Inspection on 24/03/09 for The Birches

This inspection was carried out on 24th March 2009.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Birches 04/03/08

The Birches 19/07/06

The Birches 08/11/05

The Birches 22/04/05

The Birches 17/01/05

The Birches 04/06/04

The Birches 20/02/04

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 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Birches 44 Hitchin Road Shefford Bedfordshire SG17 5JB     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Louise Bushell     Date: 2 4 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 31 Information about the care home Name of care home: Address: The Birches 44 Hitchin Road Shefford Bedfordshire SG17 5JB 01462812757 01462812264 holmesch@bupa.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): BUPA Care Homes (Bedfordshire) Ltd Name of registered manager (if applicable) Mr Sebastian Vvube Type of registration: Number of places registered: care home 31 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: Date of last inspection Brief description of the care home The Birches is situated near the main road through the village of Shefford, and is on a bus route. Village amenities such as local shops, pubs and so on are within walking distance. The home retains very good links with the local population, and many of the residents used to live in the village. Purpose-built in the 1960s, The Birches offers accommodation on two floors to thirty-one older people. The home has several lounges Care Homes for Older People Page 4 of 31 Over 65 31 31 31 0 0 0 Brief description of the care home and other seating areas such as in the entrance hall, and one large dining room. Each lounge has a kitchenette area where staff and residents prepare drinks and snacks. There is a smoking room, main kitchen and laundry as well as bathroom and toilet facilities. A conservatory/lounge leads into the landscaped garden which provides pleasant seating areas in the warmer weather. The fees for this home, at the time of our visit, were in the range of #410 to #580. In the entrance hall there is a table which holds a range of information for people, including CSCI?s latest inspection report. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for the people who use the service and their views of the service provided. The primary method of inspection used was case tracking which involved selecting three people and tracking the care they received through looking at their care records, discussion where possible with the people who use the service, the care staff and observation of care practices. The visit was unannounced and planning for the visit included assessment of the notifications of significant events, which had been received from the service to the Commission for Social Care Inspection. We looked at the last Inspection Report and information on safeguarding and complaints since the last inspection. We also looked at the Annual Quality Assurance Care Homes for Older People Page 6 of 31 Assessment (AQAA) and reviewed what the service has improved in the last twelve months and its plans for the next twelve months. During the visit information was gathered directly from the staff, people who use the service and other senior relatives and or visitors to the service. The visit took place between 14:00pm and 19:00pm. This enabled the inspector to directly and indirectly observe the care practices and the day to day operations of the service. A selected tour of the building was conducted during which the inspector spoke with people who use the service, staff and visitors and the manager. What the care home does well: What has improved since the last inspection? What they could do better: Only a few areas were identified during this key inspection as requiring development in order to ensure that the main outcomes for people who were using the service are consistently met. Since the last inspection significant progress has been made. The manager and the senior team must ensure that people are adequalty supervised at least six times a year with records maintained. Medication balances should be carried forward for medication used one month to the next to support the service with accurate audit trails. Medication must also be prescribed as administered. Care plans must be reviewed to ensure that any changes n needs are identified and met at all times. Care Homes for Older People Page 8 of 31 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information is provided to help people make decisions about their care and a thorough assessment takes place, which helps to ensure that their needs can be met. Evidence: The service has developed a statement of purpose, which sets out the aims and objectives that the person can expect to receive. This includes a guide which provides basic information about the service and the specialist care that is available. The guide details what the prospective people using the service can expect and gives an account of the specialist services provided, quality of the accommodation, qualifications and experience of staff and how to make a complaint. All people who use the service are given a copy of the guide. When requested the service can provide a copy of the statement of purpose and guide in a format which will meet the capacity of the resident. The AQAA states that comprehensive written information is provided to all prospective clients, outlining the ethos of BUPA Care Care Homes for Older People Page 11 of 31 Evidence: Homes and the home, as well as vital information to help with the process of choosing a care home. The homes CSCI reports, the Service User Guide and Statement of Purpose are made available in reception. One person using the service stated that when I moved here the staff were very kind and caring, they could not do enough for me. All of the ten questionnaires sent out to the people who use the service all responses were positive. A further person who uses the service commented that excellent support during the cold spell, I feel very lucky to have this, full marks for effort. Admissions are not made to the service until a full needs assessment has been undertaken. A senior person always