Inspection on 04/05/04 for New Bassett House

Care Home For Older PeopleNew Bassett HousePark Avenue Shirebrook Nr Mansfield Derbyshire NG20 8JWAnnounced Inspection4th May 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment New Bassett House Address Park Avenue, Shirebrook, Nr Mansfield, Derbyshire, NG20 8JW Email address Name of registered provider Derbyshire County Council Name of registered manager Susan Elsden (Appointed but not registered) Type of registration Care Home No. of places registered 40 Tel No: 01623 588000 Fax No: 01623 588004Category of registration, (with number of places) Old age, not falling within any other category (40) Registration number C020000504 Date first registered 2nd December 2003 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 2nd December 2003 NO NO 21st May 2003 If Yes refer to Part CNew Bassett HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 34th May 2004 09:15 am Brian MarksID Code071398Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNew Bassett HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementNew Bassett HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of New Bassett House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.New Bassett HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. New Bassett House is home offering 40 places to older persons, which now includes 2 places as part of an intensive assessment or intermediate care project. As well as longerterm care the home offers short-term respite care, which had been used by a number of service users to acquaint themselves with the home before making a final decision about their future. 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 good 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 who had assisted to raise the profile of health care in the home. As with all local authority provision, this home was registered under the Care Standards Act. 2000 in 2003.New Bassett HousePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection focuses on the areas that are most significant for service users lives and the areas that were identified for action and development at the last inspection of this service, which took place on 21 May 2003. For a full overview of performance against standards this report should be read in conjunction with that report, which was the first full audit of this service. A case tracking method was employed at this inspection, which is a method of inspection that centres on the strengths, needs, aspirations and performances of specific service users, in order to build up to build up a picture of how the home functions in relation to their lives. Choice of Home (Standards 1- 6) 4 out of 6 assessed standards have been met. The home had a Statement of Purpose and Service Users Guide but the latter had not been distributed top service users. Introductions to the home for planned admissions were carried out by trial visits and all service users had their needs assessed before admission. The home was operating an intermediate care project with 2 places available. Health and Personal Care (Standards 7-11) 2 out of 5 assessed standards have been met. Whilst all service users had a care plan developed at the home, the format of these was in need of development. General health care was satisfactory and supported by outside professionals; medicines were well managed but a number of shortfalls were noted in relation to record keeping. Daily Life and Social Activities (Standards 12 - 15) 3 out of 4 assessed standards have been met. Service users reported satisfactory social lives at the home and they benefited from the support of an activities organiser. Families were encouraged to maintain contact by open visiting and although a number spoken to were generally satisfied with care at the home, some concerns over preferences and choice were discussed in relation to 1 individual. Standards of catering at the home were well managed according to all reports. Complaints and Protection (Standards 16 - 18) 2 out of 3 assessed standards have been met. The issue mentioned in the last section was being dealt with by the homes management and was being responded to appropriately using the local authority procedure. Not all managers and staff had been given training in relation to Adult Protection procedures. Environment (Standards 19 - 26) 5 out of 8 assessed standards have been met. Service user bedrooms were in the middle of a refurbishment programme and fixed furniture New Bassett House Page 6 was being replaced by that of a modern design. The home had good levels of communal space and all bedrooms were in line with the Standard. Two of the rooms were set aside for an intermediate care project and were suitably equipped. Standards of heating, lighting and cleanliness were satisfactory on the day of the inspection. Staffing (Standards 27 - 30) 3 out of 4 assessed standards have been met. New investment had been made in staffing levels at the home since the last inspection and the required standard had been achieved. This was also the case with achievements in NVQ training and staff reported that had been recruited in a professional way. Management and Administration (Standards 31 - 38) 4 out of 8 assessed standards have been met. The home was well managed and standards of administration were satisfactory apart form some minor shortfalls in record keeping and health and safety training for staff.New Bassett HousePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 3 5 OP2 The registered provider must provide each service user with a contract that specifies terms and conditions of residence at the home and contains the details included in the Standard and Regulation. The registered person must review and assess the requirements of service users who have visual impairments, particularly in relation to the environment; the assistance of specialist agencies or professionals is recommended. The registered person must fit the required amount of electrical sockets and bedside lights as defined by the Standard. The individual care plans of service users must be improved to reflect the more detailed assessments of needs. 