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Inspection on 20/06/07 for New Bassett House

Also see our care home review for New Bassett House for more information

This inspection was carried out on 20th June 2007.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

New Bassett House provides a comfortable, homely, and relaxed environment for residents. Residents and relatives spoken with made positive comments about the home and staff. `highly recommended`, `staff are very kind, I`m very happy here`, `I have never regretted coming here`. The management team are seen as approachable and responsive. Communal areas of the home are comfortable and provide a range of areas for residents to use. The home was found to be generally well maintained and standards of cleanliness are high. The food was said to be `good`, a choice of meals is always offered, and meals are served in attractive dining areas. Staff spoken to were experienced, knowledgeable, enthusiastic and committed to the welfare of residents. There is a stable staff group who work well as a team. No new staff have been employed recently. Staff supervision takes place and training is given a high priority. All care staff are trained to NVQ level 2 and receive regular supervision.There is a thorough system for recruiting and training new staff and appropriate checks are carried out. There is a corporate complaints procedure, although most day to day difficulties are dealt with on an informal basis. Staff and managers are aware of safeguarding adults issues. There is an effective quality assurance programme that provides clear indications of where the home is doing well and what areas could be improved still further. The survey found that the staff and catering were rated as `good` or `excellent` by 94% of residents.

What has improved since the last inspection?

Some work has been undertaken to improve care planning documentation. The home are currently implementing the new computer based `Framework i` system which will be used by all Derbyshire County Council staff. A new sign has been installed at the entrance to the site. All managers have had medication training. The maintenance of staff records has improved. New fly screens have been put up in the kitchen. A new tumble dryer was purchased. Some electrical work has been carried out.

What the care home could do better:

The flagstones in areas outside the home are very uneven, and have not been maintained/replaced as required at the last inspection, nor has an environmental risk assessment been carried out on this area.

CARE HOMES FOR OLDER PEOPLE New Bassett House New Bassett House Park Avenue Shirebrook Nr Mansfield Derbyshire NG20 8JW Lead Inspector Denise Bate Unannounced Inspection 20th June 2007 09:30 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 New Bassett House DS0000035586.V339024.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. New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Bassett House Address New Bassett House Park Avenue Shirebrook Nr Mansfield Derbyshire NG20 8JW 01623 588000 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) www.derbyshire.gov.uk Derbyshire County Council Susan Ina Elsden Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th April 2006 Brief Description of the Service: New Bassett House is a home offering 40 places to older persons. It includes 2 places as part of an intensive assessment or intermediate care project, which is currently being reviewed. The home is built on one level and is situated in a residential area, near to the town centre of Shirebrook. Arranged on 3 wings the home offers a range of communal rooms to suit different purposes and access for persons with a physical mobility problem is assisted by wide corridors and an open central area. Facilities have been arranged with a domestic style in mind and there is access to the outside areas of the home. Access to outside professionals is routinely arranged and the home benefits from the active support of a local GP. Fees are £381.84 per week for permanent residents, with a range of prices for short term care residents. Additional charges, e.g. hairdressing, chiropody, are clearly identified in the home’s Statement of Purpose and Service User Guide. Copies of inspection reports are available in the foyer and in the office. New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven hours. During the inspection eight residents, three relatives, and two staff members were spoken with. The deputy manager and service manager were present during the inspection and provided assistance and information. Prior to the inspection a number of sources of information were looked at including the home’s service record and previous inspection reports. Twenty eight resident surveys were received prior to the inspection and comments from residents are included in this report. A pre inspection questionnaire was completed by the manager. As the manager was on leave on the day of unannounced inspection, information provided by her over the telephone a few days after inspection has also been included in this report. A number of records were examined on the day of inspection, including care planning documentation, minutes of residents and staff meetings, regulation 26 visit records, accident records, staff files and medication records. Four residents were case tracked. A tour of part of the building took place and the grounds were seen. What the service does well: New Bassett House provides a comfortable, homely, and relaxed environment for residents. Residents and relatives spoken with made positive comments