Inspection on 15/01/08 for Bryden House Nursing Home

This inspection was carried out on 15th January 2008.

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

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

Other inspections for this house

Bryden House Nursing Home 21/01/10

Bryden House Nursing Home 16/02/09

Bryden House Nursing Home 09/01/07

Bryden House Nursing Home 27/10/05

Bryden House Nursing Home 11/05/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bryden House Nursing Home Marlpool Lane Franche Kidderminster Worcestershire DY11 5DA Lead Inspector Andrew Spearing-Brown Unannounced Inspection 15th January 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bryden House Nursing Home DS0000065225.V349480.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. Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bryden House Nursing Home Address Marlpool Lane Franche Kidderminster Worcestershire DY11 5DA 01562 755888 01562 755887 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) www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Rosemary Jean Watkins Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability over 65 years of age of places (30) Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate a maximum of 6 people aged 55-65 years in either of the above categories. 9th January 2007 Date of last inspection Brief Description of the Service: Bryden House Nursing Home is registered to provide care for up to 30 older people who may have physical and sensory disabilities or may experience mental health problems. The home is also able to accommodate up to 6 people aged between 55 - 64 years. Southern Cross Healthcare owns the home. The home provides accommodation on all three floors. The home is located on the outskirts of Kidderminster town centre. Parking for visitors is provided. There are communal lounges, dining rooms, toilets and specialist bathrooms within the home. All bedrooms at Bryden House offer single accommodation. A section within the Service Users Guide makes reference to the payment of fees however the actual charges are not detailed. The reader should therefore contact the service directly for up to date information regarding the fee charged and for details regarding what is included within the fee. Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out without prior notice. One Regulation Inspector visited the home on a number of separate occasions, while another Inspector attended the home on the first day only. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was sent to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with us areas where they believe they are doing well. This document was returned to us as required. As part of the inspection process a number of questionnaires were sent to a sample number of people using the service, their relatives and health care professionals. A number of completed questionnaires were returned to us prior to our visit. Comments within these questionnaires are included within this report. The registered manager was present throughout this inspection. We also spoke to a number of other members of staff including the deputy manager as well as people using the service. A brief look around the home took place, which included communal areas. The care documents of a number of people using the service were viewed including care plans, daily records and risk assessments. Other documents seen during our visit included medication records, staffing training and recruitment records. What the service does well: Information is available for potential users of the service. The service obtains information prior to somebody’s admission to ensure that care needs can be met. People using the service appeared well attired and well cared for. Privacy and dignity matters are taken into account. We received some good comments about the service provided from representatives of people using the service and General Practitioners who visit the home. Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 6 An activities coordinator is employed who arranges a range of social events for people to participate in if they wish. We have received some positive comments regarding the food provided. A suitable complaints procedure is available and staff have received training in adult protection. These areas assist in safeguarding people against potential abusive situations. The organisation has well developed quality assurance systems. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 7 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 Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 is not applicable. Quality in this outcome area is adequate Pre-admission assessments and initial care plans are sufficient to ensure that the home can meet the individual care needs of people who are going to live there. Prospective people to use the service and their representatives have information available to them to assist in choosing the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of both the Statement of Purpose and the Service Users Guide was available within the reception area of the home. The Service Users Guide states that it is also available on audiocassette. Our last key inspection report stated that the ‘admission of new service users takes into account the individual needs, concerns and anxieties of the prospective service user and their families.’ As part of this inspection a couple Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 9 of pre admission assessments were viewed. These documents are necessary to record that a suitably training person has assessed whether the home would be able to meet identified care needs. A satisfactory pre admission assessment was seen which captured the basic care needs. From this assessment an initial care plan was generated. An internal document entitled New Service User Admission Checklist was seen. This document stated that the list ‘must be completed within 24 hours of admission’ there was no evidence that this was done. Other documents within the individuals file such as risk assessments were blank despite identified care needs in some areas. Another pre admission assessment, which again covered basic care needs, was not dated or signed by the person who had carried out the assessment. Bryden House does not provide intermediate care and the commission have no knowledge of any plans that the home has to provide this service in the future. Bryden House Nursing Home DS0000065225.V349480.