Care Home: Bluebirds Nursing Home

What the care home does well Before agreeing admission the home carefully considers the needs assessment for each person and its capacity to meet their diverse needs. The following comments were made by respondents to the Commission`s survey: "The service was very well matched to challenging early onset dementia condition. As a regular visitor I am always impressed by the determination of the care staff to provide a very high standard of care." "The service is well managed and very effective in dealing with early onset dementia cases." The home ensures that people using the service are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. When planning activities in the home and the community people`s views are sought and their Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 interests considered. Respondents to the Commission`s survey said that `the home provides a high standard of nursing care`. The home employs its own multi-disciplinary team, which consist of an occupational therapist, physiotherapist, speech and language therapist, mental health specialist nurse, consultant neuro psychiatrist and neuro-psychologist, which means that people`s health care, is appropriately managed. People live in a home that is clean, safe, comfortable, and fitted with the appropriate aids and adaptation to promote independence. The home ensures that staff are provided with the appropriate training to meet people using the service diverse and complex needs. The management arrangement in the home is open and transparent and there are systems in place to ensure that the home is run in the best interests of people using the service and to promote their safety. What has improved since the last inspection? The AQAA informed that the home has employed a quality standards manager to work with people using the service and their families at the pre-admission stage. This means that people`s choices and decisions are taken seriously. The attendance at relatives and residents` meetings has increased, which means that people are supported by family members who speak up on their behalf. The home`s recruitment processes have improved which means that people are looked after by staff that have been appropriately recruited. New furniture and pictures have been purchased in the communal areas to enhance the environment. The AQAA informed that the home has appointed a mental health specialist nurse to support staff with implementing individual behavioural management programs for people using the service and in house training support and counselling for staff. The home has introduced the employee of the month award scheme which enables people using the service and relatives to reward staff members for their hard work and performance. What the care home could do better: The manager and staff continue to offer a high standard of care to people living in the home and are aware of the areas that need improving. Consideration must be made to have a consistent practice so that any changes to people`s care needs are reflected in the care plan detailing how needs should be met. Two staff members must witness and sign for the disposal of medication in the home. Key inspection report CARE HOME ADULTS 18-65 Bluebirds Nursing Home Faraday Drive Shenley Lodge Milton Keynes Buckinghamshire MK5 7FY Lead Inspector Joan Browne Key Unannounced Inspection 13th July 2009 09:30 Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bluebirds Nursing Home Address Faraday Drive Shenley Lodge Milton Keynes Buckinghamshire MK5 7FY 01908 234092 01908 233901 carmelita@pjcare.co.uk 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) P J Care Ltd Mrs Carmelita Barnes Care Home 22 Category(ies) of Dementia (0) registration, with number of places Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Dementia (DE) The maximum number of service users to be accommodated is 22. Date of last inspection 31st July 2007 Brief Description of the Service: Bluebirds is a nursing home registered in May 2001 and is owned by P J Care Ltd. The home provides 22 beds, for younger and older people with complex physical and mental health needs brought about by cognitive impairment. All twenty-two of the rooms are single accommodation and have en-suite facilities. The garden is designed to meet the needs of people using the service. The home is close to public transport links and has its own transport to facilitate individuals’ social activities. The home is situated in a residential area of Milton Keynes which has all the facilities that a modern city can provide. Managers said that there are no set fees for the service. Fees are negotiated with NHS PCT’s and with local authority social services departments on the basis of the needs of the prospective person. Bluebirds Nursing Home DS0000019180.V376569.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 3 stars. This means that people who use this service experience excellent quality outcomes. This unannounced key inspection was carried out on the 13 July 2009 and covered all of the key National Minimum Standards for younger adults. The inspection lasted for approximately eight hours; commencing at 09:30 am and concluding at 17:30 pm. The last key inspection of the service took place on the 31 July 2007. Prior to the inspection, a detailed self assessment questionnaire known as the annual quality assurance assessment (AQAA) was sent to the manager for completion and surveys were sent to a selection of people living at the home, relatives, staff and visiting professionals. The AQAA was returned by the due date and contained detailed information demonstrating how the home had listened to people using the service and their relatives and recognising the areas that it still needs to improve and how it was planning to do this. Eight people using the service, three relatives, five staff members and two health and social care