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Inspection on 31/10/05 for St Bernard`s Residential Care Home Ltd

Also see our care home review for St Bernard`s Residential Care Home Ltd for more information

This inspection was carried out on 31st October 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

There were consistently positive comments from Service Users regarding all aspects of their care. There are relaxed routines, which are established around the needs of Service Users. They feel staff know them well, are caring and eager to help. The manager has established good systems of record keeping which ensures preferred routines and choices are known and responded to. Service users have a good degree of choice regarding when to get up, when and where to eat meals and a variety of stimulating activities to choose from. The management of healthcare is very good, there are systems in place, which ensure all concerns are monitored and followed up. All the Service Users who were spoken to spoke highly of the manager and her staff team. One said" they know my needs and ask me what help I would like". Service Users are particularly proud of their environment, they have a beautiful house with lots of personal space in their rooms. There are wonderful views over the gardens to enjoy. The house was very comfortable, well maintained clean and full of character. There is a particularly nice welcoming atmosphere, and all the staff presented as courteous and helpful.

What has improved since the last inspection?

The manager and her staff team have clearly worked hard over the last few months. There has been a significant improvement in developing records. Information for Service Users has been improved, which means they have a better understanding of the service the home provides, and whether this is the right home for them. A new assessment and care plan has been implemented, which means it`s easier to identify Service Users needs, and structure their care in a planned way. Minor improvements to the storage of medicines are evident, providing much better systems of security and safety. Dating of creams ensures the correct shelf life of prescribed treatments, which in turn benefits the Service User. There has been a new Adult Protection Policy, and training for staff. This will ensure staff know how to recognise and respond to any concerns they have regarding the welfare of individuals. An assessment of the premises has been undertaken to make sure all the equipment is safe and suitable for the needs of older people. The recruitment records have been improved which will ensure all the necessary checks are taken, before someone works in the home. This will further protect vulnerable adults. There has been an admirable, and successful effort in developing a Quality Assurance System. Service Users, their family and visiting professionals have been consulted as to their views of the home. The information gathered has led to positive improvements in the service delivery.

What the care home could do better:

Whilst there are no present concerns noted in this area, it`s recommended the use of the table in the lower lounge be kept under review. This will ensure that its position in the room does not pose any risk or obstacle to people trying to get to their seats. Its recommended that the findings of the questionnaires given to Service Users their families and visiting professionals, are included in the planned news letter and Service User Guide. This will further improve the level of consultation between the home and it`s Service Users.

CARE HOMES FOR OLDER PEOPLE St Bernard`s Residential Care Home Ltd 76 St Bernard`s Road Olton Solihull West Midlands B92 7BP Lead Inspector Monica Heaselgrave Unannounced Inspection 31st October 2005 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 St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Bernard`s Residential Care Home Ltd Address 76 St Bernard`s Road Olton Solihull West Midlands B92 7BP 0121 708 0177 0121 707 6434 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) St Bernard`s Residential Care Home Limited Miss Ann Coombs Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd March 2005. Brief Description of the Service: St Bernards provides 24-hour care for 28 service users, who are 65 years or older. It is situated in a residential area in Solihull. The house is approached via a private driveway with off road parking to the front, and extensive landscape gardens providing beautiful views from all aspects of the property. There are twenty-four single and two double bedrooms, some with en-suite facilities. All are lockable. There are three communal bathrooms with hydro hoists to assist service users. All rooms are furnished to a high standard and provide spacious accommodation in which service users can bring their own furniture. A private telephone line can be arranged in bedrooms. An Email facility run by the home, is also available to service users. There is a passenger lift to access each level of the property, and ramped access to the front and rear. Grab rails are fitted in communal areas to provide support to service users. A call system is provided in all rooms in case assistance is required. There are three lounges and two conservatories. Each is comfortably furnished. A separate laundry, hair salon and treatment room are also available. The house retains many of its original and elegant features, and was found to be clean and maintained to a high standard. Service users were particularly pleased with the facilities and comfort the home provides. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on a Monday, between 9.30 and 2.p.m. The inspector met with the manager, and some of her staff team. A number of service users were spoken to individually. Observation of the daily routine was made, to include the morning care routine, social activities and the lunch time period. A tour of the premises was undertaken. A number of records were inspected to include information for service users, assessments, care plans and risk assessments. Some maintenance and inspection documents for safety of the building were sampled to include, fire equipment tests, gas safety, storage of hazardous substances, hot water testing, and infection control procedures. Records and procedures for the recruitment, training and supervision of staff, and staff rotas were also inspected. What the service does well: What has improved since the last inspection? The manager and her staff team have clearly worked hard over the last few months. There has been a significant improvement in developing records. Information for Service Users has been improved, which means they have a better understanding of the service the home provides, and whether this is the right home for them. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 6 A new assessment and care plan has been implemented, which means it’s easier to identify Service Users needs, and structure their care in a planned way. Minor improvements to the storage of medicines are evident, providing much better systems of security and safety. Dating of creams ensures the correct shelf life of prescribed treatments, which in turn benefits the Service User. There has been a new Adult Protection Policy, and training for staff. This will ensure staff know how to recognise and respond to any concerns they have regarding the welfare of individuals. An assessment of the premises has been undertaken to make sure all the equipment is safe and suitable for the needs of older people. The recruitment records have been improved which will ensure all the necessary checks are taken, before someone works in the home. This will further protect vulnerable adults. There has been an admirable, and successful effort in developing a Quality Assurance System. Service Users, their family and visiting professionals have been consulted as to their views of the home. The information gathered has led to positive improvements in the service delivery. 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. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 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 St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 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, 2, 3, 4, 5 There is excellent information available to help Service Users make a choice about moving into the home. The comprehensive and well-established assessment and admission procedures ensure that the needs of Service Users are known, planned for, and Service Users know what to expect from the home. EVIDENCE: There has been a significant improvement in the information available to Service Users. Since the last inspection, the Manager has updated the Statement Of Purpose and Service User Guide. These now provide excellent information for Service Users, are comprehensive in their detail, and are particularly well written. Each Service User has a copy of the homes contract. These have also been improved since the last inspection, and now meet with requirements. The manager and staff team have an excellent system in place for welcoming and informing prospective Service Users. This includes giving them copies of these documents for them to read at leisure, and verbally explaining the process and procedures to them, should they decide to live in the home. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 9 Service users spoken with, confirmed that this experience has been very positive, and that they are happy with the information provided for them, which has enabled them to make an informed choice. There is an excellent and well- established, pre- admission assessment process. This includes the Service User, their family, and any relevant professionals involved with the care of the Service User. Home visits are undertaken to support this process. Service Users spoken to described this experience, positively. Records seen confirm that a comprehensive assessment of needs is undertaken, and developed into a Care Plan. The Care Plans viewed were comprehensive, and covered all aspects of needs, this included; mobility, health, risk of falls, continence, weight, manual handling needs, the use of aids or adaptations and social, religious and cultural needs. Service Users felt that at this point, they were happy that the home would be able to meet their needs, because they had been well consulted, and reassured. Trial visits have been a regular feature prior to moving in. A particularly admirable feature noted, is that the Statement Of Purpose gives specific information about the need to ensure that familiar faces are on duty, throughout the admission, to welcome the Service User and their family. It’s also acknowledged that a number of preliminary visits might need to take place at a pace dictated by the Service User, and his or her needs. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 There are very good systems in place, which ensure Service Users health and social care needs are met. Service Users are cared for in a manner that both promotes and protects their dignity and privacy. EVIDENCE: Care Plans have been completely revamped since the last inspection, and meet with requirements made at that time. They are current, and contain excellent details describing Service Users needs, and how these will be met. This ensures needs are met in a consistent and planned way. A review takes place on the daily change over of shifts, and on a monthly basis. Each Service User has an allocated Key Worker who liaises with family and other professionals to co-ordinate how needs will be met, and ensure that any significant change in care needs, is identified and acted upon promptly. Daily entries confirmed that any change in a person’s health, is recorded, and acted upon. On the day of inspection staff reported someone feeling unwell, this was recorded, and the G.P was called out. Service users falling resulted in an updated risk assessment and preventative measures being put in place. Concerns relating to weight loss, diet, and pressure sore care were well managed, and detailed in Care Plans. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 11 Staff had very good knowledge of Service Users needs, characters or idiosyncrasies, and observation of their interaction with Service Users, showed they used this well in supporting them with their care and preferred routines. Several services users commented favourably on how staff supported them. One said ‘staff know my routine, and what I like, and are always ready to help me.’ One lady said, ’nothings too much trouble, I only asked if I could have something different from the assorted sandwiches the other day, and they brought me egg mayonnaise, freshly done and it was beautiful’. A gentleman said, ‘I like the opportunity to spend time in my room, but they never forget me, always make time to chat ask me if I want anything. Other times I join in the activities, it’s quite busy here you know’. Records confirmed that Service Users have access to health care services, to include; a G.P of their choice, dental, chiropody, hearing and optical services. It was also evident that advice had been sought regarding psychological needs to include confusion, and Dementia. Staff training records showed that they had received training and guidance in these areas, so that they could understand needs and respond appropriately. The arrangements for personal care ensure that the privacy and dignity of Service Users is both protected and promoted. Care Plans provide a good insight into previous lifestyles and routines, so that the Service Users expectations are known. Service Users described their preferred routines regarding bathing, and were particularly positive that they had use of en-suite facilities, which provided privacy. Some use the communal bathrooms, which are fully equipped to assist people who have difficulties, whilst maintaining their dignity. One lady said ‘when I see my Solicitor it’s always in private’. Another said ‘I enjoy sitting in the conservatory because I like my own company at times’. Service Users confirmed that they have access to a phone in private, and handle their own mail and private affairs. Where this was not possible, arrangements were seen to be in place for these to be handled independently from the home, but with support to the individual to contact their solicitor, or representative. Standard 9 was not inspected in full at this visit. However, requirements made at the last visit have now been met. Creams are now stored separately, and the date of opening the cream, is now recorded in order to monitor it’s shelf life. Controlled drugs are now stored in a separate secure cupboard. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The lifestyle of Service Users is explored, and used positively to provide a care plan that suites their needs. Service Users benefit from a variety of stimulating activities, which they enjoy. The food provided is of a high standard, and matches the preferences and expectations of Service Users. EVIDENCE: Care plans specify the routines preferred, and the social and recreational activities, and interests Service Users have. Several people were able to describe flexible routines in relation to getting up/retiring and personal care. This was also seen to be the case at the time of the visit. Some Service Users were relaxing in their rooms, some doing ‘keep fit’ and some chatting in the lounge. At lunchtime, Service Users were seen to choose where they ate their meal, either in the lounge, dining room or their own bedroom. One lady described her evening routine and the support she received from staff, she said this was to her liking. A programme of weekly activities was on display in the foyer. This was varied and included regular exercise classes, music afternoons, quizzes and art and craft sessions. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 13 Service Users said that activities are a regular feature, as are entertainment, celebrations and parties. A music and mobility session was in progress at the time of the visit, Several Service Users engaged in this, and said afterwards how much they enjoy it. There is a designated activities worker who arranges a programme of events designed to provide interest and stimulation. It was nice to note that individual staff have a particular interest and skill in supporting Service Users in these events, and this is well utilised by the manager. Service Users said there is a visiting library, and magazines and papers can be ordered and delivered on request. One lady said that she had enjoyed a Christmas dance at a local hotel. Contact with family and visitors is known and respected. One lady said she gets support to phone her solicitor and meets with him privately. Another lady spoke fondly of a surprise family visit from relatives’ abroad, and how the staff team had provided snacks and refreshments and a private room. Meals in the home, featured highly in Service Users estimations. A number of Service Users commented very favourably, upon the quality and variety of food. Service Users said they are given choices, and can request food or drinks in between. The menu was on display in the foyer. Service Users were seen to have appropriate support to eat their meals, and food and fluid intake is monitored where concerns are evident. The meal on the day was home made meat pie, fresh green beans, Swede potatoes and gravy. Fresh fruit cocktail was available for afters. It was nicely presented, with Service Users saying the portions were to their liking. It’s recommended that the use of the dining table in the lower lounge is risk assessed to ensure it does not create difficulties for people to manoeuvre into their chairs. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 14 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 Complaints are handled properly and provide Service Users with confidence that their concerns will be listened to, and acted upon. There are robust procedures for safe guarding Service Users from the risk of abuse. EVIDENCE: There is a detailed complaints procedure, which is given to Service Users upon admission to the home. This describes how complaints can be made, and who will deal with them. Arrangements for Contacting CSCI are included. The reference to the complaints procedure in the Statement Of Purpose has an incorrect title for CSCI and will need to be amended. A record of complaints is maintained, although there were no current entries when viewed. Discussion with some Service Users confirmed that they had a copy of this procedure, and knew how to make a complaint. Service Users were confident that any concern or complaint would be dealt with quickly. Service Users also said that there are lots of other platforms available to them to air their views, and so there rarely was a need to complain. These included Service User meetings. These were sampled and showed that comments made were followed up. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 15 Service User and Visitor Questionnaires are also utilised for people to comment on all aspects of the care and service they received. Service Users felt that their comments were addressed to their satisfaction. Since the last inspection, an Adult Protection policy has been produced and implemented. Staff, have also received training in Adult Protection. These developments will ensure that a proper response to any allegation or suspicion of abuse is responded to quickly. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Service Users live in a safe, well- maintained and comfortable environment. They have the range of equipment necessary to support their care needs. Service Users benefit from high standards of cleanliness and hygiene. EVIDENCE: St. Bernard’s is a large elegant house, which retains many of its original features. It is spacious, enabling Service Users to access all parts without difficulty. There is a passenger lift to access all floors, and ramped access to the front and rear gardens. The décor and furnishings are tastefully in keeping with the elegance of the house. Service Users are positive about their surroundings, and said they are comfortable. Many have their own possessions around them, which are made possible, by the good size of many of the bedrooms seen. Service Users said they were happy with the décor and furnishings in their rooms, which are lockable providing them with security for their possessions. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 17 Bedrooms are equipped with en-suite facilities, and communal bathrooms are adapted and fitted with aids and equipment to assist those with difficulties. Corridors and communal areas are fitted with grab rails to assist Service Users. A call system is installed which enables Service Users to determine when they need help. The manager and deputy, to ensure the facilities are suited to the assessed needs of Service Users, have undertaken an assessment of the premises. Occupational therapists provide input for individuals who require specific aids or equipment. There are a number of lounge areas and two conservatories, which enable Service Users to determine to what extent they socialise with others. The lighting is domestic and creates a soft homely atmosphere. Radiators are covered to prevent burns, and window catches are evident to prevent injury from falls. There are dedicated facilities for hairdressing, a treatment room and laundry area. The facilities offer a good degree of privacy to Service Users, as they can have their hair done out of view, and have their own en-suite for personal care, and engage in small group activities of their liking. The environment is safe, comfortable and well maintained. There are extensive landscaped gardens to the rear, which Service users can access and enjoy without difficulty. All areas of the home were found to be clean, and odour free. There are dedicated staff to undertake cleaning and laundry with good infection control procedures in place. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 Service Users needs are met by a skilled well deployed, and organised staff team. Recruitment procedures have improved and provide further safeguards for Service Users. Staff are trained and competent in carrying out their role as carers, this ensures they can meet the needs of people accommodated. EVIDENCE: Rotas sampled indicated that four care staff, one senior, and an activities worker cover each morning shift. In addition to this, there is a cook, and housekeeper who ensure that standards relating to food and cleanliness are maintained. Mornings are described as the peak time of activity, the numbers of staff available, ensure that Service Users can still engage in, and enjoy wellplanned activities. Three care staff and a manager cover the afternoon shift, a kitchen assistant is also available. There is appropriate night time staff, to see to the needs of the Service Users. Rotas specify the role and responsibility of each staff member. During the inspection visit, a number of Service Users were enjoying a’ keep fit to music’, session, facilitated by a ‘mobility worker’ who visits regularly as part of the activities programme provided. At the same time, both staff and Service Users continued with their decoration and preparation for the Halloween party due to take place that night. Service Users said that it was a regular feature of the home; “always lots to do, staff are wonderful and we have a really good time”. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 19 During a tour of the building, those Service Users in their bedrooms were enjoying the company of the housekeeper who was cleaning their rooms, and the laundry person putting away their clothes. A well organised and well deployed staff team, responsive and caring in meeting the needs of the Service Users. Staff training records show that ninety percent of the team have NVQ level 2, and many are undertaking level 3. There is good awareness of the needs of Service Users, and Staff are competent in the roles they undertake, which ensures that Service Users are in safe hands. Staff files have been completely updated since the last inspection. Those sampled showed that two written references are taken, and a police and POVA 1st check is carried out. A complete application and work history is aimed for. Each had a photo of the staff member, proof of identity, contracts and terms and conditions. Clearly a lot of work has been undertaken in this area, which will provide further safeguards for Service Users. A training matrix is now available, and training and induction is now following the TOPPS requirements. This will further ensure that staff have the skills and knowledge to meet the assessed needs of Services Users accommodated. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37, 38 The management of the home is good, with clear leadership and guidance to staff. This ensures Service Users receive consistently high standards of care. The health and safety of Service Users and staff is promoted. EVIDENCE: The manager has NVQ level 4 in care and management. She is waiting completion of her Registered Managers ward. She has a wide range of experience, training and expertise in meeting the needs of older people. Observations made of the care practices, systems, routines and record keeping; clearly demonstrate that the home is well run, by a capable manager. Service Users and staff spoke positively of the ethos of the home. There are many platforms in which Service Users felt they could contribute to the way the home is run, this included Service User Meetings, Key Worker sessions, and quality audits. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 21 Staff meetings and formal supervision are well established and provide a good sense of direction for staff in undertaking their role and responsibilities. It’s recommended that the task of supervising all staff be shared amongst the senior team. This will enable senior staff to develop their skills in this area, as well as freeing up the manager to oversee the task. A format should be devised that the team can work too; this will provide a sense of continuity and direction until such time senior staff have developed their skills. Since the last inspection there has been further developments in updating training for staff. The manager has purchased the TOPPS training package, all the training records have been updated and a training matrix implemented in line with TOPPS requirements. These developments will ensure that staff have, the opportunity to develop their skill in meeting the needs of the people accommodated. A Quality Assurance Monitoring System has also been introduced. There has clearly been a lot of work put into this, and it has been effective in obtaining the views of Service Users, Family and visiting professionals. There have been some very positive returns. These are currently audited on a monthly basis, and fed back to staff and Service Users via meetings. The manager is proposing to utilise a’ news letter ‘ for families in which extracts can be included. Another possibility is to print extracts in the Service User Guide, which would help to inform prospective Service Users. Statutory records were well organised, and well maintained. The management of safe working practices is good, there are systems in place for the monitoring and review of all practice areas, this ensures the well being of Service Users and staff. It’s recommended that the use of the dining table in the lower lounge is risk assessed. Although it does not presently pose a risk to Service Users, it could present difficulties for some, in negotiating around to get to their seats. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 2 Refer to Standard OP16 OP38 Good Practice Recommendations The complaints procedure needs amending to provide the correct title for CSCI. The location of the dining room table in the lower lounge, should be kept under review, and risk assessed to ensure it does not pose a risk to service users accessing their seats. St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 St Bernard`s Residential Care Home Ltd DS0000004541.V254836.R01.S.doc Version 5.0 Page 25 - 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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