about the home and staff. ‘highly recommended’, ‘staff are very kind, I’m very happy here’, ‘I have never regretted coming here’. The management team are seen as approachable and responsive. Communal areas of the home are comfortable and provide a range of areas for residents to use. The home was found to be generally well maintained and standards of cleanliness are high. The food was said to be ‘good’, a choice of meals is always offered, and meals are served in attractive dining areas. Staff spoken to were experienced, knowledgeable, enthusiastic and committed to the welfare of residents. There is a stable staff group who work well as a team. No new staff have been employed recently. Staff supervision takes place and training is given a high priority. All care staff are trained to NVQ level 2 and receive regular supervision. New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 6 There is a thorough system for recruiting and training new staff and appropriate checks are carried out. There is a corporate complaints procedure, although most day to day difficulties are dealt with on an informal basis. Staff and managers are aware of safeguarding adults issues. There is an effective quality assurance programme that provides clear indications of where the home is doing well and what areas could be improved still further. The survey found that the staff and catering were rated as ‘good’ or ‘excellent’ by 94 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. New Bassett House DS0000035586.V339024.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 New Bassett House DS0000035586.V339024.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to ensure residents can make an informed choice about where they live. EVIDENCE: Copies of the Statement of Purpose and the Service User Guide are available in all residents’ rooms. Some permanent residents told the inspector they have got to know the home through the provision of day care and/or short term care; this was also confirmed through discussion with relatives and in information provided by the resident surveys. Prospective residents or their advocates are encouraged to New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 9 visit prior to making a decision to move to the home. Copies of pre admission assessments were seen on the care planning documentation of case tracked residents. It was noted that the new computer based system will aid the availability of up to date information to assist in providing appropriate care for residents. Residents said; ‘I spoke to someone who had lived here and he told me how good it was’, ‘I was given a lot of information, I also used to come for short term care, the home is the best’, ‘staff did everything to make me feel happy when I first came in’, ‘I used to come for day care and was very impressed’. The home has two beds that are designated for intermediate care. At the present time these are not being fully utilised so Standard 6 was not inspected on this occasion. The service manager is renegotiating the use of these beds with health colleagues. New Bassett House DS0000035586.V339024.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 good. This judgement has been made using available evidence including a visit to this service. Care plans are completed and are individualised to demonstrate that residents’ health, personal and social care needs are being met. EVIDENCE: Four case tracked residents had clearly arranged care planning documentation. Items in files included monthly summaries/reviews, personal service plans, risk assessments (moving and handling, nutrition), weight monitoring, and day to day logs. Personal service plans were resident focussed and individualised e.g. including food preferences, personal routines, etc. Personal service plans had been signed by residents, indicating that their contents had been discussed with them. The provision of high standards of care was confirmed by residents New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 11 who said; ‘ the carers are excellent’, ‘I’m quite happy and comfortable’, ‘when we need something the staff come straight away’. There was evidence of regular reviews, both filled in by the key worker and formal reviews chaired by the service manager. A relative said; ‘things get written down in reviews and care can be changed’. An example was given where the way care is delivered was changed at a review and a formal plan put in place to check with the resident that they were satisfied with the new arrangements. There were a few gaps in care planning documentation of two recently admitted case tracked residents and the inspector was informed that these are in the process of being finished. Some care plans could be completed in more detail to provide advice and guidance to staff and to reflect the high quality of care actually provided. Information on one resident’s risk assessment was not consistent. The service manager said that all care planning documentation is being transferred to the ‘Framework i’ system over the coming months and the system was demonstrated for the inspector. The home have a clear plan to quality assure all the new care planning documentation over the coming months. For each resident a second care file contains financial information and background details and copies of assessments and care plans that have been superseded. Paper copies of contracts were not available on file, but the inspector was informed that they are available on the computer system through ‘Framework i’. The inspector was informed that residents can have access to all their personal