CARE HOMES FOR OLDER PEOPLE
BUPA Care Homes West Ridings Lingwell Gate Lane Lofthouse Wakefield West Yorks WF3 3JX Lead Inspector
Tony Railton Key Unannounced Inspection 09:00 19 and 20th November 2007
th 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 BUPA Care Homes DS0000006304.V354850.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. BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service BUPA Care Homes Address West Ridings Lingwell Gate Lane Lofthouse Wakefield West Yorks WF3 3JX 01924 826806 01924 825743 fletchea@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Ltd 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) Care Home 180 Category(ies) of Dementia - over 65 years of age (150), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (150), Old age, not falling within any other category (150), Physical disability over 65 years of age (150) BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 24th January 2007 Brief Description of the Service: BUPA West Ridings, although under one registration, comprises six, 30-bed units and provides a total of 180 places for older people, some of whom may suffer from dementia, mental health problems, have a physical disability and/or require nursing care. There is a manager for each of the six units who are directly supervised by the Registered Manager. Ground floor accommodation is offered to all service users and some of the bedrooms have patio doors leading to the gardens. Other bedrooms face inner courtyards which have garden furniture for the use of service users during the summer months. Each unit has communal areas including lounges, dining rooms and quiet lounges. All bedrooms are personalised and there are assisted bathing facilities for those who require them. Prospective service users are invited into the home to test drive the services offered and visitors are welcome. There is a reception area provided with administrators and the registered manager’s office. This building also houses the central kitchen, laundry and training rooms. The home is situated in Lofthouse on the outskirts of Wakefield, is on a main bus route and is close to Outwood train station. There are some local shops nearby including a post office, public houses and health centre. West Ridings is only a few minutes journey from the centre of Wakefield and all services and amenities and is also close to the M1/M62 link roads. On 19 November 2007 the providers said the range of fees for living in the home is between £380and £600 and that there are extra charges for hairdressing (from £7) and for newspapers and Chiropody (£9). Further information about the services provided and the role of the CSCI can be obtained by contacting the home or visiting www.bupa.com BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This visit to the service took place over two days commencing on Monday 19 November at 09.00 hours and ending at 16.00 hours and on Tuesday 20 November at 08.30 hours and ending at 13.00 hours. There was the opportunity to visit all six houses and speak to people using the service, the unit managers, nurses, care staff, and domestics. There was also the opportunity to speak to the Manager, Clinical Advisor, Clinical Assessor, Responsible Individual (representing BUPA), the activities co-ordinator, the chef, kitchen staff, maintenance man and NVQ (National Vocational Qualification) assessor. Six people’s case files (one from each unit) were seen and included pre admission assessments, assessments, risk assessments, care plans, reviews, daily and medical records. Six staff records were also seen and included application forms, interview notes, references, proof of identity, supervision and training records. Other information considered included the CSCI Service History, the returned Annual Quality Assurance Assessment (AQAA), the minutes of Social Services safeguarding meetings, record of complaints, and training Matrix and maintenance records. Staffing rotas were seen and a short tour of each of the units took place. The care staff were providing was observed throughout the visit. The inspector would like to take the opportunity to thank the people using the service, the manager, unit managers and their staff teams for their hospitality and patience throughout the visit. What the service does well:
The manager said that the new Quest (person centred) documentation is in use. The Clinical Assessor said that the Quest Pre Admission Assessments are good and include people’s personal and healthcare needs as well as their choices and preferences. The assessments are comprehensive and show what people’s care needs are. The care plans are ‘person centred’ and include people’s choices and preferences. People are safeguarded and protected by the way medicines are dealt with as a sample of people’s medicines were checked and found to be correct.
BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 6 People are also protected by the way staff are recruited and selected as a sample of six staff files show that proper checks are carried out before they are employed. Throughout the visit, positive relationships were observed being fostered between people using the service and those caring for them. Discussion with the unit managers, nurses and care staff found they have a positive attitude towards people using the service and a good insight into their care needs. A tour of the units found that people using the service live in comfortable surroundings that are clean and safe. One person invited the inspector into their bedroom to have a chat and said they have everything they need and the “meals are good” and the “staff are great”. Discussion with the chef, and examination of the menus and menu checklists, show that people are offered a varied and balanced diet. A sample of the lunchtime meal found it to be well presented, well cooked and tasty. Medical records show that people are supported by ordinary community based healthcare services including General Practitioners, District Nurses, Continence Advisors and Community Mental Health Team. Discussion with the activities co-ordinator and unit managers found that individual and group activities are arranged for those who wish to participate. One person said that they are going to have a birthday party “with a cake” as they are “ninety nine”. Photographs displayed around the houses show people enjoying seasonal and festive activities. On the day of the visit there appeared to be enough staff on duty to meet people’s care needs in a relaxed and unhurried manner. What has improved since the last inspection?
