Inspection on 15/07/04 for British Home and Hospital for Incurables

Care Homes For Adults (18 ­ 65)British Home and Hospital for IncurablesCrown Lane Streatham London SW16 3JBAnnounced Inspection15th July 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment British Home and Hospital for Incurables Address Crown Lane, Streatham, London, SW16 3JB Email address Tel No: 0208 670 8261 Fax No:Name of registered provider(s)/company (if applicable) British Home and Hospital for Incurables Name of registered manager (if applicable) Miss Christine Flack Type of registration Care Home No. of places registered (if applicable) 127Category(ies) of registration, with (number of places) Physical disability (127) Registration number G020000393 Date first registered 28th March 2003 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 28th March 2003 NO NO 16/02/04 If Yes refer to Part CBritish Home and Hospital for IncurablesPage 1 Date of inspection visit Time of inspection visit Name of Inspector Name of Inspector Name of Inspector 1 2 315th & 16th July 2004 10:30 am Lynne Field Sonia McKay Vashti Maharaj Lisa WildeID Code132015Name of Inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionBritish Home and Hospital for IncurablesPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementBritish Home and Hospital for IncurablesPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of British Home and Hospital for Incurables. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.British Home and Hospital for IncurablesPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The British Home & Hospital for Incurables (BHHI) is a voluntary care home for 127 people. It is a registered charity with a Board of Management. BHHI provides purpose built accommodation for people who are chronically sick and physically disabled. The aim of the home, highlighted in the statement of purpose is: to provide high quality nursing care with high levels of clinical and recreational support thereby assisting each resident to achieve maximum possible independence. The present home was built in 1894 and in 1899 the Home was granted the status of a Royal Charter hospital. This has meant the home was not subject to Inspections by the health authority/local authority. Regulation is now the responsibility of the NCSC (CSCI from 01/04/04). The BHHI is 5 minutes from local shops and near to all the local transport facilities. It is close to Streatham Common and a short drive from all the amenities in Streatham. The building is a large Victorian building, which has a distinctive presence in the area. It is maintained to a high standard and an extension, which was built in 1996, is in keeping with the existing building. There are two wings on each floor known as East and West Wing. The newer wing created 48 single rooms all en suite. A kitchen was completely rebuilt in 2001 where the food is cooked and brought to each floor in portable Bain Maries. The Home has a physiotherapy department with one full-time physiotherapist and three full-time physiotherapy assistants who see all service users.British Home and Hospital for IncurablesPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the Inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This announced inspection took place over two days in July 2004. Many aspects of the home impressed the Inspectors, such as the physiotherapy department and the knowledge the staff have of the service users. The building, financial and ancillary services play a large part in the service users lives and give an impressive comprehensive service. The Inspector was pleased to note all staff worked together as a team to make the service users life meaningful. The Inspectors would like to thank the staff and management in the home for their hospitality and support during this inspection. Choice of Home (Standards 1-5) Of these 5 standards 5 were assessed and 3 were met. The statement of purpose is comprehensive and sets out the aims, objectives and philosophy of the home in an accessible format. The registered manager must ensure that all service users care plans are reviewed and updated in such a way that fully reflects their social / cultural history as well as addressing any specialist and emotional well-being. This is the subject of an existing unmet requirement. At the previous inspection the registered manager had shown the Inspector documents that are used for assessing service users moving into the home and this was considered a contract between the service user and the home. This document must be reviewed and developed by the registered manager to ensure that the contract that is in current use in the home covers all of the items listed in this standard and regulation 5. This is the subject of an existing requirement that has been re-stated. Individual Needs and Choices (Standards 6-10) Of these 5 standards 5 were assessed and 3 were met. The registered manager told the Inspector that each service users care plan is reviewed with service user involvement and the service user and family sign the care plan if they are willing. The Inspector found there was no consistency in the standard of the care plans throughout the home. There must be a suitable generic care plan drawn up for all service users, which records / agrees any limitations and is signed by the service user or his care manager / relatives. The Inspector was impressed by the level of knowledge demonstrated by the homes finance team and by systems that had to be put in place to ensure that full and accurate records of service users were kept and this is to be commended. Lifestyle (Standards 11-17) Of these 7 standards 7 were assessed and 6 were met. The Inspectors were impressed with number of activities that are available to the service users in the home. From speaking to the catering/manager of the home the Inspectors also learnt that a special effort is made at festivals to provide special menus for all residents. Families can come and stay over-night or longer if they live far away in the small flat that is British Home and Hospital for Incurables Page 6 available for this purpose. Friends and families are also able to join the service user for a meal at BHHI in the staff dining room. A small charge is made for visitors meals. At the last inspection it was noted that not all service users had locks on their bedroom doors. Where a lock/key is not required or the service user is not able to use manipulate the key, this must be noted within the individuals Care Plan and be signed by the service user or his care manager / relatives to this effect. This is the subject of a previous unmet requirement that has been reinstated. Personal and Healthcare Support (Standards 18-21) Of these 4 Standards 3 were assessed and 2 were met. The home has a policy on death and dying which notes, who to contact and associated guidelines were all accessible. The Inspector noted that the policy ensured that any such event would be dealt with sensitively, with regard for service users and their familys wishes, and with consideration of cultural and religious differences and needs. Each room has a light indicating whether the service user does not wish to be disturbed and the Inspector observed staff knocking on doors/bathrooms and waiting for permission before entering. The Inspector was told by the matron that Lambeth PCT have refused to provide