Inspection on 31/07/06 for Bredon View

This inspection was carried out on 31st July 2006.

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 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

Bredon View 26/10/07

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 Mrs Ruth Wilcox Key Unannounced Inspection 31st July 2006 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 Bredon View DS0000016387.V301515.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.V301515.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.V301515.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 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 £435.00 to £485.00. Bredon View DS0000016387.V301515.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 two days in July 2006. A check was made against the requirements that were issued following the last inspection, in order to establish whether the home had ensured compliance in the relevant areas. Care records were inspected, with the care of three residents being closely looked at in particular. The management of residents’ medications was inspected. Twelve residents and three visitors were spoken to directly in order to gauge their views and experiences of the services and care provided at Bredon View. Survey forms were also issued to a number of residents, visitors and staff to complete and return to CSCI if they wished; four residents, five visitors and five staff completed and returned forms. The quality and choice of meals was inspected, and the opportunities for residents to exercise choice and to maintain social contacts were considered. The systems for addressing complaints, monitoring the quality of the service and the policies for protecting the rights of vulnerable residents were inspected. The arrangements for the recruitment, training and provision of staff were inspected, as was the overall management of the home. A tour of the premises took place, with particular attention to health and safety issues, the maintenance and the cleanliness of the premises. What the service does well: Bredon View provides a safe, clean, well maintained and very homely environment for the residents living here. Residents are admitted on the basis of an assessment, so that they can be assured the home can meet their individual needs. Assessment information goes on to form the basis of clearly written and detailed plans of care for each person, which give clear direction for staff when delivering care. Each resident is afforded good access to health care services, Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 6 with appropriate medical interventions when required, to assist in meeting their health needs. Residents are very satisfied with the standard of care they receive at this home, and the way in which it is delivered, with all speaking well of the staff. Visitors to the home also echoed this, who along with residents confirmed that staff are attentive, helpful and intent on helping to address any concerns that may arise. The home has an inclusive atmosphere for visitors, with relatives indicating that they feel welcome here, and that they are consulted and kept informed appropriately. The food served is of a satisfactory standard, and residents themselves said that they enjoy the meals very much, and that they have a degree of choice as well. Staff have good access to training opportunities, and are making good progress with the National Vocational Qualification (NVQ) training programme. Recruitment is carried out using rigorous employment procedures, with new staff appropriately supervised. The home manager demonstrates very good intentions in relation to quality monitoring systems, and her interest in continually trying to find ways to raise standards and drive improvements in the home are to her credit. The home offers a safe and transparent system for safeguarding personal monies or valuables for those residents wanting such a service. What has improved since the last inspection? Residents’ nutritional needs are more comprehensively assessed now, with the introduction of a new assessment tool; this has resulted in any risks being identified, with prompt corrective actions undertaken where needed. Additional training has been sourced, and the home is working with the Environmental Health Department on the ‘Safer Food – Better Business’ course, in order to drive catering improvements in the kitchen. The manager has attended enhanced training in the protection of vulnerable adults, is to become a trained trainer herself, and is devising a staff training programme for the home. The manager is also tailoring another induction training programme for new staff, with new induction standards in mind. After a period of instability in the past, the manager has had a very positive impact at Bredon View since joining over a year ago. The care and services for Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 7 residents has improved, and there is now a more motivated, committed and knowledgeable work force. 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. Bredon View DS0000016387.V301515.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.V301515.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 at least once during a 12 month period. 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. Assessments are carried out on all prospective residents, so that they can be assured prior to admission that the home can meet their needs. EVIDENCE: Residents are admitted to the home following an assessment of their individual needs. Copies of pre-admission assessments for two of the three residents who formed part of the case tracking exercise had been completed in full by the manager, one of which had been conducted whilst the person was in hospital. The third resident had been admitted from outside the county, and the manager had been unable to conduct her own full assessment in person. In this circumstance a copy of the placing authority assessment and care plan had been obtained ahead of the admission, and there had been appropriate information sharing between the home and other social and health care professionals involved in the person’s care at that time. Bredon View does not provide intermediate care. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. There is a comprehensive care planning system in place, which can provide staff with the information they need to satisfactorily meet residents’ health and personal needs. The systems for managing medications are generally good, although some minor improvement is needed to recording to ensure consistency for some residents. Residents are treated with courtesy and respect. EVIDENCE: Residents have a recorded plan of care that clearly links to a very detailed individual assessment of their health and personal needs; plans are regularly reviewed. Three were chosen for closer scrutiny as part of the case tracking exercise. Care plans contained clear instructions for staff to follow when delivering both personal and health related care. Recording took into account residents’ personal preferences, privacy and levels of independence. The residents Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 11 concerned had been involved in their care planning, and each had had the opportunity to sign their own plan. Each plan contained appropriate risk assessments, such as for risk of falls, pressure sore vulnerability, nutrition and moving and handling, and there were associated care plans documented accordingly to address any risks identified. For those with a risk of developing pressure sores, appropriate healthcare intervention and support equipment was in place. Each plan contained records of regular weight monitoring, and comprehensive nutritional assessments. The manager has done well to introduce a new assessment tool for this purpose; The Malnutrition Universal Screening Tool (MUST). Care plans on this basis are detailed and informative to address any areas of concern. Acute care plans are recorded in cases where illness occurs. Records show regular and appropriate access to a range of health care services from outside the home, including doctors, opticians, chiropodists, dentists, district nurses, continence specialists and community psychiatric nurse (CPN). In one case the CPN had been involved in the care of one particular resident; a copy of the Care Programme Approach (CPA) document had not been obtained, although the CPN had conducted a number of reviews and had contributed to the person’s plan in the home. Residents spoke very positively about the staff and the way in which their care is delivered. A number said that staff are kind and helpful, with one person saying that residents receive ‘wonderful attention’. Visitors also spoke well of the home, the care and the staff. One visitor said that his relative’s condition and health had greatly improved since coming into Bredon View, whilst another felt that staff had been particularly kind and patient with her relative. All written survey responses indicated that the home provides a good standard of care. Staff said that they observed documented plans of care when delivering care, and in most regards this appeared to be the case, with visual evidence of appropriate care being delivered and staff able to discuss individuals’ needs. However some staff did not seem readily aware of the degree of nutritional risks posed to one particular resident, despite detailed assessments and plans having been recorded to address this. One member of staff said that valuable time spent with residents is sometimes compromised by the non-care tasks that they have to perform at certain times. Residents confirmed that staff were mindful of their privacy, with some actually saying that they get ‘plenty of privacy’. One said that the staff are very sensitive when caring for them. During conversation and observation staff demonstrated an understanding and respect for residents’ privacy and independence. Some residents have their own private telephone line installed. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 12 The system for handling residents’ medications is safe and well managed in the main, with residents able to self-medicate if they wish and are able; this is done on the basis of a documented risk assessment for the individual, which is recorded in their care plan. There are clearly printed Medication Administration Records from the supplying pharmacist, which are thoroughly recorded by the staff. In cases where a medication is prescribed on an ‘as required’ basis, there are clearly written protocols for their usage. Holes punched into the charts to place them in a ring binder have obliterated part of the directions for usage of a small number of medications. One resident has persistently refused her medications; the care plan recorded this, and showed evidence of medical review in this case. However, in consideration of the prolonged spell of refusal of vital medication a further review is recommended. Storage of medications is safe, with appropriately detailed records for receiving, disposal and management of all types of medication. The home has access to reference material, although does not have the latest Royal Pharmaceutical Guidelines. The medication policies and procedures are available, although these have not been reviewed for some time. Staff involved in the management of medications have received the necessary training from a local college. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home endeavours to provide residents with the opportunity to participate in a social activities programme according to their choice, and ensures that they can keep close contact with their families and friends. Dietary needs of residents are adequately catered for, with a selection of food available that meets their tastes and choices; identified improvements in the kitchen will improve safety standards for residents. EVIDENCE: A programme of social activities is devised each month, a diarised copy of which is displayed in the home, and issued to each resident. The current programme shows a range of group and ‘one to one’ opportunities, with things to accommodate a diverse range of interests. Residents’ assessments indicate whether they are interested in activities, including religious preferences, and there are some records relating to individual participation. Residents who have their own newspaper delivered were spending quiet time reading, whilst others were watching television. There was a game of bingo held during the morning, and one resident was enjoying an interactive board game on an individual basis with a carer. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 14 One survey response said that they would like to see more social activities in the home, and during this visit three residents commented that they didn’t think there was much to do in the home, with little choice available. Two residents spoke of feeling restricted due to their disabilities. The manager has ambitions to review the social activities for residents, and intends to broaden the opportunities available, whilst taking into account people’s interests, views, abilities and hobbies. The home arranges outings for residents, and a number have recently gone out to a party at another home within the CTCH Ltd group. One resident goes out every week to the local church, and there is a lay reader from another denomination who attends any residents from that particular faith. Visitors are free to come in an out of the home at any time of theirs or their relative’s choosing. Written survey responses from relatives confirmed that they feel welcome here, and that they are consulted about things appropriately. Residents and relatives spoken to confirmed that visitors are offered refreshment when they visit. Residents were evidently spending their time how and where they chose, with some saying that their choice not to participate in certain things is respected. Residents are able to exercise their choices in their bedrooms, and some have chosen to introduce many of their own items so as to personalise their rooms. Information relating to advice and advocacy services is made available in the home, for those residents who may want it to assist them in the management of their affairs. Lunch and teatime menus offer a degree of choice for residents, including vegetarian options. Residents’ choices had been ascertained ahead of the meals, with a list of choices supplied to the person cooking on this day, who is normally a carer; the regular cook was on annual leave. Breakfast choices rarely alter, and although the carer in the kitchen was hesitant initially when asked, residents are able to have a cooked breakfast if they want one. The dining areas were laid out pleasantly, with condiments, napkins, drinks and flowers; a glass of sherry is routinely offered before lunch. Staff served the meal according to individual’s choices from a trolley and serving dishes. All residents, without exception, confirmed that the quality and quantity of food is very good, either in conversation or through written survey responses. The carer appointed to cook on this day was wearing her carer’s uniform whilst cooking, although an apron was worn over it. All staff were observed to be freely wandering in and out of the kitchen. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 15 ‘Safer Food – Better Business’ training has been sourced for Bredon View, and further to this the home has adopted some learned principles. A ‘kitchen diary’ as a means of recording necessary catering related issues, such as high risk food, refrigerator and deep-freeze temperature checks has been implemented; there were some anomalies in the deep-freeze recordings, which the manager resolved to review. Cleaning tasks carried out each day are also recorded here. There were some open sacks of ‘foodstuffs’ stored on the floor in one of the cupboards; these were not sealed and the contents were left exposed. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system, with evidence that residents feel that any concerns they may have are listened to and acted upon. The home’s Adult Protection policies help to provide a safe environment for the residents. EVIDENCE: All written survey responses, with one visitor exception, said that they were familiar with the complaints procedure should they need it; the procedure for dealing with complaints is clearly displayed on the home’s public notice board. The home has not received any complaints recently. Residents and visitors all said that they had confidence in the home manager and staff to take any raised concerns seriously, and to act as necessary to address them. However, just one survey response indicated that the person thought that staff did not always listen if they raised anything. One visitor in particular commented on how helpful and responsive the manager had been to help their family. Another resident said that she had never had cause to complain, but knew that if she did the staff would do all they could to help. The home has written policies and procedures for the protection of the vulnerable residents. Staff were aware of these, and although the manager Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 17 said that staff regularly receive in-house instruction in this area, this was not borne out conclusively during interview with isolated care staff. Most said that they had read Protection of Vulnerable Adults (POVA) information and had viewed an adult protection training video. One carer said that adult protection training had featured in her NVQ training programme. The manager demonstrates a commendable interest and strong commitment to adult protection issues, and has attended specific training at an enhanced level with the local adult protection unit. She is introducing an adult protection training course into the home, the content of which she will deliver to staff herself, depending on an assessment of her competency by her training provider. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is satisfactory, and provides residents with a comfortable, clean and safe place to live. EVIDENCE: The home has a maintenance person, who works across all the homes in the group. Records of all maintenance carried out are kept. The home was welcoming, and had a pleasant and relaxed atmosphere. Parts of it have been refurbished to a good standard, and generally the home is well maintained and decorated throughout. There are many decorative and ornamental touches, which make the environment more homely for the residents. In the main lounge some of the armchairs are old, worn, faded and becoming unsightly; one of them has torn fabric on the arm. The carpet in here is spotted with staining. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 19 The surrounding grounds at Bredon View are well stocked, and provide a beautifully bright coloured and attractive garden for the residents to enjoy. The home is clean and generally odour free. There are plenty of gloves, aprons, liquid soap, paper towels and sanitising hand gels for the staff to observe appropriate infection control procedures. Each visitor spoken to commented on how clean and fresh the home always was. Resident survey responses indicated their satisfaction with the standards of cleanliness that are maintained here. The one washing machine had broken down in the small laundry room, and was awaiting a repair. Certain parts of this room were not adequately cleaned, and there was a build up of dirt and fluffy residue on some of the equipment in here. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Staffing provision is adequate to meet the needs of the residents currently living in the home. Robust recruitment procedures ensure that suitable staff are employed for the protection of residents. The arrangements for the induction and training of staff are good, with the staff able to learn the skills necessary for their role. EVIDENCE: Staff rotas are maintained, although staff job roles are not identifiable on the rota, making it difficult for the reader to determine who is care staff and who is catering or housekeeping staff. The rota allows for three carers to be on duty during all daytime hours, with one waking and one sleep-in carer on duty overnight. An ancillary team of two housekeepers, a cook and a maintenance person support the care team. The manager works in a supernumerary capacity. Written survey responses indicated that there are sufficient staff on duty, with one visitor saying that there could be more at weekends; the manager and the staff rotas indicated that there was no change in the numbers of carers at weekends. The numbers of housekeepers was less, and the manager is not usually on duty at weekends. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 21 All resident surveys confirmed that staff are readily available when they need them, and during conversation residents all spoke very positively about the staff group that care for them, as did the visitors. One visitor commented on how clean and presentable the staff always appeared. Staff survey responses, bar one, indicated that there is good teamwork at Bredon View, and that there is plenty of support offered to the team. Two carers said that they would like to spend more time with residents, rather than have to concentrate on non-care duties that they have to perform at certain times of the day. The home is making good progress towards achieving the standard of having at least 50 of care staff qualified to NVQ level 2 standard as a minimum. Three staff currently have the level 2 qualification, whilst five other staff have completed the course and are awaiting final verification of their work. One carer is undertaking the training at this time, and there are two others doing the NVQ in Care award at level 3. Two staff files were chosen for inspection, on the basis of their recruitment to the home since the last inspection. Records contained application forms, including a full employment history, with an explanation for any gaps in it recorded. Records of interviews were seen. Full and complete evidence of the required pre-employment checks was seen in each of the files. The enhanced Criminal Records Bureau (CRB) and POVA disclosure was seen for one, and was still awaited for the other as she had only just been employed. A POVA First clearance had been obtained, and appropriate supervision arrangements were in place for this person whilst awaiting the return of a satisfactory CRB disclosure. Training records are kept in the home, and staff are encouraged to build up their own professional development portfolios; they are issued with the General Social Care Council (GSCC) Code of Conduct. Training records show a range of mandatory and optional training for all staff. The manager is a trained moving and handling trainer. External training providers have provided training on First Aid, Medication Management and Food Hygiene. An improved Adult Protection training programme is planned, and the Environmental Health Officer (EHO) has yet to assess the home further to the ‘Safer Food-Better Business’ training. New care staff, who have had no previous experience, attend a structured induction programme with an external training provider, in addition to completing an in-house induction period. Supervision records for a new worker are kept, and this shows the named supervisor for the new worker during their induction period. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 22 The manager has the Skills for Care Induction standards, and is currently tailoring these standards for new staff being inducted at Bredon View, one of the objectives being to test newcomers’ knowledge and identify any gaps that need attention. Bredon View DS0000016387.V301515.