individually assessed and each has their own programme. Activities are arranged individually on a one to one basis and for small groups to meet individual need and preference. More outside visits and gardening activities have been introduced and residents said that these were much appreciated. A number of works of internal redecoration have been completed since the last inspection along with the provision of new equipment, the profiling beds being spoken of with particular appreciation by some residents. The home has a comprehensive maintenance and refurbishment programme and a number of workmen were working in the home on the day of this inspection. Landscape gardeners are part way through redesigning the garden to make it more easily manageable and to provide facilities more suitable for the residents needs such as raised garden beds more patio areas and a hard surface pathway around the perimeter where residents can take walks. Improvements have been made to the maintenance of the care plans with interventions for all assessed needs now being clearly documented. Improvements have also been made to the maintenance of the recording of administered medication and recording practice now allows for a clear audit trail of medicines to be made. Following the appointment of a new chef manager earlier in the year a number of changes and improvements have been made to the menus with better consultation with residents being now undertaken regularly. Further improvements works are planned for the dining room. DS0000024341.V367160.R03.S.doc Version 5.2 Page 7 What they could do better: 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. DS0000024341.V367160.R03.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000024341.V367160.R03.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service can be confident that admissions are not agreed until a full needs assessment has been carried out to satisfy that the persons needs will be met appropriately. This service does not offer intermediate care. EVIDENCE: The files of a number of newly admitted residents were seen and each one contained a pre-admission assessment. The Manager visits each new applicant either in their own home or in hospital and makes an assessment of their care needs using the new BUPA Quest Assessment documentation. DS0000024341.V367160.R03.S.doc Version 5.2 Page 10 This assessment was seen to detail their current care needs including personal hygiene needs mobility, diet, continence and cognition. Details of their past medical history, current medication needs and any known allergies were seen to be recorded. The home has a detailed statement of purpose and service users guide and brochure which includes photographs and gives information setting out the aims and objectives of the home and the services provided. People who had recently moved into the home spoke positively about their experience. They felt that they had received a warm welcome and one commented that “ The staff were very kind and helpful when I first arrived”. DS0000024341.V367160.R03.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to have their needs documented and met. The home follows its medication policy and procedures which offer protection to the residents although further improvements with the accuracy of medication administration recording are needed. EVIDENCE: Four residents files and care plans were seen and each contained a comprehensive pre admission assessment identifying residents needs covering personal care, continence, mobility, moving and handling needs and nutritional requirements. Each file had a Waterlow assessment score for tissue viability, a MUST nutritional screening assessment and Pressure Ulcer recording forms. DS0000024341.V367160.R03.S.doc Version 5.2 Page 12 BUPA has recently adopted the QUEST system of needs assessment which enables a comprehensive personal care plan to be developed from an initial risk assessment. Of the care plans seen all the assessed needs of the resident had interventions clearly planned and documented. The residents personal wishes and preferences were seen to be given every consideration along with their right to Privacy and Dignity. Each resident was seen to have a named nurse and an identified key care worker. The sample of care plans examined were detailed and informative and there was good evidence of a homely as well as a nursing approach to the individual care delivery. Comments to evidence this such as “Please give resident X time to build up a trusting relationship with you ( the carer); “ give Mrs. X time for one to one discussion with you whilst undertaking caring duties”; “If resident Y becomes anxious use a calm reassuring approach and do not argue”, were seen. Residents spoken with confirmed that staff were available and helpful. “ Staff are so kind, nothing seems to be too much trouble for them”. “I am well cared for here I have nothing to complain about”. There was evidence in the records and from discussion with residents of the home working with a number of other health professionals. Each resident has a GP of their choice (within the constraints of the location), and access to the services of an Optician, the Chiropodist, Speech and Movement Therapists a local Dentist and Community Nurses from the Mental Health services visit regularly as needed. Audio services can be accessed in the nearby town of Thetford. Comments in the pre-inspection surveys from one health professional stated “ The care staff cope well with