Inspection on 26/10/07 for Bredon View

This inspection was carried out on 26th October 2007.

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

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

Other inspections for this house

Bredon View 31/07/06

Bredon View 17/10/05

Bredon View 25/04/05

Bredon View 06/12/04

Bredon View 04/08/04

Bredon View 13/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Bredon View 24-26 Libertus Road Cheltenham Glos GL51 7EL Lead Inspector Peter Still Key Unannounced Inspection 26th October 2007 08:55 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 Bredon View DS0000016387.V353366.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. Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bredon View Address 24-26 Libertus Road Cheltenham Glos GL51 7EL 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) 01242 525087 01242 525087 CTCH Ltd Mrs Katrina Jane Mitchell Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st July 2006 Brief Description of the Service: Bredon View is a care home converted from two semi-detached older properties. It provides personal care for 26 older people, and is located in a residential area of Cheltenham, close to the railway station and local bus routes. It is part of the CTCH Ltd group of homes. Accommodation is on two floors, the first floor being accessed by a shaft lift and stair lift. All bedrooms have en-suite facilities; some have the addition of a bath or shower. The communal area consists of 2 lounges, dining room and a conservatory at the front of the property. There is a level access to the landscaped gardens at the rear of the home via a patio door from the lounges. Care staff are on duty 24 hours each day, and there are waking night staff. If nursing services are required, these are accessed from the community, and residents can register with the local General Practitioner of their choice. Information about the home is available to prospective residents and interested parties in the printed Service User Guide, and a copy of the most recent CSCI report is available in the front entrance hall for anyone to read. The charges for Bredon View range from £451.00 to £513.00. Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. One inspector carried out this inspection over one day in October 2007. A check was made against the requirements and recommendations that were made following the last inspection, in order to establish whether the home had ensured compliance and responded to the relevant areas. A number of care files and other records held in the home were examined and residents were spoken with individually and as a group. The inspector also spoke with a number of members of staff. The manager had completed an annual quality assurance assessment document, which gave key information for the inspection. No survey forms for residents and others important to them had been completed and the manager intends to complete a satisfaction survey by January 2008 and the next inspection will need to consider the responses. Documents relating to the way residents are cared for and the choices they have were reviewed as well as the way in which staff protect residents’ rights. Staffing and arrangements for the management of the home were also examined. A tour of the premises was undertaken with particular attention to the maintenance, cleanliness and the atmosphere at the home. What the service does well: Staff have done well to work through a difficult period of staff shortage, to ensure residents needs are met and that they have a good quality of life; staff have worked well as a team. The atmosphere at the home is welcoming and homely. Residents spoke positively of the care they receive and staff are relaxed. Care plans are well recorded and clearly set out to help staff meet residents needs and their likes and dislikes, receiving personal care in the way they wish and ensuring risks are identified. Staff have continued to make training a priority and have a good ongoing training programme, which Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 6 includes NVQ, mandatory and other training to support their practice with residents. The manager has done well since her return to work, to identify key areas which need her urgent intervention to ensure the home continues to be well run and that staff are supported in meeting residents needs. What has improved since the last inspection? What they could do better: At the last inspection, a requirement was made that bags of opened food must not be left on the kitchen floor and this requirement will need to be repeated. The manager should consider with the pharmacist a review of the medication chart, supplied by the pharmacy to ensure it is clear and cannot lead to confusion, concerning dates at the top of the form. The storage facilities for medication should also be reviewed since there appears to be a lack of space. The library should not be used for storage and a table needs repair or replacement so that the room is more inviting. Further work on the format of supervision may support the process and give clarity to staff to support their work. Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 7 The Registered Manager must draw up a written action/development plan to address the outcomes of quality monitoring assessments and surveys and find ways of gathering information from residents and people important to them. Following guidance from the fire officer, the provider must complete fire safety risk assessments and provide staff training regarding evacuation. 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. Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre admission procedures, assessment and documentation, ensures the home has knowledge of and can meet residents needs. EVIDENCE: Prospective residents have a brochure and can have a trial stay. The brochure is being updated and a web site is also being produced to help with information about the home. There was discussion about a request for an emergency admission, which did not take place due to lack of pre admission information. Pre admission documentation examined for two residents was comprehensive but was lacking for another person who had been at the home for some years. Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 10 It was explained to the inspector that at the time of their admission, these key records had not be maintained or provided. The inspector tracked the care of three residents and talked with two residents about choice of home and both were able to verbalise that they were happy to be at the home, one had chosen to return to the home recently. A resident talked about being unhappy due to frustration caused by their sight which was very poor and of not being able to do the things they wanted to do like watching TV, reading and knitting. Two other groups of residents were spoken with and a number said that the move to the home had been good. One said that they had come to the home due to the needs of their partner - it was a good decision to make and that being close to friends locally was important and another said she had moved to the home to be close to her daughter. A recommendation of the last inspection to seek a clinical psychiatric assessment within the admission process has not been required since the person is no longer at the home. The manager has noted that such an assessment may need to be sought for future residents. Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are comprehensive and well recorded, supporting care practice to ensure residents’ needs are well met. A review of the medication record sheet supplied by the pharmacist is needed to ensure it is not confusing, to protect residents from risk. The storage of drugs and ancillary items should be reviewed to ensure it is suitable and safe. Residents are treated with respect and privacy. EVIDENCE: Case tracking found comprehensive care planning. Since the manager had been on maternity leave, some care plans had needed review and the manager had made this a priority on return to work. The CP for 1 resident reviewed who was a challenge to the service, was detailed and clear, including Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 12 input from the GP, and the way staff should work with the resident. The personal care for one resident was reviewed on 15/09/07 and a record was seen noting that a carer will assist in the morning; nutrition and weight was reviewed on 30/10/07. All care plans had been reviewed recently for this resident. The Malnutrition Universal Screening Tool was being used by the home to ensure continuity and as a measure so staff can be aware of any changes, which may need intervention. One record reviewed could have been easier to read if it had been typed and the manager said that records were now being typed and showed good evidence of this. Daily records for the period 20/10/07 to 31/10/07 were reviewed and had been signed by staff. The records contained key information, only, to make it easier to check points of relevance. This is a relatively new approach to recording, which was said to be working well. The ‘Waterlow’ record, used to assess pressure care needs was detailed and being used for all residents. A nutritional record review was seen for October 07. The weighing of residents was undertaken monthly but the manager felt it was more appropriate to do this every two months, where there were no concerns. Records showed regular access for Residents to a range of health care professionals. A resident spoken with individually and in groups expressed satisfaction with the care they received from staff and said it was good and staff were kindly. Residents said they were aware that there had been a staff shortage and that it was “difficult for staff” but that it had not affected their care. Four staff were asked if non-care tasks had an adverse effect on time available to residents and they said it did not. They said the staffing shortage had helped the staff team to work together and had confidence in each other, staff were “multi skilled” and using their initiative to ensure tasks were completed in terms of health and personal care. Staff gave an example of the daily shift handover meeting as an important event to communicate issues and tasks. Staff were observed accessing care files during the day. The medication system for handling residents’ medication was reviewed and found to be largely effective with good clear recordings. Drugs charts had holes punched in them, which did not obliterate instructions or information. The medication for three residents’ case tracked was correct in relation to actual medication given and recorded. However one record sheet showed the correct start date but the row below, which should show the day of the month, was empty. The row below this had numbers from the start of the medication. The inspector considered that this could lead to confusion and the days of the month should have been inserted by the pharmacy. This was discussed with the manager and a new record sheet was put in place and correct dates entered. The manager must ensure these are checked in future and sent back if wrong. The pharmacist had already been seeking input about the record Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 13 sheets since he felt they could be improved and the manager will be making points about it. The home has a locked drugs trolley, which was fully utilised and a large, secure drugs cupboard in the office. During the inspection it was observed that the office cupboard was very full and it is recommended that there should be consideration of a better way to manage the drugs and items, required to be held. It is likely that there is insufficient space with the current arrangements. Medication was reviewed weekly. The home had obtained the newly published updated medication guidelines from the Royal Pharmaceutical Society of Great Britain. 3 Staff were currently undertaking the safer handling of medication training. The inspector observed staff to be respectful at all times with residents. At one point when the inspector was talking with residents, they commented on a resident whose dignity and privacy was being compromised. The inspector had not noticed this but a member of staff had immediately taken a blanket across the resident to ensure their privacy. This was also an example of how alert staff were seen to be to residents needs during the day. Bredon View DS0000016387.V353366.R01.