records, and this was also minuted in records of a residents meeting. Aspects of residents’ health needs and medication were clearly presented on care planning documentation. Residents are supported to go to hospital appointments, and a member of staff took a resident for a hospital appointment on the day of inspection. It was reported that a good relationship exists with local GPs and with District Nurses. A relative said; ‘staff go out of their way when people get ill, we are very impressed they are so caring’. Residents said ‘if I needed a doctor I know the home would make sure that I saw the doctor’, I am feeling better with the support from the doctor and staff’. ‘I get my tablets every day’. Several resident surveys mentioned how they are supported in obtaining and maintaining equipment to help reduce the impact of physical disabilities; ‘I wear a hearing aid but the staff always make sure that I have heard what they say’, ‘the staff are kind and help me to do the things I cannot do myself’. Members of staff were observed treating residents with dignity and respect. Staff said ‘it is our job to care, to make sure people are looked after well’. Members of staff was observed having very positive interactions with residents New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 12 with poor communication skills. Members of staff were also observed welcoming short term care residents and their family; providing reassurance and information. The home uses the Medidose system for medication. There is a separate medication room where medication is kept securely. Pictures of residents are kept with their medication administration records, reducing the possibility of residents being given the wrong medication. The medication records of some case tracked residents were seen and found to have been recorded correctly. The date of opening had been recorded on eye drops and creams. The fridge temperatures were being monitored. The record of controlled drugs was seen and found to be maintained correctly. The home have access to medication information about particular drugs and their uses and side effects. One resident case tracked has complex needs and arrangements were in place to ensure that medication for Parkinsons disease was administered at appropriate times. The home have a copy of the latest guidance available and are working to ensure all aspects of the home’s practice are in line with current Derbyshire County Council guidelines. A number of medication issues had been noted by the service manager in the regulation 26 meeting records, indicating that matters relating to mediation are reviewed regularly. All case tracked residents had signed medication forms. One resident administered their own medication and an appropriate risk assessment was seen on their care planning documentation. All managers have had medication training and further training is planned for other members of care staff. A record is kept of staff signatures, but some of the signatures on the MARS chart did not match very well. All case tracked residents had clear ‘end of life’ plans. In one case they were very detailed, and the resident was clearly comforted by the confidence that staff would carry out his wishes. Discussions with staff indicated that they provide care and support to relatives and other residents. New Bassett House DS0000035586.V339024.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 suitable activities and the quality of catering is excellent which contributes to a pleasant atmosphere and the high overall levels of satisfaction for residents. EVIDENCE: There is a designated member of staff who takes responsibility for organising activities. There is an activities room which can be used for craft work, etc. Records are kept of activities undertaken and these were seen by the inspector, but the records on individual case tracked files was not always up to date. The resident surveys revealed a wide range of wishes in this area; some residents preferred not to join in, others did enjoy some activities but not others, and some just liked to watch; ’I like the story reading, I join in most New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 14 activities’, ‘I don’t like bingo but I like to go out on trips’, ‘I enjoy skittles and all other sit down games but don’t like bingo’, ‘ I don’t like activities, but I sometimes come and play bingo’, ‘I take part in everything that is going on’. On the day of inspection some residents played dominoes. The home have a series of outings which are very popular. Activities are discussed at residents meetings, where residents’ views can be obtained and the programme developed further. The resident surveys indicated that many residents are Christians. The inspector was informed that church representatives visit the home regularly and residents spiritual needs are recorded and respected; ‘I like to watch songs of praise on a Sunday’. This section was filled in on the care planning documentation for all case tracked residents. Residents indicated that they feel staff are approachable and any problems can be discussed with them or with one of the managers. All indicated that they are able to exercise choice about aspects of their daily lives. The inspector was informed that resident meetings take place on a quarterly basis and the minutes were seen. Regular reviews take place and residents and their relatives are encouraged to make their views known about activities, as they are about other aspects of care provided. Copies of review minutes were seen for case tracked residents. It was confirmed by residents