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Inspection on 11/02/08 for Bryher Court Nursing Home

Also see our care home review for Bryher Court Nursing Home for more information

This inspection was carried out on 11th February 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Bryher Court provides a spacious, comfortable and pleasing environment that is clean and satisfactorily maintained. The food provided is of a good quality and enjoyed by the residents. The atmosphere at the home is relaxed, with communication between staff and residents open and friendly. The staff and management of the home are welcoming to all visitors and staff were found to be very helpful, this positive approach was commented on by all people spoken to about the service. The standard of care was found to be good with the health care needs of residents being responded to in a proactive way.

What has improved since the last inspection?

Eight requirements were made at the last inspection and although some of these have been addressed some have not been met and some have been partially met. Those that have not been met are reflected in this report. Improvements have included Staff have received training on safe guarding vulnerable adults and the recruitment practice has been reviewed to include retention of the required documentation.

What the care home could do better:

A suitable manager needs to be appointed to provide the necessary management in all aspects of the homes running. The management of the home needs to ensure that all prospective residents are suitably assessed and that the home confirms in writing to the prospective resident or their representative that with regard to the needs assessment completed the home can meet the needs of the prospective resident. This ensures that decisions around admission to the home are informed and evidenced. The care documentation needs to be improved to promote person centred care and to ensure all risks are suitably assessed and evaluated to ensure residents receive the best and safest care. Residents or their representatives need to be involved in the planning of care practice. A suitable storage facility needs to be provided to ensure the safe storage of controlled drugs. Staff need to be vigilant to ensure the safest handling of medicines and appropriate record keeping. There must be a protocol in place to meet the National Institute for Clinical Excellence (NICE) guidelines for pressure area care and the home`s quality assurance processes need further development to ensure that the views of service users are instrumental in the development of the service the home provides.The recruitment practice needs to be improved to ensure all the necessary checks are completed by the home before staff start to work in the home. This will ensure robust recruitment practice is followed and safeguard residents. A clear complaints procedure must be made available to all interested parties and all complaints received must be recorded clearly along with the action taken in response to them to evidence that complaints and concerns are taken seriously and used to improve the service provided. Staff need to receive regular supervision to monitor their performance and develop their skills.

CARE HOMES FOR OLDER PEOPLE Bryher Court Nursing Home 85 Filsham Road St Leonards On Sea East Sussex TN38 0PE Lead Inspector Melanie Freeman Unannounced Inspection 11th February 2008 09:30 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 Bryher Court Nursing Home DS0000013969.V357913.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. Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bryher Court Nursing Home Address 85 Filsham Road St Leonards On Sea East Sussex TN38 0PE 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) 01424-444400 01424 440011 Barron Kirk Quality Care Limited vacant post Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45), Physical disability (45) of places Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum service users to be accommodated is forty-five (45). Service users must be older people aged sixty-five (65) years or over on admission. Service users with a physical disability may be accommodated. Date of last inspection 27th September 2006 Brief Description of the Service: Bryher Court is a large detached building, set in its own grounds in a residential area of St. Leonards-on-Sea. The Home provides nursing and personal care for up to 45 patients of an older age. Administrative, catering, cleaning and maintenance staff support registered nurses and care staff, in fulfilling the patients’ needs. The accommodation is arranged over three floors: two internal passenger lifts enable access to all parts of the building and all areas are therefore accessible for those with limited mobility. There are hoists and bath hoists as well as grab rails and disability aids in the bathrooms and toilets. A lounge and large conservatory, which is used as a dining area, provide communal space and a large garden area to the rear also provides a relaxation area in the warmer weather. At the front of the building there is a large parking area for approximately ten cars. The home welcomes prospective residents or their representatives to view the premises, discuss their needs with the manager and spend time with the staff and residents. Weekly fees range from £500 - £660 as at 11/02/08, for full nursing care. The fees depend on the room occupied and do not include hairdressing, chiropody and any sundries, such as newspapers, toiletries or taxis: these are charged as extras. Information about the service is available from the home’s manager. Bryher Court Nursing Home DS0000013969.V357913.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. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Bryher Court Nursing Home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with two relatives and a visiting health care professional. The allocated inspector spent approximately eight hours in the home and was able to discuss matters with the acting manager who facilitated the inspection. During the assessment visits the inspector was able to spend most of her time meeting with the staff, residents and observing practice in the home. A brief tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose and service users guide, pre-admission assessment procedures, the systems in place for handling complaints and protecting residents from harm, staff recruitment files, quality assurance systems and some health and safety records. The care documentation pertaining to three residents were reviewed in depth. At the time of compiling the report, in support of the visit, the Commission received survey forms about the service from 5 relatives and 10 residents. The required Annual Quality Assurance Assessment (AQAA) was completed by the home manager, who has since left the home. The contents of the AQAA have been used to plan the inspection and inform the report. Although three requirements have had to be repeated in this report in order to promote a proportional approach it was judged that the instability caused by the new manager leaving the home has contributed to this. If these are not addressed within the timescales recorded the Commission may be minded to take enforcement action in the future. What the service does well: Bryher Court provides a spacious, comfortable and pleasing environment that is clean and satisfactorily maintained. The food provided is of a good quality and enjoyed by the residents. Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 6 The atmosphere at the home is relaxed, with communication between staff and residents open and friendly. The staff and management of the home are welcoming to all visitors and staff were found to be very helpful, this positive approach was commented on by all people spoken to about the service. The standard of care was found to be good with the health care needs of residents being responded to in a proactive way. What has improved since the last inspection? What they could do better: A suitable manager needs to be appointed to provide the necessary management in all aspects of the homes running. The management of the home needs to ensure that all prospective residents are suitably assessed and that the home confirms in writing to the prospective resident or their representative that with regard to the needs assessment completed the home can meet the needs of the prospective resident. This ensures that decisions around admission to the home are informed and evidenced. The care documentation needs to be improved to promote person centred care and to ensure all risks are suitably assessed and evaluated to ensure residents receive the best and safest care. Residents or their representatives need to be involved in the planning of care practice. A suitable storage facility needs to be provided to ensure the safe storage of controlled drugs. Staff need to be vigilant to ensure the safest handling of medicines and appropriate record keeping. There must be a protocol in place to meet the National Institute for Clinical Excellence (NICE) guidelines for pressure area care and the home’s quality assurance processes need further development to ensure that the views of service users are instrumental in the development of the service the home provides. Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 7 The recruitment practice needs to be improved to ensure all the necessary checks are completed by the home before staff start to work in the home. This will ensure robust recruitment practice is followed and safeguard residents. A clear complaints procedure must be made available to all interested parties and all complaints received must be recorded clearly along with the action taken in response to them to evidence that complaints and concerns are taken seriously and used to improve the service provided. Staff need to receive regular supervision to monitor their performance and develop their skills. 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. Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents, with a good level of information about the home, its facilities, services and the costs involved. The admission procedures do not ensure that all prospective residents are fully assessed by a competent person before admission and are not assured that their needs can be met by the home. EVIDENCE: The home has a combined statement of purpose and service users guide contained within the homes brochure. This document was available from the administrator who confirmed that it is given and sent out to anyone making Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 10 enquiries about the home. The brochure was informative but needed to be updated to reflect the current management arrangements, a full complaints procedure, to include room sizes and residents views on the service. The last inspection report was not available on request and the acting manager said that the documents would be updated and that the last inspection report would be made available. An assessment of the admission process included a review of the documentation used in respect of two recent admissions to the home. One of these residents had no record of an assessment and the other was minimal. The acting manager said that pre-admission assessments are completed and that the prospective resident and their representatives are advised verbally that the home can meet their needs. This confirmation needs to be confirmed in writing whenever possible. Intermediate or rehabilitative care is not provided at Bryher Court Nursing Home. Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst the care documentation provides a framework for the provision of care it needs to be developed to promote person centred care that covers individual choices preferences and risks. Resident’s health and care needs are met with evidence of regular input from health care professionals as necessary. The homes practice does not ensure resident’s medicines are stored and administered safely, residents are treated with respect and have their privacy and dignity maintained. EVIDENCE: Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 12 The care documentation pertaining to three residents were reviewed as part of the inspection process and each of these residents were met with during the inspection visit to the home. Each resident has a well-documented care assessment following admission and from this care plans are developed. Although the care plans are individual and indicated that regular reviews are undertaken, they were not person centred, did not address the psychological needs of the resident, and were not completed in consultation with the resident or their representative. Documentation records community health care professionals regular input into care when required. Daily records are maintained and are completed by those providing the care. Risk assessments are not always clearly documented and need to identify action to be taken to minimise any risk and be based on clear criteria. In addition the risks associated with pressure sore development and care provided afterwards need to be clearly recorded with evaluation of the care provided. The shortfalls in the care documentation were discussed with the acting manager who acknowledged them and had a good understanding of how they can be improved. All residents spoken to were very satisfied with care provided at the home and this view was supported by the surveys received. One relative commented ‘The care in the home is very good’ and a resident talked about the choices she made through out the day that were responded to. A visiting health care professional was also positive about the care provided saying ‘the residents are given a good standard of nursing care’. The home has a new medicine storage room and although this provides a good facility it was noted that appropriate storage facilities for the controlled drugs in the home had not been provided. It was also noted that Temazepan was not being handled in a way that fully safeguarded residents and staff. During the visit a pot with two unidentified tablets were found, these were immediately removed by the acting manager who was reminded of the importance of ensuring the correct procedures for administration are followed at all times. On the whole the records relating to medicines were satisfactory although when a medicine is not given the reason for this must be clearly recorded. Some residents are prescribed medicines on an ‘as required basis’ and individual guidelines need to be provided so that residents receive medicines, as they need them. Clear policies and procedures need to be provided to underpin the practice in the home. Throughout the inspection visit staff were seen to be attentive and kind to residents and to speak to them in a respectful way. Bryher Court Nursing Home DS0000013969.V357913.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): 12, 13, 14 and 15 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Links with friends, relatives and the community are encouraged and choices made are respected. The pastimes and activities that are available support the residents to experience a lifestyle that matches their expectations and preferences. They also benefit from varied and nutritious meals. EVIDENCE: A large lounge and conservatory on the ground floor at Bryher Court enables residents to sit together and watch television, read or meet with their visitors. Videos, books and games are available and there is an occupational therapy session organised twice weekly, which includes movement activity and discussions and activity around the news and history. Individual staff time with residents is encouraged and the visiting priest is an important part of the home. Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 14 Other events are organised for special occasions. Residents and their relatives are told verbally about the activities and special events are publicised in written format. Most residents who shared a view felt that there was activities that they could join in with. Some residents however felt they were not suitable and mostly entertained themselves and wanted more outings and trips. The acting manager said that she thought this would be possible and further individual assessment would identify individual needs. Visiting is very much encouraged and it was clear from observation and contact with relatives that people are welcomed and feel comfortable when they visit. Visitors are able to eat with the residents and the inspector noted that a daughter was able to eat with her mother along with her great grand daughter. Where possible residents are encouraged to maintain links with the local community with one resident saying that she attends a luncheon club. The home does not currently act as the appointee for any resident. Residents are encouraged to bring in personal possessions with them and all residents spoken to like their rooms, which were found to be attractive and personalised. Staff were seen to be respecting residents’ privacy by knocking before entering. Meals can be eaten in the conservatory or alternatively some residents prefer to eat in their own rooms. The Inspector had a meal with the residents in the dining room and this was found to be a social event in a pleasant environment. The home has a new chef who started to work in the home in December and residents have noticed a great improvement in the food provided. All residents spoken to were positive about the food and choice available and said ‘the food is always good now’ ‘ the food is good’. Bryher Court Nursing Home DS0000013969.V357913.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): 16 and 18 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst people felt that their complaints would be responded to the complaints procedure is not clear and complaints are not being recorded to demonstrate how they are investigated and resolved. Whilst staff are given training on adult protection matters the homes procedure does not ensure staff respond effectively and appropriately to an allegation or suspicion of abuse. EVIDENCE: The homes complaints procedure does not clearly set out the procedure that the registered person would follow on receipt of a complaint. It does not identify the timescales for a response and investigation in accordance with the required framework. Records held in respect of complaints were found to be incomplete as although the acting manager said that there had a been a written complaint since the last inspection there was no record of this in the complaints folder. There is no clear system for recording complaints, the investigation and the response to any findings. Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 16 An Adult Protection (safeguarding vulnerable adults) procedure was not available at the time of the inspection visit and the acting manager was not aware of the new local procedures that had been updated in June 2007. Further discussion confirmed that she had a good understanding of Safeguarding Vulnerable Adult matters and is working closely with Social Services on securing the ongoing safety of a resident. Records and staff spoken to confirmed that training on abuse has been given to most staff. Bryher Court Nursing Home DS0000013969.V357913.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): 19 and 26 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, suitable and clean environment for those living in the home and visiting. EVIDENCE: Bryher Court is situated in a residential part of St Leonards on Sea. It is a large detached property that provides accommodation and facilities over four floors, all of which can be accessed by stairs or a lift. There is a good size lounge on the ground floor, which leads into a large conservatory. The garden area has been improved over recent months and benefits from a large patio area, which is accessed from the conservatory. Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 18 The home was found to be clean and odour free with a light and airy environment and space for residents to enjoy different areas that allow for private visiting and time alone. All residents spoken to liked their own rooms that they are able to personalise and were found to be well decorated. It was noted that some of the beds in use are old and need replacement. The acting manager confirmed that this has been identified and that there was a schedule for replacement in place. It was also noted that all bedroom doors have windows in them, although curtains are in place when drawn back any one passing the room can look into a resident’s private accommodation. This privacy issue needs to be discussed with each resident with their views and wishes being responded to. The acting manager said that she would respond to this matter. During the inspection it was noted that many of the rooms are being upgraded to provide en-suite toilets and washing facilities. The communal bathing facilities are also being improved with disabled shower facilities being provided. This works is being completed in a rather disorganised fashion and needs to be planned and completed in a way that causes minimal disruption to residents and staff. Once these improvements are completed it may change the use of some rooms and this needs to be reflected in the statement of purpose. Infection control practice was found to be appropriate with staff wearing appropriate protective clothing. Domestic staff were working throughout the home ensuring a high standard of cleanliness. Residents were seen to be well dressed in well-laundered and ironed clothing. Bryher Court Nursing Home DS0000013969.V357913.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): 27, 28, 29 and 30 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is sufficient staff that are suitably trained on duty to ensure that residents receive the level of care they need although ongoing staff training needs to be established. Residents are not fully protected by the home’s recruitment procedure. EVIDENCE: At the time of this assessment visit 33 residents were living at Bryer Court Nursing Home, the residents have a mixed dependency most needing a high level of support. Staffing arrangements provide three registered nurses in the morning with two in the afternoon/evening these nurses are supported by seven and four care staff accordingly. Staffing levels on this day were found to be satisfactory with resident needs being attended to although time for one to one interaction with residents was rather limited. Two residents spoken to felt that staff were always very busy Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 20 with no time to talk and one resident said she would like more baths. These views were shared with the acting manager who felt that the improvement to the bathing facilities would enable residents to have more frequent showers if wanted. Discussion with the management confirmed that the home has a commitment to supporting staff through their National Vocational Qualification with six staff completing this training at the moment. The previous manager was planning and organising a rolling programme of training for all staff in the home. This plan needs to be followed through to ensure all staff receive appropriate training to meet the needs of residents in the home. The recruitment files pertaining to the three staff were reviewed as part of the inspection process and whilst most documentation and records were full and included Criminal Records Checks and POVA checks on all staff however it was noted that one staff member had no record that references had been sourced. It was also noted that staff had not completed a health questionnaire and a recent photograph was not held on file along with terms and conditions of employment. These shortfalls were identified to the acting manager who said that she would follow up on the references that were not available. Individual files held on staff confirmed that staff complete and induction programme. Bryher Court Nursing Home DS0000013969.V357913.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): 31, 33, 35, 36, 37 and 38 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Bryher Court is run in a friendly manner although the current management arrangements are not providing an appropriate management structure. Quality assurance processes need further development to ensure that the Home is run in the best interests of residents. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff are generally promoted and protected although practice in the home needs to be supported by appropriate policies and procedures. EVIDENCE: Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 22 The acting manager, who has worked in the home as the deputy manager for a number of years, confirmed that the appointed manager who had been in post for nine months left the home in December 2007. The homeowner has asked her to take on this role on a temporary basis until another manager can be appointed. She continues to work providing direct care and her time available to fulfil the management responsibilities is minimal. She is well respected by the staff’ residents and visitors to the home and is very approachable and makes herself available to discuss any issue. Records held by the CSCI did not include the necessary notification from the homeowner that the appointed manager had left the home or what management arrangements had been put in place. There was no evidence that the home had sought residents and their representative’s views on the service and care provided by the home as part of their quality monitoring system. The home has however completed an AQAA that demonstrated areas of improvement had been identified for action in the future. Either the residents at the home manage their own financial affairs or relatives or solicitors act on their behalf. The home does not act as the appointee for the financial affairs of any of the residents. Residents or relatives pay for services not included in the fees, either as cash on a monthly basis or as part of their monthly bill. Although some of the senior staff have attended training on completing staff appraisals and supervision, there is still no formal process whereby staff have individual time for regular supervision and appraisal this would provide them with the opportunity to discuss all aspects of practice, the philosophy and care in the home and the career development needs of the individual. In general, there is evidence that the home is managed in a way that ensures as far as is reasonably practicable the health, safety and welfare of residents and staff. It was however noted that regular fire testing in the home was not being maintained and this was raised with the acting manager who agreed to address this shortfall. The AQAA returned confirmed that most of the homes policies and procedures need to be reviewed and updated to reflect best practice and to comply with current legislation. Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 23 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 3 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 2 3 Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14(1) Requirement Timescale for action 01/03/08 2. OP7 3. OP8 4. OP8 That a full needs assessment is completed by a competent person for each perspective resident and following this if an admission is thought to be appropriate the home confirms in writing that having regard to the assessment made that the home can meet those needs. 15 That individual care plans 01/06/08 providing specific guidance on person centred care for staff to follow is devised for each resident in consultation with the resident or their representative 13 That individual risk assessments 01/04/08 that cover all residents risk are recorded and responded to and that evaluation of care is also completed and responded to. 13 A protocol, that meets the NICE 01/06/08 (1)Schedu guidelines by ensuring residents le 3 (3)(n) are referred to a tissue viability nurse specialist if they develop a Stage 2 pressure sore, must be in place.( outstanding requirement from last inspection report with a completion date of 30/11/06) DS0000013969.V357913.R01.S.doc Version 5.2 Bryher Court Nursing Home Page 25 5. OP9 6. OP9 7. OP16 8. OP18 9. OP29 10. OP31 11. OP33 That appropriate facilities are provided for the storage of controlled drugs in accordance with Misuse of Drugs (safe custody) regulations 1973. 13(2) That all medicines are handled to ensure residents safety and when medication is not administered the reason why not must be recorded on the Medicine Administration Record (MAR) chart. That each resident has an up to date photograph held on file. 22 The complaint procedure that is publicised for residents and their relatives must include details of the timeframes the home works within. A record of all complaints received and the action taken must be held. (outstanding requirement from last inspection with a completion date of 30/11/06) 13(6) That clear up to date procedures are in place to be followed when a suspicion or allegation of abuse is made. 19 (1) That a thorough recruitment procedure is operated that includes securing two authentic/appropriate references for each employee. A recent photograph and health questionnaire. 8 (1)(2) That the registered person 9(1)(2)(b) appoints a competent fit person (i) to manage the home and advises 10 the Commission of this appointment. 24(1)(a)( That a suitable quality b) (2)(3) monitoring system is maintained to ensure residents and their representatives views are taken into account and demonstrates ongoing review and improvement to the quality of DS0000013969.V357913.R01.S.doc 17(1)(a)S chedule 3(3)(i) 01/05/08 01/03/08 01/05/08 01/05/08 01/04/08 01/06/08 01/06/08 Bryher Court Nursing Home Version 5.2 Page 26 care and services in the home. The results of formal feedback from the residents, their relatives and stakeholders, about the services provided by the home, must be published and made available to current and prospective users, and the Commission. 12. OP36 18(2) Care staff should receive formal supervision at least six times a year. The sessions should cover all aspects of practice, the philosophy and care in the Home and the career development needs of the individual. (This is an outstanding requirement from the last inspection with a completion date of 31/12/06) 01/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Clear guidance should be available to staff, on all medicines prescribed on an as required basis, to take into consideration each resident’s needs and choices, in addition to the prescriber’s directions. That any building or redecoration works are completed in a way that minimises disruption to staff and residents. That all the homes policies and procedures are reviewed and updated. 2. 3. OP19 OP37 Bryher Court Nursing Home DS0000013969.V357913.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Bryher Court Nursing Home DS0000013969.V357913.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. 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