completes the assessment prior to admission to the service. A number of pre assessments were seen and completed well. The service also completes a secondary assessment on admission to review any changes in need, this information is used to inform the personal plan. The assessment explored areas of diversity including preferences, religion, gender, age and cultural needs, involvement from family, partners and advocates, race and disability. It was evident that the service strives to seek the information and assessment through care management arrangements, prior to admission. The service has the capacity to support people who use the service and respond to diverse needs that may have been identified during the assessment process. Privately funded people who use the service are provided with a statement of terms and conditions or a contract. Contracts are reviewed when there is a change in the needs of the person using the service. Care Homes for Older People Page 12 of 31 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has suitable care planning formats and arrangements in place for the receipt, storage, administration and disposal of medication, meeting all peoples medical needs. Care plans are detailed however changing need is not always noted due to lack of reviewing. Evidence: A total of three care plans were case tracked fully, it was established that people who use the service receive personal and healthcare support using a person centred approach. The service uses a care plan format called QUEST. QUEST has two stages, stage one and stage two. Stage two is the updated version of the care planning format being used. It was noted that the service iscurrently in the process of transferring all care plans to QUEST two. QUEST 2 includes further information surrounding the individuals cultural and diversity needs. The care planning format details all healthcare needs including specialist health, nursing and dietary requirements. These are clearly recored in each persons care plan. The care plan provides clear information and a comprehensive guide for staff to know how to support the person. The care plan is generated from the pre admission assessment and includes guidelines, risk Care Homes for Older People Page 13 of 31 Evidence: assessments for the management of falls, manual handling assessments and self medication risk assessments and care plans. Through case tracking of the care plans several of the care plans had not been reviewed since December 2008.This was discussed at length with the manager at the time of the inspection. The manager discussed the possible reasoning for this. Whilst it is recognised the pressures that at times services are placed under, there is a need to ensure the care plans are reviewed to monitor changes in need. In the main the care plans that had been reviewed were responsive and tailored to meet the individual choices, needs and preferences. Staff were observed to respect the privacy and dignity of all people. Staff were observed chatting to the people who use the service and engaging with them in a dignifying and respectful manner. One person who uses the service commented that I have looked through my care plan. Whilst a further person stated that all of the staff are kind and caring, they always help us even if they are busy. The service listens and responds to individual choices and decisions about who delivers their personal care. The care plan also details another additional personal preferences, this included food types, night time preferences, activities, religion, personal appearance, personal time and how the person would like to be addressed. People are supported and helped to be independent and can take responsibility for their personal care needs as detailed in their care plan. Individuals have access to healthcare and remedial services. The health care needs of people unable to leave the service are managed by visits from local health care services. The AQAA states that all residents have comprehensive Personal Plans produced with the help of the QUEST assessment tool, which are reviewed monthly and updated as necessary. Monthly audits are conducted by the regional manager assessing many aspects of care to allow continual quality assessment and improvement. This is in addition to the Reg 26s and also detailed audits on specific aspects of care done at Home level (medication, care planning etc). The service has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. The general management of medication at the service was good,however a number minor shortfalls were identified. The service has a traffic light system in place which helps to identify the status of individuals allergies. On one medication the balance from the previous months stock had not been carried forward and made it difficult to balance check the stock available. Upon checking the stock of a further medication, it was found that the balance available was incorrect and there was in fact one more tablet than there should be. A total of four peoples medication was case tracked in order to ensure compliance. Fridge and room temperatures were being recorded in all the medication Care Homes for Older People Page 14 of 31 Evidence: rooms. Ordering and returns documentation was up to date and accurate. The service works with individuals regarding any refusal to take medication. The people using the service are given the support they need to manage their medication. If individuals prefer or where they lack capacity, care staff can manage medication on their behalf. This is assessed and detailed in the care plan. The training matrix provided by the manager of the service determines that a number of staff ave completed and passed an appropriate medication course. An assessment has been carried out to ensure each member of staff is competent to handle, record and administer medication properly. The majority of care plans tracked contained suitable and sensitive plans and arrangements for the management of end of life. Care Homes for Older People Page 15 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are supported and encouraged to make positive food choices and are empowered to engage in meaningful