CARE HOMES FOR OLDER PEOPLE
St Bridgets 14 East Avenue Talbot Woods Bournemouth Dorset BH3 7BY Lead Inspector
Debra Jones Key Unannounced Inspection 23rd May 2006 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 DS0000020497.V296060.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000020497.V296060.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Bridgets Address 14 East Avenue Talbot Woods Bournemouth Dorset BH3 7BY 01202 291347 01202 291347 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) Mr A L Howell Mrs Joanna Ethne Hills Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places DS0000020497.V296060.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home may accommodate a maximum of 2 persons in Room 23. Date of last inspection 25th October 2005 Brief Description of the Service: St Bridget’s home accommodates 12 older people in need of nursing care in a large converted house. It is on a corner plot set back from the main road, in mature gardens with a small car park to the rear of the premises. The home is in the residential area of Talbot Woods within easy reach of shops, bus routes and community facilities. The residents accommodation is arranged over the ground and first floor. A passenger lift is available between floors. Two of the bedrooms are single and 5 are double. None of the bedrooms have ensuite facilities but there are communal bathroom and toilet facilities on the ground and first floor. At this visit the manager said that current fees for this home range between £500 and £550 a week. DS0000020497.V296060.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Since the last inspection 2 visits have been made to this home to encourage compliance. Of particular concern were the records kept in relation to staff, pre employment checks etc. Over the course of these visits significant progress was made. This inspection took place over two days and was the home’s key inspection for the year. The requirements and recommendations made at the last inspection were followed up to see if the home had made any progress towards meeting them. Progress had been made in most areas. The Inspector looked around the building and a number of records were inspected. On the first day the nurse in charge assisted the inspection and on the second the Matron was on hand to help. All of the residents living in the home were spoken to, along with staff on duty. Prior to the inspection the home gave out comment cards on behalf of the Commission to people living in, and interested in the service so that they could give feedback about their experience of the home. Seven cards were returned from relatives, 2 from residents and 1 from a GP surgery. Both residents said that they felt they liked living at the home, were well cared for, treated well by the staff, had their privacy respected and felt safe there. Both liked the food and felt that the home provided suitable activities. Comments from residents and relatives included :‘Outstanding care’ (a resident) ‘ I am completely happy with all the cheerful hello they give my sister’. ( a relative) ‘I find this home a very caring home with friendly and caring staff’. (a relative) ‘The staff must have the patience of Job to look after my sister who is prone to bad temper due to her dementia’. (a relative) ‘The care is 100 in every way. Cleanliness is also a top priority. I have always found staff to be efficient and helpful. I would thoroughly recommend this home from every point of view.’ The GP said that he was satisfied with the overall care provided to residents within the home. DS0000020497.V296060.R01.S.doc Version 5.2 Page 6 What the service does well:
St Bridget’s aims to provide a ‘home from home’ atmosphere and does so successfully in a house decorated and furnished in a homely way. The home is kept clean and generally smells pleasant. Before residents move into the home they are visited and assessed to see if the home can meet their needs. Assessments include finding out about social interests, hobbies and religious and cultural needs as well as about their health and personal care. Records are made of these assessments which then go on to inform the care plans. Care plans are thorough and regularly updated to make sure that staff know how to care for the residents living at the home. Daily notes, evidencing the delivery of care are thorough. Residents health needs are well met by the home and community health professionals. Generally medication is well handled at the home to promote the health and well being of residents. Residents are well cared for and treated with respect and dignity. Some activities are available and residents can join in as they wish. People are free and encouraged to spend their days as they choose. Residents are able to see visitors when they wish and make decisions about how they spend their days within the constraints of a residential care home setting and their own abilities. Meals are wholesome and varied and planned around the likes and dislikes of residents. The complaints procedure reassures residents that their views are important to the home and that any complaints they, or their supporters raise will be properly investigated. The home has a good committed manager and sufficient care staff are employed to meet the current needs of residents. Staff have access to the basic training that they need to do their jobs well. Criminal Record Bureau disclosures and POVA checks are completed for all staff employed at the home, and proof of the person’s identification obtained. This goes toward protecting residents from unsuitable staff working at the home. Documentation is also in place to show that staff from abroad have the right to be in this country and to work at the home. The home is not involved in the finances of residents.
