Care Home: Bonehill Lodge

Similar services:

• Maple Lodge
• Heathlands
• Aston Court Nursing Home
• Breme
• Ravenhurst
• Bank House
• Inspirations
• Ashcroft Hollow Nursing Home

What the care home does well Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.2 People are able to spend time in the home before making a decision to move in and talk to other individuals and staff and have information in different formats to support people to understand. As part of the assessment staff ask people how they want to be supported and write down this information. A care plan is written which explains how people like and need to be cared for; these are well written and staff understand people`s needs. The bedrooms are all different sizes and some have en-suite facilities. People are able to bring furniture and personal items to the home and as a result each room reflects the person`s interests and preferences and many display photographs of family and important past events. There are two main lounge areas and people like to sit together with their friends. One lounge area has a television and the adjoining lounge is a quieter area. People said they are able to decide which programme to watch though most people also have their own television in their room if they prefer to watch a specific programme alone. Family and friends can visit the home whenever they want to, and family members are able to continue to provide care for a relative and spend time in the home. People told us that they go out to family homes and continue to enjoy family events. There are activities arranged daily and individuals can choose whether to be involved. The activity timetable has been reviewed so people are involved in activities they enjoy doing. During our visit we saw the Christmas table decorations people had enjoyed making. People are able to go out with staff or alone in the local community and have enjoyed going for meals, having a drink out and walks with staff recently. The planned meals are written on a chalk board and displayed each day; there are two choices of main meal cooked for people to choose from or upon request can choose something different. Food can be served to people in their room or in the dining areas. People dress in their own style and if they need support, staff help individuals to apply make-up or to have a manicure and people are encouraged to continue to take a pride in their appearance. Staff provide any personal care where required and people in the home are well-presented. Staff like to develop good relationships with people and will spend time talking and taking an interest in people`s lives and adventures. Staff have a good knowledge of the care needed and what people may want. There are procedures in place to make sure that complaints are listened to and acted upon and to protect the well being and safety of people who live in the home. People said they would report anything they were not happy with to the staff. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.2 Page 8People who use the service spoke highly of the staff and comments included, `you couldn`t get better staff anywhere`, `the staff can never do enough for you`, `the staff are lovely and they always sit and talk to us, and `we have a laugh together, they`re great.` What has improved since the last inspection? The service has reviewed the activities provided in the home. A range of events and activities take place each day according to the interests of people who use the service. People have opportunities to be involved in small group activities including craft events, as well as large organised events in the home. Family and friends are encouraged to join in and are invited to events and people are able to go out for activities in the local community with staff or family. What the care home could do better: Any decision made by the person in respect to how they wish to live and the services they receive during the end of their life, should be fully explored to determine their best interests. Where a person lacks capacity the guidelines for the Mental Capacity Act need to be followed. Key inspection report CARE HOMES FOR OLDER PEOPLE Bonehill Lodge 62 Park Lane Fazeley Tamworth Staffordshire B78 3HZ Lead Inspector Mandy Brassington Key Unannounced Inspection 22nd December 2009 09:00 DS0000004919.V378806.R01.S.do c Version 5.3 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 homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The 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. Bonehill Lodge DS0000004919.V378806.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 Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bonehill Lodge Address 62 Park Lane Fazeley Tamworth Staffordshire B78 3HZ 01827 280275 F/P 01827 280275 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) Bonehill Limited Vacant Care Home 26 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (26) of places Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 26 Dementia (DE) 6 The maximum number of service users who can be accommodated is: 26 9th December 2008 2. Date of last inspection Brief Description of the Service: Bonehill Lodge is a residential home situated in the suburbs of Tamworth, Staffordshire, having access to local amenities and public transport. The home has a paved area to the rear and a small area of landscaped garden to the front of the home. The home looks out onto rural surroundings; there is limited access to public transport and local shops due to the semi-rural location. The home provides a service for 26 older people and is also registered to care for 6 individuals who have with dementia. The three-storey property provides residential accommodation on both the ground and first floor, en-suite facility is provided within a number of bedrooms. One part of the first floor is accessible via a passenger lift. Bathrooms and toilets are located throughout the home and in close proximity to bedrooms and communal areas. The property has a large lounge, divided into two separate areas, which leads to a dining area equipped with essential furnishings to meet the needs of the service users. There is a conservatory, which leads to a small paved garden. The registered provider is Bonehill Ltd who has overall responsibility for the Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.2 Page 5 home. The Service User Guide records individual fee levels. The reader may wish to approach the care provider for up to date details of the fees payable. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. We visited the home for 7.5 hours and used the National Minimum Standards for Older Persons as the basis for the inspection. The people who live there and the staff did not know we were coming. Before our visit took place we looked at information from the homes Annual Quality Assurance Assessment (AQAA) and any notifications they had sent to us about events that affect the well being of the people who live there. The AQAA gives us important information about the way the home is meeting National Minimum Standards in care and the improvements planned to create better outcomes for the people who live there. There were questionnaires sent to people who use the service, professionals and staff members. We case tracked three people who live in the home. Case tracking includes meeting people and talking about the care they receive or watching staff supporting them, looking at their care records and medicines and the way that they are helped to make choices and decisions. This assists us to understand the experiences of people who live in the home. Time was spent talking to the staff team on duty during our visit and observing the way they interact with the people they care for. We spoke to seven people about their experiences of living in the home. We looked around the building to make sure that it was clean, warm and comfortable and looked at four bedrooms, the lounge areas, the dining room, and bathing facilities on all floors. We inspected the storage system and medication procedures and we looked at records of staff training and recruitment, health and safety records and the food people are offered. There were no immediate requirements made after our visit. This means that there was nothing urgent that needed to be done to protect people who live in the home. The quality rating for this service is a 2 *, GOOD Service. What the service does well: Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.2 Page 7 People are able to spend time in the home before making a decision to move in and talk to other individuals and staff and have information in different formats to support people to understand. As part of the assessment staff ask people how they want to be supported and write down this information. A care plan is written which explains how people like and need to be cared for; these are well written and staff understand peoples needs. The bedrooms are all different sizes and some have en-suite facilities. People are able to bring furniture and personal items to the home and as a result each room reflects the persons interests and preferences and many display photographs of family and important past events. There are two main lounge areas and people like to sit together with their friends. One lounge area has a television and the adjoining lounge is a quieter area. People said they are able to decide which programme to watch though most people also have their own television in their room if they prefer to watch a specific programme alone. Family and friends can visit the home whenever they want to, and family members are able to continue to provide care for a relative and spend time in the home. People told us that they go out to family homes and continue to enjoy family events. There are activities arranged daily and individuals can choose whether to be involved. The activity timetable has been reviewed so people are involved in activities they enjoy doing. During our visit we saw the Christmas table decorations people had enjoyed making. People are able to go out with staff or alone in the local community and have enjoyed going for meals, having a drink out and walks with staff recently. The planned meals are written on a chalk board and displayed each day; there are two choices of main meal cooked for people to choose from or upon request can choose something different. Food can be served to people in their room or in the dining areas. People dress in their own style and if they need support, staff help individuals to apply make-up or to have a manicure and people are encouraged to continue to take a pride in their appearance. Staff provide any personal care where required and people in the home are well-presented. Staff like to develop good relationships with people and will spend time talking and taking an interest in peoples lives and adventures. Staff have a good knowledge of the care needed and what people may want. There are procedures in place to make sure that complaints are listened to and acted upon and to protect the well being and safety of people who live in the home. People said they would report anything they were not happy with to the staff. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.2 Page 8 People who use the service spoke highly of the staff and comments included, you couldnt get better staff anywhere, the staff can never do enough for you, the staff are lovely and they always sit and talk to us, and we have a laugh together, theyre great. 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. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.2 Page 9 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 Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5, 6. 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. People have information about the home and the service provided and can spend time in the home before deciding whether they would like to move in. There is a range of information about the home to support people to make a decision. EVIDENCE: People living in the home have a copy of the Statement of Purpose and Service User Guide which has been reviewed to provide details of the service provided, and the terms and conditions of occupancy. The Service user Guide is now Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 11 available with pictorial symbols to support understanding and can be available in large print upon request. We examined three records including one person who had recently moved to the home. Each person had been given a Service User Guide and had a contract with the fees payable. A Care Manager had carried out a single assessment identifying support needs and preferred outcomes for people funded through the local authority. Prior to moving in to the home, an assessment is completed with the individual and family members, to determine whether the home is able to meet peoples needs. Individuals confirmed they were involved in the assessment process and were also able to look around the home and view vacant rooms. Discussion with one person who used the service reported that family members had looked around the home as they were in hospital, but they were able to visit other places upon admission to ensure they were happy with their decision. All people spoken with stated they were happy that they had chosen to move to the home. Some People told us, you couldnt find anywhere better, Im happy I made the right decision, I feel happy and safe here. The home does not provide intermediate care. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 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. People who use service are able to continue to see health care professionals to make sure their health needs are met and a record of health and personal needs are recorded. EVIDENCE: We looked at care plans and risk assessments for three people who live at the home. These records describe the support that people need in their day to day lives and the safeguards in place to protect them from possible harm. Those that we looked at had been reviewed on a regular basis to make sure they reflected accurately the care and support that people need. Two plans were for people who had lived in the home for a significant period of time and one plan Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 13 for a person had recently moved into the home. The plans included information about the support people wanted for bathing, eating and drinking, personal hygiene and mobility, personal safety and health needs. Information was available regarding assessments of risk for any identified concern and mobility. This information means that all staff are aware of how to support people. The staff that we spoke to were able to describe and show us how they supported people to maintain good health and respond to any concerns that may arise. Moving and handling assessments have been completed. There is clear information to describe how to support the movement of people with mobility difficulties to reduce risks to their health and well being. One person told us I couldnt walk when I moved here, now I can, the staff got me walking again. From looking at records and talking to staff it was evident that people have regular appointments with health care professionals. The outcome of each contact is recorded so that staff have accurate and up to date information about individuals health. One plan we looked has a Do Not Attempt to Resuscitate order (DNAR) signed by a member of the family. This was discussed with the manager, as this should be explored in line with the best interests of the person and under the Guidelines of the Mental Capacity Act. The Order was six months old and this should be kept under regular review to ensure it reflects the persons wishes. The manager agreed that this would be reviewed. Staff offered discreet support to people needing assistance with personal care. We were told by seven people that the staff team is very good, friendly, and caring. From observing staff and people during the course of our visit it is evident that friendly and respectful relationships have been formed. We looked at the way medicines are managed to check that people were receiving their medicines safely and as prescribed. The home has secure storage for medicines and we were advised that only trained staff handle medication. Medication was stored appropriately in the home and observation of medication practices revealed that people were offered a drink with medicines and given time to take them at their pace. Medication Administration Records (MAR) were completed appropriately for dispensing medication. Hand written entries on the MAR Sheets were recorded by two people to ensure accuracy. A number of medicines were stored within a secure fridge. A record of the maximum and minimum temperatures had been recorded daily. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 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. People are involved in daytime activities of their own choice in the home and the local community. Individuals can welcome family and friends into the home throughout the day, who can join any activity or event. EVIDENCE: The AQAA recorded that there are three designated activities co-ordinators but all staff participate with carrying out activities. The planned activities are promoted using a weekly planner and people are also informed verbally. The activities are varied and include bingo, flower arranging and craft activities, hairdressing and manicures on a regular basis. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 15 The week of our visit had special Christmas activities. The previous day the staff had dressed up and performed a Nativity Play followed by a Christmas celebration. The people who used the service spoke highly of the play saying, the staff were brilliant, it was very funny. The staff had put so much effort into it, we really had a good time, wonderful stuff. A Christmas meal had been organised at a local pub and people were able to choose whether to share this meal. A Christmas Fayre had been organised and Christmas activities had taken place, including making Christmas tags and cards, and making calendars for 2010. Family and friends were invited and people were able to enjoy refreshments including home made cakes and have a drink. Staff informed us that all people living in the home celebrate Christmas as part of their beliefs. Links have been developed with two local schools. The school choir visited the home and sang carols. One person commented, its lovely listening to the children, they were really lovely and sweet. Many people receive visitors and people who use the service told us that they go for regular visits home. Three people said they were going to spend time with family at Christmas and were looking forward to the celebrations. One person said, Its lovely being with family but I also like coming back here. We had lunch with people during our visit. Dining tables were set with tablecloths and hand made Christmas table decorations. The days menu was written on a chalk board in the dining room and people told us that they had chosen from the two options available. The choice was liver and onions or lamb cutlet with potatoes and vegetables. People were able to eat from ordinary crockery and appropriate glass or china cups. One person told us, I eat everything here, its good home cooked food, I never used to eat much, but I eat everything now. The manager told us that people were being encouraged to take a more active role in the home and one person laid the tables and helped clear away. The staff team have also been discussing how to improve the service provision and are reviewing whether to wear uniforms and to eat alongside people and join in a family style meal. The service has had a recent inspection by Environmental Health Department and achieved a rating of four stars. This means that the catering facilities and standards are good and does not place people at risk of harm. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 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. People are given information to make a complaint so that where any concern is identified they are confident this will be acted upon. Staff are knowledgeable about how to protect people to ensure people are safeguarded. EVIDENCE: The home has a complaints procedure, which is made available to people and their relatives when they move in. We spoke to four people who confirmed that they would raise concerns and complaints with the manager or other staff should they need to. The manager confirmed that the service acts on all complaints and concerns identified. The home has policies and procedures for safeguarding people in the home and staff have received training for recognising signs of abuse and reporting possible abuse. During discussion, staff identified a good knowledge of how to safeguard people and what they would do if they suspected abuse. The service has a whistle blowing Policy and staff stated they are confident the manager Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 17 and service providers would ensure this was followed to safeguard them. The service has responded well, since our last visit, to all safeguarding incidents and worked with the local authority to ensure any issue is suitably investigated. Small amounts of money can be securely held in a safe and a record of monies and valuables are maintained and audited. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 26. 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. People are able to decorate their room with personal possessions so that it is comfortable and pleasing to each person, and use personal equipment to ensure they are safe and supported. EVIDENCE: The manager recorded within the AQAA that the service provides an accessable, homely, clean, hygienic, safe, well maintained, and comfortable environment to meet individuals and current legislation. During our visit we Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 19 found the home was clean and welcoming and had been decorated for the Christmas celebrations. The manager told us that there are comfortable and fully accessable communal facilities that reflect peoples needs and preferences, with aids and adaptions as necessary. The AQAA recorded that the environment is reviewed at least yearly in the Annual Service Review and monthly during health and safety checks and reviews with the operations manager. The checks the service carry out means that people benefit from having a safe clean environment to live in. Individuals are able to bring in small personal belongings to the home, and many people had chosen to decorate their room with photographs and personal pictures, and had a television or radio. To help people find their room, each bedroom area has been decorated in a different colour and given a name, each room has the persons name and a photograph. This supports people to identify their personal room and helps to move safely around the home. Environmental Health conducted a recent visit to the service and awarded the home four stars, which means the kitchen has a good standard of cleanliness and hygiene to ensure food is prepared safely. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 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. People are able to have confidence in the service provided as staff receive ongoing training needed to support people. There is a good recruitment procedure to ensure that people are suitable to work in the home. EVIDENCE: We looked at the homes roster, staff training and recruitment records to make sure that there are sufficient numbers of competent staff on duty throughout the day and night. There is a low turnover of staff and we spoke to care staff who were knowledgeable about their roles and are committed to delivering a good service. The staff team work closely and are exploring how to improve the service in line with good practice and peoples wishes. The people we spoke to commented that they had no worries about the number of staff on duty each day and that staff were always available when they needed them. From observing staff offering care and support to people it was evident that friendly and respectful relationships had been made. Staff Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 21 offered people discreet assistance at mealtimes and with personal care and responded promptly to the nurse call bell when it sounded. People using the service spoke very highly of the staff and the support provided. Comments included, you couldnt get better staff anywhere, the staff can never do enough for you, the staff are lovely and they always sit and talk to us, and we have a laugh together, theyre great. We looked at the recruitment records for three members of staff, which showed that a range of checks had been made to ensure that people had been protected from the risk of having unsuitable staff working with them. These included receiving written references, Criminal Records Bureau checks and a completed application form. The manager and staff reported that they are able to attend a variety of training to gain new skills and update any knowledge required to carry out their role safely. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 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. People who use the service are able to benefit from a professional management approach and a supported team, as the manager has a clear understanding of the key principles and focus of the service. EVIDENCE: Prior to our visit, the manager completed an Annual Quality Assurance Audit (AQAA) for us. The AQAA contained clear, relevant information that was Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 23 supported by a wide range of evidence. The AQAA identifies the changes that have been made since our last visit, and where they still need to make improvements. Evidence within the AQAA was sampled and found to be accurate. The current manager has worked in the home at a senior level for many years and has applied to become the registered manager with us. The staff team including the previous registered manager have reviewed the service and addressed any outstanding issues since our last visit. The information about the service has been reviewed to a format that supports peoples understanding, the plans of care record clear information about the support people require and the level of activities in the home has increased and is more varied. Staff told us they are valued as a team and have opportunities to develop their skills and competence to be able to provide a good service in the home. The staff team is exploring ways to develop the service for people with dementia including people becoming more involved in general household activities in the home. The service has a quality assurance programme which is carried out on an annual basis. This includes gaining the views of people who use the service, friends and relatives and health and social care professionals. A report is completed along with an action plan and this is made available to people. The registered person or a representative visits the home on a monthly basis and completes a report about the visit. The reports include information about the experiences of people and any planned improvements. This means that people can be confident the registered person are taking an interest in the home and maintaining the service to a suitable standard. The manager and staff are promoting positive beliefs for equality and diversity issues, especially in relation to gender and religion. People told us that they felt their opinions were valued and that staff always listened to them. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 3 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 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1. Refer to Standard OP7 Good Practice Recommendations To review any Do not attempt to resuscitate order and ensure that this has been completed alongside the Guidance for the Mental Capacity Act and is kept under review. This means that the service will act in the best interests of the person and their views are continually sought to ensure the information is accurate. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA 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. 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. Bonehill Lodge DS0000004919.V378806.R01.S.doc Version 5.3 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!