Inspection on 15/11/06 for Chesham Bois Manor

This inspection was carried out on 15th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chesham Bois Manor 06/09/07

Chesham Bois Manor 28/11/05

Chesham Bois Manor 12/04/05

Chesham Bois Manor 15/09/04

Chesham Bois Manor 20/04/04

Chesham Bois Manor 25/02/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Chesham Bois Manor Amersham Road Chesham Bucks HP5 1NE Lead Inspector Barbara Mulligan Unannounced Inspection 15th November 2006 10:30 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 DS0000022960.V312228.R02.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. DS0000022960.V312228.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chesham Bois Manor Address Amersham Road Chesham Bucks HP5 1NE 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) 01494 783194 01494 794636 info@bmcare.co.uk B & M Investments Limited (Trading as B & M Care) Mrs Elaine Ward Care Home 48 Category(ies) of Dementia (31), Old age, not falling within any registration, with number other category (48) of places DS0000022960.V312228.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 48 residents, 31 of whom may have dementia. Date of last inspection 28th November 2005 Brief Description of the Service: Chesham Bois Manor is situated a short distance from the town centre of Chesham, a small town which provides a variety of shops and other local amenities. Chesham is served by local bus routes and has a Metropolitan Line tube station connecting it to main line services. The home is one of several run by B&M Care Limited, and provides accommodation for up to 48 elderly Residents, 31 of whom may require additional support due to dementia type illness. All Service Users are accommodated in single bedrooms, 38 of which have en-suite facilities. Communal areas consist of various lounge, dining and quiet areas. The home consists of an older building and a modern extension. There are extensive, and well-maintained grounds, including a secure garden area where service users with dementia type illnesses can mobilise in a safe environment. A team of carers, a deputy manager, housekeeping and catering staff, support the homes manager, and access to healthcare professionals, including community nurses, is by direct contact or through General Practitioner referral. The fees range from £350 to £750 per week. DS0000022960.V312228.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken on Wednesday 15th November 2006 at 10:30am. The visit consisted of discussions with the registered manager, the deputy manager, staff members and service users. A tour of the premises s undertaken and the homes records and other essential documentation were examined. The inspection officer was Barbara Mulligan. The registered manager is Elaine Ward. Twenty-five of the National Minimum Standards were assessed during this visit. Twenty of these are fully met, four are almost met and Standard 6 is not applicable. As a result of the inspection the home has received six requirements. Eighteen comment cards were received from service users, their relatives and/or representatives, visiting healthcare specialists and two General Practitioners. Comments received, both from people interviewed and those who responded to the survey, expressed a high level of satisfaction with the care received from support staff. Some positive comments received include “very high standards” and “the home is lovely, the staff are great and the deputy manager is wonderful” and “always made to feel welcome, never any problems discussing any issues” and “ we are extremely pleased with every aspect of my mothers care at Chesham Bois Manor which makes her feel happy and content and feel safe”. One concern was raised by healthcare professionals that there has been a rise in the number of falls, leading to an increase in lacerations, abrasions and wounds. This was discussed with the registered manager and the deputy manager who said that they are monitoring this situation and they thought that the increase in wounds could be due to the recent hot weather when service users have been more active and venturing outside in the garden more often. The evidence seen and comments received indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. The inspector would like to thank the registered manager and the responsible individual, the staff team and service users and relatives for their cooperation and assistance during this inspection. What the service does well: DS0000022960.V312228.R02.S.doc Version 5.2 Page 6 Potential service users receive a thorough needs assessment to ensure the home can meet the care needs of the service users. Healthcare support for service users is good. Service users feel that they are treated with respect and dignity. The home provides a pleasant and comfortable environment in which service users live. Individuals are encouraged to personalise their rooms with their own personal belongings. The staff team are motivated, committed and respond to service users in a respectful and appropriate manner. Service users spoken to said that the staff were “very helpful and kind” and “ nothing was too much trouble “ Service users confirmed that they were encouraged to participate in activities as they choose. There is an effective complaints procedure with all complaints and concerns being acted upon promptly, within stated time scales. Meals are of a good standard and always presented in an appealing way. The staff team are motivated, undertaking relevant training and working towards their National Vocational Qualifications. There is good support for the home by the provider organisation, with effective monitoring and quality assurance systems in place. What has improved since the last inspection? What they could do better: DS0000022960.V312228.R02.S.doc Version 5.2 Page 7 Care staff must undertake accredited medication training that is provided by persons qualified to do so. POVA training for some care staff needs to be updated. Staff personnel files need to include a recent photo of all staff. The testing of the fire alarm must be carried out on a weekly basis and must be recorded recorded. A service certificate for the gas appliances and a hard wiring certificate need to be forwarded to the Commission. A risk assessment for Legionella needs to be carried out and a copy of this must be sent to the Commission. 