therapy services to service users living at the British Home. The registered manager and the homes visiting general practitioner both reported that this has been taken up with the community team and they are currently trying to negotiate with them in regards to this issue. However it is currently stopping service users accessing community services that they are entitled to and need. Concerns, Complaints and Protection (Standards 22 & 23) Of these 2 Standards 2 were assessed and both were met. Of these two standards two were assessed and two were fully met. There were no adult protection issues in the home at the time of the inspection. Complaints are recorded and investigated appropriately. Environment (Standards 24-30) Of these 7 Standards 7 were assessed and 6 were met. All systems inspected for preventing the spread of infection were in place. It was noted at the previous inspection that the two bathrooms in the old wing were in a bad condition with substandard flooring, wall covering and missing tiling. The registered manager told the Inspector these were to be refurbished in the near future. The timescale for action had not been exceeded at the time of this inspection. It had been recommended that locks be fitted so that those service users who are able to use the facilities independently are able to ensure privacy for themselves. This is the subject of a previous unmet recommendation that has been reinstated. It was recommended that consideration be given to a fuller smoking policy with provision of designated smoking areas. See Standard 16. This recommendation has been met. The home has good provision of communal spaces. On the lower ground floor there are separate rooms for dedicated for the use of the dentist, optician, a counselor and hairdressing. There is also a large physiotherapy area, an art room and a well-equipped sensory stimulation room. In addition each wing has sitting rooms and dining rooms. There is a chapel, which is used for services of all faith denominations. Staffing (Standards 31-36) Of these 6 Standards 4 were assessed and 4 were met. Due to the size of the home it employs a large number of staff but the Inspector found that the philosophy of the home reaches and is understood by all the staff and is reflected in the homes comprehensive recruitment procedure. Some staff have worked with many of the British Home and Hospital for Incurables Page 7 service users over a long period of time and are very proud of their achievements. One service user has been living at BHHI for over 35 years. The home has a number of staff currently undertaken NVQs and are set to achieve their 50 targets by 2005 and continue to put staff forward to undertake the award. Conduct and Management of the Home (Standards 37-43) Of these 7 Standards 6 were assessed and 6 were met. The Matron and the registered manager both have many years experience working in the health service and residential/nursing care. The registered manager is responsible to the Board of Management. The home is a registered charity and the registered manager requires a range of skills in order to fulfil this post. She has meetings on a monthly basis for senior staff and on a six weekly to two monthly basis with other staff. This is cascaded down with the senior staff meeting with the staff that reports to them. The registered manager has been formalizing quality-monitoring systems to ensure that the quality of care is reviewed and improved on a continuing basis. These reports have been shown to the Inspector. The Health and Safety systems are in good order.. The estates manager reported that he is in contact with the Fire Authority to ensure compliance with all aspects of this area of concern were met. Last LFEPA inspection was on the 10/03/04. Room by room fire risk assessments of the premises is now in place. This will be reviewed annually and when a service user vacates the room.British Home and Hospital for IncurablesPage 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action The registered manager must ensure that the 1 5 (1) (c) YA5 30/06/04 contract in current use in the home covers all of the items listed in this standard and regulation 5. 2 (2)(3), 15, Schedule 3 (2)(q) YA3 The registered manager must additionally ensure that all service users care plans are drawn up in such a way that fully reflect their social / cultural history as well as addresses their emotional well-being. The Registered Manager must ensure that a record of any limitations is to be agreed with the service user, recorded within the service users care plan and is signed by the service users and /or their representative. The registered manager must ensure that where a key is not required by a service user, this must be noted within the individuals Care Plan and is signed by the service user or his care manager / relatives to this effect. The registered person must ensure that the two bathrooms in the old wing are refurbished. The timescale for action had not been exceeded at the time of this inspection. 30/06/043(2)(3), 15, Schedule 3 (2)(q)YA730/06/04412 (2)(3), 15, Schedule 3 (2)(q) 23(2)(bYA1630/06/045YA24February 2005Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard British Home and Hospital for Incurables Page 9 .CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)British Home and Hospital for IncurablesPage 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 5 (1) (c) YA5 The registered manager must ensure that the contract in current use in the home covers all of the items listed in this standard and regulation 5. 30/06/04 now 01/01/052(2)(3), 15, YA3 Schedule 3 (2)(q)The registered manager must ensure that all service users care plans are drawn up in such 30/06/04 a way that fully reflect their social / cultural now history as well as addresses their emotional well-being. This is the subject of an 01/01/05 existing requirement that has been restated. The Registered Manager must ensure that a record of any limitations is to be agreed with the service user, recorded within the service users care plan and is signed by the service users and /or their representative. This is the subject of an existing requirement that has been re-stated. The registered manager must ensure that where a key is not required by a service user, this must be noted within the individuals Care Plan and is signed by the service user or his care manager / relatives to this effect. This is the subject of an existing requirement that has been re-stated.3(2)(3), 15, Schedule 3 YA7 (2)(q)30/06/04 now 01/01/05412 (2)(3), 15, YA16 Schedule 3 (2)(q)30/06/04 now 01/01/05British Home and Hospital for IncurablesPage 11 523(2)(bYA24The registered person must ensure that the two bathrooms in the old wing are refurbished. The timescale for action had not been exceeded at the time of this inspection. The registered provider must ensure that quantities of medication used on an as required (PRN) basis are brought-forward onto the current MAR chart to enable an accurate stock-check to be made. The registered provider must ensure that the application of all external preparations is recorded on MAR chartsFebruary 2005613 (2)YA2031/12/04713 (2)YA2031/12/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard *2YA9It would be good practice for all staff to be trained in risk assessing and for them to undertake the review all service users risk assessments in the home.