Care Home: Bluebells

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What the care home does well There was an excellent process for assessing people interested in moving into the home. The assessments formed the basis of people`s initial care plans, which were finalised after the first week of residence. A person recently admitted had been able to visit the home, by way of Ms Turner arranging to collect them from hospital. Another person had not visited, but their close family members had done so. In each case, the people concerned, and their family members, said they felt very involved in the assessment process. They were satisfied that they had made definite decisions to accept places at the home. Relatives considered the information provided in advance was good. All rooms in the home had a wall-mounted holder containing the service user guide, so it was readily available for reference by people and their visitors. Records, and talking to people, showed that staff were very responsive to health indicators. Doctors and paramedic services were accessed as appropriate. One person`s relatives said they had seen a transformation, most noticeably in nutrition and social engagement, as a result of their relative living at Bluebells. Residents that were spoken with confirmed they got up and went to bed when they liked and felt free to do as they pleased. People were seen to use different parts of the home at different times of day. It was a notable feature of the home, possibly a reflection of its relatively small size, that there was a high level of conversation between people living there, and between staff and residents. One relative commented in a survey form that this was something staff did particularly well. There was also plentiful use of music in the home, with residents being encouraged to make choices. Written guidelines to staff showed that activity provision was an expectation of every shift, together with suggestions for staff to follow. Handover sheets showed what activities had been organised and who had participated. They comprised mainly ball and board games. Bingo was also evidently popular. Residents confirmed they were involved in making suggestions about the menu, informally and at residents` meetings. There were always two choices at lunchtime. The meal shared by the inspector included fresh vegetables and locally bought meat. Meals were served attractively on good quality crockery. On the day of inspection, a resident was lingering over breakfast in the dining room at 10:00 a.m. by choice. The home had appointed a new chef. He was clearly accustomed to spending time talking with residents, and said he did so especially at breakfast times. He was aware of people`s special dietary needs. Rooms were very personalised, including that of a person who had moved in just a few days previously. They and their relative were very satisfied with the private and shared accommodation. At both this inspection, and the random inspection in January 2008, standards of cleanliness were high in all parts of the home, with no unpleasant odours. Two residents` relatives seen at the random inspection commented on obvious environmental improvements, including better standards of cleaning. Care staff were receiving monthly supervision from the deputy manager. She completed observational assessments of people`s practice by working shifts alongside them, and giving feedback through planned supervision sessions. Records of supervision showed it was a consistent process that showed staff Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 7exactly what standards were expected of them, and highlighted any issues that needed to be developed further. What has improved since the last inspection? Ms Ali Turner has been acting as manager since November 2007. She has been instrumental in securing improvements in how people`s care is planned and monitored. She has added a deputy manager to the staff complement. The person appointed, as deputy is well qualified and brings particular skills in staff supervision. Meanwhile Mr Farhan Ebrahimjee has implemented environmental enhancements, and improvements to procedures for staff recruitment and for managing complaints and safeguarding referrals. Mr Ebrahimjee provided an improvement plan to the Commission as required from the previous key inspection. There was previously a requirement that the home`s quality review must take into account the views of service users` representatives and staff working at the home. There had been two meetings for relatives of people living at Bluebells, with some resident participation, with ongoing meetings planned. They have produced a number of ideas and a shared commitment to communication. The home had also produced a quality assurance questionnaire, which had just been circulated to relatives and to a range of professionals, including GPs, who work with the home. At the previous key inspection a number of requirements were made regarding the planning and delivery of care to residents. Evidence from the random inspection visit on 23rd January 2008 showed the matters of concern had been addressed. Improvements had been sustained and built on at this inspection. All care plans were now in a new format. This provided a "person-centred" assessment of a person`s needs. Monthly reviews highlighted changes, and the current priorities for care provision. In line with a requirement made at the random inspection, all care plans were signed by the people they related to, or a representative, to demonstrate consultation and agreement. A white board, that staff previously used to write up planned tasks with individuals, had been discarded in response to a requirement from the previous key inspection, as it made personal information public. There were now good arrangements for staff to keep essential documentation at hand but confidential. Requirements concerning medicines practice had been met at the random inspection in January 2008. There were protocols for the use of any medicine prescribed for administration `as needed`. As recommended at the random inspection, this guidance appeared in both the care plan and the medicines administration folder. The previous key inspection found that provision for diabetics was poor. At the random inspection in January 2008 it was confirmed that care plans had been put in place to guide and monitor care for people with diabetes, and the kitchen contained stocks of specialist foods such as diabetic jams and sweeteners. The chef said at this inspection that most sweets and cakes were now made with ingredients suitable to the needs of