Inspection on 09/02/07 for Deerhurst

This inspection was carried out on 9th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 19/12/05

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 Key Unannounced Inspection 09:15 9th February 2007 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 DS0000020237.V321541.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000020237.V321541.R01.S.doc Version 5.2 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) DS0000020237.V321541.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Manager must be a RN on part 1 or 12 of the NMC register 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 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 19th December 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 is 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 of 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. Fees range from £506 minimum to £545 maximum per week. DS0000020237.V321541.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which was undertaken over nine 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 was also undertaken to monitor strategies agreed by a multidisciplinary agency and the home to protect an individual living at the home from an alleged mistreatment from a visiting relative. At the last inspection five 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. 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: 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 Comprehensive service users guide is given to the prospective service user to enable them to make an informed choice about living at Deerhurst Nursing Home. The prospective service user is informed on admission of a one-month trial to enable them to make an informed decision whether to stay. High quality care planning system, which is holistic, is in use and this specifies how identified needs are to be met. Care plans are regularly reviewed. Meaningful activities are provided for service users and ensure that individual interaction is provided as necessary. Good meals are provided for the residents and staff ensure that meals are not hurried and residents who are unable to feed themselves are fed in a respectful, sensitive and dignified manner. DS0000020237.V321541.R01.S.doc Version 5.2 Page 6 A robust complaint procedure is in place and all complaints are investigated properly and action taken where required. There are ongoing training courses to enable staff to meet individual residents needs and ensure residents are protected from harm and abuse. A stringent recruitment procedure is followed to ensure that appropriate staff are employed at the home. The home is adequately staffed to include care and domestic staff. Aids and equipment are provided in sufficient quantity to assist care staff in meeting the needs of residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000020237.V321541.R01.S.doc Version 5.2 Page 7 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 DS0000020237.V321541.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are properly assessed before admission to the home and are assured that their needs would be fully met. EVIDENCE: The home’s statement of purpose has recently been updated and has detailed information about services and facilities provided at the home. The Service User’s guide is given or sent to the prospective resident or their representative when they visit to look round. Two service users’ files contained ‘License to Occupy’ which is Brunelcare’s Terms and Conditions. This document contained fees to be paid and other extra charges (Hair dressing and chiropody). This document is issued to both self-funded and local authority funded residents. DS0000020237.V321541.R01.S.doc Version 5.2 Page 9 Two care files of recently admitted residents contained pre-admission assessments and care plans completed on how the assessed needs were to be met. All prospective residents and/or their families are encouraged to visit the home before admission and are informed of one month trial to enable them to decide whether to stay. Staff spoken with including the registered nurses stated that they have received training on person centred care to enable them meet individual needs of residents admitted on the Burden Trust unit. DS0000020237.V321541.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The home offers care and support to service users throughout their life and towards the end, it also protects service users by reviewing their health needs and there is appropriate drug administration. EVIDENCE: Six care plans were reviewed at this inspection There was evidence of pre assessment before admission to the home. Following from this assessment the individual’s specified needs are recorded and comprehensive care plans are put in place specifying how these needs are to be met. This is followed up by monthly reviews and intervention if needs change. The home records all contacts with health professionals as a part of its care planning documentation and care files seen had evidence of visits by health professionals to include General Practitioner (GP) chiropodists opticians and Dentists. DS0000020237.V321541.R01.S.doc Version 5.2 Page 11 One comment card received from a health professional state “we have a 16 bed EMI nursing block contract with Deerhurst it has been running since March 2005. At a recent review 30/11/06 there were no issues raised regarding care. The service has been entirely satisfactory. Brunelcare work in partnership with the local Authority on this contract and we are pleased at the progress made on individual planning.” Some comments received from relatives regarding care of their persons living at Deerhurst include “we are very satisfied with the care my mother receives”. “My mother recently moved to Deerhurst and the care she is receiving is excellent”. “ I feel fortunate and thankful that I found Deerhurst for my mum. She is so well looked after.” There was evidence of manual handling assessment to ensure safety of residents and staff. There was evidence of risk assessment around falls pressure sores challenging or aggressive behaviour and appropriate intervention undertaken when necessary. The manager undertakes pressure audits on a monthly basis to ensure that measures are put in place to prevent occurrence. Wound care plans were in place along with treatment required for managing wounds. Care plan viewed had a care plan agreement, which was signed by the resident or the representative. Medication administration was checked on two units and was found to be satisfactory. There was medicine policy in place. Evidence of receipt and disposal of medication was seen. The controlled drugs were properly recorded and signed by two registered nurses and balances were tallied. The temperature of the drug fridge checked daily and the recordings were noted. The Commission’s pharmacy inspector at the last inspection assessed this standard and requirements made were fully actioned. Care staff were noted knocking on doors before going into service users rooms. One resident stated, ‘staff treat me with respect another resident stated ‘staff make sure the door is closed when I am bathing or using the toilet.’ Staff were noted interacting with service users in a respectful manner. The homes admission documentation form has a space for staff to document a person’s wishes in the event of death. The home encourages resident or their families to discuss this very sensitive issue as soon as possible in order to reduce the difficulties that may be caused while the individual has pawed away DS0000020237.V321541.R01.S.doc Version 5.2 Page 12 Staff have attended bereavement and loss training to gain understanding of how to meet residents’ needs when terminally ill and at time of death. DS0000020237.V321541.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides meaningful activities to service users, enables them to maintain contact with families and friends end ensure that choice is provided in respect of meals and meal times. EVIDENCE: Care files examined contained activities plan, which is completed by the resident and or representative on admission to enable the home to plan a suitable activity based on the details given and individual capabilities. The home employs an activities coordinator that arranges to take residents out every Tuesday to places of interest in Bristol and also arranges external entertainments based on residents, preferences. DS0000020237.V321541.R01.S.doc Version 5.2 Page 14 This individual attended one day training course on ‘Therapeutic Activities for Older People in November 2006 to enable her develop suitable activities for the people living at the home. The activities person is supported by a group of volunteers to provide activities for the residents. One relative who is also a volunteer stated that she would be going to the Bowling Challenge booked for 22 February to help out. From discussion with this person there is a plan to take residents to the hydrotherapy centre to give them opportunity to enjoy the water. Full risk assessment would be undertaken before this is carried out. The activities coordinator showed the inspector a folder put together for two residents life history. The information was gathered from talking to family members, family photos and account from individual residents. Also noted on the outside walls of individual rooms on the Burden Trust unit were posters and photos of hobbies enjoyed by the residents when they were younger and before they moved into the home. One resident was seen looking at one of the pictures with interest. Record of activities was noted in each service care file. Session recorded included bingo, music entertainment and one to one sessions such as chatting, reading and help with cross words. A resident who declined to join in activity was recorded and reason for decline. This is good practice and evidence that the residents are given the opportunity to exercise choice over their lives. The home has an equipped hairdressing saloon and a hairdresser regularly visits the home. Three relatives spoken with on the day confirmed they are able to visit the home at any time. One resident stated that her /his family regularly visits every week. Residents spoken with stated that they have a choice of when to get up and retire, choice of having meals in their room and a choice of participating in any leisure activities at the home and a preferred name to be called. The two-week menu seen contained varied nutritional meals. There was a choice of two meals at lunchtime on the day of inspection namely Fish and chips or Fish and sausages fresh vegetables and a selection of pudding. Staff was noted assisting service users th meals and those who were unable to feed themselves were fed in a sensitive and dignified manner while interacting with them. Residents spoken with said they enjoyed the meal. DS0000020237.V321541.R01.S.doc Version 5.2 Page 15 Fridge and freezer temperatures were recorded regularly, however the cooked food noted in the fridge were not labelled. The chef met on the day is a qualified cook with NVQ level 2 and 3 in Catering All kitchen assistants had achieved NVQ in catering, and attended training on Control of Substances Hazardous to Health (COSHH). DS0000020237.V321541.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. Service users are able to complain and are confident that the home is able to protect them from abuse. EVIDENCE: The home complaints policy and procedure is displayed, in the main reception area and at the nurse’s station in the three units. The complaint procedure is also included in the Statement of Purpose and the Service User’s Guide. This document has information about the Commission for Social Care Inspection (CSCI) to enable service users and their relatives to contact the Commission if they were not satisfied with the outcome of their complaint. The inspector looked at the complaint logbook maintained by the manager. It was clearly evident that three recoded complaints were appropriately investigated with and actions taken were recorded. The Commission for Social Care Inspection was contacted by the home through a regulation 37 notifications in relation to allegation of abuse towards a resident by a visiting family member. The allegation was investigated by a multidisciplinary agency under Joint Policy on Protection of Vulnerable Adult DS0000020237.V321541.R01.S.doc Version 5.2 Page 17 from Abuse. This inspection reviewed the strategies agreed at the meetings in relation to protecting this individual and concluded that the home satisfactorily carried out the actions as agreed. Whilst the outcome of the investigation was inconclusive, it was agreed that the home continues to monitor the situation and report any new unusual events. The individual looked calm and well cared for and was being visited by a relative on the day of inspection. The home has copy South Gloucestershire Joint Policy on Protection of Vulnerable Adults from (POVA) and a Whistle blowing policy and procedure to enable staff to report any bad practices without fear of reprisal. The home has an ongoing training on abuse and staff spoken with confirmed awareness of their role and responsibilities towards the residents. New staff file viewed contained Criminal Record Bureau checks and two suitable references before commencing employment. Manager stated that all registered nurses working at the home had Personal Identification Number verified by the Nursing and Midwifery Council (NMC) before commencement and periodically. DS0000020237.V321541.