Inspection on 05/12/05 for Bafford House Rest Home

This inspection was carried out on 5th December 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bafford House Rest Home 23/03/09

Bafford House Rest Home 11/12/07

Bafford House Rest Home 16/01/07

Bafford House Rest Home 10/05/05

Bafford House Rest Home 13/12/04

Bafford House Rest Home 12/07/04

Bafford House Rest Home 02/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bafford House Rest Home Newcourt Road Charlton Kings Cheltenham Glos GL53 8DQ Lead Inspector Mrs Helen James Unannounced Inspection 5th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 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. Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bafford House Rest Home Address Newcourt Road Charlton Kings Cheltenham Glos GL53 8DQ 01242 523562 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) Mr Manmohun Ramnial Mrs Rosa Calvo Ramnial Mrs Rosa Calvo Ramnial Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2005 Brief Description of the Service: Bafford House is situated in a quiet residential area of Charlton Kings, approximately two miles from the centre of Cheltenham. It is easily accessible by public transport and car. It is an imposing detached residence with a large entrance hall where a cage of parakeets is situated. The accommodation has been adapted to provide fifteen single bedrooms and two double bedrooms, although in practice these rooms are used as singles unless occupied by a couple. Eight bedrooms have en-suite facilities, and all other rooms have hand washbasins. There are three communal bathrooms; one with a hoist. The accommodation is provided over three floors, accessed by a shaft lift or the stairs. There are two lounge areas on the ground floor, a sitting area on the first floor and a dining room on the lower ground floor. The two offices, kitchen and laundry are also located on the lower ground floor. The home is set in extensive gardens and the home has won several awards for the Cheltenham in Bloom competition for its floral displays. To the front and side of the house are parking spaces for several cars for staff and visitors to the home Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours on one day in December 2005 and was completed by one inspector. Eighteen standards for older people were looked at on this occasion fourteen were met, three were almost met and one was not applicable. The inspector spoke to the Providers, Manager, deputy manager and two residents at the home. Appropriate records and a selection of care plans relating to the residents spoken with, newly admitted or observed were looked at. The residents appeared well cared for and well nourished and all their care needs were being met. Those talked with confirmed their satisfaction with the care, nutrition, management and staff at the home. The atmosphere in the home was warm, friendly and relaxed and this appeared to benefit the residents in terms of safety, security and comfort. Since the last inspection when three enforcement notices were served the home has been closely monitored. The Providers have fully complied with the requirements of the enforcement notices and have made the necessary improvements in the home and its management. What the service does well: What has improved since the last inspection? Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 6 The procedures for the recruitment of staff are now much more robust and provide the safeguards necessary to offer protection to the residents, vast improvements have been made. The Health and safety issues have been addressed in the home ensuring that residents are protected in their environment. The recording of evidence that the home is complying with the regulations has improved ensuring that this is available for the inspection process. The Providers are also beginning to implement a Quality Assurance system in the home and provide evidence of this but this will need further development to ensure this is comprehensive. 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. Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 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 Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Arrangements are in place to ensure that each prospective resident is fully assessed prior to admission and on admission, to ensure that all their particular care needs can be met at the Home. Each resident has a contract for their care from the home and this includes the terms and conditions of residency. EVIDENCE: Residents are assessed prior to and on admission and documentation seen confirmed this. Copies of assessments are kept in the residents care plan; these provide specific details of care needs and general information. These ensure that the home can meet the needs of the individual before they are accepted for admission. A Resident spoken with confirmed the assessment process. All private fee paying residents receive a contract which includes the Homes terms and conditions of residency. Those receiving funding contributions sign a contract, which is between the Home, the funding authority and themselves, they also receive separate terms and conditions of residency from the Home itself. Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 10 There is a comprehensive care planning system in place to ensure that all members of staff have a clear understanding of the care each person requires. Residents health care needs are fully met. Residents are treated with respect and dignity and are afforded privacy. EVIDENCE: On this visit to the Home the inspector selected for inspection the care records relating to four new residents. In two cases thorough care plans had been prepared and developed, based on a full assessment of each person’s care needs. The other two residents had only been at the home for four and five days and the policy of the home is to assess them over a week before they write the care plan. The manager was in the process of identifying their care needs. Care records were well documented on this visit with all information written in an understandable format. Reviews are undertaken monthly. There is good liaison with the Community teams and the home has excellent relationships with local Gps. Residents who are being visited by the district nurse for specific nursing care have community care records which are kept at the home, and reference to Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 10 the district nurse visiting is made in the homes’ care record. All equipment needed for residents’ health care is supplied appropriately by the Community Services. Several residents have health care needs met by the Continence Nurse, the Community Psychiatric Nurses (CPN) and the Community Nurse. Two residents have wounds that are being treated. There are no residents with pressure sores. Risk assessments are well documented and moving and handling requirements are clearly recorded. Two residents who were able to converse with the inspector confirmed that they were treated with respect and that they had choice in their daily routine. They reported that they were addressed in a polite manner, by the name they wished to be called and that all care is carried out privately and respectfully. They told the inspector that they could do what they wanted and no one told them what to do unless they were putting themselves ‘at risk’. Those residents who were unable to discuss their care with the inspector due to confusion, inability to communicate or short tem memory loss were observed by the inspector. Interactions and responses of staff with residents were appropriate and residents were observed being treated with respect and dignity. Daily routines are ascertained from residents, relatives and friends and these are recorded and maintained as much as possible. Residents were observed being addressed politely, being guided, talked with and supervised. Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14 Daily routines are managed as flexibly as possible to suit the individual preferences of residents living at the Home. Visitors are encouraged and links with the community are maintained where possible. EVIDENCE: Residents at the home are free to spend their day as they wish those spoken with confirmed this. Residents confirmed that they could participate in things going on at the home but those spoken with were quite happy to pursue their own hobby/interests. The Manager takes responsibility for arranging an ‘Entertainment Programme’ to suit the residents and where possible they are consulted on what they would like to do. There is no daily programme but activities are arranged as and when and seasonal activities take place. A documented ‘activity/ hobby/ lifestyle history’ is recorded for all residents which increases the personal knowledge of individuals and assists in the planning of activities/one to one sessions with residents at the home. Care staff get involved on a ‘one to one’ basis with residents. There are no residents with nutritional problems at the moment but weights are monitored. Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards were assessed in this section. EVIDENCE: Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 Residents live in a warm, homely environment, which benefits from ongoing maintenance and improvements. All outstanding requirements relating to Health and Safety have been addressed. EVIDENCE: The Home is very clean, reasonably well maintained and decorated in a homely style. Bedrooms are generally refurbished as they become vacant. Residents are able to furnish their rooms with their own possessions if they wish. One issue relating to maintenance was identified. In room 7 the external door/window was tied shut with a belt, the resident said this was done as they rattled and couldn’t be shut properly. This was discussed with the Manager and is to be rectified. There was also an issue about the residents being able to turn the taps in the en- suite. The Manager reported that these taps were to be changed to a more suitable type of tap. Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, & 29 Staffing is adequate to meet the care needs of the residents living at the Home as the providers (administrator and Manager), are at the home each day to support the care staff. The procedures for the recruitment of staff are much more robust now and provide the safeguards to offer protection to the residents, vast improvements have been made. EVIDENCE: The staffing levels were adequate to meet the needs of the accommodated fourteen residents. 8am until 2pm = 2 Care staff plus Mrs Ramnial and Mr Ramnial. 2pm until 9pm = 2 Care staff plus Mrs Ramnial and Mr Ramnial. 