diabetics, so the individuals concerned did not have to feel marked out by being offered food different from other residents. The home had benefited from considerable investment in recent months to modernise and freshen the environment. Many bedrooms had been repainted and fitted with new wash hand basins. The sitting rooms had been redecorated to a colour scheme chosen by the relatives` meeting. The dining room had been redecorated to match new furniture. Doors off hallways were painted white to maximise light. The home has been using a consultant to help address shortfalls identified through previous inspections. To help meet a previous requirement, the consultant had delivered training to all staff about recognising and responding to suspected abuse. For staff who had joined subsequently, abuse awareness was part of induction. There was a "whistle blowing" policy, to give staff a safe route by which to raise any concern about practice in the home. At the random inspection in January 2008 the home was dependent on agency staff to maintain sufficiency of staff. Since then recruitment of staff had continued, such that agency cover was now mostly confined to night staffing. At the random inspection Mr Ebrahimjee showed a new recruitment policy and procedure. This set out the processes for application, interviewing, vetting and induction. At this inspection it was seen that this procedure had been applied to new applicants. A question in the survey for relatives asked, "Do the care staff have the right skills and experience to look after people properly?" One person wrote, "Greatly improved within the last few months." Two others wrote, in answer to "What do you feel the care home does well": "The home now gives a far higher standard of care, and residents are made to feel it is their home", and, "look after X consistently well". Following a requirement for night evacuation plans in the event of a fire, there was an evacuation plan for each resident. Farhan Ebrahimjee had taken advice from the fire authority about fire risk assessments for the home and for individual resid What the care home could do better: Given a previous history of unstable management of the home and resultant complaints and poor inspection outcomes, the Commission is concerned to see consolidation of the position now reached, by having a registered manager in place. During this inspection, it was agreed that Ms Turner would apply for registration as manager, and it is a requirement that a registration application be made swiftly.One improvement that could be made to assessments would be to show where the assessment took place and what other sources of information were obtained. Weight records were kept for all, but were not easy to track, as there was inconsistent use of metric and imperial measures. Some surveys indicated relatives and residents would like to see more opportunities for people to get outside, both in the gardens and further afield. It is a recommendation to consider ways of planning for people to spend time outside the home, in accordance with individual wishes. Generally, social and activities care plans needed to reflect more fully the interests and occupational abilities that were identified in people`s assessments. This could be expected to reduce the risk of creating dependency. It was noted that bedroom doors were not fitted with locks. People should have the option of locking their private space, subject to risk assessment. CARE HOMES FOR OLDER PEOPLE Bluebells 152 Moredon Road Swindon Wiltshire SN25 3EP Lead Inspector Roy Gregory Unannounced Inspection 09:40 29th April 2008 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 Bluebells DS0000003169.V360680.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. Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bluebells Address 152 Moredon Road Swindon Wiltshire SN25 3EP 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) 01793 611014 0870 8318894 farhan@ebrahimjee.com Mr Abitalib Ebrahimjee Position Vacant Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st August 2007 (key inspection) 23rd January 2008 (random inspection) Brief Description of the Service: Bluebells is an extended bungalow in the Moredon area of Swindon offering accommodation and care to 16 older people. It offers a mixture of double and single rooms. None of these have en-suite facilities, but personal wash hand basins are provided in the rooms and toilets are situated nearby. At the centre of the home is an open plan area incorporating two lounges and a dining room. Décor and furnishings are homely and contemporary. There is wheelchair access to the garden, where there is seating. The home is close to local shops and services. It is on a bus route, and there is on-site parking. The home offers both long-term care and respite care. Weekly fees are from £400 to £450. Bluebells DS0000003169.V360680.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. The unannounced visit for this inspection was made on Tuesday 29th April 2008 from 9:40 a.m. to 6:40 p.m. The manager, Ms Ali Turner, was available throughout the day. The inspector also spoke with carers, the deputy manager, and chef. Mr Farhan Ebrahimjee attended the home during the afternoon for the provider and joined the inspector and Ms Turner for feedback on the inspection. During the inspection there was direct contact with all residents, in the sitting rooms and individual rooms, and by joining two residents for lunch in the dining room. Medications practice and storage were examined. The entire home was toured. Prior to the inspection, survey questionnaires were sent to relatives of people that live in the home, of which three were returned. Questionnaires had also been filled out on behalf of two residents. The inspector looked at the minutes of two meetings for relatives arranged by the home, which had been very well attended. Other documentation looked at included records in respect of care planning and delivery, training, recruitment and supervision of staff, activity provision, and safe keeping of residents’ monies. A number of instances of care giving were observed. The assessment records of two people that had been admitted to the home since the previous inspection visit were looked at in detail, and relatives of each of them kindly agreed to be interviewed at the home. The judgements contained in this report have been made from evidence gathered during the inspection, which included the visit to the home. They take into account the views and experiences of people who live there. They also take into account a random inspection visit that was made to