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire YES YES YESBritish Home and Hospital for IncurablesPage 12 · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the Inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES YES YES YES NA YES YES YES YES YES YES YES YES NO YES YES YES 40 10 X YES YES YES YES 117 37 15/07/04 10-30 18.5The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls) Page 13British Home and Hospital for Incurables 0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.British Home and Hospital for IncurablesPage 14 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to `test drive the home. Each service user has an individual written contract or statement of terms and conditions with the home.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 618.00 677.00 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Hairdressing, toiletries, papers/ magazines, transport/ dial a ride, holidays, outings. 3 Key findings/Evidence Standard met? The statement of purpose is comprehensive and sets out the aims, objectives and philosophy of the home in an easy format. This document was reviewed in June 2004 to include the telephone number of the Commission. There are two brochures the home sends out, one (a smaller version) for outside agencies and a larger brochure for service users and family/friends, which provides information on the homes services. Every service user is subsidised by £150 per week by the charity. There are no extra costs involved in the fees. BHHI offer services such as hairdressing, which the service user will pay for from their weekly allowance. This standard has been met.British Home and Hospital for IncurablesPage 15 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? The Inspector viewed the files of a number of service users in the home and found that the majority of files were up to date and comprehensive. At the last inspection the Inspectors acknowledged that the home had been proactive in trying to obtain Community Care Assessment for those service users placed by social services. Some of the files examined by the Inspector it was found that information on the service users initial assessment conducted by the home and the comprehensive placing authority assessment were not available. The registered manager told the Inspector that in future all service users would have a full assessment and that the homes care plan would reflect all of the required information in Standard 2. This is reflected in the reviewed statement of purpose shown to the Inspector. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? The Home is a long-term service for people who have a chronic illness. The home provides a range of specialist staff to try to ensure that all care needs can be met. The home is a specialist home that admits people with a range of illnesses, such as brain injury and those in a vegetative state that require total nursing care and who are unable to communicate. On the day of the inspection the Inspector was able to examine the records of a number of service users. As at the previous inspection, on most of the files examined there was clear evidence that the home was working to meet the needs of the service users in the home. However, on some of the service users files there were little evidence of how or if the home was meeting service users cultural needs - and little evidence of service users social history, background and emotional well being. The registered manager must ensure that all service users care plans are reviewed and updated in such a way that fully reflects their social / cultural history as well as addressing any specialist and emotional well-being. This is the subject of an existing requirement that has been re-stated.British Home and Hospital for IncurablesPage 16 Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The policy of BHHI states that service users are invited and should always visit the home prior to moving in on a trial basis. The registered manager reported that unplanned admissions are not acceptable. However, a previous respite or longer stay person may request urgent admission. This will be agreed only if certain criteria is in place, such as an up to date assessment, suitable room sufficient and suitably qualified staff are on duty and equipment comes with the person as well as a signed funding agreement is in place. At the previous inspection it was noted that in a number of service users files there was little or no evidence of any introductory visits or any transition work that may have gone on prior to service users moving into the home. All service users admitted to the home in the future will have the opportunity to have an introductory visit to the home prior to accepting any offer to move in and this will be recorded in their notes. Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 2 Key findings/Evidence Standard met? At the previous inspection the registered manager had shown the Inspector documents that are used for assessing service users moving into the home and this was considered a contract between the service user and the home. This document must be reviewed and developed by the registered manager to ensure that the contract that is in current use in the home covers all of the items listed in this standard and regulation 5. This is the subject of an existing requirement that has been re-stated.British Home and Hospital for IncurablesPage 17 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? BHHI provides nursing care with clinical and recreational support aimed at assisting service users to achieve as maximum independence as possible. Service users that come to BHHI cover a range of illnesses and ages. Each service user has a chronic illness and requires 24-hour care. Senior staff knows each service user very well, and the nursing staff are supported by staff from the physiotherapy department to ensure each service user reaches their potential. From the service user plans examined the Inspector was able to summarise that each service user had a key worker and that plans had been generated at the time of admission. The registered manager told the Inspector that each service users care plan is reviewed with service user involvement and the service user and family sign the care plan if they are willing. However little evidence of service users social and emotional history or wellbeing was recorded on care plans. The registered manager must ensure that the care plan is drawn up with service users involvement; further to this all care plans must cover all of the listed items in standard 2 and 4.British Home and Hospital for IncurablesPage 18 Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 2 Key findings/Evidence Standard met? The Inspectors viewed ten service users files from various floors within the home, in order to get a broad sample of information. The Inspectors noted however, that there was an inconsistency in the nature of the information recorded. The Inspector had been disappointed that there was no record of evidence within the service users Care Plan that these limitations had been agreed with either the service user or his representatives. The registered manager must ensure that a suitable generic care plan is drawn up for all service users, which records / agrees any limitations and is signed by the service user or his care manager / relatives. This is the subject of an existing requirement that has been re-stated. The home uses a comprehensive computerised system in the management of the service users finances. The Inspector examined a selection of service users financial records and found them to be in order, with every transaction clearly identified, computerised and receipted. The Inspector was impressed by the level of knowledge demonstrated by the homes finance team and by systems that had to be put in place to ensure that full and accurate records of service users were kept and this is to be commended. Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 4 Key findings/Evidence Standard met? Staff informed the Inspectors that service users are offered opportunities to participate in the day-to-day running of the home, via a residents committee and meeting. The homes residents democratically choose the members of the residents committee. The residents committee meetings take place once a month, and the committee members raise issues on behalf of other residents, for discussion. The minutes of these meetings are typed up and distributed throughout the home. The Inspector saw copies of the minutes. The home has notice boards on every level publicising forthcoming events and outings. Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? As noted at the previous inspection there were risk assessments present in files and that in most cases these assessments were reviewed regularly. It would be good practice for all staff to be trained in risk assessing and for them to undertake the review all service users risk assessments in the home. Evidence indicated that risk had been assessed prior to admission and that appropriate strategies had been agreed to ensure that service users are supported to take risks as part of an independent lifestyle.British Home and Hospital for IncurablesPage 19 Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? The Inspector noted that all service user files are kept securely and confidentially in the various staff offices throughout the home. The registered manager confirmed that the home has registered with the information Commissions Office for the storage of information under the Data Protection Act 1998 and that the homes policies and procedures on confidentiality would be made available to partner agencies if they requested it. At the last inspection it was recommended that the home issue a statement on confidentiality to its partner agencies setting out the principles governing the sharing of information. The Inspector was informed that this is noted in the staff hand book and is a condition of service of all staff.British Home and Hospital for IncurablesPage 20 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate, personal, family and sexual relationships. Service users rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 4 Key findings/Evidence Standard met? The home employs an activities co-ordinator/ manager who has developed a comprehensive programme of social activities for the residents of the home. Activities were seen to be varied, including, quizzes, music and film club, indoor bowls, gardening, story telling and outings. The home also has an entertainments committee who organise BBQs, Discos etc. In addition, the home offers a weekly counselling service, Art therapy. There is a large very well equipped Physiotherapy department, with staff who aim to help service users independence by maintaining their mobility, which is open between 8am till 5pm. Service users who need to have physiotherapy first thing in the morning are visited by the staff in their rooms for individual sessions between 8-9am. The level of social activities being offered to service users impressed the Inspector. Although there was not much evidence of daily living skills being maintained or encouraged, such as cooking, there was much evidence that social independence was promoted. The home was described to the Inspector as a small village, which has a small shop, a chapel for private prayer and where spiritual needs can be met and the service users have the freedom to visit friends and generally socialise and feel safe. The Inspector was pleased to see through the use of motorised wheel chairs, many of the service users who, if they had been in any other organisation would be dependent on others to move them from place to place, had the freedom to move around the home when and where they wanted to without having to ask someone to take them. The residents within the home are drawn from a range of backgrounds and beliefs and the home actively encouraged visits from local churches of varying denominations. The home has a policy on death and dying and the policy notes, with details of who to contact and associated guidelines were all accessible. Staff informed the Inspector that death and dying is a very sensitive area and is discussed only if the service user feels comfortable.British Home and Hospital for IncurablesPage 21 Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? The registered manager informed the Inspector that the Home offers a wide range of daily group activities that service users are encouraged to join in. Due to the complex long-term conditions of the service users, none of the current service users continued employment or education once admitted to the home.Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? The activities manager informed the Inspector that some of the service users are linked to dial-a­ ride and they can organise their own trips to visit relatives and friends, who will support them in accessing the community. However, for the majority of the service users community links are maintained through the home. The Inspector found that the home offers a wide range of services within the home for service users e.g., hairdressers, dentist, sweet and snack shop and the activities manager informed the Inspector that there are always two shopping trips per year. The Inspector was impressed by the amount of community based services (brought into the home for the service users who actively chose to use them) but was disappointed that service users were reluctant to participate in the local community. When the Inspector spoke to several service users about using the immediate local services and shops, they said they didnt feel safe and the area wasnt wheelchair friendly.