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy their lives at the home and staff are working to improve choice and activity further, supporting residents to have control over their lives. The library must not be used for storage and a table needs repair or replacement. Residents enjoy their visits from relatives and people important to them who can visit at any time. A well-balanced menu is provided and the new cook will be an important member of the staff team to ensure residents have a good and interesting diet. EVIDENCE: Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 15 Opportunities for varied activity have improved since the last inspection and the manager and staff team have plans to develop this further. Restarting residents’ meetings is also a positive step. The loss of a cook for the home has had an impact and it is good that a new cook is about to start work at the home. The appointment will provide an opportunity to develop good practice and choice for residents. By case tracking and talking with one resident, it was found that he/she may try to join in with an activity but that it was difficult with their sight and the manager said she will work with this resident to try to help so that the person can have a more interesting and contented lifestyle. The home has the benefit of two lounges on the ground floor and one tends to be used by residents who prefer to be quiet. There is also a library upstairs but on the day of inspection it had a bed/chair table upside down being stored on the settee and the table for the room needed repair or replacement. The room did not look inviting and was said to be rarely used, apart from one family. A senior member of staff said that the room would be sorted out. During the morning the inspector listened to an excellent music and movement session and observed residents enjoying it. It was particularly evident that staff leading the session were very enthusiastic and it seemed to work very well for residents, who commented on it to the inspector later in the day. The inspector was given a copy of the activity poster for November, which showed an excellent range of activity, with 41 events for residents. The activity diary poster also gave the birthdays of three residents and noted key events in history. The activity was varied and included: Ball games; nail care; skittles; board games; noughts and crosses; an afternoon film and a quiz. A small number of residents prefer to spend a lot of time in their own rooms and staff are trying to encourage those residents to socialise more. Residents spoken with said they enjoy the activity at the home and one said that their daughter takes them out shopping. Unfortunately there have been no residents meetings since the manager has been away from work but the inspector was pleased to see that she had already identified it as important and a meeting was planned for the 6th November; posters had been put up about it. The manager feels that she needs to provide training in care planning to ensure care plans reflect residents varying needs and individuality and to develop a residents forum to help gather information about what residents really want as a group and individually. The view from the lounges and bedrooms to the gardens is magnificent and residents commented on the beauty and colour in the gardens, the home had again won another award, the Silver Gilt Award for Cheltenham in Bloom. The gardener who undertakes the work for this and other homes should be highly Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 16 praised for the achievement and for the pleasure the gardens bring to the residents. The home has use of a minibus, which is parked at the home and to an external driver, or other staff from the home. It has only been used once since the last inspection for a trip out and this could be increased. Residents also have access to a community bus and one resident attends a luncheon club once a week and is able to keep up with friends. Visitors can come to the home at any time and a number did during the day. Residents also spoke of visits they had from their relatives, which were so important to them. Unfortunately the home has been without a cook for some time and care staff have been delegated to the task. The inspector tried the desert, home cooked on the day, which was very tasty and one resident wanted to eat theirs all up, but said that the lunch had been so good that it was too much. Other residents commented on the food being good at the home and said there was choice. One resident told the inspector they would talk to the new cook who was about to start work at the home about their likes and dislikes since they were “very fussy about food, what you eat is what you are”. Staff now have a special tea shirt, they wear when changing role from carer to cook and any staff member going into the kitchen is required to wear an apron. No staff were seen to be wandering into the kitchen and staff have discussed the kitchen regarding infection control. Bredon View DS0000016387.V353366.R01.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): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home and company has robust complaints procedures and policies and complaints are taken seriously. Adult protection training ensures residents are protected from abuse and neglect. EVIDENCE: Complaints are dealt with on 2 levels. Serious issues or any matter a resident wishes to make into a formal complaint are taken through the full complaint procedures. If the matter is a simple issue, which can easily be resolved, then it is responded to by the home. The home has a complaints file and if there is a complaint it is recorded on a form and a copy is placed on the residents file. There is a monthly audit of complaints, concerns and also accidents/incidents. One complaint since the last inspection was addressed and the relative was happy with the outcome. There were no complaints concerning the residents case tracked. The manger considered that complaints were seen as positive by the home and an aid to improvement of practice. One member of staff spoken with said they had received POVA training and the manager said she has Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 18 refresher training planned for November. All staff have reinforcement POVA training every two years, staff also undertake the training during induction and within their NVQ training. Bredon View DS0000016387.V353366.R01.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): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained and provides a good environment for residents. The home is clean and tidy. EVIDENCE: A tour of the property was made and requirements from the last inspection were checked. Fire risk assessments were addressed in March 2007. These will need to be reviewed in the light of a recent report from the fire officer, concerning Fire Safety Risk Assessment and training regarding evacuation procedures. Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 20 Issues were identified at the last inspection concerning kitchen hygiene in relation to staff working in the kitchen and with residents. Staff now wear a special tee shirt for use in the kitchen with an apron. The kitchen was clean and tidy, but an open bag of potatoes was seen on the floor. The assistant manager supporting the inspection said they would purchase plastic bins with sealable covers to resolve the problem, however the requirement relating to this at the last inspection will have to be repeated. The manager had noted a problem of the kitchen door being propped open and a notice had been put up. It was closed when the inspector visited the kitchen. The armchairs in the lounge were replaced on 06/11/07. The lounge carpet was clean. The laundry room was clean and tidy except for the area behind the two large machines, where the inspector could see a cushion, a continence sheet and other items. The assistant manager said she had seen this too and would deal with the problem immediately. The housekeeper had left her employment at the home and the rota for ensuring satisfactory cleaning etc had fallen behind. The home does not have a sluice but uses a disinfection cycle for the washing machine. Both machines were working well. The COSHH storage area was tidy. Bedrooms were clean and tidy, homely and personalised. A cleaner was seen working, in the bedrooms during the inspection. The rooms were free of odour apart from one, where a resident had had an accident. The upstairs bathroom was particularly pleasing in that it was homely. It has a specialist bath and residents will see a lovely corner display shelf unit, which had a plant, and ornaments; there were also pictures. The gardens looked splendid and residents said how much they appreciated the flowers and colour. Bredon View DS0000016387.V353366.R01.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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst there has been a staffing shortage, the staff team have worked hard together to ensure the needs of residents are well met. The home has robust recruitment practice, including comprehensive induction and ongoing training to support staff in their work. EVIDENCE: Since the last inspection, management arrangements put in place to support the period of the managers maternity failed to work as intended. This was due to a number of staff leaving and the two assistant managers not being able to be fully supernumerary, which resulted in some tasks not being kept up to date. The two assistant managers did their best and it appears that residents were well cared for during this time. Apart from care staff, the housekeeper and cook also left the home, which made things more difficult. The manager returned to work in September for two days a week and not the three the inspector had understood would be the case. However the two assistant Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 22 managers are continuing to provide support to the manager, which the manager said was most valuable. The manager will return to full time work from the New Year. The general care manager fully accepted that the period had been difficult for the home and also that she had not been able to give the best support during this time, partly due to serious difficulties within another care home she had responsibility for. The general care manager said there had been significant difficulties with recruitment and of finding suitable staff for the home, which was sited as a general problem for care homes. However the situation for the home was now stabilizing and new staff were about to start, some six to seven staff had needed to be replaced. On the day of inspection, staffing levels were good and residents were happy and enjoying their activities. Staff spoken with talked about the staff shortage and of the long hours they needed to work. Staff made positive points about their commitment to the residents and how the staff worked well as a team, showing the strength of the team and good staff morale. The manager has complied with the recommendation to review staff training needs, which were identified within the fire risk assessment. A good record was seen concerning this. However further work is likely when the further points from the fire officer are addressed concerning evacuation plans and the responsibilities of the staff. Staff now have details of their job roles in the home e.g. night care staff and assistant managers. The manager will talk to staff at the next staff meeting about ways of giving more individual time to residents since staff had raised it and the manager felt that more time could be used during the afternoons. Staff continue to have opportunities for NVQ and other training and further funding has been accessed for this. 50 of staff qualified to NVQ level 2. The staff handbook has been updated. Staff also undertake infection control certificated training and medication reinforcement training will be provided in the coming months. Staff records were seen for two staff and they contained the key items needed. A comprehensive typed interview record was seen for one staff member. Staff have their own training file, which were well set out. The staff-training matrix for the home was seen and one member of staff had completed her induction through learning direct and has now gained an NVQ level 2 award. Another had completed NVQ level 3 and the adult services assessment skills check, which was found to be most helpful. Staff have received the new Mental Capacity training. Staff training records show that 6 Staff will receive health and safety training during November 20007. Other training being provided includes Advance sensory training, food hygiene and first aid. Staff should be praised for their achievements and commitment to training. The inspector spoke with four members of staff individually, who all spoke positively about their work. Comments included: ”The staff team at the home Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 23 is great and we all work as a team. I like being able to use my initiative. We work hard to provide a homely environment for residents. The home is run for the residents and not staff”; One confirmed that they were undertaking medication training and that their induction with an external provider had been valuable; there had been times when staff worked fourteen hour shifts, when staffing was short, that they were not complaining and that the priority was to ensure residents received good care; residents were happy at the home and there was no “false atmosphere“, which there had been in another home; a staff member, who was key worker to three residents, produces a monthly report, which goes into the care plan; the manager had given staff a thank you, which was much appreciated by staff for all their hard work over recent months. Bredon View DS0000016387.V353366.