Bluebells on Wednesday 23rd January 2008. That visit was made to examine the home’s compliance with requirements made at the previous key inspection on 21st August 2007. The random inspection, of a day’s duration, was conducted in a similar way to this inspection and included speaking with people’s relatives that were visiting the home during the day. What the service does well: There was an excellent process for assessing people interested in moving into the home. The assessments formed the basis of people’s initial care plans, which were finalised after the first week of residence. A person recently admitted had been able to visit the home, by way of Ms Turner arranging to collect them from hospital. Another person had not visited, but their close Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 6 family members had done so. In each case, the people concerned, and their family members, said they felt very involved in the assessment process. They were satisfied that they had made definite decisions to accept places at the home. Relatives considered the information provided in advance was good. All rooms in the home had a wall-mounted holder containing the service user guide, so it was readily available for reference by people and their visitors. Records, and talking to people, showed that staff were very responsive to health indicators. Doctors and paramedic services were accessed as appropriate. One person’s relatives said they had seen a transformation, most noticeably in nutrition and social engagement, as a result of their relative living at Bluebells. Residents that were spoken with confirmed they got up and went to bed when they liked and felt free to do as they pleased. People were seen to use different parts of the home at different times of day. It was a notable feature of the home, possibly a reflection of its relatively small size, that there was a high level of conversation between people living there, and between staff and residents. One relative commented in a survey form that this was something staff did particularly well. There was also plentiful use of music in the home, with residents being encouraged to make choices. Written guidelines to staff showed that activity provision was an expectation of every shift, together with suggestions for staff to follow. Handover sheets showed what activities had been organised and who had participated. They comprised mainly ball and board games. Bingo was also evidently popular. Residents confirmed they were involved in making suggestions about the menu, informally and at residents’ meetings. There were always two choices at lunchtime. The meal shared by the inspector included fresh vegetables and locally bought meat. Meals were served attractively on good quality crockery. On the day of inspection, a resident was lingering over breakfast in the dining room at 10:00 a.m. by choice. The home had appointed a new chef. He was clearly accustomed to spending time talking with residents, and said he did so especially at breakfast times. He was aware of people’s special dietary needs. Rooms were very personalised, including that of a person who had moved in just a few days previously. They and their relative were very satisfied with the private and shared accommodation. At both this inspection, and the random inspection in January 2008, standards of cleanliness were high in all parts of the home, with no unpleasant odours. Two residents’ relatives seen at the random inspection commented on obvious environmental improvements, including better standards of cleaning. Care staff were receiving monthly supervision from the deputy manager. She completed observational assessments of people’s practice by working shifts alongside them, and giving feedback through planned supervision sessions. Records of supervision showed it was a consistent process that showed staff Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 7 exactly what standards were expected of them, and highlighted any issues that needed to be developed further. What has improved since the last inspection? Ms Ali Turner has been acting as manager since November 2007. She has been instrumental in securing improvements in how people’s care is planned and monitored. She has added a deputy manager to the staff complement. The person appointed, as deputy is well qualified and brings particular skills in staff supervision. Meanwhile Mr Farhan Ebrahimjee has implemented environmental enhancements, and improvements to procedures for staff recruitment and for managing complaints and safeguarding referrals. Mr Ebrahimjee provided an improvement plan to the Commission as required from the previous key inspection. There was previously a requirement that the home’s quality review must take into account the views of service users’ representatives and staff working at the home. There had been two meetings for relatives of people living at Bluebells, with some resident participation, with ongoing meetings planned. They have produced a number of ideas and a shared commitment to communication. The home had also produced a quality assurance questionnaire, which had just been circulated to relatives and to a range of professionals, including GPs, who work with the home. At the previous key inspection a number of requirements were made regarding the planning and delivery of care to residents. Evidence from the random inspection visit on 23rd January 2008 showed the matters of concern had been addressed. Improvements had been sustained and built on at this inspection. All care plans were now in a new format. This provided a “person-centred” assessment of a person’s needs. Monthly reviews highlighted changes, and the current priorities for care provision. In line with a requirement made at the random inspection, all care plans were signed by the people they related to, or a representative, to demonstrate consultation and agreement. A white board, that staff previously used to write up planned tasks with individuals, had been discarded in response to a requirement from the previous key inspection, as it made personal information public. There were now good arrangements for staff to keep essential documentation at hand but confidential. Requirements concerning medicines practice had been met at the random inspection in January 2008. There were protocols for the use of any medicine prescribed for administration ‘as needed’. As recommended at the random inspection, this guidance appeared in both the care plan and the medicines administration folder. The previous key inspection found that provision for diabetics was poor. At the random inspection