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 4 Key findings/Evidence Standard met? The Inspector was impressed by the level of activities on offer to the service users in the Home. BHHI have a full time activities co-ordinator who manages the in-house activities and in addition to this there are two other full time workers and a vast number of volunteer staff, all of whom work with the service users with leisure activities which include discussion groups, quizzes, music appreciation, film club, indoor bowls, gardening, story telling and outings. There is an art room with a facilitator who encourages all service users to participate and they have produced some excellent work that was on show. The home has a concert hall, which is used for concerts, film shows, fetes and other events. The specially adapted kitchen is used by service users to cook in a supportive environment. There is a very active entertainments committee and the League of Friends. Organised trips are displayed on the notice boards for which service users can sign-up for. The Inspector was informed that the home arranges numerous day trips out and many of the service users at BHHI go to Lourdes with their family or through their church and where possible staff at BHHI assist service users to complete this trip.British Home and Hospital for IncurablesPage 22 Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 4 Key findings/Evidence Standard met? The Inspector was informed that BHHI ethos is to support service users to maintain links with family and friends inside and outside of the home. Families can come and stay overnight or longer if they live far away in the small flat that is available for this purpose. Some relatives visit every day, and staff support and encourage anyone who is involved with all the service users. Friends and families are welcome to share a meal at BHHI at the staff dining room. There is a small charge made for visitors meals. The Inspector spoke to a number of family and friends of service users during the inspection, who verified this information and spoke of how they were always made to feel welcome. On the day of the inspection the Inspector spoke to a service user who was going to stay with his family for a few days and was told by them that both he and his family were looking forward to this. Service users can meet their relatives and friends in private in their rooms, which are of a suitable size to accommodate this or they can use one of the sitting areas through out the home. The Inspector commended the home on its support to service users to maintain links with their family and friends.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 2 Key findings/Evidence Standard met? There was evidence that the routines of the home are resident led, residents can choose when to get up and have their breakfast in the morning. Activities are planned in advance and recorded on a weekly plan. The home has a smoking policy; service users who wish to smoke use the two designated smoking areas in the corridors, which are wide and airy. The Inspector was told they didnt have designated smoking rooms as it would mean service users would be out of sight of staff, which could cause a health and safety problem. At the last inspection there were concerns raised about smoking in communal areas with regard to the possibility of passive smoking and consideration is now being given to the use of air purifiers in these areas to combat this. The Inspector was informed that service users wishing to keep a pet at the home would have to seek the agreement of other service users via the Residents Committee. At the previous inspection it was noted that not all of the individual bedroom doors are lockable from either the inside or out by either a key or suitable locking device. Staff had informed the Inspector that many service users lacked the fine finger movement to be able to operate a key. Where a lock/key is not required or the service user is not able to use manipulate the key, this must be noted within the individuals Care Plan and is signed by the service user or his care manager / relatives to this effect. This is the subject of a previous unmet requirement that has been restated.British Home and Hospital for IncurablesPage 23 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 4 Key findings/Evidence Standard met? Food preparation within the home is tendered out but there is a full time catering manager and staff on-site. There is a menu on a three-week rota, which was nutritious and varied. The breakfast menu had a wide choice including black sausage or kippers. Lunch and supper menus had three to four choices each, including vegetarian alternatives and salads; all meals also featured fresh vegetables. The chef reported that when there have been service users in the home who wanted halal or kosher meals the meat was ordered from a specialist supplier and meals were made and frozen so that there was always an appropriate meal available. The chef monitors the popularity of meals and takes them off the menu if they are not liked. He also has chefs specials where he pilots more unusual foods and if they are successful they will be put on the menu. The chef goes to residents meetings to get service user feedback and has comment cards for people to fill in. The Inspectors received very satisfied comments from service users about the food at the home, and the food that the Inspectors saw and sampled looked appetizing and was tasty. On the floors there are kitchens available where snacks can be prepared if needed. Meals can be taken in the dining rooms or in bedrooms. The Inspector noted carers helping service users eat in a proper and unhurried manner. Diabetic food was prepared separately and food is also liquidised where needed. The chef described a trial he was carrying out to prepare soft diets which may be more palatable than liquidised diets. From speaking to the catering manager and the manager of the home the Inspector also learnt that a special effort is made at festivals to provide special menus for all residents. International cuisines had been devised but were more of a gastronomic event such as an Italian night for the service users.British Home and Hospital for IncurablesPage 24 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · Service users receive personal support in the way they prefer and require. Service users physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the homes policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Each room has a light indicating whether the service user does not wish to be disturbed. Staff and visitors respect this and do not enter until the light has been switched off. This may indicate that the service user is undergoing personal care tasks or they have a visitor and do not wish to be disturbed. The Inspector observed staff knocking on doors/bathrooms and waiting for permission before entering. Further to this the Inspector was able to observe that the service had a large range of technical aids available for service users use. A hairdresser visits the home regularly.British Home and Hospital for IncurablesPage 25 Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 3793 Key findings/Evidence Standard met? Service users are supported to make as much informed choice as possible with regards to their healthcare. All residents are registered with a local GP who visits the home twice weekly for a ward round with the service users who have been referred. The GP will visit when there is an emergency. Lambeth PCT have refused to provide therapy services to service users living at the British Home. The home pays for the dental services to come to the home to allow the service users access to dental services. An optician via Health Call services is paid for by the home and comes on a monthly basis and the home also pays privately for chiropody services for the service users. Neither does the home have support from the community services such as access to any speech and language therapists or occupational therapist support. The home employs two physiotherapists with three physiotherapist assistants who work through out the home as the need arises. The registered manager and the homes visiting General Practitioner both reported that this has been taken up with the community team and they are currently trying to negotiate with them in regards to this