challenging behaviours in a mature manner” and from another “ The home always appears well run staff seem to have the right skills and time to support the residents and the building always presents as fresh and clean “. BUPA has its own Tissue Viability link nurse who visits regularly to review the wound care management care plans and recording records. This information is collated and used to identify trends, the need for additional training and the need to purchase appropriate equipment. Training on Wound Care Management has recently been undertaken at Brandon Park to update the knowledge of the staff and since the last inspection a range of new equipment has been obtained including a number of profiling beds. Observation throughout the inspection and from the daily notes seen confirmed that the health and well being of the residents is being regularly monitored. Staff were observed to be knocking on doors and to be calling the residents by their preferred name. The care plans were seen to be subject to regular review. DS0000024341.V367160.R03.S.doc Version 5.2 Page 13 Residents spoken with were aware of their care plans and some had good awareness of these reviews but none appeared to have signed the documentation which for those who were able would involve them more fully in this process. Each care plan was seen to have the end of life wishes and arrangements of the resident recorded. The Manager commented that she planned to arrange more training on this Loss and Bereavement during the next year. The home uses an MDS, monitored dosage system for medication. The medication cupboards were seen to be well ordered and part of a medication administration round was observed. The nurse was observed to be dispensing medicines with a non touch technique and to be offering residents the choice of taking pain reliving medication that was prescribed on an “ As required” basis. The medication administration records ( MAR) sheets were each seen to have the identification photographs of the residents attached to them. A list of specimen signatures of nurses authorised to give medication was also seen. The back of the MAR sheets were being appropriately used to record the reason why any medication was not given as prescribed using the correct identification codes. However a number of gaps were noted in the signature boxes of medication administered; Better accuracy of these records must be maintained. Spot checks were made on the Controlled Drug storage and administration arrangements. The CD register was seen and a random check on the held CDs found that these stocks tallied with the records. DS0000024341.V367160.R03.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People who use this service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to be encouraged to maintain contact with family and friends, to have a life style and a range of activities to meet their expectations and to have a varied and well balanced diet. EVIDENCE: The home continues to employ activity co-ordinators covering the same number of hours as at the last inspection but since then the number of coordinators has been increased to four this giving more flexibility and enabling a wider range of activities to be offered throughout the week. An individual activity assessment is made for each resident following the Map of Life section that has been incorporated into each residents care plan. From this the coordinators prepare a weekly activities programme details of which ware seen to be displayed around the home. DS0000024341.V367160.R03.S.doc Version 5.2 Page 15 Residents spoken with were aware that they had such an activities programme tailored to meet their individual needs and preferences. One spoke of the enjoyment that they got from the homes beautiful gardens and of their involvement with the planting in the recently created enclosed courtyard area. Other residents told the inspector of planned outings for the summer months including a River Boat trip and visits to the Zoo and to the Coast. The home is able to hire local buses of varying sizes so that both small and large groups can be accommodated depending on the visit destination. Small trips by two or three persons for shopping or just lunch outings are most popular and several residents spoke appreciatively of these. Evidence found in the care plans showed that both group and individual activities are accommodated; one to one activity events even if of short duration were seen as being especially important for residents who because of their frailty choose to spend a lot of time in their rooms. The comments on one care plan which stated that as the resident quickly gets bored with activity keep this short but leave them with something to think about providing good evidence of the thoughtfulness which goes into the care planning for activities. The home has an open visiting policy and a number of visitors were seen in the home on the day of this inspection. The reception arrangements at Brandon Park enable each visitor to be welcomed and if requested the spaciousness of the building means that a private meeting place can always be found for them. All the residents files seen contained contact details of their next of kin and their relationship to the resident. Without exception all the residents spoken with were complimentary about the food the manner in which it was prepared and the range of choice available. A new Chef Manager was appointed to the home in April and since then a number of