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. DS0000022960.V312228.R02.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 DS0000022960.V312228.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Potential service users receive a needs assessment undertaken by staff trained to do so, ensuring that the home can meet the care needs requirements of service users. EVIDENCE: The care of four service users was case tracked, including those most newly admitted to the home. The registered manager, deputy manager or the assistant manager completes the initial needs assessment for potential service users. Four completed needs assessments were examined. The records show that all service users had been visited at home or in hospital prior to their move to the home and an assessment of their needs has been undertaken. These are fully completed to a high standard, dated and signed by the author. One service user spoken to said that she had visited the home prior to moving and that she was happy here. DS0000022960.V312228.R02.S.doc Version 5.2 Page 10 The assessment demonstrates that prospective service users, family members or representatives are included in the assessment process if this is appropriate. The home does not offer intermediate care. DS0000022960.V312228.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. Care planning documentation adequately provides staff with the information they need to satisfactorily meet service users needs. However, of the four plans looked at one required more detail in the action plan. Healthcare support for service users is good, which means that their health and well-being is promoted and protected. The medication policies and procedures are clear and there is consistent implementation resulting in safe working practices. However, all care workers expected to provide support with the administration of medicines need to undertake accredited training in the Safe Handling of Medicines. Service users feel that they are treated with respect and dignity and that their right to privacy is upheld ensuring personal care is delivered appropriately. EVIDENCE: The care of four residents was case tracked and their care plans were examined. The registered manager, deputy manager or assistant manager completes the initial assessment for potential service users and from this a plan of care is developed. DS0000022960.V312228.R02.S.doc Version 5.2 Page 12 There is evidence in the care plan that following the first four weeks stay at the home a review is held and the care plan is discussed and reviewed. The care plans contain details of the individual’s preferred daily living routines, likes and dislikes. Care plans looked at detail the care needs, wishes and personal goals for each service user. However, there are some entries in the care plans that would benefit from further detail and this is a recommendation of the report. An example observed in one care plan records guidance for staff to follow for a service user registered as blind. This records “ keep an eye on her” and “for staff to guide the individual around the home”. These are very vague statements and would benefit from further detail. All care plans are stored in safe and secure areas and there is documentation to demonstrate that care plans are reviewed monthly. Following the previous inspection a requirement was issued for the manager to introduce the practice of tissue viability assessments for all current service users and incorporate this as part of the initial assessments carried out on new residents. It is pleasing to see that this has been complied with. Following the previous inspection two requirements were issued, 1) the manager is to introduce the practice of tissue viability assessments for all current service users and incorporate this as part of the initial assessments carried out on new service users and 2) care staff as appropriate to be trained in the drawing up and working with tissue viability assessment tools. The home has been working closely with the wound care team that ensures these requirements have been complied with. There is a visiting Chiropody Service that visits the home on a regular basis. Additional support is accessed through the GP surgery, where service users can access physiotherapists, occupational therapists, speech therapists, a dietician and continence advisor. The home receives district nurse support and they are available for advice regarding pressure area care and can assist in the provision of pressure relieving equipment. Visits to the home from healthcare professionals take place in the service users bedrooms. Staff provide support to individuals needing to attend outpatient and other appointments. The registered manager stated that optical eye screening is undertaken six monthly and on a needs basis also. The nutritional needs of service users are identified and their weight is monitored on a regular basis. Dental screening and hearing tests are accessed on a needs only basis. Healthcare information is recorded in detail in all files looked at. At the time of the inspection there was one service user who self administers their own medicines. There is a risk assessment in place for this. The inspector examined medication records and it is pleasing to note there were no omissions observed. Medication is kept in two secure, mobile DS0000022960.V312228.R02.S.doc Version 5.2 Page 13 medication trolley. There is a medication policy in place and this covers all areas detailed in standard 9. The inspector observed the assistant manager undertaking a medication round at lunchtime. This was carried out safely and courteously. Service users were informed which medicines they were taking, what they were for and the best way to take them. This approach is to be commended. The