issue. However it is currently stopping service users accessing community services that they are entitled to and need. The Inspector acknowledges that the home has been proactive and has made repeated efforts to access primary care services. The registered manager must however continue to ensure that all service users are referred to the community team on an individual basis for any health care or support that they cannot receive within the home.British Home and Hospital for IncurablesPage 26 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 2 Key findings/Evidence Standard met? th The last inspection of medication handling was on 16 February 2004, and as this was the first inspection by an NCSC Pharmacist Inspector, the inspection was more detailed than previous inspections, resulting in a number of requirements and recommendations. This was to be expected, and a comment was placed in the previous report relating to this. The Pharmacist Inspector considered the standard to be almost met, and some of the requirements related to observations, which occurred only once, and were not widespread issues. This inspection was of the 3 units not inspected in February: First Floor West, and Second Floor East and West. As with the 3 units inspected previously, the condition of the Medication Rooms was excellent, all staff interviewed were knowledgeable and open in providing information, and the standard of recording was generally good. Issues found were: First Floor East -One prescribed item out-of stock on 3 out of 19 MAR charts for between 4-6 days -Missing signatures on 7 out of 19 MAR charts -No frequency of administration stated in words on 2 out of 9 MAR charts, time of administration circled only -Application of external products not recorded on 3 out of 19 MAR charts -Items used on an as required (PRN) basis brought forward from previous month did not have quantities added to new MAR chart Second Floor West -No missing signatures noted on any MAR charts -Items used on a PRN basis brought forward from previous month did not have quantities added to new MAR chart -One prescribed item out of stock on 2 separate occasions in June for 1-2 days -After an admission to hospital, changes had been to one residents prescribed items, however these amendments had not been made to the homes MAR chart Second Floor East -No missing signatures noted on any MAR charts -Application of external products not recorded on MAR charts -Items used on a PRN basis brought forward from previous month did not have quantities added to new MAR chart In summary, the standard is almost-met, and 2 requirements have been made relating to the recording of all external preparations, and ensuring the quantities of all prescribed items used on a PRN basis are stated on the MAR chart.British Home and Hospital for IncurablesPage 27 Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This Standard was not assessed on this inspection but was met at the previous inspection.British Home and Hospital for IncurablesPage 28 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 2 0 0 0 0 0 100 3 Key findings/Evidence Standard met? The Inspectors were able to view the homes complaints procedure. All complaints noted in the complaints file had been dealt with properly and promptly. The manager explained that a copy of the complaints policy is given to service users and there is copy of the complaints policy on notice boards throughout the home. The manager explained that most complaints come directly to her. Verbal complaints of this sort are noted in service users individual files. Recently copies of complaints and how they have been dealt with have been forwarded to the CSCI, where they have been followed up when appropriate.British Home and Hospital for IncurablesPage 29 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX3 Key findings/Evidence Standard met? From evidence gathered during the inspection it was evident that service users are protected from abuse, neglect and self-harm. There are established procedures for responding to allegations of abuse. Interviews with staff indicated that they are aware of the homes policies and procedures (including whistle blowing) to ensure the safety and protection of service users.British Home and Hospital for IncurablesPage 30 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · Service users live in a homely, comfortable and safe environment. Service users bedrooms suit their needs and lifestyles. Service users bedrooms promote their independence. Service users toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The BHHI is close to Streatham Common, near to local shops and a short drive from all the amenities in Streatham. It is next door to a pub and near to all local transport facilities. The home has two buses to take small groups of service users out. Although the home is large and is a listed building, it is bright and airy. There have been enormous improvements made over time. Most areas are now bright, airy and well decorated. Murals and pictures enliven the communal areas of the home. It was noted at the previous inspection that the two bathrooms in the old wing were in a bad condition with substandard flooring, wall covering and missing tiling. The registered manager told the Inspector these were to be refurbished in the near future. This is the subject of an existing requirement that has been re-stated.British Home and Hospital for IncurablesPage 31 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite NO YES NO 120 55 1 0 120 0117 0 1 03 Key findings/Evidence Standard met? Since the last inspection the home has phased out all double bedrooms except one, which it is keeping in case a married couple want to be admitted together.British Home and Hospital for IncurablesPage 32 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 4 Key findings/Evidence Standard met? All service users have large rooms suitable for their disabilities. Those in the new wings have en suite facilities and all others have a wash hand basin. All have ample electrical sockets and a TV aerial point. Some have an internal phone, which can be used, via a central switchboard, to dial outside; some also have a direct external phone. Next to the bed is a control board to control lights and call bell. Some of the rooms have been personalized and service users are able to bring in items of furniture and electrical appliances to help met their wants and needs. At the last inspection the Inspector had noted that most rooms did not have a table and two comfortable chairs. The registered manager had explained that this was because such furniture would not leave adequate room for hoists and other equipment. The registered manager told the Inspector at this inspection that if a second chair was needed it would be supplied. The Inspector noted that some of the rooms seemed plain and bare rather than homely. The Inspector was told by service users they were able to bring in pictures and other items from home should they wish to, but some said they preferred the rooms as they were. It had been reported that one service user had asked for pink walls when her room was decorated. This was done and apparently the result looks good. It was clear to the Inspector by speaking to service users and their relatives that service users were given a choice about how their rooms were decorated. Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The home has ample toilet and bathroom facilities throughout the home, both ensuite and free standing. At the last inspection it was noted that communal toilets do not have locks on the cubicle doors. There was a discussion with the registered manager about this and the Inspector had agreed that service user group where most are wheelchair bound and very few can toilet themselves unaided, it would not be appropriate. If locks were used it would mean that the carer would have to lock the service user in from the outside once they left the cubicle. At the last inspection it had been recommended that locks be fitted so that those service users who are able to use the facilities independently are able to ensure privacy for themselves. The Inspector had further discussions with the matron about the appropriateness of locks on toilet doors and it was agreed that at this time it would be inappropriate to put locks on the doors.British Home and Hospital for IncurablesPage 33 Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 4 Key findings/Evidence Standard met? The home has good provision of communal spaces. On the lower ground floor there are separate rooms for dedicated for the use of the dentist, optician, a counselor and hairdressing. There is also a large physiotherapy area, an art room and a well-equipped sensory stimulation room. In addition each wing has sitting rooms and dining rooms. There is a café area near the shop and sitting areas at the end of each corridor. The home also has a theatre, which is used for functions, as well as activities as keep fit and indoor bowls. The chapel, which is used for services of all faith denominations, is part of the listed building. There are large, well designed grounds at the back of the home. Staff all has ample locker space and changing facilities. The homes smoking policy allows smoking in dedicated communal areas of the home. At the last inspection the Inspector had found this led to a generally smoky atmosphere in some areas of the home. It was recommended that consideration be given to a fuller smoking policy with provision of designated smoking areas. See Standard 16. This recommendation has been met.Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 4 Key findings/Evidence Standard met? The home provides a lot of environmental adaptations for its service users. There is a range of hoists; three out of the four lifts have full length sensors and the estates manager reported that work has been approved to fit one to the remaining lift; rooms have environmental control systems and call alarm systems; there are appropriate specialist baths and where needed surfaces, sinks etc have been lowered. Where service users have sensory impairments provision has been made for talking books, radio, clock radios and Braille watches. There is also good provision for maintenance and repairs of these aids and adaptations. Hoists are checked 6 monthly and serviced annually and someone comes in to repair and maintain wheelchairs weekly and if they cannot be repaired they are taken out of service to be sent away for repair.British Home and Hospital for IncurablesPage 34 Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 4 Key findings/Evidence Standard met? On both days of the inspection the home was found to be clean and hygienic throughout. Domestic services are under the control of the catering manager and during the two days his staff were seen to be monitoring cleanliness regularly. All systems inspected for preventing the spread of infection were in place. The linen room and laundry room has five staff and is very well organized. Soiled laundry is taken through the home in sealed red bags, which are then loaded straight into the washing machines, which has a sluicing program. The laundry walls and floors readily cleanable. There were proper policies and procedures for dealing with clinical waste. For Category E waste, tiger bags are used.British Home and Hospital for IncurablesPage 35 StaffingThe intended outcomes for the following set of standards are: · · · · · · Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the homes recruitment policy and practices. Service users individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? Due to the size of the home it employs a large number of staff but the Inspector found that the philosophy of the home reaches and is understood by all the staff. The Inspectors spoke to staff members with different responsibilities, all of who had a clear understanding of the aims and objectives of the home. Staff members interviewed confirmed that they have been issued with job descriptions. The Matron or registered manager visit all the units on a daily basis, and provide support through formal and informal feedback. Staff have worked with many of the service users over a long period of time and are very proud of their achievements. One service user has been living at BHHI for over 35 years. The registered manager confirmed that all staff had now received their code of conduct from the GSCC. The home operates a group of befrienders, the registered manager reported that these befrienders are not involved in service users personal care or clinical support, but all have been CRB checked.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The home submitted the training plan for 2003 to the commission prior to the inspection and this was examined and found to be in order. The home has a number of staff currently undertaken NVQs and are set to achieve their 50 targets by 2005.British Home and Hospital for IncurablesPage 36 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 25 57 30 X 18 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XX373 Key findings/Evidence Standard met? The Inspector was given copies of the rota, which appear to be in order. BHHI is a large home with approximately 94 registered nurses / care staff. The aim of the home is to have 1 personal care staff to 4 residents on early shift. 1 staff to 7 residents on late shift ad 1 staff to 12 residents on night shift. The Early Shift is 07.00-15.00; the late shift is 13.00-2100 and the night shift 20.50-07.10. In addition to the nurses/ care staff is a physiotherapist and 3 physiotherapist helpers, an art teacher and 3 activity helpers. Ancillary staff are required to be on duty in addition to care staff as well as pantry assistants, porters, laundry staff, maintenance staff, cooks and kitchen staff. There is an overlap for nursing and care staff between the hours of 13.00 and 1500 hours to enable staff to provide a thorough hand over and released for training purposes. The matron and deputy matron are always available by mobile phone or home telephone, and a maintenance person is on-call every weekend evening and bank holidayBritish Home and Hospital for IncurablesPage 37 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 4 Key findings/Evidence Standard met? The home operates a comprehensive recruitment procedure. The matron and registered manager interview all nursing / care staff and records are kept of interviews and follow their own recruitment policy. The registered manager reported that all staff has a three-month probation period and full induction. All staff has been given the GSCC code of conduct.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection but was deemed to have been met at the last inspection.