Inspection on 19/12/05 for Deerhurst

This inspection was carried out on 19th December 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 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

Deerhurst 09/02/07

Deerhurst 03/05/05

Deerhurst 16/12/04

Deerhurst 24/06/04

Deerhurst 03/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Deerhurst 10 Deerhurst Soundwell South Glos BS15 1XH Lead Inspector Grace Agu Announced Inspection 09:30 19 December 2005 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 Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 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. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Deerhurst Address 10 Deerhurst Soundwell South Glos BS15 1XH 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) 0117 9041170 0117 9041171 cburt@brunelcare.org.uk Brunelcare Mrs Carol Burt Care Home 66 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (26), Old age, not falling within any other of places category (40) Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Staffing notice dated 21/2/1997 and Amendment dated 29/4/05 applies May accommodate up to 26 persons aged 50 years and over with Dementia Manager must be a RN on part 1 or 12 of the NMC register May accommodate up to 5 people over the age of 50 years with dementia on the Burden Trust Unit May accommodate up to 5 people over the age of 50 years with nursing care needs on the Henry Smith or Barbara Russell Units 3rd May 2005 Date of last inspection Brief Description of the Service: Deerhurst is a purpose built home, registered in March 1997 and operated by Brunelcare. Mrs Carol Burt registered manager with the Commission for Social Care Inspection. The home is situated in a residential location, within a quiet cul-de-sac and is accessible to local shops, amenities and bus routes. The property provides bedroom and communal accommodation over two floors for sixty-six service users. Bedroom accommodation is provided in good-sized rooms with ensuite facilities (a toilet, sink and walk in shower). All areas of the home are accessible via two lifts. The home is divided into three units. The two units on the first floor provide general nursing care for service users and the third unit on the ground floor is specifically designated for people with dementia. Access to this area is by the use of an electronic keypad that offers protection to this group. Each unit has a lounge and dining room. There are a suitable number of bathrooms and toilets with adaptations to meet the care needs of service users. Appropriate equipment is provided for individual use, based on the personal and nursing care needs. The home has currently redeveloped the facilities, providing an additional six beds for service users with dementia. This was completed in April 2005. As a part of the redevelopment, a link corridor was built from one end to the building to the other, forming an enclosed garden area. The home is set in its own grounds with attractively maintained gardens. Car parking is available for several cars. Visitors are welcome in the home at any time. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection which was undertaken over fourteen hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. The inspection also followed up two reports of incidents medication discrepancies sent to the Commission for Social Care Inspection by the home. The pharmacy inspector reviewed the home’s medication and her report can be found in the body of the report under Standard 9. At the last inspection three requirements were made in relation to different areas of service provision at the home. It was pleasing to note that the home had made considerable effort to ensure that all the requirements were met. This is commendable. Generally the home was found clean, warm and free from unpleasant odour. Staff were noted working as a team and interacting with residents in a positive, dignified and sensitive manner, residents were found to be relaxed and looked well cared for in this homely environment. A tour of the building was undertaken and a number of records were viewed. Seven residents, six relatives and twelve staff members were spoken with on the day. What the service does well: The home continues to provide high quality by ensuring that prospective residents are appropriately assessed before admission and are informed about options available to them in order to make an informed choice about staying at the home. The home provides meaningful activities for all the residents based on individual capabilities and ensures that individual interaction is provided if necessary In order to ensure adequate nutrition, good meals are provided and are not hurried; those who are unable to feed themselves are fed in a respectful and sensitive manner. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 6 Residents are protected and enabled to complain through a robust complaints procedure and the home would ensure that all complaints are thoroughly investigated and all required action (if any) implemented. In addition, to ensure that residents are adequately protected, ongoing training courses are provided for staff and stringent recruitment procedures are followed for all persons that are employed at the home. The home ensures that there are adequate numbers of staff to meet the residents’ needs. The home ensures that aids and equipment are provided in sufficient quantity to assist staff with meeting the needs of residents. What has improved since the last inspection? What they could do better: Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 7 The home must ensure that a record of medicines passed on to residents for self-administration is made on the medicines administration record sheet. In addition, to ensure safe administration as prescribed by the doctor, any changes must be agreed with the doctor and documented. Resident needs would be appropriately met if care plans for identified needs are developed and reviewed as required. There would be better protection for residents if staff were regularly supervised. It would be better to monitor fluid intake for residents who are unable to express their preferences based on individual assessment. 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. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 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 Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 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): 2,3 Residents are properly assessed before admission to the home are and assured that their needs would be fully met. EVIDENCE: Three care files of recently admitted residents contained pre-admission information in relation to activities of daily living, social history, likes and dislikes, medical history and medication. The above information is evaluated and care plans are provided on how the assessed needs are to be met. Terms and conditions of stay are issued to both Self and Local authority funded resident. Two relatives interviewed stated that their person was assessed before admission to the home. They stated, “Mum is well looked after here”. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The home offers care and support to residents by reviewing their health, personal and social care needs, and their right to be treated with respect and privacy is up held. However, some action is needed to ensure that records of self-administration of medicine are clear and that all changes from labelled prescription instructions have been confirmed with the doctor. EVIDENCE: At this inspection eight care files were reviewed each care file had evidence of pre-admission assessment before all the residents were admitted to enable the home to determine its suitability to meet the residents needs. Comprehensive individualised care plans were noted in most office care home files reviewed followed by daily day and night entries detailing how the assessed needs were being met. There was also documentation in relation to risk assessments, manual handling assessments and pressure sore prevention using the Braden Scale Tool. All of the above were regularly reviewed and updated when needs changed. There was a care plan agreement demonstrating the residents are consulted before care plans are developed. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 11 There was a care plan agreement demonstrating that residents are consulted before care plans are developed. However, there were areas of concern noted on three of the care files reviewed. One of the care files had information that the resident can be verbally aggressive. There was no care plan written to provide staff with information on how this need would be met. Another care file reviewed had entries on the 11thNovember 2005 ‘was rude’ to staff member and reported to the nurse in charge, 17th November 2005 ‘declined care,’ 20th November 2005 ‘refused care,’ 22nd November 2005 ‘refused assistance with personal care’. Whilst staff interviewed demonstrated awareness of how the identified needs of the above resident were being met, there was no care plan in place to ensure that all staff provide continuous and consistent care to this resident. Furthermore a resident with a medical condition and deteriorating communication had no care plan explaining how this need was being met. Some staff members spoken with confirmed that they find it difficult to communicate with the resident sometimes and that it could be frustrating. A requirement was made for care plans to be provided for all the identified needs along with an identified medical condition that may put other residents at risk. It is important and commendable to note that the home has an active Infections Control Policy and staff were noted disposing of aprons and gloves after attending to residents and washing their hands after attending to every resident. Residents interviewed confirmed that staff treated them with respect and knocked at the doors and waited for an answer before entering to attend to their personal hygiene needs. One resident interviewed stated “I like it here, staff are kind, I wake when I want to and go to bed when I want”. There was evidence of other health professional visits to include the GP, Chiropodists, Opticians and Dentists. Evidence of wishes in the event of death was noted in the care files reviewed. One comment card received from a health professional stated ‘this is an excellent home. I am coming here when I get old and frail. Best home for miles around.’ A local pharmacy provides medication using a monthly monitored dosage system. A check of the blister packs indicated that medication had been administered as recorded. All medication seen was stored securely. Medicines trolleys are used to transport medication around the home. Each unit has a medicine fridge and temperatures are recorded daily. To ensure safe storage one oxygen cylinder with no trolley was moved to a cupboard, a statutory warning notice is needed for the door of the cupboard. Controlled drugs were stored correctly and recorded in a register. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 12 A policy is available to enable residents to look after their own medicines. All medication is ordered and received by staff. Several residents look after their own medication. The medicines administration record sheet must indicate any medicines that are selfadministered. A record must be made of the date medicines are supplied to the resident along with the quantity and the nurse’s signature. The pharmacy supply printed medicines administration record sheets each month. Records of administration of medicines were clear. Two records were seen indicating that medicines had not been given as prescribed, in one case three additional doses of pain relieving medicines had been given and in another the evening dose of inhaler was not being administered. To ensure safe administration medication must be administered as prescribed by the doctor, any changes must be agreed with the doctor and documented. Records are kept of medicines received into the home. Waste medication is recorded and now disposed of via a waste disposal company. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14,15 The home enables residents to maintain contact with family and friends and local community. It also provides meaningful activities and choice in respect of meals and meal times. EVIDENCE: Residents spoken with confirmed that the home supports them to maintain contact with their families, friends and representatives and including the local community. One resident stated that his/her daughter visits regularly to take her out, another resident stated “my relatives visit me daily” other residents spoken with confirmed that the home is a friendly place and that the home never lacks visitors. On the day of inspection people were noted visiting their relatives and three relatives spoken with stated that they are satisfied with the care given to their loved ones. The home activities programme was reviewed and it remained satisfactory. An activities plan is issued to residents or their relatives on admission to complete, to enable the home to plan a suitable activity based on details given and assessed on individual capabilities. Activities recorded in each resident file include music entertainment, Holy Communion and bingo. There were also records of interaction on an individual Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 14 basis with residents who prefer to be in their rooms or declined or were unable to attend to the general planned activities. There was a planned