professionals completed surveys and their replies have helped to form judgements about the service. The registered manager, general manager, six people using the service, four staff and one relative were also involved in the inspection process and their responses and views of the home have been incorporated into the report. Further information was gained by observing staffs practice, examination of care plan documentation, staff’s records, health and safety records and a tour of the premises. Feedback was given to the manager and general manager on the inspection findings. There were no requirements and recommendations made on this visit. We (the Commission) would like to thank all the people who use the service and staff who made the visit so productive and pleasant on the day. What the service does well: Before agreeing admission the home carefully considers the needs assessment for each person and its capacity to meet their diverse needs. The following comments were made by respondents to the Commissions survey: The service was very well matched to challenging early onset dementia condition. As a regular visitor I am always impressed by the determination of the care staff to provide a very high standard of care. “The service is well managed and very effective in dealing with early onset dementia cases. The home ensures that people using the service are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. When planning activities in the home and the community peoples views are sought and their Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 6 interests considered. Respondents to the Commissions survey said that the home provides a high standard of nursing care. The home employs its own multi-disciplinary team, which consist of an occupational therapist, physiotherapist, speech and language therapist, mental health specialist nurse, consultant neuro psychiatrist and neuro-psychologist, which means that peoples health care, is appropriately managed. People live in a home that is clean, safe, comfortable, and fitted with the appropriate aids and adaptation to promote independence. The home ensures that staff are provided with the appropriate training to meet people using the service diverse and complex needs. The management arrangement in the home is open and transparent and there are systems in place to ensure that the home is run in the best interests of people using the service and to promote their safety. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The needs of prospective people to use the service are assessed thoroughly prior to admission to ensure that the home has the capacity to meet their diverse needs. EVIDENCE: We looked at three people’s pre-admission assessment documentation. The information seen verified that individuals needs were assessed prior to them being admitted to the home to ensure that their preferences and diverse needs would be fully met. The AQAA informed that assessments were undertaken by the manager and a qualified member of staff such as, a registered nurse, the occupational therapist or speech and language therapist. Before agreeing admission the home carefully considers the needs assessment for each prospective person to ensure that it has the capacity to meet their needs. Wherever possible prospective people to use the service and their relatives are encouraged to visit the home as often as they wish to prior to admission. The home provides a settling in period which is reviewed after one month with the homes staff, relatives and other professionals to make sure that all identified needs were being met. A family member spoken to during the inspection confirmed that they were involved with their relatives admission and the Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 9 homes staff were very helpful and responded to any questions asked about life in the home. Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that a care plan is in place for people using the service including risk assessments, which means that peoples needs are adequately met and their independence, rights and choices are promoted. EVIDENCE: We looked at three peoples care plan documentation which contained long term care needs and a care plan based on identified needs. Overall the care plans were clear detailing how identified needs should be met and were signed by individuals or their representatives to confirm their involvement. We were told that the home has a system in place to ensure that peoples long term care needs were reviewed six monthly and the identified care plan needs evaluated monthly or as and when individuals needs changed. However, it was noted that a particular person had recently sustained a seizure. There was no care plan in place detailing the action to be taken by staff to meet this Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 11 identified need. Consideration must be made for a plan to be put in place to reflect the new change and to ensure that care provided is adequate. Work to develop health action plans was in progress. People who responded to the Commissions survey including relatives described the care provision as very good. The following comments were noted: Bluebirds provide a high standard of nursing care. The home provides very good care and is responsive to any ideas put forward and also welcomes any suggestions to enhance a residents quality of life whether to improve comfort, engage in specific activity or accommodate dietary preferences. Bluebirds is a lovely home and the care they show towards residents and families is exemplary. None of the people living in the home on the day of the inspection had the capacity to manage their finances. We were told that family members leave a small amount of money to cover incidentals such as toiletries and hairdressing fees. The home has a system in place to ensure that individuals money is not pooled. Written records of all