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection but was deemed to have been met at the last inspection.British Home and Hospital for IncurablesPage 38 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self- monitoring, review and development by the home. Service users rights and best interests are safeguarded by the homes policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. YES4 Key findings/Evidence Standard met? The Matron of the home has many years experience working in the health service qualifying as an RGN 38 years ago. She is a registered midwife, has a nursing administration certificate and a BA in social science as well as a D32 in NVQ assessment. In her private life is a Justice of the Peace. The registered manager has been employed as a ward sister nursing office II, senior nursing office I staff officer to DNO, Divisional Nursing officer II (General) and Director of Nursing Services (Acute) at the Bloomsbury Health Authority. She has worked as Matron and House Governor at BHHI since 1987. The manager is responsible to the Board of Management. The home is a registered charity and the manager requires a range of skills in order to fulfil this post. Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The Inspector saw service users and staff feeling free to approach the registered manager to air their views as they walked around the home. The registered manager said at the previous inspection that she tries to be around the home a lot and is always happy to see anyone either by appointment or they can just grab me for a chat. This was apparent as the Inspector was shown around the home. She has meetings on a monthly basis for senior staff and on a six weekly to two monthly basis with other staff. This is cascaded down with the senior staff meeting with the staff who report to them. Before the previous inspection one of the deputies had just started to hold regular meetings with staff where the emphasis is more on a bottom up approach of making sure that management hear the views of staff. There British Home and Hospital for Incurables Page 39 are monthly service users meetings. Only a small number attend but it is intended that they should canvas the views of their fellow users. The registered manager also reported efforts to start a regular relatives group but this is proving difficult and the meetings of relatives / friends tends to take place at social occasions. The Inspector recommends the registered manager continue to hold meeting and distribute minutes to relatives who do not attend.Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? The main quality assurance system that the home has in place is a senior nurse who has been employed to audit systems being used in the home. In the past year she has produced short audits on, for instance, administering medication, night duty and dealing with pressure sores. In the past a small questionnaire was also used to get feedback from service users. One trustee each month does regulation 26 monthly reports, which have been passed, to the Inspector. Trustees at their meetings see the minutes of the service users meetings. The registered manager has been formalizing quality-monitoring systems to ensure that the quality of care is reviewed and improved on a continuing basis. These reports have been shown to the Inspector. This is the subject of a previous requirement that has been met. Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection but was deemed to have been met at the last inspection.British Home and Hospital for IncurablesPage 40 Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 4 Key findings/Evidence Standard met ? The Inspector was shown records of how the service users finance was administered which was accurate and up to date. Guidelines are in place to ensure that a service user is supported to handle money safely. The Inspector interviewed everyone who works with the service users to help them to claim income support, negotiate with local authorities, and talk to service users relatives regarding any financial queries that they may have. The Inspector was impressed with the cross referencing system that is in place and could see that the home was operating good practice procedures. From the discussions the Inspector had with the staff in the finance department and the matron, it was clear that they were aware of their responsibilities and to promote good practice at all times. Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The Health and Safety systems needed in the home were in good order. The fire safety systems were up-to-date and well recorded. The estates manager reported that he is in contact with the local brigade to ensure compliance with all aspects of this area of concern were met. Last LFEPA inspection was on the 10/03/04. Room by room fire risk assessments of the premises is now in place. This will be reviewed annually and when a service user vacates the room. This was the subject of a previous requirement that has been met. The fire doors had been refurbished. Fire drills conducted on a 3 monthly basis. Food hygiene in the kitchen was excellent. COSHH legislation was in place and handled with great care. The catering manager has introduced a system to ensure all items were traceable to the floor that had ordered them, so if they were found anywhere where they shouldnt be, he could identify which staff had left them there and take appropriate action. There were regular checks for legionella and all electrical and heating systems were regularly checked as well as the lift. Small electrical appliances had been tested. Weekly hot water outlet logs were seen by the Inspector and were up to date.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 4 Key findings/Evidence Standard met ? The homes accounts and budget are published as part of the annual report. The Inspector saw the budget up to December 2003 and all was in order. Insurance certificates were seen to be up-to-date.British Home and Hospital for IncurablesPage 41 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateLynne Field Alan Thomas 08.01.05Signature Signature SignatureBritish Home and Hospital for IncurablesPage 42 Public reports It should be noted that all CSCI inspection reports are public documents.British Home and Hospital for IncurablesPage 43 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 15th & 16th July 2004 of The British Home and Hospital for Incurables and any factual inaccuracies: Please limit your comments to one side of A4 if possibleBritish Home and Hospital for IncurablesPage 44 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The Inspector believes the report to be factually accurateYESYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. ,You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here British Home and Hospital for IncurablesPage 45 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Noelle Kelly of The British Home confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Matron and House Governor 08/01/05 Noelle KellyPrint Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.British Home and Hospital for IncurablesPage 46 British Home and Hospital for Incurables / 15th July 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000032400.V168354.R01© This report may only be used in its entirety. 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