bus outing on the day and special Communion services for residents on the Burden Trust Unit. The Manager stated that the special Holy Communion service is in recognition of importance of inclusiveness of people in that unit to ensure that they do not lose out due to their varying medical conditions. In relation to choice in their daily routine, residents spoken with stated that they have a choice of when to get up and retire. One resident stated, “The place is marvellous. The people are very kind to me indeed. If I want anything special, if it is within their power they give it to me. I can have a bath when I want.” Another resident stated, “There is never a dull moment here”. The menu on the day contained a choice of two nutritional meals and a choice of pudding. One of the puddings tasted by the inspector was delicious. Staff were noted assisting the residents during lunch in particular residents who were unable to feed themselves. All residents interviewed after lunch stated that they enjoyed their food one resident interviewed stated, “I eat and eat and eat. If I say I would like to have roast beef they will try and make it possible”. The kitchen was found to be clean and tidy. It was pleasing to note that a piece of equipment noted at the last inspection that needed attention had been beautifully refurbished. The chef stated that staff working in the kitchen have attended basic food hygiene training and Control of Substances Hazardous to Health (COSHH) Training. The chef also stated that new seals have been installed in the fridges and freezers to provide better food protection. Laundry staff interviewed confirmed that they have attended COSHH Training and that two new industrial machines and a tumble dryer have been purchased to provide better Laundry services for the residents at the home. There are risk assessments of both laundry and kitchen. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 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 the following standard(s): 16,17,18 Residents are enabled to complain and are confident that the home is able to protect them from harm and abuse. EVIDENCE: The home’s complaint procedure contains required information details of how to contact the Commission for Social Care Inspection if they were not satisfied with the outcome of their complaint. This procedure was noted displayed at the entrance of the home. There was one recorded complaint and evidence from discussion with Manager and from the complaints book confirmed that the complaint has been satisfactorily resolved. One resident interviewed stated that “he is satisfied with his care, the night staff are excellent and the day staff are good too” I have no complaints and will definitely complain to the Manager if necessary. Two relatives spoken with stated that their person’s care is satisfactory. They were not aware of the complaints procedure but would obtain the information from the Manager. One relative, at a discussion, stated that he/she was concerned about drinks not being served to residents between 10.45 am and 11am as stated in the residents information at Burden Trust Unit. This had been ongoing. The inspector confirmed this concern whilst in that unit between 10am and 11am. This was discussed with the Manager and Sister in charge of the unit. The explanation given was not satisfactory and it was agreed that residents must be offered drinks at those times as stated based on individual assessments. A requirement was also made to ensure that this was implemented. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 16 The inspector also followed up an allegation of inappropriate treatment of a resident by one staff member. The staff member was disciplined and was issued with a final warning letter. The resident confirmed that the matter had been satisfactorily resolved and that he/she gets on well with the staff member. The staff member at a discussion during the inspection also confirmed the issue had been resolved and that he had assisted the resident with personal care that morning. Two new staff members’ files reviewed evidenced that two satisfactory references and Criminal Record Bureau Disclosures had been obtained before commencement of employment. The Manager stated that she raised and discussed the mild concern noted on one of the references provided for one of the new staff members. The explanation provided by the staff member was satisfactory. Evidence from the records showed that Registered Nurses working at the home had their Personal Identification Numbers (PIN) verified by the Nursing and Midwifery Council (NMC) before commencement of employment and periodically to ensure that residents are adequately protected. Residents spoken with stated that they felt safe at the home. One resident spoken with stated that he voted at the last inspection using the postal voting system. Response received from the relatives and visitors inspection questionnaire were positive and complementary of the home. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. The home has a safe, clean, hygiene and well maintained environment, and it also provides specialist equipment suitable for residents needs. EVIDENCE: Whilst touring the building, the units were found to be generally clean, warm, well lit and free from unpleasant odours and suitable for its stated purpose. Residents sitting in the lounges, looked relaxed, well cared for and enjoying each other’s company. Some residents interviewed in the lounges stated that they felt safe at the home and that they have access to the garden. One resident spoken with in the link corridor on the ground floor stated “I always come down here daily, I like watching the birds pointing towards the enclosed garden, he/she stated “look at this beautiful garden.” We use it very much in summer, it is so good then, I can’t go out there because it is very cold. Staff are very kind, they would help me if I want to sit out here”. Residents spoken with in their bedrooms stated that they are happy and comfortable with the cleanliness of Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 18 the home. Staff were noted well presented in uniform and wearing disposable aprons and gloves and more importantly washing their hands after attending to individual residents. This demonstrated that infection control and principles of hygiene are of paramount importance to the home. Laundry facilities have been discussed previously. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The recruitment procedure of the home is robust and offers protection to residents at the home. There are adequate numbers of staff that are competent to meet the needs of the residents. EVIDENCE: As noted in the last inspection report BrunnelCare is an organisation committed to ensuring that appropriate training is given to its staff to provide a high standard of care. Evidence from staff records and discussion with the Manager and staff showed that staff have attended training on Protection of Vulnerable Adults (POVA), some staff interviewed stated that they have been booked for POVA updates. Other training attended included, fire safety and first aid. Brunelcare has implemented Person Centred Care training to enable staff to learn more about individualised care of residents. One staff member spoken with stated that she is the training co-ordinator of the home and assists the manager to identify individual training needs through supervision and staff documentation on the units. The training co-ordinator stated that the home receives extra funding for staff training from the organisation. One staff member stated ‘BrunnelCare is giving us good training here’. The home also accessed training through social services whenever possible. Two registered nurses spoken with confirmed that they have attended training on wound care, pharmacology update, loss and bereavement, catheterisation and dementia. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 20 In addition to the above training, 24 care staff have completed National Vocational Qualification (NVQ) at Level 2, 8 Care staff have completed undertaking NVQ at level 2, 6 care staff are undertaking NVQ at level 2, 6 care staff demonstrates that the home has achieved a minimum ratio of 75 trained members of care staff (NVQ Level 2) by 2005. This is commendable. The training plan for 2006 seen included mandatory statutory training updates and protection of vulnerable adults training for all staff. Discussion with Manager and staff and records viewed evidenced that staff are receiving supervision; however not regularly; the Manager stated that she would ensure that all staff receive regular supervision including the newly recruited staff members. The Manager stated that one senior staff was off sick on the morning of the inspection and that no cover could be found due to short notice. However this shortage had no adverse effect on the care of the residents. Staff rota reviewed for the previous week and the remaining part of the month was satisfactory. Residents interviewed confirmed that the home provided adequate numbers of staff to meet their needs at all times. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 The manager is supported well by the registered provider and staff to provide clear leadership throughout the home with all staff demonstrating understanding and awareness of their roles and responsibilities. EVIDENCE: A well-qualified and competent manager who has been at the home for many years manages Deerhurst; Carol Burt is a first level registered nurse and has attended many training courses to enable her to provide quality care for all the residents. Ms Burt has a qualification at level 4 NVQ in management and is considering studying extra units to enable her to achieve the Registered Managers Award (RMA). The manager stated that she is supported and supervised by the senior clinical manager on both clinical and management issues. The organisation provides her with opportunities for personal development. She has the autonomy on Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 22 budgeting to ensure that the home had adequate resources to meet the needs of the residents. Staff are supportive and the manager stated that with the recruitment of the deputy manager, she has more to spend on ‘hands on’ nursing with the residents. Residents and staff spoken with on the day, commented positively on the manager’s ability to manager the home. One resident stated that ‘ the manager is very good; she would listen and is approachable. One staff stated that staff work as a team (this was clearly demonstrated on the day) and that Carol is a good leader. The home’s quality assurance system was reviewed. During a discussion the manager stated that the home recently conducted a friends and family survey to obtain feedback on the range of services provided at the home. Topics noted in the survey included staff politeness, care of residents, complaints, further improvements and home information. Care of residents scored the highest mark of 93 . Other ways of monitoring the service include pressure sore monthly audit, residents survey, residents and supporters bi- monthly meeting, senior staff meeting, care plan reviews and registered providers Regulation 26 visits. The staff meetings had poor attendance, the manager stated that she would continue to explore areas to motivate staff to attend meetings to ensure that their opinions are included in future developments at the home. The fire logbook is well maintained as well as the home maintenance book. There is evidence that staff have attended fire lectures and regular fire drills. There is a service record of lifts, hoists, fire alarm systems and portable appliance tests (PAT) of all electrical appliances. Accidents are recorded and are followed up. Policies and procedures in the home include, whistle Blowing, confidentiality, Health and Safety, complaint and protection of Vulnerable Adults from Abuse. All residents’ information and records were securely locked away. Residents monies are individually recorded however are deposited into one bank account. The administrator requests a lump sum from the financial department as required. All resident’s spending money is taken from this amount and is accounted for individually. The amount in the safe tallied with the overall balance in the book. The administrator stated that she is not authorised to withdraw money from the account however can deposit into the account. Staff supervision is discussed in the previous standard. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 3 Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 24 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. 2. 3. 4 Standard OP7 OP36 OP8 OP9 Regulation 15 18 12 13 Requirement Timescale for action 20/12/05 Ensure that care plan are provided for identified residents Ensure that staff receive regular 20/01/06 supervision Monitor residents fluid in take 27/12/05 based on individual assessments. A record of medicines passed on 19/12/05 to residents for selfadministration must be made on the medicines administration record sheet. . To ensure safe administration 19/12/05 medication must be administered as prescribed by the doctor, any changes must be agreed with the doctor and documented. 5 OP9 13 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 25 No. 1. Refer to Standard OP38 Good Practice Recommendations Domestic staff should have specific training on COSHH. Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Deerhurst DS0000020237.V266179.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!