activities. Evidence: People who use the service have the opportunity to develop and maintain important personal and family relationships. Feedback from one person using the service on the day of the inspection confirmed that relatives and or representatives are always welcome. One persons husband visits her every day for lunch. One person commented that its nice when family come to visit, they are always made to feel so welcome. One relative commented that we are always made to feel welcome and can talk to any of the staff on duty if we need to. The service respects the human rights of people using the service with fairness, equality, dignity, respect and autonomy underpinning the care and support being provided. This was indirectly observed through the practices of the staff on duty. A number of people who use the service were seen to be very relaxed and calm within their own environment and engaging with staff in an equal manner. Individuals are involved in some meaningful daytime activities of their own choice and Care Homes for Older People Page 16 of 31 Evidence: according to their individual interests, diverse needs and capabilities. The care plan details life maps for each individual which supports the service in providing meaningful activities of their choice. There is also reference in the care plan to the preferences of each individual for activities and previous interests. The service has recently become a member of the National Association for Providers of Activities for Older People (NAPA). A new activities folder is being established. This was discussed with the manager. The service appears to be making a greater commitment to the provision of activities. Currently the service provides five hours per week plus the activities that staff are able to provide. A number of positive comments have been received from the people who use the service. One person stated that we can do lots of things for example bingo and dominos, the staff always help us and make it fun. Discussions with a team leader occurred regarding the provision of activities at the service, she commented that there has been an increase in activities and staff have become more aware and are now recording it accurately. Individuals can access and enjoy the opportunities available in their local community, such as a library services, the local pub, and local leisure facilities. Some people commented that they would like to access the community more frequently. The manager added that the activity plans would be drawn up on a weekly basis in consultation with the people who use the service. The menu is varied with a number of choices including a healthy option. It includes a variety of dishes that encourage individuals to try new and sometimes unfamiliar food. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. The service has a menu display board, however during the inspection this was not reflective of the foods being offered and or consumed. Comments received from the people who use the service included, we like the food, we want good food and good food is what we get, the chef is really good, he often comes to talk to us about the food. It was observed that the chef spent a short period of time engaging with the people who use the service before the end of his shift. Snacks are available 24 hours a day and the kitchenette areas were seen to be well stocked. One person who uses the service commented that the food is good and I do get a choice, I can always have something else later. The care staff are sensitive to the needs of those people who find it difficult to eat and give assistance with feeding. They are aware of the importance of feeding at the pace of the resident, making them feel comfortable and unhurried. Care Homes for Older People Page 17 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a robust complaints procedure in place, good staff awareness and attitude towards safeguarding issues so people who use the service are safe and protected. Evidence: The service has an open culture that allows people who use the service to express their views and concerns in a safe and understanding environment. People who use the service have commented that they are happy with the service provided, feel safe and well cared for. A number of comments received determined that people who use the service and relatives and friends are aware of what to do if they have any concerns. A verbal complaints log is in place and is effective. One person using the service commented The staff always listen to us. A further person commented that I would always talk to my keyworker if i had problem. It was evident that complaints are also well managed, resolved quickly in the best interest of the person using the service. The service has a complaints procedure that is clearly written and easy to understand. It is available in a number of formats such as different languages on request. The complaints procedure is supplied to everyone living at the service and is displayed in a number of areas within the service. There is a detailed record of all complaints and compliments made and received. The policies Care Homes for Older People Page 18 of 31 Evidence: and procedures for safeguarding adults are available and give clear specific guidance to those using them. Staff commented that they have received training in safeguarding and felt confident in reporting any issues as they occurred. Staff had a clear understanding of the Whistle blowing policy and when the use of this may be put into practice. The service understands the procedures for safeguarding adults and attends meetings or provides information to external agencies when requested. The AQAA determines that BUPA Care Homes is currently reviewing its complaints policy. The current policy has agreed timescales for managing complaints. The information that accompanies the policy is prominently displayed in the home. The policy includes a three tier framework including the home, the regional management team and the national Quality and Compliance department. BUPA Care Homes has robust allegation of abuse and neglect policies, allowing staff to raise concern within the home or to senior staff outside the home. The