Inspection on 29/04/05 for Bybrook House Nursing Home

This inspection was carried out on 29th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Bybrook House Nursing Home 16/12/08

Bybrook House Nursing Home 25/07/08

Bybrook House Nursing Home 19/09/07

Bybrook House Nursing Home 17/05/07

Bybrook House Nursing Home 02/06/06

Bybrook House Nursing Home 30/09/05

Bybrook House Nursing Home 08/10/04

Bybrook House Nursing Home 02/07/04

Bybrook House Nursing Home 11/02/04

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

CARE HOMES FOR OLDER PEOPLE Bybrook House Nursing Home Middlehill Box Wiltshire SN13 8QP Lead Inspector Tim Goadby Unannounced 29 April & 5th May 2005 th 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 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. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bybrook House Nursing Home Address Middlehill Box Wiltshire SN13 8QP 01225 743672 01225 744281 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Avon Care Homes Limited Mrs Gillian Penelope Lloyd Nursing Home 30 Category(ies) of 30 OP Old age registration, with number 6 PD(E) Physical dis-over 65 of places 2 TI(e) Terminally ill Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 No more than 30 persons aged 65 years and over may be accommodated at any one time 2 No more than 28 persons aged 65 years and over may be in receipt of nursing care at any one time of which no more than 2 persons may be in receipt of terminal illness care 3 No more than 6 persons with a physical disablement aged 65 and over may be accommodated at any one time. These persons may not also be in receipt of nursing care 4 Rooms 25, 26, 27 & 28 may not be used for nursing care due to unsuitable access 5 The staffing levels set out in the Notice of Staffing Levels issued by Wiltshire Health Authority on 20 March 2000 must be met at all times 6 Only the one, named, female service user referred to in the application dated 31 August 2004 may be aged 64 years and under Date of last inspection 13th January 2005 Brief Description of the Service: Bybrook House provides care and accommodation for up to 30 older people. Most service users have nursing care needs. But the home can also take up to 6 people who have physical disability, and 2 people for terminal care. The home is privately owned and operated, by Avon Care Homes Ltd. The company has another nursing home in Wells, Somerset, where its administrative operations are centred. The principal company director is Mrs Maria Cristina Bila, who has regular input into Bybrook House. The home is located in a rural position, close to the village of Box. The city of Bath is approximately 5 miles away. The house is an attractive older building. It has extensive grounds, with pleasant views of surrounding countryside. The majority of service users have single rooms. There are 3 bedrooms which may be shared, if people wish. These can also be occupied as singles, for a higher fee. There is a passenger lift serving the home’s 3 floors. But some rooms can only be accessed via small flights of steps. A number of bedrooms have en-suite toilets, and 2 have baths also. There are 5 baths for general use, with at least 1 per floor. An adapted bath is situated on the first floor. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place in April & May 2005. The first visit was unannounced. A shorter return visit then took place, by appointment, to conclude the inspection and give initial feedback. The total time spent in the home was 8.75 hours. The following inspection methods have been used in the production of this report: indirect observation; sampling care plans, and other records; sampling a meal; case tracking; discussion with 10 service users, and 3 visitors; discussion with staff and management; and a tour of the premises. What the service does well: What has improved since the last inspection? Care plans have continued to improve, covering a wider range of needs. Service users are regularly reviewed, and care plans are updated. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 6 Substantial recent improvements have been made regarding food in the home. This has been an area of concern for some time, and had generated several complaints during 2004. The appointment of a new chef had had an immediate impact. At this inspection, service users were very complimentary about the changes now brought in. There are improved systems for responding to complaints, although these have not yet been fully tested. After a lengthy hold-up, a number of care staff have now completed NVQ training. Others are undertaking this, and are expected to finish it during 2005. The registered manager has also commenced studying for the final element of her required qualifications. The principal director of the company has now instigated a new approach for the required visiting and reporting on the operation of the home. Following consultation with the CSCI, she has opted to use a format suggested by the Commission. The first such report was received around the time of this inspection. If this is maintained from now on, it will provide much stronger evidence for effective oversight of Bybrook House. In response to previous issues, a revised system has been implemented for consultation with service users and their families. This has already helped to bring out some issues that were causing concern for people. The home has been able to take relevant steps in response. What they could do better: Bybrook House received additional