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): 31,33,35,36,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team have worked hard since the last inspection to ensure the home is run in the best interests of residents and that their health and safety has been protected. Further work on the format of supervision may support the process and give clarity to staff on key aspects arising. The fire safety risk assessments for the home and staff training regarding evacuation procedures must be completed to protect residents. Review of performance must be completed with quality assurance work and formalising the approaches to gather feedback from residents and others important to the ongoing development of the home. Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 25 The manager demonstrated that she is aware of key issues, which need her input and already has plans to respond. The homes policies and procedures protect residents’ financial interests. EVIDENCE: Staff shortage had has led to a difficult time for everyone and a number of key areas of work have been put to one side. The manager will now need support to bring these areas up to standard and it is good that the assistant managers will continue in their role. The inspector found a number of instances where the manager had already identified shortcomings, with plans to respond to them. It is positive that new staff have been appointed and the home should be able to move forward and continue to make improvements, which make residents lives better. Staff supervision had lapsed during the time the manager was away, however she had already identified it as a key task and is working hard to ensure all staff receive their minimum of six formal supervisions for the year. Five supervisions had been completed with thorough typed notes. One member of staff said they had not received formal supervision since they started work at the home and this was discussed with the manager. There had been supervision but more a more formalised approach would be helpful so that staff are clear about the purpose and outcomes of the supervision they receive. The inspector discussed the format of supervision and the manager agreed to consider producing a document for the supervision record to formalise staff supervision more effectively. This may also include key items/headings, which would normally need to be discussed. The last report noted that this inspection would follow up Quality assurance and the approaches the manager is using to gain feedback from residents and relatives and wider agencies. A recommendation was made for the manager to draw up a written action/development plan to address the outcomes of quality monitoring assessments and surveys. The home did not have a development plan and surveys had not been sought recently and analysed. This work is still outstanding and a requirement will be made to complete the task. A residents meeting has been arranged for November 6th and thereafter every 8 weeks. There is often a lot of informal discussion with residents in the lounge and this feedback is used to make improvements, however the manager wants Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 26 to encourage more resident involvement. No feedback satisfaction surveys had been returned for this inspection due to the manager being away and lack of staff time to complete the task. The manager plans to produce a residents’ survey, including relatives and other visitors/professionals, by January 2008 at the latest and she sees this as a key area of work to target. Internal audits for health and safety were seen and mandatory training had been provided. The audit for fire dated 31/10/07 found a fault on a smoke detector. A maintenance form was sent to the provider so that the fault could be remedied. Good records were being maintained with a system for random checks, concerning fire was seen. The manager considers that she needs to ensure more regular service assessments of equipment are undertaken by staff but that the external contracts for servicing equipment like the lift has been maintained and is up to date; new accident forms have been put in place. The inspector spoke with the general care manager during the inspection about the shortfall identified by the fire officer regarding the fire risk assessments for the home. The general care manager said that these will be completed by the end of the year. These assessments include evacuation plans and the responsibility of staff members and staff training must be reviewed in the light of these new assessments. The finances for residents’ was reviewed for the 3 residents being case tracked and all were found to balance. The home has a simple and organised system for handling residents’ money, which the home holds for some residents. Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 27 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 X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 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 2 X 3 2 X 3 Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 28 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 OP19 Regulation 23(4) Requirement Following guidance from the fire officer. Complete fire safety risk assessments and staff training regarding evacuation. The Registered Manager must ensure that bags of foodstuffs are not stored on the floor, that they are sealed and do not leave the contents exposed. (Timescale of 31/08/06 not met.) The Registered Manager should draw up a written action/development plan to address the outcomes of quality monitoring assessments and surveys. The library must not be used for storage and the table cover should be repaired or replaced. Timescale for action 31/12/07 2. OP15 16(2g) 31/12/07 3. OP33 24 (1)(2)(3) 29/02/08 4. OP19 23(a); 23(2)(b) 31/12/07 Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 29 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 OP9 Good Practice Recommendations The Registered Manager should consider with the pharmacist a review of the medication chart, supplied by the pharmacy to ensure it is clear and cannot lead to confusion, concerning dates at the top of the form. There should be a review of the storage of medication and ancillary items. Current storage facilities appear to be full and more space may be needed. The manager should review staff supervision and consider adopting a standardised format for recording supervision. 2. 3. OP9 OP36 Bredon View DS0000016387.V353366.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Bredon View DS0000016387.V353366.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. Re-publishing this information is in breach of the terms of use of that website. 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