PoVA procedures are well documented should the need arise. The AQAA also tells us that the service has made improvements to the service over the last twelve months by reducung the number of complaints received. Care Homes for Older People Page 19 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the service enables the people who use the service to live in a safe and comfortable environment. Evidence: The service provides a physical environment that is appropriate to the specific needs of the people who live there. The environment provides a homely feel with specialist aids and equipment to meet needs as required. The service is a pleasant, safe place to live, the bedrooms and communal room provide a personal and homely feel. The decoration throughout the building is tired with some areas being worn, however every effort has been made to make the service fell like a home. The layout of the building enables people to move freely where they reside, with several different seating areas throughout to encourage socialising or enabling the person to have privacy. People are encouraged and supported to move amongst different living areas on the same level. The people who use the service appear to like the environment, were relaxed, comfortable, and settled. The garden is well positioned and mainatined and is secure. A number of people who use the service commented that they often like to sit in the garden in the warmer weather. The garden areas have flowers and tables and chairs, promoting independence and a homely feel. Care Homes for Older People Page 20 of 31 Evidence: Each area has a kitchenette so snacks and drinks can be readily accessed by all. The service must ensure that risk assessments are in place to ensure the safety of all people using the kitchen area as per the needs identified in the care plan. The people who use the service are encouraged to personalise their bedrooms. All the fixtures and fittings meet the needs of individuals and can be changed if their needs change. The dining rooms are laid out to encourage communal dining with a calm relaxed atmosphere. The environment promotes the privacy, dignity and autonomy of individuals. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. The service has an infection control policy. The service is clean, well lit and smells fresh. A person using tr he service commeneted that I like my room, I am very lucky, they clean, do my laundry and also cook my meals, its like a five star hotel. A further person commented that its always nice and fresh here. There was restricted access to high risk areas such as the main kitchen and the laundry areas to reduce the risk of cross infection. The AQAA states that Residents, families and visitors have always commented on friendly atmosphere of the home. The home is odour free. Redecoration is on going as when requested. New cleaning regime in place. Over the next twelve months the service is planning to create a sensory garden. Care Homes for Older People Page 21 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service can be assured that they are kept safe and are supported with a suitably qualified, competent recruited staff team. Evidence: Feedback from the people who use the service shows that they have confidence in the staff who care for them. Staff Rotas were seen and displayed adequate numbers of staff on duty to meet the needs of the people using the service. A deputy manager was usually on shift as the duty supervisor in addition to the team leaders and care staff. This enables staffing levels to be maintained for the safety of all and that record keeping was completed and monitored as required. One staff member commented, the staff work really well together as a team, its a friendly supportive place to work. Managers encourage and enable staff and recognise the benefits of a skilled, trained workforce. Accurate job descriptions and specifications clearly define the roles and responsibilities of staff. People who use the service report that staff working with them are very skilled in their role and are consistently able to meet their needs. There is a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of Care Homes for Older People Page 22 of 31 Evidence: effective recruitment procedures in the delivery of good quality services and for the protection of individuals. Four staff files were audited and were seen to contain all the required documentation. Two individual staff commented on the strong team culture of the service and felt that following recent recruitment, there are enough staff on duty to meet the needs of the people who use the service. Staff confirmed that the service was clear about what was involved at all stages and was robust in following its procedure. There are clear contingency plans to cover for vacancies and sickness and the use of agency staff is monitored through the management team. Once recruited staff receive induction and training. The induction process, known as personal best is a process where the staff member is trained and mentored through a complete programme. The programme is then signed at the end of each stage. Staff confirmed that the senior team provide supervision, however records showed that formal supervision was not occurring at regular intervals. The manager of the service also commented that the supervision schedule for 2009 needed to be followed and that members of the senior team conduct these. One staff member stated that she had not received supervision for some time now. The service has scheduled specific mandatory training for each month and is conducted by qualified trainers within the group. Comments were received from staff regarding the Dementia training that is made available to staff. This awareness course in Dementia is scheduled for June 2009. BUPA offers all staff an initial awareness training into supporting people with Dementia, this is later backed up through the attendance on the Dementia course. Staff confirmed that staff meetings occur and a number of comments received on the staff surveys determined that the staff feel fully involved and updated. The mix of staff is suitable to meet the cultural needs and mix of people that use the