regulatory input from the CSCI over the inspection year from April 2004 to March 2005. This was due to concerns identified at inspections, and complaints made to the Commission about the home. The most recent inspection before this visit, in January 2005, was an additional visit in response to a complaint. Improvements are needed to the management support given to the home by the company which owns it. Arrangements need to be fully clarified. Existing measures of quality should also be collated to identify key themes, and produce suitable development plans. Not all required areas of documentation are fully in place as yet. In particular, not all service users have updated versions of the home’s terms and conditions of residence. These are particularly important, as they may need to be relied upon if issues arise regarding continued placement at the home. There is a reduced programme of activities. But the home is actively trying to recruit someone to lead on this. Some premises issues need addressing to ensure the safety and welfare of service users. These include the provision of hot water at appropriate Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 7 temperatures; covering or removal of certain radiators; and the provision of an effective call system, especially for summoning urgent attention. In addition to these key issues, some elements of décor could be improved. Recruitment practices are poor, placing the protection of service users at risk. 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. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) We looked at outcomes for standards 1, 2, 3 & 4 Service users are not provided with all required information about the operation of the home. Some service users do not have up-to-date contracts, and statements of terms and conditions of residence. Prospective service users have their needs assessed, and can enter the home knowing that these will be met. EVIDENCE: The Statement of Purpose covers almost all required areas. It does not yet include information on arrangements for consultation with service users; or detail about the organisational structure. The CSCI has required the company’s principal director to clarify information on the second point, so that it is clear to service users and families who to approach on particular issues. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 10 Details of specific therapeutic techniques used could be made clearer, especially regarding the phsyiotherapy service that is available. The Service User Guide does not include service users’ views of the home. All other required areas in this document are well explained. 3 service user files were checked for evidence of terms and conditions. One had the most up-to-date set. One had a previous version, which had not been updated. The other had no evidence of a relevant document. The manager acknowledged that service users who had been in residence for longer were unlikely to have current versions in place. The sampled records showed that pre-admission and assessment processes are carried out effectively. The format used by the home covers all required areas. The home’s newest admission, who had been in residence for 6 days when their file was checked, had all assessments completed and a satisfactory care plan in place. Service users are re-assessed following hospital admissions. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Care plans ensured that service users’ assessed needs are clearly documented. Health care needs are well supported. There are effective systems for the management of medication in the home. Service users have their privacy and dignity respected. EVIDENCE: Sampled care plans covered a range of needs. Auditing systems showed that each care plan is reviewed by nursing staff at least once a month. Service users’ physical, emotional and psychological needs are recognised in the plans. Medication systems were checked. Arrangements for storage and recording were viewed, and seen to be appropriate. Relevant procedures were available in the medication folders. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 12 Arrangements for individuals’ personal care were set out in the sampled care plans. Privacy and dignity issues were recognised in the guidance given to staff. Support to service users needing assistance at mealtime was observed to be given sensitively and respectfully. Service users reported that the care received from staff is good. They were confident that their health needs were being addressed effectively. People said that they could report issues to staff, and action would then be taken. For instance, the individual’s GP would be called if they asked for this. Sampled care records contained evidence that relevant health professionals are contacted regularly, as required. Care plans had a focus on health promotion, and the prevention of potential problems, as well as setting out steps for treatment of existing needs. Specific health issues were fully planned for in sampled records. An individual who had been admitted from hospital with MRSA had suitable guidelines for prevention of further infection. The same person had also been admitted with existing pressure sores. Clear wound care records were in place, including photographs. Bybrook House has the services of a physiotherapist for part of each week. Service users confirmed that they benefit from this. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Service users’ expectations and preferences in social and recreational needs are not being fully met. Service users are able to maintain important relationships and community contacts. Service users can exercise choice and control in various aspects of their daily lives. There have been recent significant improvements in the quality and variety of food provided. EVIDENCE: The home is trying to appoint a new activities co-ordinator. A service user commented that they miss the opportunity to join in the group sessions that used to take place. Other staff aim to provide some input in this area when they can. Some service users are able to occupy themselves. During this inspection people were seen reading, listening to music, knitting, and doing a jigsaw. Some service users also take daily walks in the grounds, or the local lanes. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 14 Visitors were seen to be made welcome. Some met with service users in their own rooms, and some in communal areas, including sharing a meal. Sampled care records contained details about contact with families. One service user had been supported to visit their spouse in hospital. A new chef has been appointed, who has a suitable catering qualification. He has begun consulting with service users about a new menu. More fresh ingredients were being used. Service users spoke highly of the improvements already made. They praised the quality and variety of food served. One commented that it encouraged him to eat well. Food served at the midday meal on the first day of the inspection was of a good standard. Care had been given to presentation, for those people needing pureed meals. Menus are presented to service users each morning, so they can choose their meals for that day. One person commented that staff occasionally forget to do this. Another said that, after making a choice, it is still possible to change this without it being a problem. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 17 Suitable procedures and systems are in place to respond to any complaints received. There is a documented commitment to the upholding of service users’ rights. EVIDENCE: The home’s complaints procedure is displayed in the main entrance hall, and included in the Service User Guide. Contact details for the CSCI are shown. There is a suitable recording format to show actions taken in response to issues raised. No complaints had been received since the previous inspection. A rights policy is included in the pack of information prepared for service users. A number of people had received postal ballots for the general election that was taking place around the time of this inspection. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22, 23, 24, 25 & 26 Improvements are needed to the quality of the environment, including health and safety issues which require attention. Service users continue to be put at risk of harm. Previously set timescales for completing environmental risk assessments, and taking suitable actions, have not been met. Not all equipment is suitable to ensure the welfare of service users. But positive steps are taken to identify and obtain items that will help maintain independence for individuals. Individual and communal accommodation is homely and comfortable. There are appropriate arrangements to maintain required standards of cleanliness and hygiene. EVIDENCE: Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 17 Areas for repair and decoration, itemised in previous inspection reports, remained unaddressed. There was evidence of water damage to various parts of walls and ceilings. Some interior and exterior woodwork was also in need of renewal. Some radiators remain uncovered. Documented risk assessments have been completed for some of these, but not all. There is no information about current measures to minimise risk, or the actions planned in the longer term. Hot water temperatures at outlets for service users exceed the prescribed level. The most effective method for regulating temperature at delivery is to fit thermostatic mixing valves at each required point. This has not been done. In the meantime, some risk assessments have been documented. But this has not been done for all affected outlets. As with radiators, there is no information about current measures to minimise risk, or the actions planned in the longer term. The home’s call bell system is outdated. It is not easily audible in all parts of the building. Conversely, the volume from the central panels is of nuisance value to some service user bedrooms. Most seriously, there is no effective emergency call system. The present arrangement is to sound a bell 3 times, to signal the need for urgent assistance. But this does not work if another call point has already been activated. It was observed, as at previous inspections, that there are frequent periods when an alarm sounds for some time before it is silenced again. Service users said that response times from staff vary, depending what they are doing. Some times are reported to be particularly busy, such as when people are getting up. It was observed that care had been taken to ensure that people had easy access to call bells. For instance, pinning the device in place for someone who otherwise might have accidentally dislodged it. A range of adaptations and equipment are available to meet the needs of service users. For one individual with progressively deteriorating mobility, due to a degenerative condition, steps were being taken to maximise the independence the person could have. Specialist nurses had been contacted to carry out assessments. Relevant equipment was then provided. The service user had just received a new telephone that did not require any manual operation. A number of bedrooms were seen during the inspection, at the invitation of their occupants. All were homely and comfortable. Service users commented on how much they liked them. Rooms are let fully furnished. But people may also bring in their own items. All rooms have television points, and people can have their own phone lines installed. The main communal areas were also seen. These too were pleasant. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 18 The home appeared clean and hygienic in all areas seen during the inspection. Service users said that the home is always very clean. Infection control measures have been thoroughly reviewed, following an outbreak earlier in 2005. The source of this was traced to a service user who had been discharged from hospital. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 29 Staff are provided in suitable numbers. There is stability in the staff team, with very low turnover. Skills of the care staff team are being enhanced via nationally recognised qualifications. Service users are put at risk by poor recruitment practices. EVIDENCE: The nursing and care staff team remained stable from the previous inspection. There had been only one change. There were no vacancies. Rotas demonstrated that required cover is maintained. Service users also confirmed that there are sufficient staff on duty, both day and night. Progress has been made on NVQ training for care staff. 4 employees have now completed the Level 2 award. 2 more are currently studying for this, and are expected to finish by August 2005. Other staff working as carers are people with nursing qualifications from other countries. These individuals will undertake an adaptation course, which will enable them to practise as nurses in the UK as well. New staff have been starting without a satisfactory check of the national list of people deemed unsuitable to work with vulnerable adults. Employment records seen at the inspection showed that other required recruitment checks are completed. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35, 37 & 38 The registered manager is a fit person to be in charge of the day-to-day running of the home. But the organisation needs to ensure that she is able to give sufficient attention to Bybrook House to discharge her responsibilities fully. The organisational structure needs clarity about the roles of the registered manager, and of the principal company director. Quality assurance measures are in place. They need to link to clear plans for service improvements and developments. There are appropriate systems in place for most required areas of record keeping. Health and safety issues are addressed. But further attention is needed to ensure best practice on some specific topics. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 21 EVIDENCE: The registered manager, Penny Lloyd, had been giving input to another home owned by the director of Avon Care Homes. This had meant she was absent from Bybrook House for up to 3 days a week. This arrangement was reported to be coming to an end. The deputy matron and other nursing staff had provided management cover as necessary. Mrs Lloyd had her registration approved by the CSCI in October 2004. She has the relevant nursing qualifications and experience for her role. She is also now undertaking a management course at NVQ Level 4, and had just completed the first unit towards this award. Mrs Maria Cristina Bila, the principal director of Avon Care Homes, is in the process of applying to the CSCI to become the designated ‘responsible individual’ for the company. The Commission is seeking some further information before reaching a final determination. One element of this is satisfactory evidence that Mrs Bila carries out the monthly visits and reports required by care standards regulations, meeting all the prescribed criteria. Following discussion of this issue, the first such report was received around the time of this inspection. This had been done using a template suggested by the CSCI. Quality assurance measures include both objective audits, and subjective feedback from service users and others. Examples of the former include checking that care plans are reviewed each month; infection control audits; and checks on the premises. For the latter, a system has been implemented of holding care review meetings for each individual. These are intended to take place every 6 months. Sampled records showed that they have already been helpful in enabling people to raise issues of concern. Records also need to show what is done in response. The quality assurance system should also involve collating all sources of information to produce an annual development plan for the service, with some goals for future progress. Bybrook House’s policy is not to hold or administer money on behalf of service users. In most cases, people are assisted by their families, or other representatives. Information about this was seen on sampled files. Anyone still retaining management of their own money is provided with lockable storage. Stair carpets continue to show signs of wear on edges. Some have been taped. But none had been replaced since previous inspections, as recommended. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 22 The fire risk assessment has been reviewed, and a new procedure implemented. The home’s fire log book showed that the recommended replacement of smoke strips on some doors has not yet taken place. Checks on fire fighting equipment, to check proper positioning and for signs of any obvious defects, had not taken place since January 2005. These are recommended to be carried out once a month. Equipment had all been serviced by the relevant contractor in January. Records of staff instruction in fire safety were not all clearly set out in the log book. The manager stated that they were available elsewhere. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 x 1 3 3 1 3 STAFFING Standard No Score 27 3 28 3 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x 3 x 3 x 3 x 3 3 Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 4; 5; 6; Schedule 1 Requirement The persons registered must review and complete the Statement of Purpose, and Service Users’ Guide, in line with the criteria set out in Regulations and Standards. (Timescale of 31/10/04 not met) COMMENT: Only a couple of areas are left to address. The requirement should be met soon. Information must be supplied to each service user regarding the terms and conditions in respect of accommodation. Any revision must be notified to service users within 28 days. (Timescale from 02/02/05 not met) COMMENT: Not all sampled files were up to date on this topic. Continued failure to address this requirement by the appropriate timescale will lead to further enforcement action. Service users must be given opportunities for stimulation through leisure and recreational activities, in and outside the home. (Timescale from 11/10/04 not met) COMMENT: The home is trying to recruit a staff member to lead on this. Timescale for action Not later than 30/06/05. 2. OP2 5(1)(b); 6 From 05/05/05. 3. OP12 12(1); 16(2)(m) & (n) From 05/05/05. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 25 4. OP19 23(2)(b) & (d) 5. OP22 12(1); 13(4)(c); 23(2)(n) 6. OP25 13(4) 7. OP25 13(4) 8. OP25 13(4) 9. OP25 13(4) Repair and decoration must be carried out in areas where there is evident damage. (Timescale from 11/10/04 not met) COMMENT: There had been no progress since previous inspections. Outstanding issues are due to be addressed when the home has a programme of works undertaken over the coming months. This is considered reasonable. Call systems within the home must include an effective means of summoning emergency assistance. (Timescale of 17/12/04 not met) COMMENT: Continued failure to address this requirement by the appropriate timescale will lead to further enforcement action. There must be a documented risk assessment for all remaining uncovered radiators. (Timescale of 30/09/04 not met) Following risk assessment of uncovered radiators, suitable actions must be taken where identified as necessary. COMMENT: Not all necessary assessments were in place, and there was no documented action plan arising from those completed. Documented risk assessments must be in place on all hot water outlets for service users. COMMENT: Not all necessary assessments were in place, and there was no documented action plan arising from those completed. Hot water at outlets for service users must be delivered at temperatures close to 43°C. (Timescale from 11/10/04 not met) COMMENT: This work is also Not later than 30/11/05. Not later than 29/07/05. Not later than 17/06/05. Not later than 29/07/05. Not later than 17/06/05. Not later than 29/07/05. Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 26 10. OP29 7; 9; 19; Schedule 2 scheduled to be addressed shortly. Continued failure to address this requirement by the appropriate timescale will lead to further enforcement action. Employees must not commence work in care positions until a satisfactory result has been received from a POVAFirst check. From 05/05/05. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP18 Good Practice Recommendations Care plans should develop in areas of additional need for individual service users, such as mental health. Guidelines on whistle blowing should be reviewed and expanded, to give more information for staff. COMMENT: This recommendation was not checked at this inspection. It is carried forward. Risk assessments should be clearly linked to appropriate measures for risk management. These can include steps being taken currently; and future actions proposed, with timescales. The roles of senior staff within the home and the company should be clarified. This information should be made available to all service users and their representatives. Quality assurance systems should lead to the production of an annual development plan for the service. The newly devised supervision and appraisal systems should be implemented without delay. COMMENT: This recommendation was not checked at this inspection. It is carried forward. There should be clear evidence that all fire safety checks and instruction are carried out at the recommended frequencies. Stair carpets which are becoming worn should be replaced, before the problem worsens. COMMENT: This issue will be made the subject of a requirement once the situation deteriorates further. Some particularly frayed edges have been taped since the previous inspection. 3. OP25 4. 5. 6. OP32 OP33 OP36 7. 8. OP38 OP38 Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 27 Commission for Social Care Inspection Suite C, Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bybrook House Nursing Home D51_S15894_BYBROOK_V186254_290405Stage4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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