home uses controlled drugs, and the controlled drugs register was checked. This was completed with two signatures, was legible and up to date. All controlled drugs are stored in a metal cupboard, which complies with the Misuse of Drugs Regulations 1973. The deputy manager described the training that care staff are expected to undertake before they can administer medicines. This involves care staff observing medication rounds, they will then undertake three supervised rounds. The registered manager, deputy or assistant manager will then deem the care worker competent if appropriate. Medication training needs to be provided by an accredited trainer and this will be a requirement of the report. The manager is aware of the need to retain medication for a period of seven days after a service user has died. Service users were observed to have had assistance with their personal hygiene and to be wearing their own clothes. Individuals spoken to said that carers were kind when assisting them with personal care. Individuals receive care from staff and health care professionals in complete privacy. Staff were observed during the inspection to knock on service users bedroom doors before entering. Preferred terms of address are recorded in service users care plans and likes and dislikes are recorded in most service users plans. DS0000022960.V312228.R02.S.doc Version 5.2 Page 14 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems in the home ensure that where appropriate service users are supported to exercise choice and control over their lives. Service users are able to receive visitors at the home and there are no restrictions imposed on visiting unless requested by the service user. Service users are encouraged to bring personal possessions in with them allowing personal space to reflect the character and interests of its occupant. The presentation and standard of food is good and meets the nutritional needs of service users. EVIDENCE: Care plans show routines of daily living and include bathing, rising and retiring times. Religious observance is recorded in care plans and service users interests are recorded in the initial assessment. As part of the admission process, the home ask service users and/or their families to complete a pen picture of their life to give staff information about previous leisure pursuits, hobbies and other interests. The home employs the services of an activities organiser for 20 hours per week. Following the previous inspection it was identified that more designated hours wee needed to develop the activities programme, including one to one DS0000022960.V312228.R02.S.doc Version 5.2 Page 15 sessions if appropriate. It was recommended that the number of hours currently made available to an activities organiser be increased by 50 . This has not been actioned yet and the activities organiser was off on sick leave at this inspection. However, the registered manager has identified this as an area for further development and this recommendation will remain following this inspection. The registered manager said she was in the process of recruiting two volunteers to provide extra support for the provision of activities in the home. On the day of inspection there was a visiting entertainer/musician and service users were observed to enjoy this. Other examples of involvement in the home by local community groups and individuals are visits by mobile hairdressers, and a manicurist, various visiting entertainers, a monthly church service and the local school. The inspector was informed that one service user who resides at the home was due to attend the local school to give a talk about the Second World War. Family and friends are invited to participate in some of the social event organised. Service users and/or their families are encouraged to look after their own financial affairs whenever possible. If this is not practicable a chosen solicitor will be responsible for an individuals financial dealings. An invitation to bring in personal items of furniture and other belongings is included in the service users guide and this was evident during a tour of the premises. When questioned about service users having access to their personal records, the manager said that this could be facilitated if it was requested. The home holds a Resident Forum on a six monthly basis and minutes are maintained of these and were made available for inspection purposes. Service users are offered three meals a day. The menu is rotated on a four weekly cycle and these menus are changed seasonally. No choice of main meal was witnessed although the menu does state that an alternative can be made available. It is recommended that the alternative choice of meal is made clear for service users. The inspector had the opportunity to observe a lunchtime meal in the upstairs dementia unit. Two care staff were available to assist ten service users with the lunchtime meal. This was relaxed, unrushed and well organised. All meals seen are attractively presented. The inspector was told that service users could take their meals in their rooms if they wish and this was the choice of one individual on the day of inspection. The home offers drinks and snacks throughout the day in accordance with needs of the service users. The nutritional needs of service users are assessed and there is evidence of regular monitoring in all care plans seen. Discussions with service users confirm that all meals are always of the same standard. DS0000022960.V312228.R02.S.doc Version 5.2 Page 16 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 the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an effective complaints procedure to ensure that service users or their representatives are listened to. Policies and procedures to protect service users from abuse are in place, including financial protection. Care workers have a good knowledge and understanding of Adult Protection issues that protect service users from abuse. However, there is a lack of POVA training for care workers, leaving service users at risk of abuse and harm and their