DS0000020497.V296060.R01.S.doc Version 5.2 Page 7 The home is regularly checking their fire equipment and keeping appropriate records of this. Accident records are also kept and regularly analysed and actions taken to reduce the risk of accidents happening again. What has improved since the last inspection? What they could do better:
The home need to make sure that they undertake a manual handling assessment for all the residents living at the home and that this assessment if regularly reviewed. Care plans also need to include a section on how the home will meet the individual resident’s medication needs. Where equipment is introduced that restrains the movement of residents, for example bed rails, the home needs to carry out an assessment to confirm the use of the equipment is in the resident’s best interests. Once undertaken this assessment must be regularly reviewed. DS0000020497.V296060.R01.S.doc Version 5.2 Page 8 When there is a change to a medication administration record e.g. if something is added or a dose changes; 2 competent people should check that the change that is made is correct and both should sign to confirm this. The home should produce a programme of maintenance and renewal in respect of the premises and this must include the requirements that the Commission has said that the home must comply with e.g. restricting the temperature of water in the wash hand basins that residents have access to. The home must also produce written risk assessments in respect of individual residents and any dangers posed to them by radiators and pipe work around the home. All residents’ bedroom windows must be fully curtained. It would be good if the home got someone who had the right professional training to carry out an assessment of the premises to confirm that it was suitable for the people living there. It would also be good if more care staff had an NVQ level 2 qualification in care. This would make care staff more knowledgeable about the job they do and potentially improve the quality of care delivered to residents at the home. The home carries out surveys of residents’ views every year and also asks other people that visit the home what they think in order to improve services for the residents. It would be good if the home would pull all the responses together and write, and make available, a report about what they have found out. In addition some good practice suggestions have been made throughout this report. 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. DS0000020497.V296060.R01.S.doc Version 5.2 Page 9 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 DS0000020497.V296060.R01.S.doc Version 5.2 Page 10 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A thorough pre admission procedure is in place and assessments are undertaken to ensure that only residents whose needs can be met by the home are offered places there. EVIDENCE: Files for two residents who had recently moved into the home were examined. One resident had moved in the evening before. Their file contained a thorough pre admission assessment and written confirmation that the home could meet their needs. The home had also obtained the assessment and care plan from the local authority. The other file, for a resident who had been at the home longer, also contained a pre admission assessment and a letter confirming that the home could meet their needs.
DS0000020497.V296060.R01.S.doc Version 5.2 Page 11 The manager said that the newest resident was about to be issued with a contract and that she was waiting for the family of the resident who had been at the home longer to return a signed copy of the contract. DS0000020497.V296060.R01.S.doc Version 5.2 Page 12 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, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear care planning system in place to make sure that staff have the information they need to meet residents needs. The health needs of the residents are well met with evidence of good support from community health professionals. The medication at this home is generally well managed promoting the good health and well being of residents. Residents are treated with respect and their right to privacy upheld. EVIDENCE: Comprehensive care plans and risk assessments of a good standard are in place. Plans are easy to read, to the point and informative. They clearly set out individual care needs and how they are to be met. Plans are clear about
DS0000020497.V296060.R01.S.doc Version 5.2 Page 13 what residents can do for themselves and what staff need to assist them with. The plans are reviewed regularly and updated as needed. However not all care files included a manual handling assessment, and those that were seen had not been reviewed recently. Where bed rails and bumpers are in use, although these are referred to in the plans and permissions are sought from relatives there are no assessments as to why they are in use. Specific written plans as to the medication needs of residents were also not in place. Daily notes support and evidence the delivery of care to residents. Three residents currently have sores / ulcers that are being treated. All three had wound charts and treatment logs to monitor the progress of their recovery. The tissue viability nurse, who both visits and is available for advice by phone, supports the home in delivering wound care. Most residents were not able to talk about the care they received but all spoken to smiled and those able to express themselves said they were very happy ‘they really look after me’ ‘it’s ‘lovely’. When asked if the home could do anything better one resident said ‘oh no!’ Of the seven relatives who responded to comment cards all said that they were happy with the level of information regarding they got important matters and consultation they had with the home in respect of their relatives/ friends. It was clear from discussions with the person in charge and from documentation on file that residents have access to the health services they need. There was evidence to show that residents get support from General Practitioners, the tissue viability nurse, chiropodists, opticians and dentists. The GP surgery that returned a comment card to the Commission said that the home communicated clearly, worked in partnership with them and that staff demonstrated a clear understanding of the care needs of residents. They also said that the home took appropriate decisions when they could no longer manage the care needs of residents. No residents are administering their own medication. Medication at the home is only administered by the qualified staff who are all confident in carrying out this task. Samples of their signatures are held at the front of the medicines file. Photographs of residents are also kept on this file. Medicines and dressings were tidily stored in appropriate places e.g. the medication cupboards and the trolley. No controlled drugs are currently in use and no medicines are being kept in the fridge. A system is in place for the disposal of medicines that are not used at the home and records are kept. Details of any residents’ medicine sensitivity or ‘none known’ are noted on the medication administration records. Where there is a choice of dose of medication it is noted how much is actually given. Some hand written changes to the medication administration records made by staff at the home had not
DS0000020497.V296060.R01.S.doc Version 5.2 Page 14 been signed by two people. Staff record the date that medicines are opened/ brought into use and when this happens is also noted on the medication administration record. The home are not auditing themselves in respect of their medication administration and it is suggested that they do. The inspector was told that through being ill and being visited by the GP, having a general visit from a GP surgery or through being newly admitted to the home all residents will have had their medication reviewed in the last year. The GP surgery that returned a comment card to the Commission prior to the inspection said that their opinion was that the residents’ medication was appropriately managed in the home. Staff were seen treating residents with respect. Where residents share rooms their privacy is not compromised as fitted curtains across rooms provide screening when needed. Staff confirmed good practice in the way that they described delivering personal care in a manner that respected the dignity of residents. ‘You have to put yourself in their position and ask yourself would I like that?’ One care plan viewed had a section in it headed ‘dignity and pride’ and focused on encouraging the resident, who had always taken a great pride in her appearance, to choose the clothes she was to wear. Two residents returned comment cards to the Commission prior to the inspection. Both said that they liked living at the home, felt well cared for, were treated well by staff and that their privacy was respected. The GP surgery that returned a comment card to the Commission confirmed that they are always able to see their patients in private. DS0000020497.V296060.R01.S.doc Version 5.2 Page 15 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ lives are enriched by the social opportunities afforded by their visitors, activities at the home and the choices they are able to exercise day to day. The meals in this home are wholesome and varied and are served in a pleasant environment. EVIDENCE: As part of the assessment process residents are asked about their interests, hobbies, social and family networks and religious needs. These are then catered for when people move into the home. The home organises some activities in the home. There is a regular exercise class and occasionally entertainers come to the home. Residents can choose whether to join in or not. Daily papers are available. A hairdresser visits. Residents have radios and televisions as they wish. DS0000020497.V296060.R01.S.doc Version 5.2 Page 16 On the ground floor there are two lounges giving residents choice as to where they spend their days if they wish to come out of their rooms. Care plans are clear about what people like and don’t like to do. Both of the residents who returned comment cards to the Commission said that they felt the home provided suitable activities. The visitors book confirmed the number and range of visitors to the home. All seven visitors who returned comment cards said that they felt welcome in the home and would be able to visit their relatives in private if they wished. Residents are encouraged and supported in making choices about their daily lives. They are able to get up and go back to bed when they wish; have what they want to eat and drink, where and when they want it; spend time in the communal areas / their bedrooms as they choose; do as they wish in the day and see visitors as it suits them. Staff are made aware of the importance of respecting the individuality of residents at their induction. The meal served on the day of inspection was a choice of savoury lamb mince, chicken and gravy or fish fingers, served with creamed potatoes and fresh cauliflower with broccoli. Dessert was stewed apple and custard or ice cream. Fresh juices are available and on offer throughout the day. Menus are based around the known likes and dislikes of the residents. The home tries to ensure that residents get ‘5 portions of fruit and vegetables’ daily. Special diets are being catered for – one resident does not eat meat, one resident is diabetic and two are Jewish. Five residents need to have their meals pureed and 5 need help with eating. The cook on duty was very clear about who needed what. Food preferences are noted on the pre admission assessment as well as in the care plan. The cook meets with residents to find out what they like and gets feedback as to what generally ‘goes down well’ from staff and residents. The cook had met with the resident who had moved in the evening before to check what they wanted for their lunch and to ascertain their preferences. No budget is imposed on the purchase of food at the home and residents can have what they like. One resident talked of how she had a cooked breakfast every day and of how it was the meal she enjoyed the most. The cook on duty said ‘whatever I need I get.’ The microwave had recently broken and had been replaced within a day. Records are kept of the meals provided and individual records are held for residents as to what they have to eat each day and their general appetite. The home has a ‘nutritional assessment tool’ should they need to use it if they were concerned about a resident. DS0000020497.V296060.R01.S.doc Version 5.2 Page 17 It is suggested that the cooks are offered the opportunity to have training in nutrition for older people. It is also suggested that where dry goods are decanted into other containers that information about the product e.g. when it was decanted and its use by date are transferred to the new container. Prior to the inspection 2 comment cards were received from residents. Both said that they liked the food. DS0000020497.V296060.R01.S.doc Version 5.2 Page 18 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A system is in place to deal with any complaints that might be made by residents. The home’s adult protection policy demonstrates an understanding of abuse and of how to protect residents from it. EVIDENCE: The home has a complaints policy / procedure that is included in the information given to residents. No complaints have been received by the home since the last inspection or by the Commission. The two comment cards received prior to the inspection from residents both confirmed that residents knew who to speak to if they were unhappy with their care. Five of the seven relatives who returned comment cards said that they were aware of complaints procedure. All seven said that had never had to make a complaint. The home has an adult protection policy to guide staff as to how to recognise signs of abuse and to tell them what to do about it if they do. The policy has now been updated and refers to the implementation of the Protection of Vulnerable Adults list and it’s implications in respect of the recruitment of staff
DS0000020497.V296060.R01.S.doc Version 5.2 Page 19 and the potential referral of unsuitable staff to the list. It is suggested that the home keep the local (Dorset) guidance ‘No Secrets’ in respect of adult protection with this policy for easy reference. Since the last inspection abuse training has taken place at the home. More is planned. The two comment cards received prior to the inspection from residents both confirmed that residents felt safe at the home. DS0000020497.V296060.R01.S.doc Version 5.2 Page 20 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, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate facilities are available to meet the number of the current residents. Residents enjoy living in a clean and pleasant smelling home. More needs to be done to ensure that the home is suitable and safe for residents. EVIDENCE: The home has a homely feel. Last year the hallways were redecorated and since the last inspection a number of bedrooms have also been redecorated. One resident talked of how pleased she was with her newly decorated bedroom. Some bedroom furniture has been replaced. Residents are able to bring personal possessions into the home with them. There are an adequate number of communal bathrooms and toilets, with aids and adaptations, available in the home for the number of residents living there. There is a bathroom on the ground and one on the first. Most residents
DS0000020497.V296060.R01.S.doc Version 5.2 Page 21 and staff prefer using the ground floor bathroom, but the upstairs one is used sometimes. Communal facilities are spacious for the number of people living at the home with a dining / lounge area and an additional large lounge being available. A programme of routine maintenance and renewal of the fabric and decoration of the premises has not been produced, although there is evidence of ongoing decoration and the manager talked of plans to improve the facilities. The home has not been assessed by qualified persons, including an occupational therapist to see if the premises are suitable for the residents living there. One bedroom has a number of windows. One smaller side window has only a net curtains. At the last inspection it was noted that ‘a full curtain to block out the light should be fitted so the resident can choose if they wish it to be open or not.’ A rail has been fitted above the window but a curtain has not yet been put up. The temperature of the water in the baths is controlled but not the hand basins in residents’ bedrooms or the communal bathrooms. In respect of this it has been required at previous inspections that to prevent risks from scalding pre set valves, of a type unaffected by changed in water pressure and which have fail safe devices, be fitted to provide hot water close to 34 degrees centigrade. This has not been done. There are a number of radiators in the home that are not covered and are not guaranteed low temperature surface radiators. The risk to residents is minimised by their immobility and the positioning of furniture. Individual risk assessments do not cover radiators and pipe work. Progress has been made in eradicating the offensive odour in one bedroom mentioned at previous inspections. The rest of the home remains clean and odour free. The laundry is appropriately sited. Suitable washing machines and sluices are in place. DS0000020497.V296060.R01.S.doc Version 5.2 Page 22 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient, suitably trained nursing and care staff are employed and deployed to ensure that the care needs of residents can be met. Significant progress has been made in the collection of appropriate documentation in relation to staff employed at the home, ensuring that residents are not at risk from unsuitable people working there. EVIDENCE: Clear staffing rosters are in place that show who is on duty and when. A qualified nurse is on duty at all times. 