9pm until 8am = 2 Waking care staff. A domestic/cleaner from 8am until 2pm and kitchen assistant from 8am until 2pm. Although Mr and Mr Ramnial are at the home and assisting in the care, catering and administration of the home their hours are not recorded. It is imperative that the hours worked are recorded in the home, otherwise it appears that there is a shortfall in care and support staff hours. This was discussed with Mr and Mrs Ramnial. There have been four new members of staff since the last inspection and on examination of the four personnel files the recruitment practice was vastly improved and more robust with almost all the information required under the Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 15 amended regulation 19 in place, obtained prior to or during the supervised period of induction for the individual starting work. The details missing on two files were the full employment history (there were gaps in the dated entries) Mrs Ramnial reported that this was discussed at interview with the candidates. But there was no evidence to support this, as there was no interview checklist in place where this information would be recorded. The Providers must obtain written verification of the reason the person left the previous employment. Mrs Ramnial now has an interview checklist available for use and will use this to record the interviews with staff (this was seen at the inspection). There was evidence of POVA First clearance on all new staff but two CRB results were awaited, one member of staff starts tomorrow and the other started last week and reportedly is still being inducted and supervised. CRB’S were examined by the inspector and can now be destroyed in compliance with Data Protection. Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, & 38 There appears to be better leadership, guidance and direction to staff from the Manager now she is back, to ensure that residents receive consistent quality care, whilst ensuring their choice and dignity. Service users financial interests are safeguarded within the home. The Quality Assurance processes in the home are continuing to be implemented and developed to ensure the home is meeting its aims and objectives and statement of purpose. EVIDENCE: The Registered Manager has many years of experience running a care home but has not completed the NVQ level 4 in management, although the Deputy Manager is completing the NVQ level 4 at the present time. The Providers are in the process of deciding on the future management of the home. Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 17 Evidence was seen of the staff supervision and appraisal system and the records that are kept. This now appears to be established and well coordinated by the manager and deputy. This will be monitored as it is in its early implementation. Staffing now appears to be more stable and there appears to be a happy working environment with only one staff vacancy. All accidents and incidents are now recorded appropriately and notification sent to the Commission. Residents’ personal finances are not managed by the home it is all done through the billing system. The home supplies most of the residents with personal toiletries and then sends the bill to the Relatives/representatives quarterly or half yearly. Records were seen pertaining to this. Evidence displayed confirmed that the Home is fully insured. A Residents feedback sheet has been implemented. This is kept in the residents’ room for completion by the resident/visitors or relatives to ensure that there is satisfaction with the home and its staff. To date no one has completed one they have all tended to talk to the Manager or the deputy about issues, concerns, compliments or queries. Further work needs to be undertaken to ensure a comprehensive, continuous self-monitoring system is in place in the home to ensure the Quality Assurance standards are met and that there is evidence available to demonstrate the system. Since the last inspection evidence has been seen of the Portable appliance testing done in 2005, the Gas safety checks done 2005 and the Hoist maintenance undertaken in October 2005. The Hot water temperature valves have been tested and Legionnella testing has been undertaken. All radiators have now been guarded. The Fire Officer visited the home in September 2005 and wanted a small hole filled in the wall by the office and a sign to be displayed. All the required weekly and monthly Fire checks are being completed. 21st November Fire drill and training was done with day and night staff. The Homes Fire Risk Assessment has been documented and is displayed in the home with a nominal role and plan of the home displayed at each exit. The Nurse call system is checked weekly and recorded. Mandatory training is being given by Mrs Ramnial and video material. This is now being evidenced through signed records. Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 18 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP31 Regulation 8(1b)(iii) & 2. 19 (1b) Sch 2(4) 17(2) Sch 4(6e & f) Requirement The Providers need to make a decision on the future Management of the home. The Providers must obtain written verification of the reason a person left a former care position wherever practicable. Ensure all employed staff have contracts and statements of terms and conditions of employment on file. Repair the identified external door/window that doesn’t shut properly. All hours worked by Mr and Mrs Ramnial must be recorded in the home, as they are part of the staffing complement. Ensure a comprehensive, continuous self-monitoring system is in place in the home (Quality Assurance System). Timescale for action 20/03/06 2. OP29 20/03/06 3. OP38 20/03/06 4. OP19 16(2c) 20/03/06 5. OP27 Sch 4(7) 20/03/06 6. OP33 24 20/06/06 Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 20 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 OP2 Good Practice Recommendations Ensure terms and conditions of the resident contract comply with the Office of Fair Trading Standards 2004 Bafford House Rest Home DS0000016378.V267141.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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