rights to be safe are not protected. EVIDENCE: The home has a complaints procedure, which is accessible to residents and their representatives. A record of all complaints is maintained, and this was viewed. Three complaints have been received since the previous inspection and these have been dealt with within the stated timescales, record the investigation and outcomes of complaints raised. A summary of the complaints procedure is included in the Statement of Purpose and Service Users Guide. The home has a corporate adult protection policy. This includes guidelines for staff about the responsibilities of the staff, types and signs of abuse and what to do if you suspect abuse. Abuse awareness training commences at induction. However, training records demonstrate that some care staff require an update of their POVA training and is a requirement of the report. DS0000022960.V312228.R02.S.doc Version 5.2 Page 17 The telephone number for the Action on Elder Abuse Helpline is on display in the home. The home also has a whistle blowing policy. DS0000022960.V312228.R02.S.doc Version 5.2 Page 18 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 the following standard(s): 19, 20, 21, 22, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good, providing service users with an attractive and homely place to live. The overall quality of the furnishings and fittings is good to ensure the safety and comfort of service users. Standards of cleanliness at the home appear to be good meaning that service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. EVIDENCE: Following the previous inspection, three requirements were issued regarding improvements to the environment. These were 1) Repair the ceiling outside bedroom 7 2) Take all necessary action to ensure bedrooms 1 to 4 are adequately heated. 3) The carpet at the doorway to bathroom 1 must be repaired or replaced. (Previous timescale of 02/05/05 not met) It is pleasing to note t hat these have been complied with. DS0000022960.V312228.R02.S.doc Version 5.2 Page 19 The home provides accommodation for up to forty-eight older people. Thirtyone of these may require additional support due to a dementia type illness. All service users are accommodated in single bedrooms, twenty-three of which have en-suite facilities. The internal decoration of the home is mainly in good repair. However in the downstairs dementia unit there are many areas along the hallways where the wallpaper is ripped and torn. This area would benefit from redecoration and is strongly recommended. The kitchen is clean, spacious and well looked after. There are three areas available for dining. These are bright spacious and suitable for the purpose of dining. Communal areas consist of various lounge, dining and quiet areas. The home consists of an older building and a modern extension. The lounges are nicely decorated and there are personal touches around the home such as flowers, plants, books and pictures. There are extensive, and well-maintained grounds, including a secure garden area where service users with dementia type illnesses can mobilise in a safe environment. Lighting in communal areas is domestic in character and sufficient to facilitate reading and other activities. The furnishings observed in communal areas are of good quality and suitable for the range of interests and activities preferred by service users. There are accessible toilets available for service users throughout the home and several are close to the lounges and dining area. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The laundry floor finishes are impermeable and these and the wall finishes are readily cleanable. The home has an infection control policy and the inspector observed this. Instructions are in place for the washing of soiled linen. DS0000022960.V312228.R02.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels, although adequate, require a high use of agency staff which does not ensure staff have developed clarity of roles and responsibilities to ensure continuity of care. Service users benefit from a staff team who are up to date with their training, to ensure that staff are competent to do their jobs. There are effective recruitment procedures in place to ensure service users are protected from harm. However. Recent photos of all staff need to be kept on file. There is a staff training and development programme which ensures staff fulfil the aims of the home and meet the changing needs of service users. EVIDENCE: The staffing rotas were viewed, and these identify eight care staff are on duty through the working day. Observation during the visit, and discussion with staff, evidenced that the home ensures adequate staffing to meet the identified needs of service users. However, at the time of the inspection the home has several vacancies and the use of agency has been high. The registered manager stated that she was in the process of recruiting for these posts. The home has four waking night staff on duty at all times through out the night. There are no staff members under the age of eighteen and there are no staff under the age of twenty-one left in charge of the home at any time. DS0000022960.V312228.R02.S.doc Version 5.2 Page 21 There are adequate numbers of ancillary staff to ensure the home is maintained in a clean and hygienic state. Progress is being made with NVQ training. Thirteen care staff have achieved NVQ level 2 training and two care staff have achieved level 3. Staff files are kept in the home. These are well maintained and contain the necessary documentation as detailed in standard 34, except for a recent photograph of all staff employed by the home. This is a requirement of the report. The home are fortunate in that they have a designated training room in the home where training sessions can take place and where a variety of information about care tasks and practice are held for staff to refer to. All staff receive an induction programme which includes fire safety, moving and handling techniques and core skills training. Training records show that staff are up to date with mandatory courses and there are regular staff meetings. DS0000022960.V312228.R02.