transactions were being maintained and two staff members are involved in any transaction process. Staff spoken to were able to demonstrate how they involve individuals in making decisions. For example, people choose what clothes they wish to wear and what activities they wish to participate in. Any decisions made by others in peoples best interests were recorded in the care plan. To comply with best practice and current legislations such as the mental capacity act and deprivation of liberty safeguarding (DOLS) any decisions made by others in peoples best interests should be kept under regular review. The three care plan documentation that was examined contained risk assessments relating to moving and handling, falls, tissue viability, nutrition and daily living activities. Action plans were in place for any identified potential and actual risks detailing how the risks would be managed and were regularly reviewed. The following comments were noted from a relative respondent to the Commissions survey: A high priority to risk assessments is given by the home to ensure residents safety whilst looking at alternative ways of allowing a resident to enjoy the things they like doing. Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16 & 17 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that people using the service are involved in activities of their own choice and according to their individual interests, diverse needs and capabilities. Meals provided are healthy and served in pleasant and relaxed surroundings. EVIDENCE: The home employs an activity team to support people using the service to maintain their chosen lifestyle and to live an ordinary and meaningful life in the home and the local community. People were being supported to promote their spiritual needs and pursue their own interests. Visitors were able to visit at anytime and are kept up to date with any activities taking place. The home has its own mini bus and company cars to facilitate activities outside of the home. To ensure that the activity provided is personalised and improves the quality of peoples life the team works with individuals to seek their views and Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 13 takes into consideration their varied interests when planning the activity programme. Staff support people to be part of the local community and outings to the local parks and shopping trips are arranged. Garden parties, barbecues, and tea parties are also arranged. Special events such as birthdays, Easter, Christmas and cultural theme days are celebrated. Information in the AQAA indicated that friends and family are invited to attend these special events and links with the local community are promoted. For example, students from the local schools and health and social care sector spend time in the home on work placements. The following comments were noted from a relative respondent to the Commissions survey: The home is good at organising activities with weekly outings in a mini bus as well as trips in the car and walks by the lake. The AQAA reflected that peoples daily routine is planned to suit their diverse needs. Staff spoken to confirmed that consideration is made to ensure that the homes routine is flexible to enable people to make choices in relation to what time they wish to rise and retire be assisted with personal care and how to spend their day. The AQAA informed that the menus are planned on a four week cycle to reflect fresh seasonal produce and in house baking. Staff encourage mealtimes to be a social and relaxing activity, promoting independence. Breakfast was observed on one unit. Staff provided assistance to those individuals who needed help or had difficulty with swallowing or chewing in a sensitive and discrete manner. The activity was relaxed and staff were patient and allowed individuals the time they needed to finish their breakfast. The head chef confirmed that he attends meetings with people using the service and their relatives and responds to any requests made. Work was in progress to introduce picture menu charts to assist people when making choices. We were reassured that if people did not like what was on the menu an alternative would be provided. Respondents to the Commissions survey said that the catering provision in the home was very good and individuals dietary preferences were being accommodated. Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 &20 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service receive effective personal and health care support using a personalised approach based on the rights of dignity, equality fairness autonomy and respect. EVIDENCE: The randomly selected care plans examined clearly recorded peoples personal and health care needs detailing how these needs should be met. Staff spoken to were confident that the care they were providing was flexible and consistent to meet peoples changing needs and were able to demonstrate how individuals dignity and preferences were being respected. For example, personal care is conducted in private and staff encourage individuals to choose what clothes they wish to wear. It was noted that peoples attire was clean and tidy with attention to detail. All the people living in the home was registered with a general practitioner surgery in the area. The general practitioner visits the home weekly or as and Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 15 when necessary. The home is able to access specialist advice and support from the tissue viability nurse, dietician, diabetic nurse and continence adviser. If required people are provided with aids and equipment to maximise their independence. The organisation also employs its own physiotherapist, occupational therapist, mental health specialist nurse and a neuro consultant psychiatrist to ensure that peoples health is monitored and any potential complications and problems are identified and dealt