improvements have been introduced. New menus have been compiled with four major changes each year to follow the seasons with each of these having a four week rotation of options. The chef regularly consults with the residents to learn of their choices. On each day a cooked breakfast is available for those who prefer this, two hot choices are offered at lunchtime and a hot dish along with a variety of cold non cooked choices always being available at tea time. The home also provides the BUPA” Nite Bite “ late evening and night time menu choice with cooked items being available throughout the night as required. The majority of residents prefer to have their main meal at lunch time but one who had chosen to have a main evening meal was accommodated as were residents to took breakfast in their rooms and one who had her supper in her room. DS0000024341.V367160.R03.S.doc Version 5.2 Page 16 The home is fortunate in having a number dining rooms so that residents can choose with whom to share their mealtimes and staff have good space to enable them to help those who need such assistance. Individual and small group dining tables were seen to be attractively laid with table clothes napkins and co-ordinated crockery. Fresh water or juice was available with wine for those who chose this option. Individual small teapots were served for each resident which staff confirmed had very much improved the quality and taste of the tea. Where staff were seen to be assisting residents they were doing so in an appropriate manner offering the food at a speed which met the residents ability and pureed food was seen to be served retaining its individual constituent portions. The manager explained that it is planned to establish a food service area in the largest dining room so that better control of portion sizes can be given to residents able to make such individual choices. The new chef manager who is qualified NVQ level 2 has recently completed training on specialist food requirements especially for residents with dementia. DS0000024341.V367160.R03.S.doc Version 5.2 Page 17 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. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to have any complaint handled properly and to be protected from abuse. EVIDENCE: There have been no incidents concerning Safeguarding Adults since the manager returned to the home. Staff all attend training on the protection of vulnerable adults and whistle blowing procedures. Staff spoken with during this inspection were familiar with what action they should appropriately take if ever they had suspicions concerning possible abuse. No complaints have been made to the CSCI Commission for Social Care Inspection, concerning this home since the last inspection. One complaint that had recently been made to the Manager from a relative was seen to have been properly recorded investigated and a prompt response sent. The manager discussed what follow up action she had taken to prevent a re-occurrence of this problem. DS0000024341.V367160.R03.S.doc Version 5.2 Page 18 Residents spoken with confirmed that they knew about the homes complaints procedures and would use these if they had to, but several just said “ I know that if there was a problem I would talk to the nurse or manager and I think that they would sort it out”. The home keeps a record of compliments received and a number could be evidenced since the last inspection. One from a relative said “ Please thank the staff for their thoughtfulness in sitting with X when she was so ill and reading the bible to her.” DS0000024341.V367160.R03.S.doc Version 5.2 Page 19 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 , 21 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to live in an attractive clean well appointed and well maintained home. EVIDENCE: Brandon Park House is a large imposing grade 11 listed building that was built in the 18oo’s and has had a history of being a hotel. A more recently built extension consists of two sympathetically built wings that enclose a sunny courtyard. The house is surrounded with well laid out flat gardens which are currently the subject of extensive remodelling so as to be more accessible to infirm people providing more hard patio areas raised beds and a perimeter hard surface pathway. Surrounding this are extensive grounds which now form DS0000024341.V367160.R03.S.doc Version 5.2 Page 20 part of the public Brandon Park which was seen to be being well used for picnicking on the day of this inspection. These grounds too are well established and maintained and provide beautiful views for the residents from many of their windows. A tour of the building with its high ceilings and large windows found it to be spacious with a light and airy feel. It was found to be very clean and with one exception well ordered. The decorations and furnishings are maintained to a high standard and in design are in keeping with the many period features found through out the building. Despite the grand style and large size of many of the rooms the home retains a homely atmosphere with the residents bedrooms seen to be well personalised with small items of furniture pictures photographs and ornaments. These rooms reflect the individuals interests and tastes one was seen to have his painting equipment and another an electronic keyboard. Residents said that they were happy with their rooms and were seen to have the equipment that they needed to meet their needs. Overall the home is very well maintained and the