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home has a safe and well-maintained environment, comfortable bedrooms and specialist equipment suitable for service users needs, however if fails to keep the kitchen area clean. EVIDENCE: Deerhurst is a purpose built care home, opened in 1997 and therefore complying with all spatial and environmental standards. It is situated in a residential area surrounded by large areas of garden. The home is divided into three units. The Burden Trust unit is for those people with specialist dementia care needs who also require nursing care. The unit is secured with a key padded DS0000020237.V321541.R01.S.doc Version 5.2 Page 19 entrance. The unit is on the ground floor and currently accommodates 20 people in single bedrooms, all with en-suite facilities. The other two units are on the first floor and can be accessed either via stairs or a passenger lift. Both the Henry Smith and Barbara Russell units accommodate 20 people each. Each of the three units has it’s own lounge and dining area. The home is entered via automatic doors and as part of the redevelopment an internal porch has been formed and entry to the home is by an intercom system. The home was found clean, tidy and free from offensive odours. Air freshener units were installed on the corridors and the visitor’s toilet on the ground floor. There is a link corridor built to connect the new six-bedroom development on the dementia unit. This corridor connects two ends of the unit to form an enclosed garden area for service users on Burden Trust unit. The unit has a key padded entrance to ensure protection. All bedrooms have en-suite facilities consisting of a toilet, wash hand basin and a walk in shower. The six new completed bedrooms on the dementia unit have similar facilities. All bedrooms viewed were personalised, colour coordinated, clean and pleasantly furnished. One resident met in his room with a relative stated that he felt comfortable in their room. A disused toilet on the middle floor has been converted into a storage room after consultation with the Commission. The inspector reviewed the number of toilets on this floor accessible to the residents and concluded that the ratio of the toilet facilities to the number of residents is satisfactory. All the corridors have handrails fitted on both sides. The toilets and bathrooms had grab rails and various manual handling equipment and aids to assist the staff with meeting service users needs. Staff were seen using this equipment in a professional manner. Some service users were noted using specialist cutlery and plate guards on a non-slip tablemat to maximise their independence. Staff were seen attending to service users wearing gloves and aprons, indicating awareness of infection control. The laundry includes washing machines with sluicing facilities. The home has a policy on infection control and staff working in the laundry are aware of their responsibilities in regards to infection control and have attended training on Control Of Substances Hazardous to Health DS0000020237.V321541.R01.S.doc Version 5.2 Page 20 However it was disappointing to note that the kitchen was found very untidy with various areas of the kitchen covered in dust and the floor was littered with what looked like food particles. The chef stated that there is no cleaning schedule for the kitchen but all that all kitchen staff participate in cleaning the kitchen daily. This was discussed with the manager and a requirement was made to remedy this situation to ensure that residents, staff and visitors are protected. DS0000020237.V321541.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The home’s recruitment process demonstrates safeguards are in place, and also ensures staff competency, adequate numbers and skill mix along with training to protect service users. EVIDENCE: The home has a robust recruitment policy and procedure in place to ensure that only appropriate staff are recruited at the home. Records of recently appointed staff members contained required information to include CRB disclosures, two references, proof of identity and medical questionnaire to ensure fitness for employment. Evidence from the records show that registered nurses working at the home have satisfactory checks from the NMC for proof of registration. Deerhurst stated in its Statement of Purpose that the organisation “all staff receive comprehensive mandatory training and are encouraged to undertake further training suitable to their individual needs”. DS0000020237.V321541.R01.S.doc Version 5.2 Page 22 Evidence from the training records show that 26 care National Vocational Qualification (NVQ) at level 2 and achieved NVQ at level 3. There are also 11 NVQ Assessors home to provide NVQ training to almost all care staff. have also undertaken NVQs at different levels. staff have achieved 14 care staff have that has enabled the House keeping staff Furthermore trained nurses have also undertaken various courses to update their clinical skills to enable them to support the care staff in meeting the needs of the residents. One trained nurse spoken with on the day confirmed that they had undertaken training on diabetes, catheterisation and wound care. This is commendable and demonstrates that Brunelcare is committed to providing good service by ensuring that it’s staff are adequately trained and are competent to meet the needs of service users. All staff spoken with at this inspection stated that they have achieved NVQ level 2 in care and have attended various training to include, Manual Handling, First Aid, Health and Safety, Food hygiene and Infection Control. There was adequate numbers of staff to meet the needs of present category of residents. On the rota, there were three registered nurses; eleven care assistants on morning shift, three registered nurses, seven care assistants on afternoon shift, and two registered nurses and five care assistants on night duty. There is also a care staff from 4pm –10pm to assist with the high demand of residents needs at that time. One resident spoken with on the day inspection stated, “Staff are very kind and caring”. One comment care received from a relative states “my mother recently move to Deerhurst and the care she receives is excellent and the staff are very caring and very kind and have made her really feel at home, they have also made me feel very welcome and involved.” The home employs separate staff to work in the kitchen and laundry and for domestic duties. There is also an activities organiser and an administrator. DS0000020237.V321541.