and relatives that visitors to the home are welcomed. Most residents have regular contact with relatives and friends and some go out on a regular basis. Good communication was reported with the home, who always keep relatives informed of any issues or problems. Staff said ‘we get families involved and they are invited to celebrations’, ‘we had a very good Christmas and the staff on duty enjoyed it as well as the residents’. Most residents are local and the cultural background of residents reflects the local area, which is close knit and supportive. Many of the staff and residents know each other, and some residents have renewed friendships with people they were at work or at school with. Residents are encouraged to maintain links with the local community. There is support and interaction between residents and some special friendships have formed. One resident said they were all‘ pals’; ‘I am happy here, and I have made a lot of friends in the lounge I sit in’. Meals are served in the lounge/dining areas. Residents spoken to were very positive about the standard of catering, and the choice of menus that are available; ‘I’m not a big eater but I love the food here’, ‘food is very good, if there is something on the menu I don’t like I would get something I did like’, ‘the cook should have a medal’, ‘there is plenty of choice’; ‘they always ask what we prefer, which must be hard work but they always do it’. New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 15 The environmental health officer had recently visited and the home are in the process of complying with his recommendations and requirements. New fly screens have been provided in the kitchen, and the home are making arrangements to remove two wall heaters that are no longer used. New Bassett House DS0000035586.V339024.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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and accessible complaints and safeguarding adults procedures are in place to ensure residents can be confident that any issues raised would be acted on effectively and promptly. EVIDENCE: There is a corporate complaints procedure, although most relatives and residents prefer to raise issues on a more informal basis. As well as the formal complaints procedure there is a book for minor complaints. The complaints procedure is displayed and is in the Statement of Purpose and Service User Guide. No complaints have been made to the home or to CSCI. Most residents and relatives were aware that there was a formal complaints procedure. Residents and a relative said that issues raised are dealt with promptly. An example was given where a resident had raised a concern, new care planning arrangements were agreed at a review, and arrangements made to formally follow up whether the resident was satisfied with the new arrangements. Other comments from relatives and residents included; ‘if there was anything New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 17 wrong I would tell you’, ’when he complained they tried to sort it out’, ‘I would speak to the person in the office’, ‘I know how to make a complaint but I’d tell my family first of all’, ‘I would talk to my key worker’. Staff said ‘if there are any complaints or concerns we sort them out straight away’. The inspector was informed that Derbyshire County Council has clear procedures for dealing with the safety of residents and safeguarding them from harm. Staff spoken to showed an awareness of safeguarding adults issues, were clear about their responsibilities and would pass any concerns on to their line manager. Training in safeguarding adults has been provided for staff via NVQ and other courses. Staff said their training had raised their awareness of safeguarding adults issues, ‘we know what to look for’. New Bassett House DS0000035586.V339024.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, 23, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home generally provides residents with an attractive and homely place to live. However, lack of maintenance in the garden area means that residents are not provided with a safe and attractive outdoor environment. EVIDENCE: The building has been maintained to a reasonable standard overall. There is a rolling programme for maintenance and redecoration and new carpets, curtains and furniture. The home have a local maintenance scheme which works well and ensures that, generally speaking, routine work is carried out promptly. New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 19 There is a choice of lounges and dining areas, and the atmosphere is homely and relaxed. A kitchenette is available for residents and their friends or relatives to make cups of tea or snacks. The home have several areas of garden for residents to enjoy, and there are plans to develop one garden area with a financial donation the home has received for this purpose. However, there are very uneven paving stones in several areas outside the home and a requirement was made at the last inspection for these to be maintained. This requirement was still outstanding on the day of inspection. One resident has recently had a fall in an area outside the building and CSCI had been notified of this via a regulation 37 notice. The inspector was informed that no environmental risk assessment had been carried out in relation to the garden paths that are paved. Residents spoken to were happy with their bedrooms. Bedrooms are personalised according to residents’ preferences; ‘I like my own room’, ‘I enjoy spending time in my room’. All areas of the home seen on the day of inspection were very clean and residents and relatives said that standards of cleanliness within the home were excellent; ‘everywhere I’ve been in the home is lovely’, ‘the home is lovely and clean’, ‘they keep it very clean, including my bedroom’. New Bassett House DS0000035586.V339024.