manager could show the plans for a regular rolling maintenance programme. Builders were working in the home repairing a ceiling in the staff room on the day of this inspection and the manager explained that an extra decorator had been employed to commence the following week to enable the good standard of decorating found in most areas of the home to be kept up to date everywhere. The assisted bathrooms were found to be of bland decoration and to unfortunately be being used to store equipment thereby not providing a congenial atmosphere in which to take a bath. It is recommended that improvements are made to the arrangement of these facilities so that residents dignity whilst taking a bath is enhanced. The laundry was visited and found to contain good provision of washing machines with sluice programmes and two large dryers. The facilities in this area were very well organised with a good system of soiled linen management to prevent cross infection. Staff spoken with said that they had had training in infection control (this was confirmed by the training matrix) and they appeared to have a good awareness of the importance of maintaining these known procedures. Protective gloves and aprons were noted at key locations throughout the home and staff were observed to be using them. Liquid soap and paper towels are provided at hand washing facilities. DS0000024341.V367160.R03.S.doc Version 5.2 Page 21 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. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to be cared for by trained and experienced staff who have been recruited to the required standard which offers the residents protection. EVIDENCE: The duty rotas were seen and showed that there are two registered nurses on duty throughout the twenty four hours. They are supported by eight carers on the early shift six in the afternoon and evening and four during each night period. An administrator, a receptionist, four activity co-ordinators, housekeepers , kitchen staff and a maintenance person complete the team. The manager ‘s duties are totally supernumerary and those of the deputy manager partially so. Evidence gathered for this inspection showed that these staffing levels were sufficient to meet the needs of the current number of residents. Staff agreed that whilst it would always be their wish to have more staff so as to be able to spend more individual time with residents their present needs were being met. DS0000024341.V367160.R03.S.doc Version 5.2 Page 22 Residents confirmed that their call bells are usually promptly answered which is to be commended considering the distances that have to be covered in this spacious building. The manager reported that the home is able to retain a stable core group of staff and has sufficient bank staff so that agency staff do not often have to be used. But if needed then one known agency with staff who are familiar with Brandon Park are engaged. .Newly appointed staff all undertake an induction training and initially work on a supernumerary basis. The home is currently fully staffed but the manager explained that the retention of trained carers poses an on going problem as no sooner are they qualified and experienced than they are poached by other organisations usually residential homes where they take on more responsibility than in a nursing home setting. This causes a fluctuation in the levels of trained care staff and currently with only 44 of them holding NVQ at level 2 the home is not achieving the minimum standard (50 ). However 5 new staff are to commence training for this qualification in September 2008. The difficulties of staff retention are being considered more widely throughout the BUPA organisation. Staff told the inspector that there was good morale amongst them with all grades working well together “ there is no them and us “, one said. Another carer commented “if we are short the nurses will help us.” Staff of all grades confirmed that they felt well supported by their managers and that they had good training opportunities although several mentioned that more dementia care training would be desirable. The homes training records evidenced that core mandatory training is maintained up to date and that special courses are bought in to meet specific needs such as “Dealing with Challenging Behaviours” and updating training on POVA. The new deputy manager has completed training on Tissue Viability so that she now holds the link nurse role for this home and since her appointment she has also undertaken training to become the homes Manual Handling Trainer. The Manager reported that she had recently completed training concerning the Legal Aspects of Employment and that she and the senior staff team have all completed training on the Mental Capacity Act which they are now cascading down to the other staff. The residents care plans now contain a section dealing with the requirements of this act. The recruitment files of three new staff were examined and found to contain evidence of a full work history, interview records and two references. There was evidence of a criminal record bureau check and POVA check being undertaken prior to the member of staff starting work at the home. DS0000024341.V367160.R03.S.doc Version 5.2 Page 23 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, 36 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service can expect the registered manager to be a competent person and that there are administrative systems in place to protect the rights of