Care Home: Bedford Charter House

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What the care home does well The home understands the importance of having enough information when choosing a care home. Admissions are not made until a full assessment of needs has been carried out, so that prospective residents and their representatives can be sure their needs will be met. Medications records are fully completed, contain required entries and are signed appropriately by staff. People receiving care in this home are generally happy with the way most staff deliver care and respect their dignity. Residents in this home are involved in meaningful daily activities and have the opportunity to join in local community events. People are encouraged to make personal choices about their lives. There is a full programme of activities available for the residents in this home, which ranges from whist drives and dominoes, to exercise groups and outings. The menus are nutritious and varied, giving choice and variety to the residents. Residents were very complimentary about the food. One person said. "I`m perfectly satisfied with the food". And another said. "The meals are lovely here, I shall miss them as I `m going home this afternoon". The complaints procedure is supplied to everyone living in the home. Staff working at the home understand the procedures for safeguarding, and know when incidents need to be reported externally. This home provides a clean, comfortable and homely environment for the people who live here. This home is well staffed with 12 care staff rostered on duty for the a/m shift, 8 staff for the p/m shift and 4 for the night shift. There are in all, 6 care managers employed in this home ensuring that every shift has the appropriate skills available. The care staff are supported by an activity organiser, a hairdresser, 5 housekeepers, 3 kitchen staff, 1 laundry worker and numerous administrators. The manager demonstrates a clear understanding of the key principles and focus of this service. She is enthusiastic and is striving to make continuous improvements to promote the health, safety and welfare of the residents who live in this home. Supervision records were examined, and indicated that staff are receiving regular 1:1 sessions with their line manager. What has improved since the last inspection? Since the last inspection lounge areas have been redecorated, the kitchen has been re aligned, a spray cleaner for dishes, a plate warmer and an emergency gas cut off installed. Some areas have had new flooring laid and the activities room has had air conditioning fitted and new equipment such as a large screen television and a `Wii` games consol have been purchased. What the care home could do better: Due to limited information being documented in some care plans; there may be an inconsistency in the delivery of care. We acknowledge that the manager in this home may have been misguided by information received from CSCI relating to staff recruitment, however we now believe she has a full understanding and we are confident that she has rectified this matter since our visit. CARE HOMES FOR OLDER PEOPLE Bedford Charter House 1a Kimbolton Road Bedford Bedfordshire MK40 2NT Lead Inspector Ms Louise Trainor Unannounced Inspection 20th August 2008 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bedford Charter House DS0000014999.V370432.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. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bedford Charter House Address 1a Kimbolton Road Bedford Bedfordshire MK40 2NT Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01234 359313 01234 352004 denisehookham@bchal.org.uk Bedford Citizens Housing Association Mrs Denise Hookham Care Home 64 Category(ies) of Dementia - over 65 years of age (64), Old age, registration, with number not falling within any other category (64), of places Physical disability over 65 years of age (64) Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21/03/07 Brief Description of the Service: Bedford Charter House is a purpose built home for older people situated next to an entrance of Bedford hospital. It is operated by a not for profit organisation. The location offers easy access to Bedford town centre and the roads leading there. The home provides accommodation for 64 service users, four places are reserved for breathing space care (following discharge from hospital), and three for respite care. The home caters for older people with dementia, some with physical disabilities and some generally affected by old age. The home is divided into 3 areas for operational purposes: breathing space area, and one unit per floor. Service users from the breathing space unit are invited to use a dining room and activity room in the main part of the building, if they wish. Service users usually provide their own furniture, and this adds to the homely environment. There is a garden with hard paved areas and paths, and raised beds. Fees for this home range from £2017.53 to £2170.39 per month depending on standard or premier room accommodation. Hairdressing, chiropody and other personal services are available at an additional cost. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. This was the first Key Inspection for this year for this service. Regulatory Inspectors Mrs Louise Trainor carried it out on the 20th of August 2008 between the hours of 08:00 and 15:30 hours. The home Manager was present throughout the visit to assist with any required information. Verbal feedback was given periodically throughout the inspection and at the end of the visit. During the inspection the care of three people who use this service were case tracked. This included a recent admission to the home. This involved reading their records and comparing what was documented to the care that was being provided. Documentation relating to: staff recruitment, training and supervision and medication administration, complaints, quality assurance and health and safety in the home were also examined. We also spent some time in the communal areas of the home, talking to staff and residents and observing the care practices, including the service of the midday meal, that were carried out during this seven and a half hour inspection hour inspection. We would like to thank everyone involved for their support and assistance during this visit to the home. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 6 What the service does well: The home understands the importance of having enough information when choosing a care home. Admissions are not made until a full assessment of needs has been carried out, so that prospective residents and their representatives can be sure their needs will be met. Medications records are fully completed, contain required entries and are signed appropriately by staff. People receiving care in this home are generally happy with the way most staff deliver care and respect their dignity. Residents in this home are involved in meaningful daily activities and have the opportunity to join in local community events. People are encouraged to make personal choices about their lives. There is a full programme of activities available for the residents in this home, which ranges from whist drives and dominoes, to exercise groups and outings. The menus are nutritious and varied, giving choice and variety to the residents. Residents were very complimentary about the food. One person said. “I’m perfectly satisfied with the food”. And another said. “The meals are lovely here, I shall miss them as I ‘m going home this afternoon”. The complaints procedure is supplied to everyone living in the home. Staff working at the home understand the procedures for safeguarding, and know when incidents need to be reported externally. This home provides a clean, comfortable and homely environment for the people who live here. This home is well staffed with 12 care staff rostered on duty for the a/m shift, 8 staff for the p/m shift and 4 for the night shift. There are in all, 6 care managers employed in this home ensuring that every shift has the appropriate skills available. The care staff are supported by an activity organiser, a hairdresser, 5 housekeepers, 3 kitchen staff, 1 laundry worker and numerous administrators. The manager demonstrates a clear understanding of the key principles and focus of this service. She is enthusiastic and is striving to make continuous improvements to promote the health, safety and welfare of the residents who live in this home. Supervision records were examined, and indicated that staff are receiving regular 1:1 sessions with their line manager. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 8 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 Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 People who use this service experience good quality outcomes in this area. The home understands the importance of having enough information when choosing a care home. Admissions are not made until a full assessment of needs has been carried out, so that prospective residents and their representatives can be sure their needs will be met. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: This home provides a detailed information pack and practical ‘applicants guide’. This had been reviewed within the last year, and is issued to all prospective residents and their representatives at the point of enquiry. These documents are available in different languages and formats upon request. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 10 We viewed the files of four residents who live in this home, including one who is only visiting for a respite period of one month. All had fully completed pre admission assessments that had been carried out well in advance of the admission, and contained sufficient detail to ensure that staff would be able to meet their needs. We looked at terms of conditions and contracts for four residents. These were appropriately signed and dated. This home does not provide intermediate care. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, People who use this service experience good quality outcomes in this area. Medications records are fully completed, contain required entries and are signed appropriately by staff. People receiving care in this home are generally happy with the way most staff deliver care and respect their dignity, however due to limited information being documented in some care plans, there may be an inconsistency in the delivery of care. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: During this visit we checked the Medication Administration Record (MAR) sheets for approximately half of the residents. Medications were appropriately stored in locked trolleys that were secured to the wall in locked rooms. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 12 A sheet with sample signatures of all staff was present in the file with the MAR sheets as was photographic identification for each resident. All the MAR sheets were accurately completed with signatures and omission codes where appropriate. The stocks remaining for ten residents were checked against their MAR sheets and all reconciled correctly. Bottles and topical applications such as creams and eye drops had been dated on opening. Controlled drugs (CD’s) were stored appropriately and all administrations had been recorded accurately with two signatures in the CD registered. The only criticism was that there was a stock of 336 paracetamol in the cupboard. These were not prescribed for any particular individuals, and record of how and whom these were administered to, was not available. During this inspection we looked at the personal files of three residents, and spoke to other residents as the opportunity arose throughout the day. Comments from the residents were generally very positive and complimentary of staff. One person told us. “Everyone’s very good, I couldn’t do more if I worked here myself, it’s very clean and they provide us with a convivial home, but I ‘d rather be at home”. Another told us. “I’m only here for a very short time but it’s very comfortable and very very good”. One person did however comment that. “Some people are a little abrupt”, but this did seem to be a minority opinion. All the files that we looked at had pre admission assessments in place, which clearly outlined the individual’s needs, and included personal choices and wishes. Care plans were generated from this initial assessment. One of the files we looked at was for a resident who had been admitted very recently. It indicated her preference for showers, and the level of assistance required. Care plans were numerous including, constipation and how it is relieved, diet and dentures, mobilising, this included a risk assessment for slips, trips and falls, short term memory problems, arthritis and pain relief, medication and self administration, and details relating to a dressing on her foot. This resident was keen to talk about herself and the areas of care that she needed assistance in, and the conversation was clearly reflective of her care plan, indicating that she had been involved in discussing these matters as the care plan was formulated. However not all the care plans that we looked at were as specific, and did not give clear guidance for care delivery. For example one resident had a catheter in situ, and although this was identified in the care plan, there was no detail relating to catheter care, fluid intake / output, or other related matters. When we asked a member of staff about this person’s fluid intake, she told us. “We just check he has enough fluid”. This member of staff also made reference to this resident stating. “He can be violent”. When we asked where this was documented she told us. “You wouldn’t know from his file”. Reference was made to this person’s mental Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 13 health condition and a need for depot injections, however more specific information was required to ensure that continuity of care, and an understanding of their condition was provided. We discussed this matter with the manager and it transpired that this resident was not of a violent disposition, and infact more detail relating to their needs both physically and mentally was documented, however this demonstrated that some care plans were both difficult to locate in the files and difficult to follow. The manager agreed to address this matter immediately. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience good quality outcomes in this area. Residents in this home are involved in meaningful daily activities and have the opportunity to join in local community events. People are encouraged to make personal choices about their lives. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: There is a large dining room, where most of the residents choose to attend for their meals. Tables are set prior to mealtimes with condiments, and some place settings have individuals’ names and photographs in place to assist people to find their seats. Some residents do prefer to take their meals in their bedrooms, however in general the mealtimes are very much treated as social occasions. The menus are nutritious and varied, giving choice and variety to the residents. On the day of the inspection there was a choice of chicken pie with Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 15 vegetables, ham salad, jacket potatoes or vegetarian sausage. All choices were well presented, including those in pureed form, and all smelt and looked appetising. Staff were observed to be assisting residents in a sensitive and unhurried manner throughout the mealtime, and aids such as plate guards were in use where appropriate. Some residents knew what meal to expect as they had been offered a choice earlier that day, however we did note that not all staff were offering choices to some of the more confused residents. One resident became particularly agitated, stood up and started waving her arms about, when she was the only person on her table without a meal for quite some time and she clearly thought she had been forgotten. Residents were very complimentary about the food. One person said. “I’m perfectly satisfied with the food”. And another said. “The meals are lovely here, I shall miss them as I ‘m going home this afternoon”. Hot drinks and beverages are served periodically throughout the day, and the home is presently involved in a ‘Health on Tap’ initiative, that is being led by the Anglia Water Authority. This is a promotion for ‘Hydrating with Water’, and there are presently two water coolers freely available to residents, staff and visitors. Visitors are welcomed into this home at all times of the day, and the manager informed us that they are invited to join their loved ones for a meal, for a small contribution of £2.00 per meal. This home has an activity organiser, who works Monday to Friday, and she is assisted by a Scheme Manager in the afternoons. There is a full programme of activities available for the residents in this home, which ranges from whist drives and dominoes, to exercise groups and outings. The corridor in the entrance of the home, presently displays photographs of a recent trip to ‘Althorpe House’. The home has recently purchased a Wii games consol, which the manager advised us has provided some great fun, particularly through the recent ‘tennis season’, when both staff and residents have been able to show off their own skills. If residents do not wish to join in with group activities, there are jigsaw puzzles, a library facility and reminiscence cabinets in the smaller lounge areas. Residents can also enjoy a more personal pampering at the home’s hairdressing salon where residents can make appointments for manicures and waxing as well as having their hair done. All the residents that we spoke to were aware of the facilities in the home, and although some preferred not to join in, they were positive about the choices available to them. Residents told us that in general they could retire to bed when they wished, however one person insisted. “It is frowned upon if you have a lie in, in the morning”. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People who use this service experience good quality outcomes in this area. The complaints procedure is supplied to everyone living in the home. Staff working at the home understand the procedures for safeguarding, and know when incidents need to be reported externally. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: This home has a clear complaints policy, which is summarised in the Statement of Purpose and the Service User Guide document. It gives clear timescales of expected responses, and it details contact information for other authorities such as the Commission for Social Care Inspection (CSCI), so that complainants know what to do if they are not satisfied with the way a complaint is managed by the home. We looked at the complaints file. There had been two complaints received by the home this year. Both were well documented. One related to the attitude of a member of staff and the other was related to an individual’s contractual Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 17 agreement. Both had been responded to appropriately and within the given time frame. Safeguarding issues were also clearly recorded, and reported appropriately. There had not been any referrals made in 2008, however documentation indicates that the manager liaises with the safeguarding team as and when necessary. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20. 21, 22, 23, 24, 25, 26 People who use this service experience excellent quality outcomes in this area. This home provides a clean, comfortable and homely environment for the people who live here. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: A full tour of the premises took place during this inspection. There are very high standards of cleanliness throughout, and the premises are well maintained for the safety of both the residents and the staff. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 19 The home is surrounded by large garden areas, which are very well maintained and have been recently furnished with garden furniture funded by a local authority grant. These make for a very pleasant and relaxing environment. The rooms in this home all provide an en suit facility, and residents are encouraged to furnish and personalise the rooms when they move in. If for any reason this is not possible then basic furniture is provided. All the rooms we visited were clean, comfortable and homely. One resident that we visited was very keen to show off her family photographs, particularly those of her new great grandson. There is a large dining room, where most of the residents choose to attend for their meals. Tables are set prior to mealtimes with condiments, and some place settings have individuals’ names and photographs in place to assist people to find their seats. Some residents do prefer to take their meals in their bedrooms, however in general the mealtimes are very much a social occasion. There are numerous lounge areas throughout the home, with large television screens and audio equipment, and in addition there are smaller, more personal seating areas/ rooms, furnished with armchairs and drinks machines, where residents can meet with friends and relatives more privately if they so wish. Residents also have the option of an incoming telephone line in their bedrooms. All areas of the home were clean and well decorated. There is a hairdressing salon with a ‘resident hairdresser’ in this home, who works several days each week. There is a large activity room, where we saw an exercise class with ball exercises in progress on the day of this inspection. There are four main bathrooms in this home which have each been decorated with wall murals each in a different theme, for example one was an underwater scene, one the beach, one Egypt and the fourth was the jungle. There are additional bathrooms in the ‘respite suite’ and the ‘breathing bed suite’. Throughout the building the corridors displayed photographs of past activities, and information about forthcoming events, mealtimes and other available services such as ‘fruit delivered to your door’. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience adequate quality outcomes in this area. This service recognizes the importance of staff training, and there are sufficient competent and experienced staff to meet the needs of the people who live here. However some staff had recently commenced work in the home prior to the completion of current police checks, so that residents maybe at risk. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: This home is well staffed with 12 care staff rostered on duty for the a/m shift, 8 staff for the p/m shift and 4 for the night shift. There are in all, 6 care managers employed in this home ensuring that every shift has the appropriate skills available. The care staff are supported by an activity organiser, a hairdresser, 5 housekeepers, 3 kitchen staff, 1 laundry worker and numerous administrators. 