with. The home arranges training on health care topics relating to the health care needs of the people using the service. The following comments were noted from respondents to the Commissions survey: All staff including consultant and general practitioner are available if required to relatives and patients. The home informs relatives of any health issues, incidents, outcome of assessments etc. Medication records were checked and no unexplained gaps were noted on the medication administration record (MAR) sheets. Photographs of individuals were in place to minimise the risk of errors occurring during medication administration. Trained nurses are expected to leave a sample of their signature, which is dated in the medication folder to comply with best practice. No controlled drugs were at the home on the day of the site visit. A handwritten entry on the MAR sheet for a particular person was not countersigned by a second member of staff. Staff must ensure that their practice is consistent and handwritten entries are countersigned by a second staff member to minimise the risk of errors when transcribing. A record is maintained for the receipt and disposal of medication. It was noted that only one staff member signature was recorded for the disposal of medication. To comply with best practice guidelines this practice should be reviewed to ensure that two staff members witness and sign for the disposal of medication in the home. Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a complaints and safeguarding policy in place to ensure that people are able to express their concerns and are protected from abuse and have their rights protected. EVIDENCE: The home has a complaints procedure which was displayed in the home. The procedure outlined the action that staff should take on receiving a complaint and the time it should take for a complaint to be investigated. The home maintains a record of all complaints made and the actions taken in response to them are fully recorded. It learns from complaints in order to improve the service. The AQAA reflected that the home had received two complaints, which were satisfactorily investigated. Respondents to the Commissions survey said that they had confidence in the homes complaints procedure. The following comments were noted from a respondent: We are absolutely clear about who we could speak to at Bluebirds or in PJ Care, the parent company. The home has a safeguarding of vulnerable adult policy which is in line with Milton Keynes multi-agency policy and a whistle blowing policy. Staff undertake yearly updated training in the safeguarding of vulnerable adults. Policies and procedures regarding safeguarding adults are made available to staff to give them guidance about what action should be taken. Those spoken to were aware of the action to take if they suspected or witnessed an incident Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 17 of abuse. The home is fully aware with the local safeguarding procedures and notified the Commission of three safeguarding incidents which were satisfactorily investigated. The home has a system in place to ensure that money handed in by family members to cover incidentals such as, hairdressing and toiletries is managed appropriately. Records are kept of all incoming and outgoing payments. Internal audits of peoples accounts are conducted monthly and two staff members are expected to witness and sign for any transactions. Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enable people using the service to live in a safe well-maintained and comfortable environment, which encourages independence and protects their privacy and dignity. EVIDENCE: The home is a single storey spacious building which is designed to provide a small group living where individuals can enjoy maximum independence in a discrete non-institutional environment. It is divided into two wings of eleven places each. The bathrooms showers and WCs in each wing were fitted with the appropriate aids and adaptations to meet the needs of the people using the service. All bedrooms were single occupancy and have en suite facilities (WC and hand basin.) Individuals rooms were personalised to their choice. The bedroom walls have been fitted with protectors to protect them from damage caused by beds and equipment. The layout of the home and the enclosed Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 19 garden enables people to use the garden freely. Information in the AQAA reflected that monthly joint environmental and clinical audits were carried out to ensure that the home is appropriately maintained and safe for people to live in. There is an ongoing maintenance programme to ensure that the home is well maintained and reflects the individuality of the people living in the home. The following comments were noted from respondents to the Commissions survey: “The home is always spotless and always smells fresh and clean. The environment is pleasant and clean with a nice garden for more mobile residents to walk around. On the day of the inspection the home was clean hygienic and free from offensive odours. Systems were in place to control the spread of infection and the staff team are provided with updated training yearly on infection control to prevent the spread of infection and communicable diseases. Hot water temperatures are monitored regularly and records seen indicated that temperatures were within the appropriate range. The laundry room was clean, tidy and equipped with driers and washing machines of the specified programming ability to meet disinfection standards. The kitchen area was clean, tidy and well organised, Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are trained skilled and available in sufficient numbers to fulfil the aims of the home and meet the changing needs of the people using the service. EVIDENCE: The staff rota demonstrated that the number of staff on duty to provide