To make sure the service can meet people’s personal and healthcare needs the pre admission assessments are better as they include people’s choices, preferences and social history. The new Quest assessments and care plans are better and give care staff clear instructions as to what they need to do to meet people’s care needs. The Annual Quality Assurance Assessment and staff training records show that people using the service are cared for by more staff that have a National Vocational Qualification with the intention of improving the quality of care offered.
BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 7 To make the service more homely, lots of bedrooms have been decorated and provided with new bedroom furniture. Lounges and dining rooms have been decorated and new corridor carpets provided. What they could do better:
Despite the improvements to the assessment and care planning documentation that show people’s choices and preferences, the care plans should have a monthly review to see if people’s needs and choices are being met. People’s care needs are set out in their individual plan. However, to meet minimum standards fully, these should be signed and agreed by the person using the service or their relative wherever possible. The daily records would also benefit from the use of descriptive words to reflect and show people’s preferences and choices and include any activities they choose to participate in. Although the medicine administration systems were checked and found to be safe, to ensure that people continue to be protected, the way medicines are dealt with should be checked regularly by a Pharmacist. It is acknowledged that new members of staff receive POVA (Protection of Vulnerable Adult) training as part of their induction. However, to better safeguard people from any kind of abuse, all staff need to have POVA training. A recent safeguarding meeting found that, on one occasion, the local Wakefield Social Service and Health Safeguarding protocols regarding investigating allegations of abuse were not strictly followed by the home’s manager. Although people were observed living in clean and well maintained surroundings, the two vacant domestic posts should be filled as soon as is practicable to maintain standards of cleanliness throughout the home. For the benefit and comfort of one person using the service on the Calderdale unit, the commode in their bedroom should be replaced as it is corroded and has an unpleasant odour. To make sure that staff have the induction and mandatory training they need to perform their duties safely, a proper record should be maintained and training records updated accordingly. To make sure that people using the service and those caring for them are protected, staff looking after people with mental health problems should have training in how to deal with challenging and aggressive behaviour. BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 8 People using the service, and their relatives, need to be confident that they are cared for by staff that are properly supervised. Recent letters of complaint from relatives and some staff expressed concerns at the staff changes taking place in the home and, in particular, on Airedale House, the services ability to meet people’s personal and healthcare needs. Throughout the two day visit, there was no evidence to show that people’s care needs are not met by the service, however, the manager should monitor the deployment, qualification and numbers of staff provided to make sure that people receive the support and care they need. To make sure people are happy with the service, minutes of the meetings with relatives and the Satisfaction Surveys show that their views are sought on the quality of care provided, however, the views of other stakeholders should also be sought and form part of the quality assurance process. 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
BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 9 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 10 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 BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 11 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. To make sure the home can meet people’s personal and healthcare needs, these are assessed before they are offered a service. The home does not provide a specialist rehabilitation service. EVIDENCE: The manager said that there is a new Quest Assessment document used to assess people’s needs before they are admitted to the home. The manager also said that the new assessment includes people’s social history and personal choices and preferences, likes and dislikes. This was confirmed by looking at a sample of six people’s case files including pre admission assessments. BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 12 Discussion with the Clinical Assessor found that they are employed by the service to go out and assess people’s care needs before they are offered a service. The Clinical Assessor and Unit managers said that the new assessment is better and offers more detail regarding people’s care needs than before. The manager said that the home does not provide a specialist rehabilitation service. BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 13 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 using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. People’s’ health and personal care needs are set out in their individual plan of care but these should be reviewed regularly and signed by them or their representative. People are protected by the way medicines are dealt with within the home. EVIDENCE: A sample of six people’s records show that they have individual care plans that reflect their health and personal care needs. However, the records show that some of the care plans have not been looked at or reviewed to reflect any progress or changes. The care plans also show that they have not been signed by the person requiring a service or their representative to say that they agree with the care to be provided.
BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 14 Discussion with six unit managers found that they are happy with the new Quest, Person Centred assessment and care planning process, as it shows staff what they need to do to meet people’s individual needs. The daily records and medical records and reviews show that people’s personal and healthcare needs are met. However, the daily records do not contain enough descriptive words to reflect people’s choices and preferences, likes and dislikes. A visit to all six units found people relaxing in the lounges, dining rooms and bedrooms. People using the service were observed having their personal care needs met in a relaxed and unhurried manner. People using the service are protected by the way medicines are given as six people’s medicines were checked and found to be correct and administered safely. Discussion with the unit managers found that staff giving out medicines have been trained to do so correctly and safely and the staff training records confirmed this. Discussion with the unit managers found that the medication systems have not been checked recently by a Pharmacist to make sure the system remains safe for people using the service. Throughout the visit, people were observed being treated with dignity at all times and having their wishes respected. Positive relationships were observed being fostered between people using the service and those caring for them. One person said that the staff are “great” and another that they are “wonderful and caring”. BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 15 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 using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. People find the lifestyle experienced in the home matches their expectations and they are assisted to make choices and are offered a varied and balanced diet. EVIDENCE: The manager and unit managers said that relatives are made to feel welcome and take part in life in the home. The visitors’ books on all six units and the Annual Quality Assurance Assessment confirmed this. One unit manager said that relatives attend meetings and participate in fund raising events for the home. The photographs displayed confirmed this. People spoken to say that they have visitors and one said that they look forward to seeing their daughter and grandchildren. One person said that their family take her out on a regular basis. People were observed throughout the visit being treated with dignity and having their choices respected. However, the choices people make about their day-to-day lives are not reflected in the daily records.
BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 16 The menu checklist show that people have a choice of menu and that there is a varied and balanced diet provided. Discussion with the chef and examination of the menus found that they are seasonal and the menus delivered on a rotational basis. People were observed to be enjoying their meals in relaxing and pleasing surroundings, and those requiring help to eat their meals were assisted in a relaxed and unhurried manner. A sample of the lunchtime meal found it to be well presented, well cooked and tasty. One person said that the meals are “very good”, another said that they “enjoy the meals provided”. The unit managers confirmed this and also said that the meals provided are good and popular. The Annual Quality Assurance Assessment shows that the Chef has been nominated for a Care Home Chef of the Year Award. Discussion with the activities co-ordinator found that there are individual and group activities arranged for those who wish to participate. The record of activities, Annual Quality Assurance Assessment and the unit managers confirmed this. People were observed throughout the visit relaxing in the lounges, dining rooms and bedrooms, with some listening to music, others watching television, some reading newspapers and others socialising with carers. A number of people said that they like living in the home and that they have everything they need, another said that they are well cared for. One said that they are looking forward to having a party as they were gong to be ninetynine, they went on to say that they are “having a cake and something to drink”. BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good adequate outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. People using the service, and their relatives, know that their complaints will be listened to and acted upon. People using the service would be better protected and safeguarded from abuse if all staff had POVA (Protection of Vulnerable Adults) training. EVIDENCE: The Annual Quality Assurance Assessment shows that the home has received eight complaints since the previous visit by the CSCI. This was confirmed by the manager and by the CSCI service history. The record of complaints, minutes of relatives’ meetings and discussion with the manager and unit managers found that these complaints related to staff changes around the home, and concerns that people’s care needs are not being fully met. These complaints were discussed with the Responsible Individual, representing BUPA Care Homes, and the manager who gave reassurances that the staff changes were necessary and that they have not impacted on the quality of care provided for people using the service. BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 18 The record of complaints show that they were appropriately dealt with using the home’s complaints policy and procedures. The service history shows that there have been four safeguarding referrals following allegations of physical abuse and threatening behaviour by staff since the previous visit. Following investigations by Social Services, and the Police, the minutes of the multidisciplinary safeguarding meetings show that only one of these has not been concluded. One allegation of physical abuse was found to be untrue and no further action is anticipated. Another was inconclusive and no further action is to be taken. However, one was investigated and found to be true and disciplinary action against a member of staff is anticipated. Only one is outstanding with the allegation still under investigation. The minutes of one of the safeguarding referrals show that the manager of the home did not strictly follow the local safeguarding protocols when investigating an allegation of abuse. For the continued safety and protection of people using the service, all staff working in the home need POVA (Protection of Vulnerable Adult) training as discussion with the unit managers, the manager and responsible individual and the staff training records found that many staff had not had POVA training or update training. It is acknowledged, and the induction training records show, that new staff cover adult abuse, what it is and how to deal with it, as part of their induction training. BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. People live in comfortable homely surroundings that are clean and safe. EVIDENCE: People live in a clean home; a short tour of all six houses found them to be clean and free from any unpleasant odours. People were observed relaxing in comfortable and homely surroundings that are well maintained. Discussion with the maintenance man and examination of the units’ maintenance and repair book found that houses are well maintained and repairs dealt with promptly. The AQAA, and discussion with the manager and unit managers, show that there have been many physical improvements to the environment. These
BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 20 included new carpets in the corridors, re-decoration and new furniture in bedrooms and new lounge furniture on some units. This was confirmed by a short tour of all the houses. For the comfort and benefit of one person using the service on the Calderdale unit, a new commode should be provided in their bedroom as the old one is corroded and has an unpleasant odour. Discussion with the domestic staff found that they have the training and equipment they need to do their work properly. BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28,29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. People’s needs are met by the numbers and skill mix of staff, and they are supported and protected by the home’s recruitment policy and practices. EVIDENCE: On the two days of the visit, there appeared to be enough staff on duty to meet people’s care needs in a relaxed and unhurried manner. The staffing rotas on each of the six units show that there are enough staff planned to be on duty to meet people’s personal and healthcare needs. A sample of six people’s case files including assessments, care plans, daily records and reviews showed that their care needs are met by the service. To make sure people’s care needs are met by trained staff, the staff training records on each of the six units should be updated. This was confirmed by the manager who said that the staff training matrix also needs updating to reflect the training already provided and any future planned training. Throughout the visit, positive relationships were observed being fostered between people using the service and those caring for them.
BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 22 Discussion with the unit managers, nurses and care staff found that they have a good understanding of the care needs of those they are caring for. To make sure that people remain safe, it was noted that some mandatory training such as Moving and Handling, First Aid, Infection Control and Health and Safety needed to be updated as some records showed that staff had received this training in 2005 and should be updated. To make sure that people are cared for properly, staff working with people that have mental health problems and behaviour that is aggressive or challenging should have the appropriate training as the minutes of one safeguarding referral showed that one staff felt that he had not been trained to deal with aggression. People are protected by the way staff are recruited as a sample of six staff records show that appropriate checks including references, proof of identity. Police and POVA (Protection of Vulnerable Adults List) checks are completed before they are employed. BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. People live in a well managed home that is run in their best interests and where their health, safety and welfare is promoted and protected. EVIDENCE: The service history shows that the home is currently without a registered manager and the law says there must be one. However, records show that there is an application being processed by the CSCI central registration team. The record of complaints, and discussion with some staff in the home, show that there are concerns about the new manager and feel that she is not
BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 24 approachable. Others, however, said that the new manager has been very supportive and is good at making sure people’s care needs are met. There was no evidence throughout the two-day visit that the staff changes and change of manager has affected service delivery or that people’s personal and healthcare needs are not being met. The manager said that the views of people using the service, and their relatives, are sought on the quality of care provided. This was confirmed by the Care Home Resident satisfaction surveys. The manager said that the surveys are currently been collated at the BUPA Head Office and a report will be provided showing the outcomes for people using the service. A sample of six staff records show that some staff have not received the right amount of line management supervision to make sure that they doing their jobs properly. The health, safety and welfare of people using the service is promoted and protected as the health and safety audit reports and record of maintenance, including fire tests, show that the premises are checked regularly. Staff training records show that people using the service are safe as they show that they receive Moving and Handling, First Aid, Infection Control and Food Hygiene training. However, records also show that some staff are ready to have this training updated. The financial policies and procedures ensure that people’s financial interests are safeguarded and protected. BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP18 Regulation 13 (6) Requirement Timescale for action The registered person shall make arrangements by training staff, 01/03/08 or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. 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 OP7 Good Practice Recommendations To make sure that people’s choices and preferences are catered for, the daily records should have more detail by way of descriptive words to reflect and show what planned care has been given. To make sure that people are getting the care they need, the care plans should be looked at every month and a record made describing any changes made to people’s planned care. Wherever possible, care plans should be signed and agreed by the person using the service or their representative. Any decisions made by people using the service should be
DS0000006304.V354850.R01.S.doc Version 5.2 Page 27 2 OP7 3 OP8 BUPA Care Homes 4 OP9 5 6 7 8 9 OP12 OP18 OP24 OP26 OP27 10 OP30 11 12 OP30 OP33 13 OP36 reflected in the daily records by using descriptive words to show and reflect the control they have over their own dayto-day lives. As a matter of good practice, and the continued protection of people using the service, the medicine administration system should be checked regularly by a Pharmacist. Descriptive words should be used in the daily records to reflect residents’ choices and preferences with regard to participation in activities. To further protect people using the service, the manager should adhere to the local Safeguarding Protocols set out in the Wakefield Safeguarding Policy and Procedure. To keep one person’s room free from any unpleasant odours, the commode in the bedroom identified should be cleaned or replaced. To make sure that people using the service continue to live in a clean and pleasant environment, the two vacant domestic posts should be filled as soon as is practicable. To make sure that people’s care needs continue to be met by the numbers and skill mix of staff, the staffing levels on all six units should be monitored and staff deployed accordingly. To make sure that people using the service are appropriately cared for, and their care needs fully met, those looking after people with mental health problems and, in particular, with challenging behaviours or aggression, should be trained in how to do deal with this properly. To make sure people are cared for by staff that are appropriately trained, a proper record should be maintained and updated to reflect the training provided. The views of other stakeholders such as visiting healthcare professionals should also be sought regarding the quality of care provided by the home and their views form part of the quality assurance report. People using the service should be cared for by staff that are supervised and receive at least six line management supervision sessions per year. BUPA Care Homes DS0000006304.V354850.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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
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