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32.33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from good leadership and management; its practices have offered protection to health and safety of service users. EVIDENCE: Leslie Hobbs has recently taken over manager few months ago as of Deerhurst following the resignation of the previous manager due to personal reasons. Leslie is a registered nurse on part 1 of the Nursing and Midwifery Council) NMC) and has 24 years experience of working with Older People and specifically two years experience of working with Dementia across Bristol and South Gloucestershire. DS0000020237.V321541.R01.S.doc Version 5.2 Page 24 Leslie has attended various training courses to enable her to perform her duties effectively. These include Leadership in Dementia care, Effective Supervision skills, Meaningful Occupation for people with dementia, Abuse awareness and First Aid. It is expected that Leslie would formally apply to the Commission for Social Care Inspection to be the registered of Deerhurst in due course. Residents, staff and relatives spoken with on the day of inspection commented positively and highly on the Leslie’s ability to manage the home. One resident stated ‘she is good’ another stated ‘Manager is excellent’, one relative said, “Leslie is nice, she will listen to any concerns and she comes round every day. She is hands on”. A group of relatives met on the day stated that ‘things have changed since Leslie came here. She is very approachable. Two staff members stated ‘ manager is approachable and would listen when you go to see her’. On the day of inspection, although supernumerary, she was met in nurses uniform and on several occasions seen on the units interacting with staff and service users. A deputy manager who is responsible for dealing with clinical issues at the home supports the manager. The fire logbook is well maintained as well as the home maintenance book. The home completes all weekly and monthly checks and the last fire officer visit for advice was in September 2006. Staff have attended fire lectures and regular fire drills. The home has regular maintenance contracts lifts, hoists, Nurse Call system, fire alarm service and portable appliance tests (PAT) of all electrical appliances and electrical wiring central heating systems. All potential hazardous places at the home have been risk assessed and measures have been outlined to minimise or prevent accidents. Accidents were recorded and followed up. The home ensures that Regulation 37 Notification is completed and sent to the Commission for Social care Inspection when required. The administrator manages the personal spending allowance of majority of the residents and the manager checked records of deposits and expenditure with the inspector and found that balances tallied with the amounts stored in the safe. DS0000020237.V321541.R01.S.doc Version 5.2 Page 25 Staff were supervised regularly, staff members spoken with stated that they have had supervision. This was evidenced in the staff files viewed. One registered nurse stated that she had received supervision every six weeks and appraisal in the last six months to enable her to discuss area of concern and the training needs supervise the care staff on the unit. The home has different ways of monitoring the quality of its services. These include Regulation 26 visits by the provider, care planning reviewing processes, residents and relatives meetings two monthly, staff meetings monthly, pharmacy audits policies and procedure reviews, pressure sore, wound and falls audits. The manager stated that she sent out letters of introduction to all residents and their representatives when she took over as manager, she visits the residents on a daily basis and has breakfast with residents at least once a week. This gives her the opportunity to sample the food and listen to residents concerns if any. This is a good practice. The home has a structured induction programme for newly employed staff members which is expected to last as long as it takes for induction to complete and are not able to work until they have completed mandatory training. This to ensure that the new staff member is competent and confident to work with residents independently and with other staff members to meet their needs. Care records were seen locked in cabinets in each unit at the nurse’s station and keys held by the trained nurse in charge of the shift. Staff records are maintained in the manager’s office in lockable cabinets. Along with other confidential files. Policies and procedure manual was viewed was recently updated to include whistle blowing, Infection Control, Medication, Manual Handling, confidentiality, Complaint, Training, Death and Dying and Challenging Behaviour, admission of residents and recruitment. DS0000020237.V321541.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 2 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 X 3 3 3 3 DS0000020237.V321541.R01.S.doc Version 5.2 Page 27 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. 2 Standard OP26 Regulation 13 (4)(c) Requirement “The registered person shall ensure that unnecessary risk to the health and safety of service users are identified and so far as possible eliminated” Ensure that cooked food stored in the fridge is labelled to prevent food poisoning “The registered person shall having regard to the number of service users ensure that all parts of the home are kept clean” Ensure that the Kitchen is kept clean at all times to prevent risk of infection. Timescale for action 09/03/07 2 OP26 23 (d) 09/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000020237.V321541.R01.S.doc Version 5.2 Page 28 DS0000020237.V321541.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000020237.V321541.R01.S.doc Version 5.2 Page 30 - 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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