service. Staff reported that they felt supported in their roles and that they were able to discuss issues with a member of the senior team if required. A comment received from a staff member states that; I feel that the manager and the other team leaders do support us and we all work very well together. A further staff member commented that Sebastien is very good, he is always here and very Care Homes for Older People Page 23 of 31 Evidence: helpful if we have any concerns he always listens and tries to help where he can. One person who uses the service commented that the manager always comes to spend time with us and talks to us, he is great, we all get on very well with him. The AQAA determines that BUPA Care Homes has comprehensive Human Resource policies and procedures to aid staff management and recruitment. We endeavour to maintain agreed staffing levels at all times. We perform appropriate CRB, PoVA and NMC PIN checks on all staff. There is a training matrix specific to the home that identifies the training requirements of staff. We have a good level of staff retention Care Homes for Older People Page 24 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from living in a well-managed service but some improvements are needed in relation to health and safety, record storage and staff management, in order to ensure that all people are protected and safe. Evidence: The Registered Manager has the required qualifications and experience and is competent to run the home. The Registered Manager and senior team have a clear understanding of the key principles and focus of the service, based on organisational values and priorities. They work to continuously improve the service. Feedback received on the day of the inspection from staff and as part of the feedback questionnaires received determines that the management are effective and approachable. With the introduction of the new care planning format and training around its implementation, there is a focus on person centred thinking, with the people who use the service becoming increasingly more involved. Care Homes for Older People Page 25 of 31 Evidence: The Registered Manager and senior team lead and support a stable staff team who have been recruited and trained to satisfactory levels. The manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. The service has sound policies and procedures, which are corporately and internally reviewed and updated, in line with current practice. The manager ensures that staff follow the policies and procedures of the home. The staff team are positive in translating policy into practice and showed good knowledge of care principles, health and safety and safeguarding issues. This includes the management of finances within the service, where systems were directly observed to be transparent and open, with detailed records being maintained at all times. There was some evidence on staff records that staff have supervision but this is not always carried out on a one to one basis where staff have the opportunity to discuss their personal development. One staff member had commented that they had not had supervision for a while. There is a need for all staff to be offered guidance about the role of supervision and for periodical one to one sessions to be documented. Staff confirmed that supervision does occur but not on a regular basis. The manager confirmed that continued development and progress is being made with training and supervision and it was seen that progress had been made. Staff meetings take place regularly and minutes of the meetings are available. The home works to a clear health and safety policy. Safeguarding is given high priority and the home provides a range of policies and guidance to underpin good practice. In house training is scheduled for safeguarding. Through discussions with the management team and it was determined that priority is given to ensure that all staff are in receipt of adequate training, including in house refresher courses and a full complete induction programme. The AQAA states that Regular Health and Safety meetings take place, with a standardised agenda giving staff the opportunity to communicate on Health and Safety issues. The minutes from there go to the Regional Manager and Quality and Compliance team. There are regional and national experts available within the company for advice and guidance if required. The Home is supported by a national Care Homes for Older People Page 26 of 31 Evidence: team of Quality and Compliance Officers whose role includes supporting quality issues within the home, auditing and providing guidance on policies, procedures and practice. There are dedicated Health and Safety staff within the regions, supported by a National Quality and Compliance team. This includes Health and Safety and Fire Management Leadership. BUPA Care Homes has a comprehensive suite of policy and procedure manuals that are regularly reviewed by experts and updated when required. We have an annual internal and external customer satisfaction survey. BUPA SOP (Surveying Our People) is conducted annually. The Personal Best programme encourages a person centred approach. Care Homes for Older People Page 27 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 28 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 15 Care plans must be up to date and reviewed. To ensure that the holistic needs of the people who use the service can be monitored and met at all times. 15/05/2009 2 9 13 Medication must be administered as prescribed. To ensure that people who use the service receive all prescribed medication to protect them. 15/05/2009 3 35 18 Staff must receive regular 29/05/2009 supervision at least six times a year. To ensure that the staff team is consistently well managed in the best interest of the people who use the service. Care Homes for Older People Page 29 of 31 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 Balances should be carried forward on medication used from month to month. Care Homes for Older People Page 30 of 31 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 31 of 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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