Inspection on 27/01/06 for Rivermead

This inspection was carried out on 27th January 2006.

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.

Other inspections for this house

Rivermead 29/06/09

Rivermead 19/04/07

Rivermead 06/12/05

Rivermead 22/01/05

Rivermead 28/06/04

Rivermead 16/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Rivermead Halsey Road Kempston Bedfordshire MK42 8AU Lead Inspector Dragan Cvejic Unannounced Inspection 27th January 2006 08:00 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 Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 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. Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rivermead Address Halsey Road Kempston Bedfordshire MK42 8AU 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) 01234 851573 01234 843643 westfies@bupa.com BUPA Care Homes (Bedfordshire) Ltd Sharon Elizabeth Westfield Care Home 33 Category(ies) of Dementia - over 65 years of age (33), Old age, registration, with number not falling within any other category (33), of places Physical disability over 65 years of age (33) Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Rivermead was one of the BUPA’s homes in Kempston, close to Bedford and to the local amenities in this suburban part of the town. The home was situated a short distance from the main road and between a day centre that some service users attended and the health centre with dentist and chiropodist. The building was purpose built, on two levels, and offered accommodation to 33 service users. The majority of service users were frail elderly, some with short memory problems and some with dementia. The home was divided into three Units - Cedar, Willows and Oaks. This division was more of the operational nature, as service users used the entire home, regardless of the unit where they were accommodated. Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took part during 3.5 hours in the morning. The home continued to provide stable and appropriate care in a pleasant and homely environment. The manager had sent a reviewed statement of purpose two days prior to this inspection. Five care plans were inspected. Three service users were case tracked and their comments were used for this report. Records of service users personal allowances and financial viability of the home were also checked. Two staff provided their views of life in the home. What the service does well: What has improved since the last inspection? What they could do better: The newer care plans, drawn up in the last three months were not all signed by service users or their relatives. The manager responded the day after the inspection with an action plan to ensure the signatures were obtained at the earliest opportunity. The list of private possessions did not have dates recorded of when new items were added to the list. The manager addressed this issue the day after the inspection. Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 6 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. Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 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 Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4, The home ensured that up to date and complete information was available to potential service users and their referral representatives. The home carried out a comprehensive assessment before offering a place to potential users to ensure that their needs could be fully met upon admission. EVIDENCE: The home had just sent their reviewed statement of purpose, as they followed their routine of reviewing it on a regular basis and updating all relevant subtitles. Five inspected service users’ files contained well organised, structured and written preadmission assessments. The files contained information and previous care plans from social services or other places of residence. By properly assessing users and knowing their own capabilities, the home ensured that all users needs were met once they were admitted. Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10,11 The home ensured that users healthcare needs were fully met and appropriate documentation contained the evidence of how the staff met these needs. EVIDENCE: The home had good care plans that were used as working documents. The care plans appropriately addressed needs and actions to meet realistically set goals for service users. Some newer plans, up to three months old, were not yet signed by service users or their representatives and the manager responded to this issue the day after the inspection with a suggestion and action plan to obtain signatures as soon as practicably possible. The home kept original care plans in their surgery room, while copies were held in units. Reviews were regularly carried out, monthly and appropriately recorded. All changes were clearly presented in the original plans. Service users files contained clear evidence of external health care professionals’ visits. Care plans addressed the main needs identified during the assessment and extra charts were introduced where the daily records were necessary to monitor users’ health and wellbeing. Service users confirmed that they were treated with a high level of respect. The care practice observed also confirmed that staff treated users with full respect. Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 10 Service users’ files contained documented wishes of service users or their relatives in case of death. The file of a user with terminal illness illustrated that extra care was arranged and provided. Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14 The home recorded service users preferences and ensured that their views and wishes were fully respected when their care was planned and delivered. EVIDENCE: Service users stated that they were able to decide on their daily routine. They were listened to and their preferences were recorded in care plans. They commented that they were deciding on their regular meetings about the menu and, as a result, “the food was excellent”. List of activities was displayed on the notice board in addition to the one published in their local, home produced newsletter. Autonomy and choice were also promoted and respected. The freedom of movement and choice for users with dementia was remarkable. Staff were sensibly and discreetly ensuring the safety of the users and offered support when it was assessed as necessary. Some service users enjoyed having some small change with them and when it happened that some of them lost a coin or two, the staff tried to identify the owner and return money to them. A £1 coin was marked in the office as waiting to be returned to its owner. Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The home displayed a complaints procedure in the entrance hall and in each unit, making it clear and available to anyone who might have a complaint. Service users were well protected by the company’s policy that was strictly implemented in the home. EVIDENCE: “If I had any complaint, I would come to complain to you, if the manager did not respond as I wanted”, stated a service user demonstrating how clear and well known the procedure was in the home. The home had not received any complaints since the last inspection. Service users’ finances were dealt with according to BUPA’s corporate policy and recording system. This system ensured protection from potential financial abuse. Three records of finances were inspected and found to be well kept and documented and included receipts of transactions. The balances matched the records. Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None These standards were not inspected on this occasion, but the home was bright, clean and service users felt comfortable throughout. EVIDENCE: Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 The home employed sufficient, competent and committed staff that undertook appropriate training and were able to completely meet the needs of service users. EVIDENCE: The home created a rota taking into account service users’ needs. This resulted in more staff being employed in peak periods. The rota was displayed in the office and in the staff room, but was simplified when it was written down on a notice board so that service users could see it for each day. The NVQ training programme was very popular in the home and the high demand from staff to complete it had to be carefully planned. The number of qualified staff varied slightly, but exceeded requirements at the time of the inspection. Staff on induction confirmed that they were inducted according to “Skills for Care” principles. The company offered comprehensive training and the home planned and arranged for each individual staff member to attend all mandatory and extra training related to users conditions. Dementia training was particularly well attended and popular and ensured that staff had a good knowledge and base to appropriately support service users. Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, The home was managed in a stable and competent way that provided a safe, comfortable, enjoyable and homely place for service users. EVIDENCE: The home was being managed by the same manager who had already met the standard requirements on previous inspections. Her open and creative style of management ensured that service users and staff influenced the atmosphere in the home in the way they wanted and resulted in the satisfaction of all, as emphasised to the inspector during the inspection by three staff and 6 service users. The home carried out a customers’ survey as a part of the quality assurance process and service users, their relatives, staff and some professionals involved in the care process were consulted. The home displayed all certificates as required by the standards. Service users spoken to confirmed that they knew how to contact the regulation authority if they needed to. Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 16 The home’s administrator presented financial information about the home to the inspector and confirmed the financial viability of the home. Service users’ money, that the home offered to support service users with, was appropriately recorded and copies of transactions were held in the home. The balances checked were accurate. Staff confirmed that they were supervised about once monthly and that they could approach the manager at any time if they wanted to discuss any matter that would affect their work. The home exceeded standard requirements, both in a quantitative and qualitative way. All record checked were up to date. Safe working practices were observed and confirmed by service users and staff. Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 17 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 4 X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 4 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 3 3 4 3 3 Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 18 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP37 Good Practice Recommendations The property list kept in service users’ files should be kept up to date and all changes should be dated and signed. This recommendation was set on the previous inspection and the process of updating it was running. The manager should ensure that the process is finished as planned. The manager should ensure that all new care plans are signed by service users or their representatives, as per her plan to complete this recommendation. 2 OP7 Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Rivermead DS0000014953.V281638.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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