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home reviews aspects of its performance through a good programme of self-review and consultations, which includes seeking the views of residents and their relatives. There are good management systems in place to ensure that the interests, health and safety of the residents are safeguarded. EVIDENCE: The manager has been in post at Bredon View for over a year, and has been registered with the CSCI for her role. She has achieved the NVQ level 4 Registered Manager’s Award, and has previous management experience at another home within the same care group. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 24 She remains committed to her role, and ensures her continual professional development, as a carer and a manager. She provides leadership and motivation to the staff group. The manager conducts internal quality checks in the home, such as medication and care plan audits; records for this were not seen on this occasion. Regular checks are also made around the rooms, to ensure that facilities and service for the residents remain appropriate; the manager directs staff accordingly if needed. The manager evidently strives to remain accessible to residents and visitors. A residents’ meeting was offered but not supported two months ago, and the home plans to provide a further opportunity for another meeting, along with families and friends, so that people’s views, opinions and ideas for the home can be sought and discussed. The manager demonstrated a commitment to considering ways to increase and improve the opportunities for residents and visitors to provide feedback on the home; progress with this will be followed up at the next inspection. It is to her credit that she sought advice regarding ways to continually raise standards in the home, whilst showing an interest in the Regulatory Lines of Assessment criteria used by CSCI in its assessment of the home’s performance. She also utilises the CSCI reports for informing and directing staff in the home’s areas of weakness and strength. Residents received survey forms from the home two months ago, so that they could have the opportunity to provide feedback on their views regarding food and privacy arrangements. The results of these surveys have been collated. Nothing has been done further to this, and there was no development plan for the home, which took into account any of the quality monitoring assessments. Some residents have placed personal money with the home for safekeeping. Clear and transparent records for each person, which include transaction details, running totals, and receipts, are kept. A random audit trail on a resident’s money in relation to their record proved to be accurate. Residents or their representative can sign to acknowledge some transactions, but where this is not possible in nearly all cases at this time, two staff members sign the record to witness on behalf of the resident. The safety of equipment in the home is reviewed under servicing agreements, and up to date certificates are in place for the lifts and electrical equipment; the manager agreed to send a copy of the recent hot water and heating boilers service certificate, as this could not be located during the visit. Hot water temperatures at outlets accessible to residents are regularly checked, and are generally maintained at a safe level. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 25 The fire alarm system and emergency lighting is regularly checked, and staff receive regular fire safety training. A fire risk assessment has been conducted. It is recommended that the training needs of the staff should now be incorporated on the basis of individual risk assessment, rather than the ‘one size fits all’ approach currently adopted. All care staff have undertaken training in First Aid. Accident records are maintained, with regular auditing carried out. A recent EHO inspection raised some concerns in the kitchen, which the manager confirmed had been addressed. Bredon View DS0000016387.V301515.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 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 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 2 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 x x 3 Bredon View DS0000016387.V301515.R01.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. 1 Standard OP9 Regulation 13(2) Requirement The Registered Manager must ensure that instructions for the usage of medication are not obliterated by the use of a holepunch in the chart. The Registered Manager must ensure that: • An alternative uniform is worn by care staff allocated to meal preparation • Care staff are not permitted to access the kitchen unnecessarily, and are kept to the absolute minimum, in order to reduce any risk of cross infection and contamination. 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. The Registered Manager must ensure that damaged armchairs in the lounge are removed from use and/or replaced. The Registered Manager must DS0000016387.V301515.R01.S.doc Timescale for action 31/08/06 2 OP15 16(2j) 31/08/06 4 OP15 16(2g) 31/08/06 5 OP19 23(2c) 30/09/06 6 OP26 23(2d) 30/09/06 Page 28 Bredon View Version 5.2 ensure that: • The lounge carpet is thoroughly cleaned • The laundry room is thoroughly cleaned. 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 3 4 Refer to Standard OP7 OP27 OP33 OP38 Good Practice Recommendations The Registered Manager should obtain a copy of the CPA, in cases where the psychiatric services are involved in the care and admission of a resident. The Registered Manager should identify individual job roles on the staff rota. The Registered Manager should draw up a written action/development plan to address the outcomes of quality monitoring assessments and surveys. The Registered Manager should review the training needs of staff identified within the fire risk assessment. Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bredon View DS0000016387.V301515.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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