in January 2008 it was confirmed that care plans had been put in place to guide and monitor care for people with diabetes, and the Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 8 kitchen contained stocks of specialist foods such as diabetic jams and sweeteners. The chef said at this inspection that most sweets and cakes were now made with ingredients suitable to the needs of diabetics, so the individuals concerned did not have to feel marked out by being offered food different from other residents. The home had benefited from considerable investment in recent months to modernise and freshen the environment. Many bedrooms had been repainted and fitted with new wash hand basins. The sitting rooms had been redecorated to a colour scheme chosen by the relatives’ meeting. The dining room had been redecorated to match new furniture. Doors off hallways were painted white to maximise light. The home has been using a consultant to help address shortfalls identified through previous inspections. To help meet a previous requirement, the consultant had delivered training to all staff about recognising and responding to suspected abuse. For staff who had joined subsequently, abuse awareness was part of induction. There was a “whistle blowing” policy, to give staff a safe route by which to raise any concern about practice in the home. At the random inspection in January 2008 the home was dependent on agency staff to maintain sufficiency of staff. Since then recruitment of staff had continued, such that agency cover was now mostly confined to night staffing. At the random inspection Mr Ebrahimjee showed a new recruitment policy and procedure. This set out the processes for application, interviewing, vetting and induction. At this inspection it was seen that this procedure had been applied to new applicants. A question in the survey for relatives asked, “Do the care staff have the right skills and experience to look after people properly?” One person wrote, “Greatly improved within the last few months.” Two others wrote, in answer to “What do you feel the care home does well”: “The home now gives a far higher standard of care, and residents are made to feel it is their home”, and, “look after X consistently well”. Following a requirement for night evacuation plans in the event of a fire, there was an evacuation plan for each resident. Farhan Ebrahimjee had taken advice from the fire authority about fire risk assessments for the home and for individual residents. What they could do better: Given a previous history of unstable management of the home and resultant complaints and poor inspection outcomes, the Commission is concerned to see consolidation of the position now reached, by having a registered manager in place. During this inspection, it was agreed that Ms Turner would apply for registration as manager, and it is a requirement that a registration application be made swiftly. Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 9 One improvement that could be made to assessments would be to show where the assessment took place and what other sources of information were obtained. Weight records were kept for all, but were not easy to track, as there was inconsistent use of metric and imperial measures. Some surveys indicated relatives and residents would like to see more opportunities for people to get outside, both in the gardens and further afield. It is a recommendation to consider ways of planning for people to spend time outside the home, in accordance with individual wishes. Generally, social and activities care plans needed to reflect more fully the interests and occupational abilities that were identified in people’s assessments. This could be expected to reduce the risk of creating dependency. It was noted that bedroom doors were not fitted with locks. People should have the option of locking their private space, subject to risk assessment. 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. Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 10 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 Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 11 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. (Key standard 6 is not applicable to Bluebells). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person’s needs are assessed in detail to ensure that their needs can be met. People and their close relatives are given good information, and are invited to visit the home to help decide whether it suits their needs and wishes. EVIDENCE: There was a recently produced new pictorial brochure giving basic details about the home. There had been two people admitted permanently to the home since January 2008, each from hospital stays. There were written assessments carried out by the hospital social workers and by Ms Turner. Each section of the home’s assessment form particularly considered risks and how they would be managed. The assessment considered among other things, the person’s communication needs, everyday occupational preferences and how the person would need support with finances. The assessment concluded with a recorded decision whether the home could offer a place on the basis of the assessment. It also showed that allocation of a key worker had been discussed Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 12 with the person, and arranged. The assessments formed the basis of people’s initial care plans, which were finalised after the first week of residence. One improvement that could be made to assessments would be to show where the assessment took place and what other sources of information were obtained. One of the recently admitted people had been able to visit the home, by way of Ms Turner arranging to collect them from hospital. The other person had not visited, but their close family members had done so. In each case, the people concerned, and their family members, said they felt very involved in the assessment process. They were satisfied that they had made definite decisions to accept places at the home. Relatives considered the information provided in advance was good. All rooms in the home had a wall-mounted holder containing the service user guide, so it was readily available for reference by people and their visitors. One person’s relative said that whilst it was “early days”, they were confident the home was the right place for their relative, and they felt confident of their inclusion in ongoing planning for meeting the care needs of their relative. Relatives of another person said they had seen a transformation, most noticeably in nutrition and social engagement, as a result of their relative living at Bluebells. Residence agreements showed the charges applicable, what was and was not included in the fees, the notice period, the room allocated to the individual, and the arrangements for receiving and handling complaints. Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 13 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 – 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s personal and health care needs were met by planning and monitoring care. People were treated with respect and their right to privacy was upheld. Residents were protected by the home’s procedures for the safe handling of medicines. EVIDENCE: At the previous key inspection a number of requirements were made regarding the planning and delivery of care to residents. Evidence from the random inspection visit on 23rd January 2008 showed the matters of concern had been addressed. Improvements had been sustained and built on at this inspection. All care plans were now in a new format. This provided a “person-centred” assessment of a person’s areas of need. Monthly reviews highlighted changes, and the current priorities for care provision. For example, for a person where notifications about falls had been made to the Commission, the review showed responses that had been made, including referrals to an occupational therapist. The care plan had been amended, and there was a system in place for staff to Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 14 sign to show they were aware of care plan changes. On handovers between staff shifts, staff were verbally updated on issues concerning all residents, and a handover sheet ensured certain matters were always handed over. In line with a requirement made at the random inspection, all care plans were signed by the people they related to, or a representative, to demonstrate consultation and agreement. For each person with diabetes, there was a specific care plan about management of the condition, which staff had signed to show they had read them. Pressure area care was a standard component of all care plans. Pressure area risk assessments and nutritional risk assessments were in place. For the recently admitted people, these had been done as a priority on admission. One of them had been receiving nutritional supplement drinks in hospital, but these had not been included in the discharge prescription. Attempts were being made to reinstate these. For another person, a prescription for nutritional supplements had been reinstated after the home was able to demonstrate from monitoring records that the person had lost weight despite eating a healthy diet. Where appropriate, records were kept of people’s fluid and food intake, and continence management. Weight records were kept for all, but were not easy to track, as there was inconsistent use of metric and imperial measures. Records, and talking to people, showed that staff were very responsive to indicators of possible deterioration in wellbeing. Doctors and paramedic services were accessed as appropriate. There were detailed records of doctors’ visits and appointments with various specialists, such as audiologist and physio therapist. Staff kept daily diaries that demonstrated care being given in line with people’s care plans. The plans emphasised individual choice and preferences and handover records underlined this. For example, for one person it was recorded they had breakfast in their room by choice, and would say when they wanted to go to bed. Residents that were spoken with confirmed they got up and went to bed when they liked and felt free to do as they pleased. People were seen to use different parts of the home at different times of day. A white board, that staff previously used to write up planned tasks with individuals, had been discarded in response to a requirement from the previous key inspection, as it made personal information public. There were now good arrangements for staff to keep essential documentation at hand but confidential. Ms Turner is accredited to train staff in medications practice. She delivered training to the staff group in January 2008 and staff files showed those who had demonstrated competency. There was also a competency form for use with all staff supplied by agency. The supplying pharmacist had visited the home in January 2008. Requirements concerning medicines practice had been met at the random inspection in January 2008. There was a sheet for each person in the Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 15 medicines administration record (MAR) folder that had their photograph, a list of their current medicines, guidance to staff on any preferred way of supporting the individual with taking medicines, and the person’s GP details. There were protocols for the use of any medicine prescribed for administration ‘as needed’. As recommended at the random inspection, this guidance appeared in both the care plan and the MAR folder. For example, there was guidance in both that a person should be offered a pain relief medicine. They were offered it, and declined it, at the meal table. The MAR record showed the appropriate coding. The MAR charts were well kept and there were good systems for checking receipt and return of medicines. Storage arrangements were satisfactory. Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 16 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 – 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home identified people’s social, religious and recreational needs, and arranged some activities as an integral part of the care offered. People were encouraged to make choices and were able to keep in contact with family and friends. People had a choice of meals, served in a pleasant environment. EVIDENCE: Written guidelines to staff showed that activity provision was an expectation of every shift, together with suggestions for staff to follow. Handover sheets showed what activities had been organised and who had participated. They comprised mainly ball and board games. Bingo was also evidently popular. There had been a residents’ meeting the previous week, mainly to discuss how to continue to provide small prizes for bingo. Daily records showed that where people declined to join an organised activity, they could expect some individual attention. It was a notable feature of the home, possibly a reflection of its relatively small size, that there was a high level of conversation between people living there, and between staff and residents. One relative commented in a survey form that this was something staff did particularly well. There was Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 