75 of the care staff are trained at NVQ level 2 and 5 of the senior staff have achieved their level 3 certificates. There is an ongoing training programme in place, which addresses mandatory training for all staff, and training in more specialist subjects such as Dementia and Parkinsons Disease are also available and encouraged. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 21 2 staff are presently doing a course on the End of Life Gold Standard Framework, and the home is planning to introduce a ‘bereavement file’ for relatives in the near future. We look forwards to hearing feedback on the support this provides. The staff in this home are well catered for with a large staff room and training area on the first floor. The home manager and her team managers lead a ‘bite size training programme’ within the home. This consists of brief sessions of about 20 minutes, on basic care topics such as, the correct use of scales, slings and hoists, risk assessments, continence issues, hydration and personal choices. All staff are expected to attend these sessions. We viewed the personal files of three members of staff all who had been recently recruited. All had fully completed application forms including evidence of work history, and proof of identification in the form of passports, birth certificates and other documents. However we found that the staff were being permitted to start work on Criminal Record Bureau (CRB) certificates that had been issued at their previous job. The manager told us that this was advice that she had previously been given by CSCI personnel. We explained that this was not the case and that these documents were not transferable from one place of work to another. The manager immediately made contact with the staff concerned, to inform them that they were not able to work until the present checks were completed. We acknowledge her quick response to this matter. We looked at a further three sets of staff records. These all contained the appropriate documentation, with the exception of one, where the CRB could not be located. The manager explained that due to the recent departure of the member of staff who managed the recruitment checks, there might be some gaps identified, and she would address them immediately. Evidence within the staff files, and from talking to staff, indicated that they all receive regular supervision from a line manager. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38 People who use this service experience good quality outcomes in this area. The manager demonstrates a clear understanding of the key principles and focus of this service. She is enthusiastic and is striving to make continuous improvements to promote the health, safety and welfare of the residents who live in this home. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The manager of this home has been working here for almost twenty-one years. She is very committed to this home and clearly has a passion for her job. From this inspection it was very evident that she is very focused on an individual Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 23 approach to care and individual’s choices and preferences are a priority in care delivery. She is supported by an administration team that results in documentation being very organised and generally well presented. Resident and staff are all kept well informed about changes, and progress in the home through, meetings, newsletters and a manager who is visible and freely accessible to them. Supervision records were examined, and indicated that staff are receiving regular 1:1 sessions with their line manager. Health and safety records showed that fire alarm call point tests are done weekly, emergency lighting is checked monthly, water temperature checks are done in every area every month, fridge temperatures daily. There were records of three ‘fire drills’ in the last eight months, and copies of two fire reports dated within the last year. Moving and handling and fire equipment was labelled to identify that it had been tested within the last eight months. Accidents and incidents are being recorded and reported appropriately, and this process is audited internally every three months. The manager of this home does not deal with any resident’s personal financial issues within the home. This is dealt with by the Charity’s Head Office. Quality assurance is addressed annually in this home, and a report is generated that is available to residents, relatives, staff or any other interested parties. This provides an annual review summary, that looks at the years accounts, highlights of activities, staffing updates, comments from people using the service, and attempts to answer frequently asked questions about the Charity. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 24 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 4 4 4 4 4 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 25 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. 1. 2. Standard OP7 OP29 Regulation 15(1) 19(1)(b) Requirement People who live in this home must have a plan that details how their needs should be met. People who live in this home must be cared for by staff that have been appropriately recruited as outlined in this regulation. Timescale for action 30/09/08 31/08/08 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 OP14 Good Practice Recommendations The home should consider different ways of offering choices to people with cognitive impairment, such as menu pictures. Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Bedford Charter House DS0000014999.V370432.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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