30.12.03823OP19OP 2230.12.03916OP2430.12.031515OP730.12.03Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 OP7 The registered person should develop a front sheet that records basic background information on all individual service users.New Bassett HousePage 8 7 9OP29 OP34The registered person should ensure that all volunteer workers are subject to a check by the CRB by September 2004. Details of the homes financial planning should be available at the home for inspection.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)New Bassett HousePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 5 OP1 The registered person must provide each service user with a copy of the Service Users Guide. The manager must ensure that the records for management of medicines are properly maintained. The manager must develop a system for recording the temperature of the medicines refrigerator. (i) The manager must develop a strategy for ensure that service user preferences are fully supported. (ii) This must be linked with systems for managing complaints and quality monitoring. 5 16, 23 OP24 The registered person must ensure that all wardrobes are accessible by service users without assistance. The registered person must ensure that all staff records retained at the home contain the elements described in the Schedules. The registered person must develop a local system to indicate the achievement of checks by the Criminal Records Bureau (CRB). 30.6.04213OP930.6.04313OP931.08.04412OP14(i) 31.08.04 (ii) 30.11.0430.6.04617, 18, 19 Schedule 2 OP29 and 4 19 OP2931.08.04731.08.04New Bassett HousePage 10 8 98, 9 26OP31 OP33The manager must apply to register with the CSCI. The homes line manager must complete a written report of any visits to the home. The registered person must ensure that all staff receive instruction in moving and handling, emergency first aid, fire safety and food hygiene.30.06.04 30.06.041013, 18OP30OP3 830.11.04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 OP11 The funeral wishes of service users and/or their families should be ascertained and written into individual case notes.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.New Bassett HousePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES NO YES YES YES YES YES NO YES YES YES YES YES YES YES YES NO YES NO YES 7 4 10 YES NO YES NO 23 0 04/04/04 09:15 8.0New Bassett HousePage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.New Bassett HousePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 279 To (£) 331Any charges for extras If yes, please state what the extras are:YESHAIRDRESSER, CHIROPODY, TOILETRIES. 2 Key findings/Evidence Standard met? A Statement of Purpose and a Service Users Guide had been developed for the home, although the latter, newly produced had not been distributed to current or prospective service users. The scale of charges indicated was for 2003-04 due to unavailability of charges form April 2004.New Bassett HousePage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 2 Key findings/Evidence Standard met? Whilst service users staying at the home on a short term basis made payments locally with an individual contract, all others, following a detailed financial assessment, contracted with the Social Services Department centrally and were not given a contract that specified local terms and conditions that related directly to residence at the home.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? All service users spoken to as part of case tracking attended for at least one days preadmission assessment and social visit. Access to the respite care service also allowed for the build up of assessment material and knowledge of the prospective service user. The 1 service user in residence under this basis confirmed that it had allowed her to gradually get used to the idea of residence and she had been able to make a number of new social acquaintances. From the files of service users examined all had been admitted with full and comprehensive documentation had been prepared by the community-based workers, in conjunction with staff from the home; this had including those at a local resource centre. All aspects of the standard were noted to have been met within those documents examined. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The statement of purpose for the home the role of the home within the Social Services overall aim, and how this fitted in to a local continuum of care, including care in the community. There were clearly established boundaries as to what type of service user could be accommodated at the home, although from the case tracking process a variety in the range of needs and dependency was observed. In comparison to observations made at a previous inspection the range of service users accommodated changes over time ­ the previous manager had stated that this was dependent on the dynamic within the home at the time. The staff members spoken to demonstrated a considerable breadth of experience in working with older persons and from discussion they demonstrated a good understanding of the wide-ranging needs of the people coming into the home for a service. Their commitment to caring for the service users as a group and as individuals was noted.New Bassett HousePage 15 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? As noted above, all service users had the option to come into the home for at least a days stay and relatives were invited to visit on drop-in basis to get a better idea of how the home operated. Similarly respite stays allow for the service user to make decisions about their futures and 1 service user spoken to had been staying on that basis. Planned admissions had also been made at weekends, with a crisis worker based at the home at that time who was able to make assessments and then care arrangements within the local continuum of care. Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 3 Key findings/Evidence Standard met? A continued development at the home had been the assignment of two specific rooms that are part of an intensive assessment service linked to discharges from local hospitals. Specialised equipment had been provided but and some staff had been given training in the principles of the projects operation. It was planned that the number of beds available for this type of work would increase and the manager and staff reported that links with health care professionals had become more routine, both specifically to this and in relation to the home generally. The general standard of care plans examined at the home demonstrated the need to strengthen the care planning process if this project is to be a continuing success.New Bassett HousePage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? All service users files examined had care plans that were linked to the initial assessment of needs, although these remained with the same structure examined at the previous inspection, developed into only 4 broad areas. Whilst a broad range of basic information was held within the service users files, this was not retained in one place in all files; the manager reported that she was in the process of completing the front sheet document for all files. The files examined had been reorganised with this activity in mind. A number of risk assessments, both formal and informal, were noted on files, as were contributions from outside professionals including those from health care. Documentation indicated that care plans were evaluated internally by the homes staff and more strategic reviews were held with the service manager on an annual basis. There was evidence that plans had been rewritten and changed following the review/evaluation discussion. Service users were routinely involved with the annual reviews.New Bassett HousePage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 1 23 Key findings/Evidence Standard met? All service users were registered with the local GP practice and one of the doctors has a highlighted role within the home to support general as well as specific health care needs and to promote better access to services. Improvements in health care had been targeted within the home and this extended to the use of the intermediate care beds and working to release people from hospital care. The targeted programme of prescription medicine, aimed at building up calcium levels in service users to diminish the risk of falls and fractures, had successfully become an established practice. Management of continence problems and pressure sores was satisfactory, with a range of equipment available and good support from the district nurse; the latter was in the home at the time of the inspection. Individual records indicated that access to other services was arranged either in the home or at local clinics and hospitals. A programme of 3-monthly health checks was included in the files examined. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? At the time of the inspection there were no service users who managed their own medication. The overall system of medication administration was managed in a satisfactory way although a number of gaps in the signed record were noted and a system for recording the temperature of the medicines refrigerator had not been developed. The dispensing pharmacist and another form the local authority had both recently examined systems at the home. The 4 managers were the responsible persons for medicines in the home and formal instruction from a pharmacist had been received.New Bassett HousePage 18 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? From discussion with service users and observation during the inspection, staff were attentive to privacy and dignity and maintained a balance of a professional approach with `everyday informality and warmth. Service users reported that they used their rooms as they required and a good number were doing so on the day of the inspection; for those with mobility or other risk problems staff were observed to be on hand and to manage the needs of safety of the less able service user. A variety of communal spaces where visitors could be received were available, including a small `library for use in private, as well as bedrooms. Service users spoke very positively about the care they received at the home and were fully supportive of the staff and the personal input from them. The home had a mobile payphone that could be used in number of private areas within the home. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 2 Key findings/Evidence Standard met? Discussion with the manager demonstrated her experience of this subject, and a supportive and flexible approach to this aspect of service user care was described as continuing at the home. Both sudden deaths and terminal care had been experienced since the last inspection and family members, other residents and staff had been supported in appropriate ways, with the option for relatives to stay at the home in a `companion room at the final stages if required. He manager had not completed a programme of identifying funeral wishes on case notes.New Bassett HousePage 19 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? From discussion, service users at the home were satisfied with options to manage their own lifestyles, daily routines and activities, and all were able to move around the home as freely as they wished. This included options outside the home for those willing and able