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A trained and competent workforce are in place which meet the dependency needs of residents currently accommodated within the home. EVIDENCE: On the day of inspection there were sufficient care staff to meet the needs of residents accommodated within the home. There is a stable staff group and this continuity was appreciated by residents, several of whom commented on the good relationship they had with their key worker. Staff spoken to were responsible, enthusiastic, competent and committed to the welfare of residents. Staff said ‘we work well together as a team’. They enjoyed their work, and were proud of the standards of care given; ‘the residents here get a high standard of care’, ‘the key worker system works well’. New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 21 Staff meeting minutes indicate that practical issues relating to the care of residents and the day to day management of the home are dealt with in a timely and appropriate fashion. The inspector was informed that all mandatory training was up to date. Further staff training is planned on an ongoing basis. All staff are trained to NVQ Level 2, the three newest staff members are undertaking it at the moment. Staff spoken to were keen to take advantage of training opportunities. The initial training was described as ‘a really positive experience’ and training opportunities were ‘brilliant’. Two staff files were seen and found to have evidence of CRB checks having been undertaken, copies of references and applications forms. There have been no new members of staff appointed for some time. Derbyshire County Council has a thorough recruitment and selection procedure. New Bassett House DS0000035586.V339024.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is suitably qualified and experienced and staff demonstrate an awareness of their roles and responsibilities, thus ensuring the home is run in the best interests of residents. EVIDENCE: Residents, relatives and staff spoke positively about the manager and the management team. The manager has the required qualifications and experience to fulfil the responsibilities of her role. There is a management New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 23 team and individual deputies take responsibility for various aspects of the day to day running of the home and for staff supervision. Staff said ‘there is an open door policy and you can go to the manager any time’, ‘this is a lovely place to work’. Copies of Regulation 26 visits were made available and indicated that matters relating to the day to day running of the home are dealt with. The service manager said that local home managers were commencing regular meetings together to share good practice ideas and support each other. Staff said they received regular formal supervision, usually every two months. Details of the quality assurance results are prominantly displayed in the foyer and a formal plan has been drawn up to address issues raised.The results were very positive with 94 of residents rating key aspects of their care as ‘good’ or ‘excellent’. The inspector was informed that the home has a computerised system for managing service users’ finances, which appears to work satisfactorily. The information provided by the manager indicates that the home makes every effort to ensure safe working systems are in place and equipment maintained satisfactorily. Matters identified by the Environmental Health Officer were in the process of being addressed, new fly screens were in place, and arrangements being made to remove wall heaters that were no longer used. However, the inspector was informed that there had been no environmental risk assessment in relation to the paved areas outside the home. New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 24 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 X X 3 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 X 3 X 3 X X 3 New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes 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 Standard OP19 OP19 Regulation 23 (2) (o) 23 (2) (o) Requirement External paths and patio areas must be maintained safely. (original date 30/06/06) An environmental risk assessment must be carried out on areas outside the home to ascertain whether residents are able to access areas of the garden safely. Timescale for action 30/10/07 25/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 2. Refer to Standard OP7 OP7 OP9 Good Practice Recommendations Care planning documentation should updated on the new ‘Framework i’ care planning system to ensure all staff have up to date information on residents current care needs. Individual risk assessments should be kept up to date to ensure that information on care planning documentation is consistent and up to date to ensure residents safety. All signatures on the sample signature sheet should match the signatures actually used by staff on the MARs sheet to DS0000035586.V339024.R01.S.doc Version 5.2 Page 26 New Bassett House ensure it is easy to identify which member of staff administered medication to individual residents. New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 New Bassett House DS0000035586.V339024.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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