care and attention to people using the service for any twenty-four hour period was suitable to meet their assessed needs. Staff spoken to said that the team support each other and knowledge and skills were shared. A relative spoken to said that the staff team were very skilled dedicated and determined to provide a high standard of care. The AQAA informed that 65 of the staff team had attained the national vocational qualification (NVQ) at level 2 in direct care. Examination of the recruitment records for three staff recently employed reflected that the files contained all the information required under the care homes regulations 2001 Schedule 2. We noted that staff members had commenced employment with PoVA first checks. The manager said that staff Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 21 members working without a full CRB disclosure work alongside an experienced member of staff. It is advised that the practice is strengthened further by ensuring that written records are maintained to verify that an experienced and qualified person is appointed to supervise until the full CRB is obtained. There may be more than one named person but this would need to be clearly identified. The home has a six week induction programme for new staff and a good ongoing mandatory programme which means that the training provided is targeted and focused on improving outcomes for people using the service. The manager informed that the service uses external trainers to deliver some training if they have not got the skills within the organisation. Recent training provided included dementia, rarer neurological disorders, end of life care, Huntington disease, picks disease, equality and diversity, deprivation of liberty safeguards and management of peoples skills. Information in the AQAA indicated that staff meetings were used to share ideas with colleagues and cascade information. Individual supervision sessions take place regularly and these are known as mentoring. Staff spoken to said that they find them useful for their development. Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has the experience to run the home which means that the home is well managed and there are systems in place to continuously improve the service delivery and provide an increased quality of life for people using the service to promote their safety. EVIDENCE: The registered manager has the required qualification and experience to run the home and meets its stated aims and objectives. She is a registered general nurse and holds the registered managers award. The AQAA informed us that the manager updates her skills and knowledge by undertaking regular updated training. She is involved in business planning and budget meetings and has a clear focus of the strategic development of the service. The manager Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 23 demonstrated a clear vision of the home based on the organisations values and priorities. Staff who responded to the Commissions survey said that the manager communicates a clear sense of direction and was approachable. Staff volunteer to be nominated as dignity champions, which demonstrates that the way the home is run ensures that peoples diverse needs are understood and respected and there is a proactive approach to improve outcomes for individuals whatever their race, age, disability or religious belief. Relatives and residents meetings are held monthly which are well attended. Relatives who responded to the Commissions survey said that the communication system in the home was very good and the home responds to any ideas put forward and welcomes any suggestions to enhance the quality of people using the service lives. The homes quality assurance system has been recognised by Investors in People which is an authoritative independent accrediting body. The AQAA informed that the manager undertakes joint environmental and quality audits monthly. Some health and safety audits are undertaken weekly and issues identified as requiring attention are actioned in a timely manner. Personnel from the organisation visit the home monthly to inspect the premises, examine record documentation and meet with people using the service and staff to monitor the service delivery and obtain their views in order to form an opinion of the standard of care in the home. The outcome of surveys from people using the service, relatives and other stakeholders are made available and published. The manager ensured that the AQAA was returned on time. It contained detailed information demonstrating how the home had listened to people using the service and their relatives and recognising the areas that still need improvement and how it is planning to achieve this. The home has health and safety policies and procedures to promote and protect people using the service and staffs health and safety. The safety systems in the home are regularly reviewed and updated. Training records examined reflected that staff undertake regular updated training in health and safety, first aid and moving and handling. The AQAA informed that maintenance and safety checks on gas and electrical appliances had been undertaken as recommended by the manufacturer. The fire panel records revealed that weekly checks were being undertaken to promote safety and staff participate in regular fire drills so that they know what to do in the event of an emergency. Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X X 4 X Version 5.2 Page 25 Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc No Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action 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 Bluebirds Nursing Home DS0000019180.V376569.R01.S.doc Version 5.2 Page 26 Care Quality Commission Southeast Region Citygate Gallowgate Newcastle upon Tyne NE1 4WH National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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