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate The care needs of people using the service are not always consistently set out within care plans and risk assessments. The management of medication needs to improve to ensure practices are safe. Staff demonstrated a good understanding of the needs of the people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A random sample of care plans were viewed as part of this inspection. Some of the care plans required more information to provide an accurate detailed reflection of the health and personal needs of people using the service. One person had angina but no care plan was in place while some others required strategies in relation to diabetes. Other entries such as ‘Ensure ** has adequate fluid’ or ‘ Observe urine, colour amount’ failed to guide staff as to the plan of care devised and failed to inform staff of the actions they should be Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 11 taking to meet these care needs or the action to be taken if unable to meet the need or signs to look out for such as problems with somebody’s diabetes. One care plan identified a care need and stated that ** is unable to carry out his/ her personal hygiene. No details as to how this was to be achieved were recorded. A number of care plans giving instructions to staff appeared to have later amendments due to different handwriting. These potential amendments were not dated, however the manager stated that these were actually added on the same day as the original entry. It was of some concern that we received some mixed messages as to whether or not a person using the service continued to have an infectious condition. The only way of establishing whether the condition was clear was via a swab and this had not happened. Despite the shortfalls in care planning we saw no evidence during this inspection that personal and health care needs are not met. People using the service have access to services such as community nurses and opticians. As part of this inspection a review of the management of medication took place. At the time of the random inspection (July 2007) we had a number of concerns that needed to be addressed regarding the recording of medication and the need to ensure that medication was available. The qualified nurse on duty holds the keys to the medication along with some other keys. We were assured that these keys would not be handed to any unauthorised person. The medication trolley was clean and tidy. A number of the current months Medication Administration Record (MAR) sheets were viewed. A sheet showing a specimen signature of each person authorised to administrate medication was held. Details of any known allergies were not always recorded on the MAR sheets, if none are known this should also be recorded. We had some concern about the information recorded regarding medication prescribed on differing doses on certain days of the week to one individual. The records indicated that the incorrect dose was given. Due to the fact that the medication was not booked into the home an audit of the stock held was not possible. The registered manager undertook to investigate these findings. At the time of writing this report we had not received a copy of the outcome of this investigation. It was possible to carry out an audit of some painkillers. The audit did not balance as we found 4 too many tablets remaining. Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 12 We saw some evidence that medication may at times be signed for prior to administration as signatures were over signed with a code such as one for refused. When medication was prescribed on a variable does we saw evidence that the actual amount given is recorded on the individual’s MAR sheet. The supplying pharmacy visited the home to carry out an audit during October 2007. A number of recommendations were made as a result of that visit. The majority of these recommendations have received the necessary action. It was noted that regarding homely remedies the pharmacist stated ‘none used’. During this inspection we found a supply of homely remedies although the nurse on duty was not aware of their existence. Temperature records are maintained of both the fridge and the room in which medication is held. The room was warm, this needs to be carefully monitored and suitable steps should be introduced if the temperature levels exceed the limit for medication storage. A suitable reference book (BNF) regarding medication dated March 2007 was available. We saw no evidence that the privacy and dignity of people using the service is not maintained. People using the service looked suitably attired taking into account gender issues and the weather conditions. Bryden House Nursing Home DS0000065225.V349480.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good Social and recreational activities are provided to meet individual’s expectations. People are offered a choice of nutritious, wholesome and wellbalanced meals that helps in maintaining their health and wellbeing. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A dedicated activities coordinator is employed for 24 hours per week. These hours are divided into shifts consisting of 6 hours per day Monday – Thursday each week. During these hours this member of staff is able to, along with some other duties, work directly with people using the service to ensure that they are provided with opportunities for stimulation, and are enabled to do the things they enjoy. Activities include bingo, quizzes, cards, pub lunches or watching a video. Another member of staff was reported to do a couple of hours on a Friday. Information is displayed in the foyer regarding activities. Throughout our visits to the home the information on display was for December 2007 (this inspection Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 14 took place during the second half of January 2008). Following the inspection we were provided with a copy of a four weekly schedule, this included events similar to those above plus manicure and massage, gentle exercise and crafts. We were informed that entertainment is provided about once per month. No dedicated hours are provided over the weekend to enable social or leisure activities. Sundays are described as ‘Quiet Day’ on the social activity sheets. The majority of people who responded to our survey when ask whether activities are arranged by the home stated either ‘always’ or ‘usually’. One person stated ‘There is but I don’t wish to take part’. One relative stated that they felt that ‘Whilst the home does the aspect of socialization reasonable well, I guess there could always be more . . . . ’ A hairdresser visits twice weekly. The prices charged were displayed in the reception area. During the previous random inspection a relative commented that ‘hair is always done’. Similar to the random inspection visit it was noted that people using the service appeared to have clean and tidy hair. Documentation regarding activities such as individual plans of care were insufficient. Some people had no care plan at all while those that were in place were often not dated or contained no evaluation. During our visits everybody was within their own bedrooms as the management were concerned about a possible outbreak of a sickness bug, which was prevalent within the local area. Therefore we saw no group activities taking place. As a result of the above concern no meals were served to people using the service within the communal dining areas. Meals were plated from a heated trolley located in the hallway. On the first day of this inspection the mid day meal consisted of beef stew and dumplings or meatballs (pork). We were informed that vegetables consulted of 1 fresh and 1 frozen. Staff appeared to have knowledge regarding the likes and dislikes of individuals. The meals looked well presented. One person commented that ‘The meals are homely and ample.’ In response to our survey the vast majority of people indicated that they enjoy the meals although one person stated ‘if dinners are warm.’ During our visit one person stated ‘can’t say it’s cold’ and ‘food very good’ another person stated that the food is ‘faultless’ with ‘lots of variety.’ It was stated that it is planned to obtain some food moulds therefore possible to reshape an item such as liquidised carrots into an identifiable shape The menu was displayed in the entrance hall of the home. The size of the font was however very small making it very difficult to read. We were informed that the menu was also available within the dining areas, this was not found to be the case during our visit. Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. The service has a complaints procedure, which is accessible to people using the service and therefore carers therefore assuring people that any concerns will be dealt with appropriately. Staff have attended training upon safeguarding to ensure that they are aware of their responsibility in the event of suspected abuse occurring. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection the registered manager had just completed her investigation following a formal complaint made by a relative of somebody who used to reside within the home. The registered manager did not up hold any of the allegations made. We were aware of the circumstances of the complaint and the matter was also referred to the local safeguarding coordinator employed by Social Services. A multi agency meeting was scheduled to take place a few days after this inspection. The overall outcome of this inspection was reported to this meeting where upon it was agreed that a full review of training needs would take place and be reported back to the members of the meeting. Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 16 The complaints procedure was displayed within the home. In addition a procedure was also included within the Service Users Guide which was available in the entrance hall. The procedure gives an address by which the Commission for Social Care Inspection can be contacted. During the visit to the home one person when asked about making a complaint stated that she ‘would speak to Rosie’ (registered manager). Comment cards were freely available within the reception area. The card states ‘We welcome your comments on the service provided by Southern Cross Healthcare. Please leave the completed card with Reception or post to the address overleaf.’ At the same time as this inspection was taking place we received a letter complementing the service provided at Bryden House. The AQAA and information displayed within the home demonstrated that the manager holds a regular ‘surgery’ when she is available to speak to representatives and people who use the service. The vast majority of staff have undertaken ‘ Abuse and PoVA’ training during the last 12 months (Protection of Vulnerable Adults). In discussion with care staff it was evident that staff are aware of the actions they should take in the event of actual or potential abuse happening at Bryden House. Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 25 and 26 Quality in this outcome area is adequate The environment in which people reside to generally safe and comfortable. Improvements are necessary to ensure care needs are met especially regarding the supply of hot water. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home may accommodate up to 30 people. Bedrooms are provided on all three floors of the home. All bedrooms offer single accommodation, seven bedrooms have en-suite facilities. People who use the service are able to personalise their own bedrooms. At the time of this inspection work was underway to improve bathing / showering facilities. Bathing facilities will consist of one bath with a hoist on Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 18 the ground floor, a bath and a shower room on the first floor and a bath (without a hoist) on the second floor. During a tour of the home we noticed some personal toiletries within a bathroom including a comb, a notice was displayed reminding staff to return items to peoples bedrooms after use. As part of the review of facilities a new hairdressing salon is going to be fitted on the second floor. It is planned to make the hairdressing facility available to relatives as well as people using the service to make the experience more personal. The environment is generally to a good standard. The manager is aware of some areas where improvements are needed and these are scheduled to take place. Although we have received some comments about bad odours within the home none were detected during our visits to the home. It became evident during this inspection that Bryden House has had problems with hot water supply to some parts of the home for a number of months. It was apparent that a problem with a boiler was brought to the attention of the company sometime ago however the problem continues. Some bedrooms had hot water temperatures recorded to be as low as 14° C (the cold water was the same temperature). One bedroom was tested during the inspection the hot water ran cold. It was reported that an officer from Hereford and Worcester Fire Authority was due to visit the home shortly after this inspection. The findings of that visit will be taken into account as part of a forthcoming inspection made by the commission. A fire risk assessment dated August 2007 was briefly viewed. Occasional gaps were seen in the weekly fire log; it appeared that these were when the maintenance person was on annual leave. A number of doors were recorded as not closing however it was established that these were doors without self closures leading to areas such as linen cupboards. Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate Mandatory raining is provided however some employees have not undertaken any clinical up dates for a period of time which could potentially place people using the service at risk or result in care needs not being fully met. Staffing levels are usually sufficient to meet care needs. The recruitment procedures that are in place need some improvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We asked staff on a questionnaire whether there are enough staff on duty to meet individual needs. The responses were equally divided between ‘Always’ and ‘Usually’. Staff rotas confirmed that at least one qualified nurse is on duty 24 hours per day. It was reported that 5 carers are usually on duty during the waking day. Recent rotas were viewed and generally confirmed that this number of staff had been present within the home. We did however note a couple of occasions when this level of staffing was not in place. It was of some concern to note Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 20 that one a recent Sunday only 3 carers had worked. It was stated that agency staff are not used. Two carers and a nurse