Care Home: Bernash

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What the care home does well A gentleman with cultural needs said that the skills, attitude and experience of the staff has ensured a feeling of safety and comfort at the home. A relative said that the home has ensured that their relative`s deep religious convictions are respected. One person said through the survey that `We are delighted with the individual care given to each person.` The GP said through comment cards that `Exceptional care from a dedicated team under the guidance of the manager. It is a pleasure to work with this team.` Staff said `every person living at the home is an individual, care must be flexible and pictures used to support people with communication needs to make decisions.` This comment shows a clear person centred approach to meeting needs. What has improved since the last inspection? Repairs and adaptations made ensure that people living at the home have a safe and homely environment. What the care home could do better: There is one requirement arising from this inspection and relates to fire risk assessments. The manager must undertake fire risk basements to consider the potential of a fire in the home and from the assessment an action plan must be developed to reduce the risk of fire at the home. Other areas that require attention from the manager include updating the Statement of Purpose, care planning and supervision. The manager must update the Statement of Purpose to ensure the information is up to date and accessible to the people for whom it`s intended. While care plans are person centred, the care plans would benefit from additional information. For example, further information must be included about relationships, communications and Equalities and Diversity needs. Individual supervision must be provided to discuss staff`s performance, personal development and training needs. CARE HOMES FOR OLDER PEOPLE Bernash 544-546 Wells Road Whitchurch Bristol BS14 9BB Lead Inspector Sandra Jones 7 &8 th th Unannounced Inspection October 2008 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 Bernash DS0000026497.V373019.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. Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bernash Address 544-546 Wells Road Whitchurch Bristol BS14 9BB 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) 01275 833670 01275 545342 bernash@bernash.fsnet.co.uk Bernash Residential Home Limited Mrs Deborah Williams Mrs Beryl Nash Care Home 23 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (17) of places Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2006 Brief Description of the Service: Bernash is a detached property that can provide personal care and accommodation for 23 older people. It is arranged over two floors with a passenger and stair lifts to the first floor for less mobile residents. There are two double bedrooms and thirteen bedrooms are en-suite. Shared space is on the ground floor and consists of a lounge, dining area and conservatory. The property is on a main road, with shops, local amenities and bus routes located nearby. Fees range from 450.00–525.00 pounds per week. Bernash DS0000026497.V373019.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 star. This means the people who use this service experience Good quality outcomes. This key inspection was conducted unannounced over two days in October 2008 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedures. During the site visit, the records were examined and feedback was sought from individuals and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection including the Annual Quality Assurance Assessment (AQAA). This information was used to plan the inspection visit. “Have your say” surveys were sent to the people living at the home and health care professionals. Four surveys were received from people living at the home and two from Health Care professionals in advance of the inspection. At the time of the inspection twenty-two people were accommodated and four were case tracked. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the people living at the home and staff were gathered through face-to-face discussions What the service does well: A gentleman with cultural needs said that the skills, attitude and experience of the staff has ensured a feeling of safety and comfort at the home. A relative said that the home has ensured that their relative’s deep religious convictions are respected. One person said through the survey that ‘We are delighted with the individual care given to each person.’ Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 6 The GP said through comment cards that ‘Exceptional care from a dedicated team under the guidance of the manager. It is a pleasure to work with this team.’ Staff said ‘every person living at the home is an individual, care must be flexible and pictures used to support people with communication needs to make decisions.’ This comment shows a clear person centred approach to meeting needs. What has improved since the last inspection? What they could do better: There is one requirement arising from this inspection and relates to fire risk assessments. The manager must undertake fire risk basements to consider the potential of a fire in the home and from the assessment an action plan must be developed to reduce the risk of fire at the home. Other areas that require attention from the manager include updating the Statement of Purpose, care planning and supervision. The manager must update the Statement of Purpose to ensure the information is up to date and accessible to the people for whom it’s intended. While care plans are person centred, the care plans would benefit from additional information. For example, further information must be included about relationships, communications and Equalities and Diversity needs. Individual supervision must be provided to discuss staff’s performance, personal development and training needs. Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 7 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. Bernash DS0000026497.V373019.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 Bernash DS0000026497.V373019.