the service users. There is room for further improvement in the quality and frequency of staff supervision. People who use this service can expect to have their opinion of the service sought and their welfare protected. DS0000024341.V367160.R03.S.doc Version 5.2 Page 24 EVIDENCE: The registered Manager is a trained nurse who is experienced and knowledgeable about the care of older people. She has completed the Registered Managers Award and has a number of year’s experience of care home management. This Manager returned to work full time at Brandon Park in November 2007 having spent a period working else where managing another BUPA home. A new Deputy Manager was appointed at the beginning of 2008 she is also a qualified and nurse who is experienced and knowledgeable about the care of older people. This new management team appeared to be working very well together on the day of this inspection. Staff spoken with confirmed that the whole staff team do work well together and that they feel well supported by the managers. One told the inspector “ there is always someone to talk to both managers are very approachable”. One relative made the comment that “ the home has been much better managed since the Manager returned”. The home has the appropriate systems in place to enable good communication between the various groups of staff. Records of staff meetings (held 3 monthly), Heads of department meetings , Health and Safety meetings, Nursing meetings and Personal Best meetings all evidenced good participation from a range of staff covering all aspects of care delivery and personal development. We were shown evidence on the inspection day which confirmed that water temperatures are regularly tested and these were found to be within acceptable limits. Regular contractual arrangements are in place to ensure that hoists and other electrical equipment are serviced to maintain good safety. Appropriate systems for ensuring that faulty equipment is reported and dealt with as soon as possible are now being followed. The BUPA organisation carries out regular quality assurance surveys in its homes. The most recent results for Brandon Park whilst overall evidencing a positive result, 93 said that overall the staff were excellent, 93 judged that the environment was good and 81 commenting that the food was excellent, other aspects of the survey did show some marked differences from the previous years survey. Further work is being done by the homes management to understand these differences and to improve the areas which showed a decline. The homes administrator manages residents personal monies if they request this. Since the last inspection these arrangements have been changed so that cash amounts can be clearly identified for each individual and records of individual interest can be easily tracked. DS0000024341.V367160.R03.S.doc Version 5.2 Page 25 All receipts for items and services purchased for residents are kept and there is a computerised record to allow an audit trail. Spot checks made on three of these accounts found that they tallied. The residents interests are safeguarded by the good maintenance of these accounting and financial procedures. The records relating to Fire testing were seen to be well maintained. Regular Fire Awareness training is arranged and the manager discussed with the inspector the improvements that had been made by the Fire Company (the provision of extra smoke detectors) following an electrical malfunction that had been identified early by staff. During this inspection the Fire Alarm Bell was accidentally triggered by a workmen and staff went immediately into fire alert mode.; the inspector was therefore able to witness that during this alert period staff knew what to do, followed these procedures calmly, maintained good communication between themselves and gave very good consideration to the safety and well being of the residents in a reassuring manner. Staff interviewed as part of this inspection confirmed that they receive supervision with a senior member of staff which they found helpful as was the fact that they know that they can have regular discussions with the manager when ever needed. However the manager said that she recognised that staff supervision was an area which needed further management development and the sparse records of current practice seen supported this view. The home appeared to be benefiting from the now more stable management team. Their confident and calm approach to the work appeared to positively influence the homely and relaxed atmosphere in the home where the nursing and social care needs of the service users were found to be being met in a well integrated manner. DS0000024341.V367160.R03.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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 2 x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 3 3 DS0000024341.V367160.R03.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP9 OP21 Good Practice Recommendations Good accuracy of medication administration records (signatures) must be improved. Changes should be made to the storage arrangements for equipment in the assisted bathrooms to create a more homely and welcoming bathroom environment. The quality and regularity of staff supervision should be improved. 3 OP36 DS0000024341.V367160.R03.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 DS0000024341.V367160.R03.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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