to do so. Residents were observed using the grounds on the day of the inspection, circuiting the outside of the building on a level maintained path. A member of staff with responsibility for organising activities had commenced at the home since the last inspection, holding 2 afternoon sessions a week, mainly in the room set aside for the purpose. The maintained records gave an excellent insight into the success of this project, and residents were positive in the support for her. The home celebrates with 3 big parties at Easter, Halloween and Xmas and other theme nights are arranged in the year, and in house entertainment. Spiritual life was catered for, with weekly communion in the home from the Anglican vicar; and individual support from the Catholic priest, much welcomed by 1 service user spoken to. The Salvation Army had visited on an irregular basis for hymns or carols. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? The manager encouraged open visiting by families and friends and a good number were noted during the inspection; those spoken indicated satisfactory arrangements. There were two volunteer visitors to the home, both ex-residents, and they carried out informal and support activities with service user and supported a formal service user meeting.New Bassett HousePage 20 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 2 Key findings/Evidence Standard met? The local authority acted as appointee in relation to the finances of 17 service users and detailed records of transactions were maintained. Whilst most of the others had their affairs managed by their families, the home was integral in looking after personal weekly allowances. There was not an advocacy service active at the home at the time of the inspection but Age Concern had been involved with individuals in the past. Service user spoken had been made aware of their right to bring furniture and personal possessions with them at admission to them but most had restricted them selves to smaller items, photographs and pictures. A number of issues, being dealt with by the homes management as a complaint, were discussed at length with a service user and their relatives and advice was given. This issue highlighted the need to be mindful of service users expressing their preferences and the value of the availability of advocates to assist them to speak out. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Regular meals are provided at the home at times suitable to the service users, and these could be flexibly arranged if required. The service users spoken to were very positive about the catering service, food quality and quantity; a traditional style of home cooking was the service users preference and this included a cooked options available at breakfast and tea on alternate days. Drinks were observed being served to service users throughout the day and although there were kitchenette facilities available for self-help, these were not observed in use. The manager confirmed that only a small minority used this facility. There were 7 people with diabetic needs and 1 service user described how her condition was handled appropriately; the manager described the use of a calcium supplement in consultation with support of the local GP. The menu was on display in the reception area and, being arranged on a 3-week basis this offered sufficient variety; the recording of options being taken was maintained in the kitchen and the manager was advised that retaining these over the 3-week cycle was sufficient. The kitchen staff were observed in contact with service users and received feedback regularly.New Bassett HousePage 21 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 1 0 0 0 1 0 100 3 Key findings/Evidence Standard met? The home operates to an extensive complaints policy and procedure common to the whole of the local authority and a recording system was in operation. A complaint currently being dealt with by the provider organisation was discussed and advice was also given to the complainants during the inspection regarding resolution and the role of the CSCI. The Social Service Department had additionally advertised a `Complaints and Compliments approach as an element of quality monitoring. A large selection of cards and letters from ex residents families was available at the home. The managers spoken to stated that it was normal practice at the home to deal with problems as they arose before they became a serious matter. Apart from the issue mentioned above, none of the service users spoken to raised any matter of complaint during the inspection.New Bassett HousePage 22 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? The manager reported that the majority of service users were registered to vote but that only a small minority exercised their right by post at the last election. Advocates from Age Concern had been involved with individuals at the home in the past but were not active at the time of the inspection. (see section 14 regarding the role of advocacy)Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES X2 Key findings/Evidence Standard met? The Social Services Department has lead responsibility in the local Adult Protection process and the home had been party to the operation of the procedures in the past. Not all managers and staff had been given training in relation to their responsibilities in relation to the policy and procedures. As previously stated the management of service users finances at the home was satisfactory.New Bassett HousePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The home is situated on a residential estate, close to Shirebrook town centre and is situated on 1 floor, giving wide easy access to people with mobility problems; wheelchair users were observed to negotiate their way around the home with or without staff assistance. Service users with visual impairment raised no issues of access but specialist assessments had not been carried out to identify possible improvements. The home had the services of a maintenance man which allowed for speedy minor repairs and redecorating to both the inside and outside of the building, as well as a central service department for larger problems. There were sitting areas both inside and outside; the manager stated that the latter were well used during good weather. This was supported by as service user who gained a lot of enjoyment form the homes surroundings. Compliance with the most recent reports from the Environmental Health and Fire Officers had been achieved. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 4 Key findings/Evidence Standard met? The home was to a `site visit as part of the registration process and the communal area size was found to be well in excess of the required standard. In addition to 3 lounges and 2 dining rooms space had been set aside for smokers, for hairdressing and for small private meetings. The home has recently introduced an intermediate care project and 2 beds are specifically used for this purpose (see Standard 6 above). Since the last inspection a kitchenette had been completed for use as part of this service. Overall, the impression of the communal rooms was domestic in character with varied furnishings and colour schemes. New Bassett House Page 24 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? The home provided sufficient toilets and bathrooms and these offered a variety of facility to service users depending on preference. The manager reported that plans were in hand to convert a large toilet into an additional shower. None of the bedrooms had en-suite facilities.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 2 Key findings/Evidence Standard met? Whilst the home had suitable equipment to aid service users with mobility problems ­ mobile hoists, bath hoists, rotunda, handrails, and wheelchairs ­ the comments in relation to the needs of sensory impaired service users made in Standard 19 apply here. One service user spoken to had been supplied with a specialised bed to meet her individual needs. The home had a mobile loop to assist service users with a hearing impairment.New Bassett HousePage 25 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 40 0 0 0 40 00 1 0 03 Key findings/Evidence Standard met? The bedrooms at the home all exceeded the size standard, all were single rooms and none was fitted with en-suite facilities. The room occupied by the wheelchair user was below the size standard, but the manager stated that he was settled with the arrangements of his room.New Bassett HousePage 26 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? From discussion service users had been made aware of the ability to bring furniture and personal possessions with them to the home at admission and bedrooms were personalised to varying degrees. A number had taken the opportunity with the help of families and keyworker to decorate their rooms to their own style and taste. Specialist beds had been made available within the 2 rooms used for intermediate care, and for the service user noted above (see section 22). It was noted that bedrooms did not have sufficient electrical sockets and few had bedside lights. Work was underway at the time of the inspection to refurbish all the homes bedrooms. This included the replacement of fixed furniture and vanity units, the provision of new carpets and furnishings and redecoration. A service user reported that the doors of her new wardrobe were very difficult for her to open; further examination proved this could be a problem for other service users. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? Standards of heating and lighting around the home were satisfactory on the day of the inspection. Radiators were fitted with covers and control valves in bedrooms could be operated by service users. All hot water pipes had been subject to a programme of covering, and all hot water taps had been fitted with thermostatic controls.New Bassett HousePage 27 Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? Standards of cleanliness and hygiene at the home were noted to be good on the day of the inspection and facilities within the laundry were satisfactory; service users commented positively about this aspect of their care.StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 0 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence New Bassett House 4 30 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 576 X X XX 21 7 Standard met? 3 Page 28 As it has been agreed that this home is to be considered an `existing registration as far as staffing levels are concerned, the expectation is that the existing staffing levels should meet the previously agreed standard. Since the last inspection the provider has invested in additional staffing and the core rota now exceeds that standard. From inspection of the catering section and the standards of cleanliness of the home the assigned hours for kitchen and domestics was satisfactory. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 20 95 4 Key findings/Evidence Standard met? Almost all established care and night care staff had achieved NVQ level 2 as had a high proportion of relief staff, and a number had commenced on level 3. The standard of achievement for 2005 had already been achieved. Staff spoken to were very positive about this aspect of their employmentStandard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The home operates the extensive recruitment and selection procedure of the parent organisation and all staff spoken to reported that they had gone through a rigorous and professional process. The home is supported by a locally based personnel section of the organisation. Whilst all staff spoken to stated that they had completed a check by the CRB, and the manager confirmed this, there was no local information system in place to confirm this. From the staff files examined not all the required elements were in place, as required by the Regulation: 2 written references, a statement regarding health and proof of a positive check by the CRB. Staff had been given copies of the code of conduct published by the GSCC. The volunteer workers at the home had not been subject to checks by the CRB.New Bassett HousePage 29 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? Staff reported that the Organisation had introduced an extensive induction/ introductory training programme that had lasted for some months; this had been developed centrally to National guidelines (Training Organisation for the Personal Social Services). It was part of the contractual agreement that for all newly appointed staff this would progress to NVQ2 within 18 months. Night staff were reported to be completing NVQ3. A personal profile is developed within supervision sessions to identify further training needs.New Bassett HousePage 30 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? As the manager had bee recently appointed, an application to register had not been received. The manager had completed a registered managers course at NVQ level 4 and had other management training (NEBSM). The deputy managers had also been targeted for NVQ level 4 and as a group commanded complementary skills and experience across a broad range. The manager reported good regular support from a line manager and from the wider organisation around her. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? From conversations with the manager and staff an open atmosphere and style of management was being encouraged; the manager reported that by being `hands on and visible within the home she was a source of support to all. As well as a human approach in her style the manager used the systems available to her to build on the standards developed by the previous manager. At the time of the inspection the manager was establishing herself within the home and reported that she was on a steep learning curve. The development of the intermediate care system was one example of innovation being encouraged at the home, and staff reported that new ideas were welcomed in the home, regardless of their sourceNew Bassett HousePage 31 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? A service user survey had been completed within the previous year and the manager stated her intention to repeat this exercise imminently as information analysis of that exercise was not available. An annual development plan for the home had been prepared. The wider organisation had instituted a number of initiatives involved with quality monitoring, including Government projects and locally based audits of activity. A residents meeting had been held on an irregular basis and the outcomes of these meetings were instrumental in encouraging service users to feel confident in expressing themselves. The manager reported that regular care reviews were also regarded as part of quality monitoring. The homes line manage was in regular contact but had not completed any reports of her visits. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 2 Key findings/Evidence Standard met? The overall financial plan for the home was stated to be part of the parent organisations activities and details were kept centrally, rather than locally at the home. Financial transactions were recorded and regularly audited. Details of the homes insurance were on display.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 0 0 03 Key findings/Evidence Standard met? As indicated in previous sections the management of service user finances was satisfactory and subject to outside audit on a regular basis.New Bassett HousePage 32 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? From staffing records and comments from staff, supervision as individuals and keyworker groups had been achieved to a satisfactory standard, although regularity had slipped and was now revived by the new manager. Staff were positive about the benefits of the activity.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? The administration of the home was well maintained and all required records were in order at the time of the inspection apart from the contents of staff files (See Standard 29).Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Aspects of the maintenance of health and safety at the home were found to be satisfactory apart from the following: Instruction of staff in the core skills related to moving and handling, emergency first aid, fire safety and food hygiene.New Bassett HousePage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateBrian Marks Deborah Turner 16th July 2004Signature Signature SignatureNew Bassett HousePage 34 Public reports It should be noted that all CSCI inspection reports are public documents.New Bassett HousePage 35 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 4th may 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleNew Bassett HousePage 36 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection reportNONOProvider comments are available on file at the Area Office but have not NO been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 11th June 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. D.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther:NONew Bassett HousePage 37 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Kieran Hickey of Derbyshire County Council confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Kieran Hickey of Derbyshire County Council am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.New Bassett HousePage 38 - 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. 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