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. The home operates various methods of quality assurance resulting in the home being proactive in identifying issues that may affect the well being of services users. Protocols and systems are in place to ensure service users financial interests are safeguarded. There are several areas of the homes health and safety procedures that need to be improved to ensure the service users health, safety and welfare are protected and promoted. EVIDENCE: There are clear lines of accountability within the home and with the external management. DS0000022960.V312228.R02.S.doc Version 5.2 Page 23 The manager appears competent and sufficiently experienced to manage the home. She has completed her registered managers award. The registered manager feels that the staff team understand and can relate to the aims and purposes of the home. This is usually achieved through regular staff meetings, staff supervision and annual appraisals. The home undertakes a six monthly service user forum where individuals can provide feedback about any area of living in the home. This has included feedback regarding the standard of the food, issues around the environment and activities and entertainment in the home. Regulation 26 reports are carried out on a monthly basis and are detailed and informative. The registered manager said that service satisfaction questionnaires were due to go out imminently. Previous attempts to gain feedback from service users and their relatives or representatives have included an evening surgery where the manger has made herself available for discussions. However this was not found to be popular or beneficial and has since ceased. Service users are encouraged to look after their own financial affairs where at all possible. If this is not practicable then families will undertake this role. There are secure facilities available for the safekeeping of money and valuables and record and receipts are kept of possessions left for safekeeping. Following the previous inspection a requirement was issued that bedroom doors must not be held open unless a device approved by the fire officer is in place. This has been complied with and there was no evidence during this inspection of doors being wedged open. Records for fire safety were examined and most of these were found to be up to date. However, routine weekly testing of the fire alarm has not been recorded on a weekly basis. The registered manager felt sure this has been carried out but has not recorded. This was found later during the inspection. Fire safety equipment was last serviced on 20/07/06. The previous inspection to the home by Bucks and Milton Keynes Fire Authority was undertaken in July 2006. One requirement was made following this visit and has been complied with. Fire training records show that staff receive in house fire training on a regular basis. The Deputy Manager carries this out with all staff but has not received recently undertaken any up to date fire training except for that provided in the homes fire safety training video. It is strongly recommended that the person who is responsible for future fire safety training obtains up to date training/briefing from the fire safety officer, especially in light of the new fire safety regulations. Service reports are in place for the maintenance of the lifts and hoists. PAT testing was last undertaken on 29/09/06. On the day of inspection the registered manager was unable to find a service certificates for gas appliances DS0000022960.V312228.R02.S.doc Version 5.2 Page 24 and a hard wiring certificate. The inspector request that copies are forwarded to the Commission and this will be a requirement of the report. There is no evidence of a risk assessment for Legionella and this will be a requirement of the report. Infection Control guidelines are available for staff. DS0000022960.V312228.R02.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 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 X X 3 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 3 X 3 X 3 X X 2 DS0000022960.V312228.R02.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 NU9 Regulation 13(2) Requirement The registered manager is required to ensure that all care staff undertake accredited medication training that is provided by persons qualified to do so. The registered manager is required to ensure that all care staff are up to date with POVA training. The registered manager is required to ensure that a recent photo of all staff is maintained in staff files. The registered provider is required to ensure that a service certificate for the gas appliances and a hard wiring certificate are forwarded to the Commission. The registered provider is required to ensure that a risk assessment of Legionella is undertaken and a copy of this is forwarded to the Commission. Timescale for action 30/06/07 2. OP18 13(6) 30/04/07 3. OP29 Schedule 2 23(2) 30/01/07 4 OP38 30/12/06 5 OP38 23(2) 30/03/07 DS0000022960.V312228.R02.S.doc Version 5.2 Page 27 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. 3 4 5 Refer to Standard OP7 OP27 OP15 OP19 OP38 Good Practice Recommendations It is recommended that care plans contain more detail in the action plan where the guidance appears to be vague. It is recommended that the number of hours currently made available to an activities organiser be increased by 50 . It is recommended that the menu details the alternative choice of meal and is made clear to service users It is recommended that the corridors in the downstairs dementia unit be redecorated. It is strongly recommended that the person responsible for future fire training obtains up to date training/briefing from the fire safety officer, in light of the new fire safety regulations. DS0000022960.V312228.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 DS0000022960.V312228.R02.S.doc Version 5.2 Page 29 - 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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