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) & (3) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. People wishing to live at the home can make informed choices about the staff’s abilities to meet their needs. EVIDENCE: The Statement of Purpose in place says that its main objective is to keep the home informal and homely while providing the care that each person requires. The information included is adequate in that it gives a brief overview of the services provided, the manager must review the document to ensure that information is up to date and accessible. The home’s admission procedure is described in the Statement of Purpose and confirms that admissions are based on an assessment of needs. The home offers accommodation to people with dementia and it is specified that there Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 10 are close links with the In-Reach team to provide the best approach for people with dementia. People wishing to live at the home are encouraged to visit so that they can meet the staff and trial periods are offered to ensure the staff have the skills to meet the individuals needs. The case file of the person that recently moved into the home was examined to determine the process followed. The initial assessment indicates that before an admission to the home, the manager conducts an assessment of need. Within the case file, the Avon and Wiltshire Partnership (AWP) care plans from the social worker was also available illustrating that the home follows the admission procedure. Relatives giving feedback described the admission process. This relative said that the public inspection report was viewed before visiting the home. The welcome received was warm and welcoming and felt that the homely environment would be suitable to their parent. Comments through surveys from four individuals indicate that enough information about the home was received to make decisions about moving into the home. Bernash DS0000026497.V373019.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) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Individual’s health and personal care is based on individual’s needs, which is provided in a respectful and sensitive manner. EVIDENCE: The home’s care planning process includes pre-admission information obtained through initial assessments and social workers care plans. Life history’s are based on background information is sought during the admission process and includes relationships, past education and occupation. Care plans are person centred and include the individuals preferred routines. For example preferred times to rise and personal care to be provided. Care Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 12 plans are reviewed monthly and the progress made described. Personal care needs are part of the care plan and with the daily routine guide; staff are guided to consistently meet the individuals needs. For people with dementia, care plans include the type of dementia and the assistance needed from the staff. Communication is also included and detailed is the actions that staff must take to understand the person. While care plans are person centred, the care plans would benefit from additional information. For example, further information must be included about relationships, communications and Equalities and Diversity needs. Equalities and Diversity needs are an element of the care planning process. The home offers accommodation to people with religious and cultural needs. Monthly non-denominational meetings are arranged at the home for people that wish to have communion, while others make individual arrangements to visit places of worship. One black person is accommodated and their cultural needs form part of their care plan. The senior care assistant on duty said that devising, monitoring and updating care plans is part of the role. Four people responding through surveys said they receive the care and support they need. Health assessments based on eating, drinking, continence and mental health are completed monthly. Staff said that this is used as a quick overview to assess any deterioration of the person’s health care. A separate record of health care and outcome of visits is maintained. When GP’s visits are requested staff will record the reasons for the visit. Documentation kept indicates that individuals have input from health care professionals and include district nurses, Community Psychiatrist nurse and other health care. People at the home access NHS facilities such as the dentist, chiropodist and optician. Details of the input and frequency of the visits are kept in individual’s bedrooms to ensure they are aware of the visit and the cost that may be incurred from the visit. A GP that visits the home said ‘Exceptional care from a team of dedicated staff under guidance from the managers. It is a pleasure to work with this team.’ Four surveys from people at the home state that they receive the medical support they need. Staff said that through communication books and handovers when shift changes occur, the staff consistently follows medical advice. Where people have mobility impairments, the assessed need is included in the care plan. The action plan guide the staff on the equipment needed and the number of staff needed to support the person. Risk assessments are in place for activities that may involve an element of risk, it includes the aim of the assessment and the actions to be taken to reduce the level of risk. Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 13 Medications are administered through a monitored dosage system. The records of administration show that staff sign the records after administrating the medication and use the correct codes for medications not administered. Homely remedies are administered when required from a stock of medications, which are recorded separately and include a running balance. Medication profiles that describe the purpose of the prescribed medication and their side effects are in place. Feedback about the way individuals are respected was sought from people living at the home. People at the home said that the staff were friendly yet respectful and staff said that providing discreet personal care and ensuring that every person is an individual is the way rights are respected. Bernash DS0000026497.V373019.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): (12), (13), (14) & (15) Quality in this outcome area is (Excellent). This judgement has been made using available evidence including a visit to this service. People at the home can pursue their hobbies and interest. EVIDENCE: In-house daily activities are provided by the staff and include board games, bingo, music and pampering sessions, with outside entertainers visiting monthly. Activities formed part of the home’s Quality Assurance system and as a result of the feedback received. For example, people said that they were not able to participate because of sight impairments and because they are female focussed. There are opportunities through the residents meetings for people living at the home to influence the activities provided. A symbolised (pictures and words) agenda is displayed before the monthly meeting to ensure that people for whom it’s intended can understand it. Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 15 Feedback about the arrangements for activities was sought from four individuals at the home. One individual said that during the morning they will stay in their bedroom and in the afternoon they sit in the lounge with other people. Another individual said that while they sit in the lounge with others, it’s their preference not to participate in activities. Comments through surveys from four people state that activities are always arranged. One person said ‘there are chair exercises in the mornings and in the afternoon staff read the newspaper to people living at the home. Staff said that in-house activities are organised each day, Arts & Crafts, games, sing a along and poetry readings are provided. A senior carer said that chair exercises generally take place in the morning to stimulate and engage with people and in the afternoons there is music and film shows to provide a more relaxed approach. The arrangements for visiting is included within the Statement of Purpose and it’s recognised through the procedure that maintaining links with friends and relatives is important. There is open visiting at the home and during the inspection, visitors were observed arriving and leaving the home at differing times. One relative was consulted during the inspection about the arrangements for visiting. It was stated that visitors are welcome, there are no restrictions on visiting and can occur in bedrooms for additional privacy. This person also commented about the steps taken by the home to ensure the deep religious convictions of their relative are respected The manager said that people at the home make their own financial arrangements. One person has a solicitor involved and relatives are involved with the others. A menu book with pictures is used for people to make choices for teatime meals. The picture book is sectioned into main meals and desserts. Information about the individuals likes, dislikes, size of meals and allergies are kept in the kitchen and symbolised menus ensure that people can make choices about their preferred meals. Individuals consulted about the meals served at the home said that the food is good. A relative said that the home caters for spiritual needs and feedback from an individual with cultural needs was also sought. This individual said that the staff skills, attitude and care far outweigh their need for cultural food. Comments from two people at the home through survey state they always like the meals served, one said this was usual and one said it was sometimes. A record of meals provided is maintained and shows that there are meal choices at each mealtime, at teatime it’s the individual’s choice. The range of Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 16 fresh, frozen and tinned foods support that people at the home have a varied diet. At the recent Food Agency visit, the home was awarded five star. Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 17 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) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The home recognises the importance of feedback from people living at the home and takes steps to safeguard people from abuse. EVIDENCE: The Complaints procedure is appended onto the Statement of Purpose and displayed in the home. It confirms that feedback is welcome and action will be taken to resolve complaints received. The complaints procedure displayed in the home and bedrooms are symbolised to ensure that people for whom it’s intended can understand it. The record of complaints received at the home was examined and one anonymous complaint was received at CSCI since the last inspection. The complaint was passed onto the manager for investigation and documentation in place shows that appropriate action was taken. A grievance was also received from a member of staff and steps were taken to resolve the grievance. Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 18 Equal Opportunities & Diversity, Safeguarding Adults and Whistle Blowing procedures support the home’s commitment towards safeguarding people from abuse. The Safeguarding Adults procedure defines the factors of abuse and instructs staff to pass concerns to the manager. This policy requires amendment to include the contact details of outside agencies that must be contacted in the event of an allegation of abuse. In terms of the Whistle Blowing policy it is made clear that staff have a duty to report poor practice and endorses that staff raising concerns will be protected from reprisals. The three individuals giving feedback about the arrangements for protection, named the staff that they would approach with complaints. Relatives consulted said that they would approach the manager or the service provider. Regarding their protection from abuse, the individuals consulted said that they felt safe. Three survey comments from people at the home state that they know how to make complains and one person said they did not know how to complain. Staff consulted said that complaints received would be logged and passed onto the manager or senior carers. A senior carer said that complaints received at the home are taken seriously and where they cannot be resolved immediately, they are logged and passed onto the manager. In terms of safeguarding adults from abuse, staff were clear about the factors of abuse and the actions to be taken. The manager said that there are no outstanding Safeguarding Adults referrals. Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 19 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) & (26) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. People live in a comfortable and homely environment. EVIDENCE: Bernash is a detached property offering accommodation over two floors with a passenger lift and stair lift to ensure the individuals independence with moving around the home. Accommodation is mainly in single occupancy, however, there are two sharing rooms. The home is well furnished and domestic in style, with a comfortable and homely atmosphere. Shared facilities consist of a lounge, dining room and conservatory. There is a large lounge at the front of the premises, with seating for 11 people and in the Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 20 conservatory there is seating for a further 11 people. The dining area has sufficient tables and chairs for the people living at the home to sit together and eat their meals. As thirteen rooms are en-suite the ratio of people sharing communal toilets is 2:8. Toilets and bathrooms are in close proximity to bedrooms and shared space. There is a passenger and stair lift to assist people with mobility impairments to move around the home independently. Grab rails and assisted bathing facilities are installed to maximise the individual’s independence in the home. With the exceptions of two, bedrooms are single. The double bedrooms are en-suite offering privacy with personal care. Bedrooms contain a combination of the home’s furniture and personal belongings and, are furnished and equipped to meet the needs of the individual. Privacy is promoted through lockable doors with additional lockable space in bedrooms. The manager and service provider continue to maintain the property to a good standard. Since the last inspection, the dining room tabled and chairs were replaced and the downstairs toilet was converted into a wet room. The laundry room is sited away from the kitchen. The floor covering and walls are impermeable making surface readily cleanable. The washing machine has a specific programme for sluicing and there is a tumble dryer. Five surveys received from people at the home indicate that the home is always fresh and clean. Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 21 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): (27), (28), (29) & (30) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The needs of the people at the home are met by staff that are competent and qualified. EVIDENCE: The recruitment process at the home was examined to assess the robustness of the procedure in place. The home’s application form requires candidate’s full employment histories, the names of two referees, one of which must be their most recent employer and declare any criminal background. The personnel files of the most recently employed staff was examined and contact details and proof of identification are held. Also kept in the personnel files are completed application forms, two validated written references and Criminal Record Bureau checks obtained. It was noted that risk assessments are not completed for staff that declare convictions through the application form. The rota in place shows that the manager works supernumerary from 9:304:00. A senior and three care assistants are rostered throughout the day, with Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 22 two staff awake at night. Ancillary and catering staff are also employed to prepare meals and keep the home clean. There is training programme in place and staff must attend Manual Handling, Health & Safety, Infection Control and First Aid training, with refresher training two yearly. Staff consulted said that statutory and specific training to meet the needs of the people accommodated is provided. Three individuals were consulted about the skills of the staff and it was stated that the staff know how to meet their needs. Comments through surveys from four people at the home indicate that the staff listen and act on what they say and three said they are always available when needed. Mental Health Awareness training is provided by the In-Reach and is based on dementia and its effects, depression and behaviours that challenge. Medication training is also provided for staff that administer medication. There is an in-house induction programme and the manager is aware that new staff must complete the Common Induction Standards that follow Skills for Care guidelines. The most recently employed staff have vocational qualifications and for this reason an in-house induction programme will be provided. The In-house induction covers familiarisation with the property, the role, Codes of Conduct and supporting people at the home. It is then signed and dated by the manager and member of staff. Vocational qualifications is encouraged at the home and currently four have NVQ level 2 and four are working towards the qualifications Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 23 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), (33), (35) & (37) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The home fulfils its stated purpose and meets the needs of the people at the home. People live in a safe environment and standards are subject to ongoing monitoring EVIDENCE: The manager was consulted about the way the home meets its stated aims and objections. The manager explained that the aim is for staff to achieve Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 24 vocational qualifications and to improve the home’s quality rating. Providing formats that are accessible to the people at the home and to maintain the décor of the home will also fulfil the purpose of the home. It was further reported that the home is operating above minimum staffing levels, which has ensured that people with increased needs can remain at the home for much longer. The management style that ensures the purpose of the home is met formed part of the discussion. It was stated that an open and contactable approach is used and systems that ensure consistency was described. The manager said that consistency is achieved through yearly staff meetings, with shift meetings occurring four monthly and handovers when shift changes occur. Formal supervision is not currently in place and the manager is aware of the benefits in terms of consistency. Individual supervision must be provided to discuss staff’s performance, personal development and training needs. Members of staff were consulted about the manager’s style of leadership. One member of staff said that there is a fair and role modelling management style used at the home. Another member of staff confirmed that a firm but fair style of management is used. It was further stated while there is a structure and decisions made are followed, these structures could be flexible. Regarding consistency of care, it was stated that there is an expectation that staff follow care plans and people living at the home must be treated as individuals. Two people living at the home and relatives giving feedback about the care said that the staff are excellent, the manager and service provider are ‘fussy about the care provided.’ The home operates a Quality Assurance system that entails seeking information about the standards of care from people at the home and their relatives. Action plans are then developed from an analysis of the survey and newsletters are also used to pass information to individuals living at the home. The most recent newsletter was based on events, policy changes and Infection Control. While fire alarm systems checks and practices are conducted at regular intervals, fire risk assessments are not in place. Fire risk assessments that consider the potential of fire to then formulate an action plan, which reduces the level of risk, must be completed. The manager ensures that the home meets other Health & Safety legislation, contractors are used to annually service gas systems, lifting equipment, passenger lift and portable electrical equipment. Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 25 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 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x 2 x Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 26 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 OP38 Regulation 23 (4) Requirement Fire Risks assessments must be completed to ensure that where risk are identified action is taken to minimise the risk Timescale for action 30/12/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Bernash DS0000026497.V373019.R01.S.doc Version 5.2 Page 28 - 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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