Latest Inspection
This is the latest available inspection report for this service, carried out on 14th December 2007. CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
For extracts, read the latest CQC inspection for Ilsom House Residential & Nursing Home.
What the care home does well There is a comprehensive system in place to ensure a person`s needs are both assessed and planned for well. A high standard of food is provided and served in a very attractive setting. There are robust arrangements in place to ensure that any complaints are managed correctly and that people living in the home are protected. The environment is particularly comfortable and clean. The service is able to look at shortfalls within the service and demonstrate a genuine desire to improve upon these.All aspects of health and safety are taken very seriously and robust arrangements are in place to ensure these systems are maintained. What has improved since the last inspection? All people admitted to the home for care can now receive a copy of the homes Terms and Conditions and receive all information necessary regarding their financial responsibilities or entitlements. Care Planning is more robust and offers better guidance to staff. Agreed plans of care are very specific to the individual. Additional assessments are now well maintained. The standard of food has improved and people living in the home are able to discuss their likes and dislikes with the cook. All verbal complaints and concerns are being recorded. Staff now have improved knowledge regarding Safeguarding Adults and the company`s policy offers clearer guidance to staff. Extra hand towel and soap dispensers have made it easier for staff and visitors to maintain good infection control. What the care home could do better: Staff must improve their recording practices following the administration of medicines. Repair the roof as soon as possible. Ensure that people do not experience another year not being able to access the main terrace. Keep the numbers of staff trained to NVQ level at 50% or above. CARE HOMES FOR OLDER PEOPLE
Ilsom House Residential & Nursing Home Tetbury Glos GL8 8RX Lead Inspector
Mrs Janice Patrick Key Unannounced Inspection 14th December 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ilsom House Residential & Nursing Home DS0000016483.V356153.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. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Ilsom House Residential & Nursing Home Address Tetbury Glos GL8 8RX 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) 01666 504131 01666 504308 pitcheja@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd Mrs Janet Elizabeth Pitcher Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability (38) of places Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 28th March 2007 Brief Description of the Service: This care home provides care for the elderly person requiring predominantly nursing care, although admission for personal care only is possible. Set back off the main road overlooking the countryside, the home offers spacious accommodation with extensive gardens and ample car parking. Accommodation is over two floors and consists predominantly of single bedrooms all with en suite facilities. A few bedrooms are large enough to share if this was a particular request. This would also depend on the number of residents already living in the home. There are spacious communal rooms on the ground floor and ample communal bathing and toilet facilities. The home has a passenger lift and stair lift to aid access to the first floor. All entrances into the home are level to the ground making wheelchair access easy. This home is popular and well established in the local area. Fees currently range from £850.00 and £1,016. The last CSCI inspection report on the home can be seen on request. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. One inspector carried out this unannounced inspection on one day between 10.50am and 5.30pm. We (The Commission) sent questionnaires to people living in the home and to seek their views of the services provided. Four survey forms were returned. Any views and comments received have contributed to this report. As part of the inspection process the care of three people was selected and relevant records were inspected in detail. In addition to this many other related care records and documentation was inspected. Specific areas such privacy and dignity, individuals’ ability to make choices and have their preferences met were looked at. The degree of involvement and control over their care and inclusion in decisions made in the home was also considered. Social and recreational needs were explored along with the arrangements to meet these. The choice and standard of food was inspected. Arrangements for staff training were inspected. The general management of the home including all aspects of health and safety practice were explored and records inspected. The systems required to enable a home to identify shortfalls and improve on these were discussed. What the service does well:
There is a comprehensive system in place to ensure a person’s needs are both assessed and planned for well. A high standard of food is provided and served in a very attractive setting. There are robust arrangements in place to ensure that any complaints are managed correctly and that people living in the home are protected. The environment is particularly comfortable and clean. The service is able to look at shortfalls within the service and demonstrate a genuine desire to improve upon these. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 6 All aspects of health and safety are taken very seriously and robust arrangements are in place to ensure these systems are maintained. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 7 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 Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 8 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): 2&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for all people to receive relevant information, including that pertaining to financial responsibilities and to have their needs assessed prior to their admission. EVIDENCE: We (The Commission) made a requirement in the previous inspection for people who were in receipt of a contribution towards their care from a funding authority, to receive a copy of the homes Terms and Conditions. Confirmation was given during this inspection that this has been carried out and all the home were waiting for were the signed copies back from the relevant people. Peoples’ care needs are always assessed prior to admission so that staff can be sure that they are able to meet the individual’s requirements. We saw examples of two pre admission assessments. Both these were slightly different admissions compared to an admission for long-term care.
Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 9 One person had been evacuated from her home during the county’s floods earlier in the year. This person was unhappy in the care home her family had initially chosen for her and whilst visiting Ilsom House she decided not to leave. The Registered Manager, who is an experienced nurse, was sure that the home could meet her needs and completed the written assessment on that day. The second person was only admitted for one week but documentation showed that the person’s care needs had been assessed prior to their admission. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In the process of planning and meeting peoples’ health and personal care needs, staff recognise the need and preserve people’s privacy and dignity. EVIDENCE: The company have introduced new care documentation, which includes a new format for care planning. It encourages assessments and the planning of care to be far more individualised. This has helped the home meet a requirement made in the previous inspection report, which was to make sure that all individual needs were planned for. The company will also be introducing additional paperwork to take into account new legislation relating to the Mental Capacity Act. This demonstrates that current and relevant legislation is being considered. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 11 Several care files were inspected and we were shown how the assessments and care plans cross reference with each other. The findings in the above pre admission assessments were cross-referenced with written care plans, which demonstrated that the planning had been very specific to that individual person (‘person centred’). The Registered Manager explained that the care planning for the person who was only staying a week would have evolved and become more detailed if she had been staying longer. There was evidence of auditing taking place as the information from old care records were transferred to the new system. This has raised the standard of accuracy and will continue to ensure that staff cross reference information correctly. The care planning for another person who gets very disorientated and anxious particularly at night was very ‘person centred’. The plan of care had been agreed with this person and gave staff clear guidance on how this was to be managed. We specifically revisited the care of one person living in the home. In the previous inspection this person was extremely poorly. Even though there is still a total dependency on staff for all care needs, we could see a huge improvement in this person’s presentation. There was evidence to show that the care being delivered was following the written care plan. There was also evidence to show that relatives were very involved in any decision-making and that staff were supporting them, as well as caring for their relative. Two people were specifically spoken to about their admission to the home. One said she had been made very welcome on arrival. The other was able to directly compare the care she was receiving in this home with the care she had received in her previous home. She said: “ it has been completely different here. They are so kind, I cannot fault it”. One particular nurse was described as ‘highly professional and very kind’. Two further people spoke of similar experiences and were clearly very content. There was evidence to show that the home liaises with many external healthcare professionals. The Registered Manager confirmed that advice is sought from several professionals such as the Continence Advisor and Continuing Healthcare Nurse. One person confirmed that they see the Community Nurse on a regular basis. Another person confirmed that the Community Psychiatric Nurse (CPN) had been in to see his loved one. The local General Practitioners visit the home when the staff make a request. The medication system was not fully inspected during this inspection, although several Medication Administration Records (MAR) sheets were seen. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 12 A requirement was made in the previous inspection to ensure that staff were following correct practice when recording. There were still recent gaps seen on some MAR sheets and double signatures required on another. Following the previous inspection the Registered Manager had reminded staff via a memo (seen) of their professional obligations regarding signing for medicines that they have administered. Although these shortfalls were still evident in places, we are satisfied that these were being identified in regular audits (which were also seen during this inspection) and that appropriate action will be taken. The local Community Pharmacist has also been involved in trying to rectify some shortfalls, which has included improving the standard of the printed administration record supplied to the home. One nurse was observed administering some medications and her practice was both safe and helpful to the resident. We observed staff speaking to people in a polite and respectful manner. Those living in the home spoke highly of the staff and agreed that the majority were extremely helpful and polite. Two people were specifically asked if they felt that their privacy and dignity is maintained and they agreed it was. One person said that she had not liked being washed by male staff in her previous care and that when she had said something about this, nothing changed. She said that here she always has a female to help her wash and dress and feels far more comfortable. Another person confirmed that he had always witnessed staff being gentle and polite with his relative. He said: they are even the same when she gets confused and can be quite rude to them, they seem to understand her”. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in this home are experiencing improvements in arrangements for in house activities and in the provision of food. They live in a home that already acknowledges that friends and visitors are integral to their quality of life. EVIDENCE: There is a person who co-ordinates activities within the home three days of the week. The Registered Manager is hoping that another person may start soon and cover the two other days of the week. A very popular quiz is still held on a weekly basis. Within the new care planning system there is a document called ‘a map of life’. People are asked to complete this and given help if needed to do so. Some examples were seen during this inspection. This is designed to explore the person’s life when they were younger and highlight any particular skill, hobby, interest that they may have. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 14 People living in the home already choose with the activities co-ordinator what they would like to do, but the latter highlights specific interests. The Registered Manager gave an example of how this could be used and explained that if there were a group with a particular interest in music or reading, then a music group or literature group maybe suggested. And, for those less able, it helps the activities co-ordinator choose a more familiar or appropriate pass time for that individual. People were seen during this inspection either reading, watching the television or passing time doing things like jigsaw puzzles. Some said they like to join in activities others said they prefer their own company. Visitors are welcome at any time and that was the case during this inspection. One set of visitors were observed organising a trip out for the following day with their relative, as it was her birthday. The home does advertise advocacy services and a very good example of someone needing advice on this was witnessed at the time of this inspection. Some people, in the last inspection, were extremely unhappy about the standard of food and the way it was being served. They also felt that nothing was being done to address this. Relatives had also made some comments. A requirement was made by the Commission for the home to ensure that everyone’s preferences were being taken into account and that each person was having wholesome and nutritional food. Since that inspection the home has changed its cook and people have been consulted regarding what they felt the problems were. They have also been offered the opportunity to start a group up, which would meet regularly to monitor and review the situation, which they declined. Several people spoken to during this inspection said that the food had improved hugely. The Registered Manager has asked the new cook to seek people’s views on the food. The cook was therefore observed talking with some people in the dining room. This looked relaxed and those living in the home appeared to have a good rapport with her. People who require more support to eat receive this quietly in the main lounge where there are staff who provide this in a sensitive and unrushed manner. One person agreed she could be ‘picky’ with her food but said she usually manages to enjoy what she chooses. Another person could not remember what she had chosen for that day and said it would be a surprise. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 15 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. An improvement in how the home has approached some areas of discontentment has resulted in better recording of concerns and verbal complaints and has led to people feeling listened to. People living in the home, who already feel very safe there, will also benefit from staffs’ increased awareness of abuse issues. EVIDENCE: There is a complaints policy and the procedure is displayed in the reception area. The procedural information is also within each bedroom. The new contact information for the Commission still needed to be added. The complaints file was inspected. Five complaints were recorded, but the Registered Manager explained that she is now recording verbal complaints that have been easily sorted out. One related to the food and another was a small issue regarding care. Three referred to the ongoing poor condition of the roof and the lack of being able to use areas of the garden and terrace; again this year. The Registered Manager confirmed that monies have now been secured for this but thought this would not be commenced before the end of 2008. We will seek clarification on this outside of this report. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 16 Training records demonstrate that nearly all of the staff have now received basic awareness training in adult abuse. This complies with a requirement made in the previous inspection. One member of staff was able to confirm she had done this via a learning pack and video. BUPA also amended their Safeguarding Adults Policy in 2007 this made the action to be taken by staff far clearer. One senior member of staff will be taking responsibility from January 2008 to ensure staff receive awareness training on the Mental Capacity Act and will see that this is considered in the care planning process if a person lacks mental capacity. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 17 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, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home is a very comfortable and clean place to live, although problems with the roof have been going on for some considerable time and has caused some inconvenience to some living there. EVIDENCE: A tour of the property inside was carried out and several rooms visited. All looked attractive and many were very personalised with people’s own processions in place. There were no offensive odours and cleaning staff were seen around the building carrying out their tasks. The main communal areas were decorated for Christmas and the positions of armchairs had been altered in the main sitting room so that everyone could see the visiting entertainment.
Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 18 There has been no further refurbishment since several ensuites were altered in 2006/2007, but all areas looked well maintained. As discussed in the above outcome the main terrace was still out of bounds due to problems with the roof. The Registered Manager confirmed that there are currently no areas within the home experiencing water coming in. Near completion are pathways around the gardens that will accommodate wheelchairs. Records are kept of various checks carried out on a weekly and monthly basis on the water, heating and lighting systems. Arrangements are in place to promote good infection control and recently each ensuite has been fitted with a paper towel and soap dispenser for staff and visitors to use. Alcohol based hand cleansers were seen around the home for staff to use and specifically in one bedroom where the occupant currently has an infection. Plastic aprons and gloves are available for staff and protective clothing was worn during the serving of meals. A senior member of staff has taken on the lead for Infection Control within the home and has trained some staff in competent hand washing. Correct arrangements are in place for the disposal of clinical waste. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in this home consider their needs to be very well met by staff who are well recruited and given the training to carry out their tasks. EVIDENCE: The Registered Manager confirmed that the home was adequately staffed; this was a requirement from the last inspection. This requirement also required an improvement in staff competencies. The Registered Manager confirmed that the home aims to have seven members of staff on duty in the morning and six in the afternoon. These numbers include qualified nurses but not the Registered Manager. There has been more qualified staff on duty recently to accommodate the task of transferring the nursing documents over to the new system. One member of staff said that the present numbers of staff are adequate in the mornings but if there is only one nurse on in the evenings (or the home drops by one) it can be a struggle to meet everyone’s needs. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 20 One person living in the home commented that the staff were always extremely busy and although this person is happy with their care, they do have to wait sometimes longer than they feel is acceptable for the amount of fee they are paying. There is now a receptionist seven days a week who can transfer telephone calls, answer some queries and answer the front door. Evidence shows that there has been an improvement in keeping staff updated in basic knowledge required for their work. Most staff members have now completed training in basic dementia awareness also. One of the senior staff has taken on the responsibility of being the home’s training co-ordinator and also trains staff in safe moving and handling, which is up to date. Out of 17 full time and part time care staff, 30 have completed the National Vocational Qualification (NVQ) through BUPA. The Registered Manager confirmed that another 30 were due to commence in the next phase of training in 2008. The recruitment documentation for two new members of staff was inspected. There were no obvious gaps in employment. Clearances against the list for the Protection of Vulnerable Adults (POVA) had been successfully completed. One member of staff did not have a clearance completed from the Criminal Record Bureau (CRB) but the cleaning staff always work in pairs so this member of staff would be being supervised. Both had two successful references. Both had received fire awareness training early on in their induction training. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home benefits from being managed by an experienced person who along with the company have not been frightened of identifying shortfalls and improving on them. There is a proactive attitude to keeping those who live in the home safe. EVIDENCE: The Registered Manager of this home has been a manager with BUPA for many years and is an experienced Registered Nurse. She works predominantly weekdays and is supernumerary to the rest of the nursing team. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 22 BUPA are in the middle of changing their quality assurance, auditing arrangements and home managers will commence a new tool in January 2008. The Registered Manager said that this should be far more user friendly and should make it easier over a months period, to focus on shortfalls and improvements required. We also receive, as part of this process a monthly report following an unannounced visit to the home by an outside BUPA Manager. This complies with Regulation 26 of the Care Homes Regulations 2001. As previously mentioned in the report ongoing auditing has been taking place on the care plans and documentation generally, including the medication records. People who live in the home can run ‘in house accounts’ for small amounts of personal money. The records for these are kept electronically and all systems were audited by BUPA two weeks prior to this inspection so this process was not repeated. Two people however confirmed that they could access small amounts of money when they wish. The maintenance person carries out many health and safety related checks and keeps records of these. We noted that the visual checking of all fire exits, escape routes and equipment had been increased to a daily check. This is a decision taken by BUPA. All moving and handling equipment has been serviced appropriately within the last six months. The home has a Fire Risk Assessment and staff receive fire awareness training. All potential generic and individual risks to people living in the home are considered and the action taken to reduce these recorded. One risk assessment regarding a bedroom had another person’s name on it other than the current occupant. The Registered Manager explained that it was pertinent to the bedroom space and not the occupant. She would make sure all staff understood this. Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 23 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 X 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement The Registered Manager must ensure that the recording of medication records is carried out straight after administration and that two signatures accompany handwritten instructions on the MAR sheets to prevent errors in transcription. (Timescale of 01/03/06 & 15/05/07 not fully met) The Registered Persons must make arrangements for the repairs to the roof to be carried out as soon as is practicable and confirm formally, with the Commission when this will be by the date given here. Timescale for action 01/02/08 2 OP19 23(2)(b) 11/02/08 Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 25 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 OP18 Good Practice Recommendations Consideration should be given to some staff attending the Enhanced training in Safeguarding Adults provided by the county’s Safeguarding Adults Team. The home should have 50 of its care staff trained to the recognised National Vocational Award in Level 2. 2 OP28 Ilsom House Residential & Nursing Home DS0000016483.V356153.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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
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