2 health care assistants are on duty between 8am and 8pm and one health care assistant is on duty at night. The matron, who is also the registered manager of the home gets 6 hours a week of dedicated management time. Six of the seven relatives who returned comment cards to the Commission said that in their opinion there were always sufficient numbers of staff on duty. The GP surgery who returned a comment card to the Commission said that there was always a senior member of staff to confer with at the home. DS0000020497.V296060.R01.S.doc Version 5.2 Page 23 Out of the 10 health care assistants employed at the home 1 has completed their NVQ level 2 in care and 6 other staff are working towards the qualification. Files were reviewed of the two members of staff who had started work at the home since the last visit. Both files were well ordered and contained all the information required by law including – • Proofs of Identification • Criminal Record Bureau Disclosures (CRBs) • Self declaration of criminal offences • Self declarations as to mental and physical fitness • Permissions to work • When they started working at the home • What hours they work every week The standard of documentation in respect of staffing is significantly improved since the last inspection. The recruitment procedure could not be found at this visit and so it was not possible to evidence if the recommended changes had been made to it in respect of the pre employment checks that need to be made e.g. to prevent illegal working. Not all staff have been issued with statements of terms and conditions (of employment). Whilst there was evidence that staff are getting a comprehensive induction, the Skills for Care induction package (the new ‘industry standard’ ) was not in use. The matron told the inspector that it is the intention of the home to start using this induction package and that she was due to attend a matrons meeting about introducing it the following week. Information reviewed at the last inspection in respect of staff training showed that staff have access to training such as emergency aid, health and safety, food hygiene, moving and handling and abuse. Since that visit staff have had manual handling and abuse training. More training is planned. DS0000020497.V296060.R01.S.doc Version 5.2 Page 24 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, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Progress has been made in compliance with the law, national minimum standards and in promoting and safeguarding the health, safety and welfare of the residents during the last year. Whilst there is nothing to demonstrate that the home is not run in the best interests of residents a quality assurance system has not been fully implemented yet. DS0000020497.V296060.R01.S.doc Version 5.2 Page 25 EVIDENCE: The home is managed by Jo Hills who is an experienced nurse and manager. Ms Hill has a hands-on approach to her job and this has a positive impact on the home in that she leads staff by example and residents know her well and speak highly of her. The annual quality assurance survey and report have not yet been completed this year and therefore not circulated to interested parties. The home is not handling any money belonging to residents. The manager confirmed that formal supervisions are not now taking place regularly. Staff meetings are also held. Fire records were in place and internal and external checks are being carried out at the required regularity. Fire training records for staff showed that all staff had had fire training at the required intervals. Accident records are appropriately kept and regular analyses are undertaken describing how risk of such accidents occurring again are minimised. The home has been inspected by the water board to see if they complied with the Water Supply (Water Fittings) Regulations 1999 and a letter has been seen at a previous inspection confirming that they had. The home has a file containing data product sheets for the cleaning products etc in use at the home. It is suggested that this is reviewed to ensure that it is up to date with the products in use. No products are decanted into other containers at the home and those seen clearly stated what should be done if the products are used inappropriately e.g. if they are swallowed. The insurance certificate on display was up to date. DS0000020497.V296060.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable DS0000020497.V296060.R01.S.doc Version 5.2 Page 27 CHOICE OF HOME Standard No Score ENVIRONMENT Standard No Score 1 2 3 4 5 6 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x
DAILY LIFE AND SOCIAL ACTIVITIES 19 20 21 22 23 24 25 26 2 3 3 2 X 2 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 12 13 14 15 Score 3 3 3 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X 3 3 X 3 DS0000020497.V296060.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13 Requirement • Care files should all include moving and handling assessments, which are regularly reviewed. • Where bed rails are in use an assessment must be in place that has involved appropriate people. The reason for use must be clear and how the bed rails are to be used. The assessment must be regularly reviewed. • Each care plan should include a section on medication. 2. OP24 16 All external bedroom windows must be fitted with curtains or blinds (not just nets). (previous timescale of 01/12/05) • To prevent risks from scalding the temperature of water must be controlled, in hand basins that could be used by residents, to about 43 degrees centigrade. (previous timescale of 31/3/05)
DS0000020497.V296060.R01.S.doc Timescale for action 01/07/06 01/07/06 3. OP25 13 01/07/06 Version 5.2 Page 29 • Written risk assessments of the risk of harm through contact with radiators and pipe work to residents must be made, acted upon where appropriate and reviewed regularly. 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 OP9 Good Practice Recommendations When medication administration records are altered a second competent person should check the changes that have been made and sign to confirm this. A programme of routine maintenance and renewal of the fabric and decoration of the building should be produced and implemented with records kept. Where a timescale has been set for compliance with any standard relating to the physical environment of the home, a plan and programme for achieving compliance should be produced and followed with records kept. It is recommended that an assessment of the premises be undertaken by qualified persons, including an occupational therapist. It is recommended that 50 of care staff achieve NVQ level 2 in care (or equivalent). • It is recommended that recruitment procedures are updated in line with the Home Office guidance for employers to prevent illegal working. All staff should be issued with terms and conditions of employment. 2. OP19 3. 4. 5. OP22 OP28 OP29 • 6. OP33 It is recommended that results from quality assurance surveys be analysed and a report be compiled.
DS0000020497.V296060.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000020497.V296060.R01.S.doc Version 5.2 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