17 also plentiful use of music in the home, with residents being encouraged to make choices. Some surveys indicated relatives and residents would like to see more opportunities for people to get outside, both in the gardens and further afield. Ms Turner said taxi tokens had been obtained for all residents as one way of facilitating more community access. It was anticipated one person would use these to meet their wish to attend church. A wheelchair was awaited for one person, to increase options for taking them outside. Ms Turner said one-to-one support to people to go outside or to the nearby shops could be accommodated on most shifts, although at weekends it would be difficult. It may be that planned excursions would be more certain to occur than spontaneous ones, with key workers taking a lead to ensure the wishes of individuals are known and acted upon. Care plans had a section for ‘social and cultural needs’. However, in an example seen, this section did not reflect the person’s specific interests that had been identified elsewhere, neither did it refer back to the ‘every day tasks’ section of the person’s initial assessment. There was therefore scope for improvement in ensuring people keep up their interests and occupational abilities, which could be expected to reduce the risk of creating dependency. Visitors that were seen, both at this inspection and the random inspection in January 2008, considered they were well received at any time, and were kept informed about things affecting their relatives. One resident was having a telephone installed in their bedroom at the suggestion of their relative. Mr Ebrahimjee said it was planned to install facilities for a line into each bedroom. There were two sitting rooms, each easily accessed. One of them had a television. One person liked to listen to the radio in the other sitting room, and to join people elsewhere as he chose. People made various choices about spending time in bedrooms. Some people chose to have televisions in their own rooms. One sitting room had budgerigars in a cage. The home had appointed a new chef. He was clearly accustomed to spending time talking with residents, and said he did so especially at breakfast times. He was aware of people’s special dietary needs. Generally he made all sweets and cakes with sweeteners and other ingredients suitable to the needs of diabetics, whilst the kitchen had stocks of diabetic jams and other specialist foods. The main meal of the day was served at lunchtime. There were always two choices, although on the day of inspection, the choice was between two fairly similar meals. The chef said further alternatives, such as omelettes, could always be provided at short notice. Residents confirmed they were involved in making suggestions about the menu, informally and at residents’ meetings. The meal shared by the inspector included fresh vegetables and locally bought meat. Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 18 Service in the dining room was relaxed but efficient. Meals were served attractively on good quality crockery. There was new, comfortable dining furniture, with round tables that seated up to four people and chairs designed for stability. People could take as long as they liked to eat. Where assistance or prompting was necessary to support someone to eat, this was provided discretely at table level. On the day of inspection, a resident was lingering over breakfast in the dining room at 10:00 a.m. by choice. The chef prepared teatime meals ready for care staff to serve. He had discussed with the provider improvements that could be made to the kitchen. These included a need for a larger range in order to keep meals hot more easily, as resident numbers were set to grow. Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 19 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. There is provision for receipt of and response to complaints. Staff and management understand and exercise responsibilities in respect of keeping residents safe. EVIDENCE: The home had a complaints procedure, which was displayed at the entrance to the home. The procedure was also incorporated into the service user guide, a copy of which was placed prominently in every bedroom; and in the residence agreement drawn up for each person at the commencement of placement. In addition, minutes showed that the complaints procedure had been discussed and fully explained at a recent relatives’ meeting. Mr Ebrahimjee had introduced a new system for receiving and tracking the progress of complaints in a consistent fashion. None had been received since the previous key inspection. However, Ms Turner acknowledged that “low level” complaints, which were dealt with quickly, should be recorded as such. This would enable periodic monitoring to establish if there were any patterns in the nature or source of complaints addressed in this way. Ms Turner and Mr Ebrahimjee both regarded receipt and resolution of complaints as a way of correcting any shortfalls in the quality of service that people should expect. The home has been using a consultant to help address shortfalls identified through previous inspections. There was evidence that the consultant had delivered training about recognising and responding to suspected abuse, to all Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 20 staff in November 2007. For staff who had joined subsequently, abuse awareness was part of induction. There was a “whistle blowing” policy, to give staff a safe route by which to raise any concern about practice in the home. The brief “No Secrets” guidance to local inter-agency safeguarding procedures was available in the entrance hall as well as in the office. The home has experience of working with these procedures. There was a folder for recording all safeguarding matters, to show how they were received, the process by which they were addressed, and outcomes. This information was not made generally available to junior staff, to preserve confidentiality. However, Ms Turner anticipated drawing on actual experiences in the home when delivering refresher training to staff about protection of vulnerable adults. An alert by Ms Turner and Mr Ebrahimjee in December 2007 has led to the successful prosecution of a person who had been supplied to the home by an agency. The home has ceased using that agency to supply staff. Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 21 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, 22, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was homely, safe and well maintained. There were good standards of hygiene around the home. Residents did not have the facility to lock their rooms. EVIDENCE: The home had benefited from considerable investment in recent months to modernise and freshen the environment. Many bedrooms had been repainted and fitted with new wash hand basins. The sitting rooms had been redecorated to a colour scheme chosen by the relatives’ meeting. The dining room had been redecorated to match new furniture. Doors off hallways were painted white to maximise light. The sluice and a toilet had been reconfigured to improve access and a bathroom was scheduled for upgrading, including installation of a hairdressing sink. Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 22 Rooms were very personalised, including that of a person who had moved in just a few days previously. They and their relative were very satisfied with the private and shared accommodation. One person had been assessed by an occupational therapist as needing additional mobility equipment in their room, including a height adjustable bed that had been delivered. However, use of this was impractical in their current room and their care manager had been asked to act as advocate for the person in considering a change of room. It was noted that bedroom doors were not fitted with locks. People should have the option of locking their private space, subject to risk assessment. At both this inspection, and the random inspection in January 2008, standards of cleanliness were high in all parts of the home, with no unpleasant odours. Two residents’ relatives seen at the random inspection commented on obvious environmental improvements, including better standards of cleaning. The housekeeper was scheduled to undertake National Vocational Qualification (NVQ) in cleaning. There were schedules of domestic duties to be undertaken by night care staff (with resident care always to take priority), and evidence of monitoring by the manager to ensure these were kept up. All laundry was done in-house. At the relatives’ meeting on 22nd April 2008, people had been asked specifically about satisfaction with laundry arrangements. The minutes stated, “There are less errors of incorrect laundry being delivered to service users. All relatives commented that laundry was now ironed and well presented.” The laundry itself was not inspected on this occasion, but all clothing and bed linen seen were in good order. Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 23 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 – 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have support from competent, trained staff who are provided in sufficient numbers. People are protected by sound recruitment practices that ensure nobody works at the home until checks on their background are complete. EVIDENCE: At the random inspection in January 2008 the home was dependent on agency staff to maintain sufficiency of staff. However, agency staff were consistent, and were mostly as familiar with the home and residents as permanent staff. Since then recruitment of staff had continued, such that agency cover was now mostly confined to night staffing. Relatives told the inspector, and also expressed at the recent relatives’ meeting, that there were now more permanent staff. At the random inspection Mr Ebrahimjee showed a new recruitment policy and procedure. This set out the processes for application, interviewing, vetting, induction, probationary period and supervision and appraisal. At this inspection it was seen that this procedure had been applied to new applicants. Recruitment records were checked in respect of two recent appointments. In each case there were an application form, two written references (three in one case), an employment history, proof of medical fitness and clear enhanced Criminal Records Bureau disclosure. There were full records of interviews. The Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 24 same standard of recruitment practice was evident at the earlier random inspection, demonstrating compliance with requirements set at the previous key inspection. Ms Turner showed how the home’s induction for new staff was being linked to recognised core induction standards for care services, which was also subject of a previous requirement. Job descriptions set out an expectation of achievement of National Vocational Qualifications (NVQ) in care for care staff. Over 50 of care staff held at least level 2. A deputy manager who was appointed in January 2008 already held NVQ level 4 and other staff had been appointed with NVQs obtained elsewhere. It was intended that the deputy manager would qualify as a NVQ assessor. The award of NVQ to one member of staff had been challenged, as Ms Turner’s view was that their assessment had been inadequate. At night, staffing consisted of one awake member of staff and one person sleeping-in, who could be called on if necessary. The previous key inspection recommended that there should be two waking members of staff at night. Ms Turner said it was intended to change to that level of staffing once resident numbers increased. There were said to be prospective night staff awaiting the certainty of working hours available before applications for employment were progressed. By day there were two care staff on duty at any time, with Ms Turner supporting care tasks where necessary, and particularly with early routines. When resident numbers increased from the present level of seven, it was planned that care staffing would increase accordingly. All staff spoken with during the inspection considered staffing levels to be sufficient. The quality of observed interactions and of recording by staff suggested this was so, although clearly any one-to-one attention has to be balanced by availability to support the other staff member on duty at any time. Training records showed clearly what training each member of staff had accomplished, and where renewal training was due. It was intended to access dementia training during the current year, having recognised the increasing needs of one resident in particular, through supervision feedback from some staff. Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 25 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, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team provides leadership and direction so people benefit from a well run home, although there has been no registered manager for a significant time. Quality assurance systems include obtaining the views of service users and their supporters to monitor and improve the service. There are systems in place to identify and promote the health and safety needs of residents and staff, and to provide safekeeping of people’s monies where desired. EVIDENCE: The home has been without a registered manager for a considerable time. Ms Ali Turner has been acting as manager since November 2007. She has been instrumental in securing improvements in how people’s care is planned and monitored. She has added a deputy manager to the staff complement. The Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 26 person appointed as deputy is well qualified and brings particular skills in staff supervision. Meanwhile Mr Farhan Ebrahimjee has implemented environmental enhancements, and improvements to procedures for staff recruitment and managing complaints and safeguarding referrals. Mr Ebrahimjee and Ms Turner display a good working relationship, with Mr Ebrahimjee being at the home at least once a week. Mr Ebrahimjee provided an improvement plan to the Commission as required from the previous key inspection. Given a previous history of unstable management of the home and resultant complaints and poor inspection outcomes, the Commission is concerned to see consolidation of the position now reached. During this inspection, it was agreed that Ms Turner would apply for registration as manager, and it is a requirement that a registration application be made swiftly. Another area of improvement has been in arrangements for quality assurance. There was previously a requirement that the registered person must ensure the quality review takes into account the views of service users’ representatives and staff working at the home. As part of an improvement strategy, Mr Ebrahimjee engaged the services of a consultant in social care services. The consultant has focussed on, among other aspects, how the service should engage with people that have a stake in the future of the home. She had begun her work with the home by interviewing several staff, talking with most of the residents, and holding a relatives’ meeting. People from six families (there were seven residents at the time) and two of the people that live at Bluebells had attended the meeting. It produced a number of ideas and a shared commitment to communication. This inspection showed a further relatives’ meeting had taken place on 22nd April 2008, with another planned for July 2008. The home had also produced a quality assurance questionnaire, which had just been circulated to relatives and to a range of professionals, including GPs, who work with the home. Each person’s care plan included information about arrangements made with families or others to safeguard people’s financial rights. Modest personal monies were kept individually in safe keeping if people required this. Support to access personal monies was restricted to management level. There was a safe system for recording monies received from relatives, and paid out, always with double signing, and receipts were numbered. The most common items of expenditure were hairdressing and chiropody. Inventories of personal belongings had recently been compiled for all residents as an additional safeguard of their possessions. Care staff were receiving monthly supervision from the deputy manager. She completed observational assessments of people’s practice by working shifts alongside them, and giving feedback through planned supervision sessions. Records of supervision showed it was a consistent process that showed staff exactly what standards were expected of them, and highlighted any issues that needed to be developed further. For example, where a member of staff had identified a lack of confidence in an aspect of caring for a resident, a decision Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 27 was made about their future training needs. Care staff were also encouraged to extend confidence and competence by taking responsibility as “shift leaders”. There was written guidance on what this entailed according to the time of the shift, and a checklist to ensure areas of responsibility were covered. Following a requirement for night evacuation plans in the event of a fire, there was an evacuation plan for each resident. Farhan Ebrahimjee had taken advice from the fire authority about fire risk assessments for the home and for individual residents. He intended seeking further advice, to include a query about reconfiguring the kitchen. Staff were up to date with training in first aid, fire procedures and manual handling. There were people handling assessments in care plans. Notifications of incidents cross-referred well with the accident book. There was, however, no documentary evidence of manager attention to the accident book; it would be good practice to sign to show each entry had been seen. There was evidence of routine testing of health and safety indicators such as water temperatures, and of management oversight that this was done. Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 28 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 4 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X 2 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 2 X 3 X 3 3 X 3 Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 29 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. Standard OP24 Regulation 12 (4)(a) Timescale for action Service users’ bedrooms must be 31/08/08 fitted with locks that meet National Minimum Standard 24. Application must be made to the Commission to register a manager for the service. 30/06/08 Requirement 2. OP31 8 (1) 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 OP3 Good Practice Recommendations On the form used for assessing prospective service users, show where the assessment took place, and from what sources information has been obtained. Weight records should consistently use the same unit of measure. Ensure that social and occupational needs care plans always take account of individuals’ assessed interests and activity needs. DS0000003169.V360680.R01.S.doc Version 5.2 Page 30 2. 3. OP8 OP12 Bluebells 4. 5. 6. OP13 OP15 OP16 Consider ways of planning for people to spend time outside the home, in accordance with individual wishes. Make sure choices at meal times offer real alternatives. Maintain a log of minor complaints and how they are resolved, and monitor the record periodically in order to identify any patterns in shortfalls thus identified. The home manager should sign accident book entries to show that they have been seen. 7. OP38 Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 31 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 Bluebells DS0000003169.V360680.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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