cover the night shift apart from at the weekend when three carers and a nurse are on duty. We examined the staff training records these showed that generally the mandatory training was up to date, any slippage or need for refresher training in the near future was identified upon a training matrix. However some shortfalls were evident in clinical training or refreshers for some of the nurses. Shortfalls identified included wound care and diabetic care. Following this inspection the manager and deputy manager made contact with the local Primary Care Trust who provides free training for homes providing nursing care to access. It was reported that palliative care training including the use of syringe drivers was already scheduled to take place during April 2008 According to the AQAA document, submitted prior to this inspection, and then discussion during the inspection a total of seven carers currently hold a level 2 NVQ (National Vocational Qualification) or above. Although a number of staff are currently working towards this qualification the number of staff trained to this level continues to be below the National Minimum Standard which is 50 of care staff. The files of a number of newly appointed employees were viewed. The files were generally satisfactory although some concerns were discussed at the time of the inspection with the registered manager. On one file a reference was initially missing, this was located prior to the end of the final visit to the home. Another file did not contain an application form applicable to the employee’s current position. Files contained evidence that suitable CRB (Criminal Records Bureau) checks are carried out. Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is good Management systems within the home have improved in order to ensure a safe, open and respected service is in place. An effective quality assurance system is in place and the staff team is lead by a qualified manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last key inspection the manager has become registered with the Commission for Social Care Inspection. The manager was registered with us at the time of a random inspection, which we carried out during July 2007. The manager is a registered nurse and has completed the Registered Managers Award which is a level 4 NVQ (National Vocational Qualification). The manager Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 22 has attended mandatory training provided since taking on the role and will attend further training which will take place (some as a result of this inspection) in the future. The manager feels that the home has improved over the last 12 months however she is aware that further improvements are necessary in order to provide a service which is able to meet all the required standards and to ensure further positive outcomes for people using the service. One member of staff commented ‘Overall everything is very good. Management is very alert and active.’ We received a letter from a relative of somebody who recently died at Bryden House. ‘Family & friends will never forget the care & kindness shown by all members of staff, who gave generously of their love and time. The ethos from management was obvious: People first.’ Under Regulation 26 of the Care Homes Regulations a representative acting on behalf of the company needs to visit the home on a monthly basis and prepare a written report. The registered manager confirmed that these visits take place although only a few reports could be found. The organisation has developed systems for quality audits for all areas and seeks the views of people who use the service. At the time of the inspection the registered manager was carrying out some further audits. The Service Users Guide provides the collated results from a ‘Client Satisfaction Questionnaire’. The guide acknowledges that the results are based on a response rate of 28 however they show that the majority of the results were favourable. Some additional comments and a response to the comments are also included within the guide. We viewed the records regarding money held in safekeeping for a number of people using the service. The records were well organised and in good order. Due to the system in place it was not however possible to check any actual balances. The registered manager and deputy manager are aware of the National Minimum Standard in relation to formal supervision sessions with carers. Although the standard was not met during 2007 plans are in place to ensure that staff receive the necessary level of supervision sessions during the current year. It was noted that we had not received any notifications of incidents which had happened in the home for a considerable period of time. It became evident that this was due to a miss understanding as to who was forwarding these to the commission between the home and the regional office. This matter was sorted at the time of the inspection and no further problems are anticipated. Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 23 A random sample of service records were viewed and found to be in order. A range of regular safety checks are carried out including window restrictors and wheelchairs. The records regarding these checks were in good order. Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X X 1 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans need to be improved to fully reflect all identified care needs. Care plans need to give strategies for staff to meet care needs and are to be reviewed on at least a monthly basis. Timescale for action 31/03/08 2. OP9 13 (2) The previous timescale for action prior to 31/07/07 was not fully met. This requirement must be met in full. Medication Administration Record 15/01/08 (MAR) sheets are to be completed at the time of administration. Either a signature or code for why the medication was omitted must be in place. The previous timescale for action prior to 08/07/07 was not fully met. This requirement must be met in full. Attention must be given to the central heating system in order to maintain a suitable environment for the comfort of people using the service. Suitable and sufficient staff must DS0000065225.V349480.R01.S.doc 3. OP25 23 (2) (p) 31/03/08 4. OP27 18 (1) 28/02/08 Page 26 Bryden House Nursing Home Version 5.2 5. OP30 18 (1) be on duty at all times to ensure the health safety and welfare of people using the service. Staff must receive suitable and 31/03/08 appropriate training in relation to the work they are doing in order to meet identified care needs. An action plan as to how and when this is to be achieved must be in place within the timescale given. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP36 Good Practice Recommendations Staff supervision should be provided in line with the National Minimum Standards for older people. Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Paradise Circus Queensway Birmingham B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bryden House Nursing Home DS0000065225.V349480.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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