Inspection on 22/09/05 for Balmoral Nursing Home

This inspection was carried out on 22nd September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

Other inspections for this house

Balmoral Nursing Home 15/07/08

Balmoral Nursing Home 08/10/07

Balmoral Nursing Home 17/04/07

Balmoral Nursing Home 18/08/06

Balmoral Nursing Home 19/04/06

Balmoral Nursing Home 06/05/05

Balmoral Nursing Home 02/11/04

Balmoral Nursing Home 01/06/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Balmoral Nursing Home 6 Beighton Road Woodhouse Sheffield South Yorkshire S13 7PR Lead Inspector Shirley Samuels Unannounced Inspection 07:30 22 September 2005 nd 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 Balmoral Nursing Home DS0000021767.V251186.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. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Balmoral Nursing Home Address 6 Beighton Road Woodhouse Sheffield South Yorkshire S13 7PR 0114 254 0635 0114 254 8159 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) None Four Seasons Healthcare (England) Limited (Wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Trudi Ashmore Care Home 90 Category(ies) of Old age, not falling within any other category registration, with number (90) of places Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th May 2005 Brief Description of the Service: Balmoral is a pupose built home,which provides nursing and personal care to older people. It is situated in the village of Woodhouse, within easy reach of shops, churches, public transport and small parks. Balmoral is a large home and accommodation is provided over three floors. There are stairs and lifts to each floor. It has TV lounges and sitting rooms. There are separate dining rooms were service users are able to have meals with other service users or their relatives. Chiropodist, hairdressers and various complementary therapist attend the home. Whist the majority of the service users are permanent, the home also provides short term and respite care. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over five and a half hours. Ten service users, three visitors, four staff and the manager of the home were spoken to, and an inspection of the building was made. What the service does well: What has improved since the last inspection? Since the last inspection some furniture has been replaced and a refurbishment programme is ongoing. A document detailing terms and conditions of their stay at the home has been finalised and being prepared for distribution to service users. NVQ training has recommenced for three members of staff and other training to enhance the skills and knowledge of the staff group, with the aim of providing a better service to the service users has been identified. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 6 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. Balmoral Nursing Home DS0000021767.V251186.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 Balmoral Nursing Home DS0000021767.V251186.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 Each service user did not have a contact/statement of the terms and conditions with the home. EVIDENCE: The manager said that the document detailing the terms and conditions had now been finalised and were being prepared for distribution to the service users. A copy of this document was given to the inspector. The provision of this document to service users and there representatives will ensure that they are informed in writing of the terms and conditions attached to their stay at the home. Balmoral Nursing Home DS0000021767.V251186.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): 7,8,9 &10 Service users health, personal and social care needs were in the main set out in an individual plan of care. Their healthcare needs were fully met and service users were in the main protected by the homes policies and procedures for dealing with medicines. Service users did feel they were treated with respect and that their right to privacy was upheld. EVIDENCE: Three service user care plans were checked, they contained the majority of the information required. The quality and detail of the information was inconsistent and some of the information was out of date. This made finding relevant information difficult and the system for recording and retrieving information more time consuming than necessary Details of care provided to service users were not all recorded in the service users files. Nursing staff information was recorded in the service user files care staff records were recorded in a communication book. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 10 Service users said their health care needs were fully met. The relatives spoken to added that they were kept informed of the their relatives changing health care needs. This ensuring that they felt consulted and informed. Three service user medication records were checked. Issues were noted regarding recording of medication received into the home and the system for stock control. The keys to the medication storage were found insecurely stored. Providing potential unauthorised access. This was brought to the immediate attention of the manager. Service users said they were treated with respect and that their right to privacy was upheld. They Said staff always spoke to them in a proper manner and always offered them reassurance and a kind word. This promoted a sense of wellbeing and worth. Relatives said staff were attentive, kind and thoughtful towards service users, and visitors were always made welcome. Balmoral Nursing Home DS0000021767.V251186.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, & 15 Service users find the lifestyle and experience in the home matches their expectations and preferences. They were able to maintain contact with friends and family and with the local community as they wish. Service users were helped to exercise choice and control over their lives. The meals provided were wholesome appealing balanced and provided in pleasing surroundings at times convenient to them. EVIDENCE: Service users said that activities were provided on a regular basis. The records showed that various activities took place both inside and outside of the home. This ensured that service users were offered the opportunity to socialise and provided stimulation. Relatives said they were encouraged to keep in touch and visit the home. They confirmed they were made welcome when they visited, and that they had been provided with information about the home and of the care to be provided. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 12 Service users said that staff were very supportive and encouraged them to make choices. Staff gave examples of how on a daily basis they promoted the service users rights to choice. Service users said being given a choice about how to spend their day and who to spend time with was important and provided them with control over their lives. Service users said in the main they were satisfied with the food provided, they were given a choice and the menu was varied. They said they were offered an alternative if they did not like what was on the menu. This ensured that service users received a diet that was in line with their wishes and preference. Staff were observed offering assistance with eating where necessary, this was done discreetly and sensitively. This ensured that service users dignity was respected. Service users were offered drinks and snacks between meals, it was observed that only tea was offered. When staff were asked why this was there was no reason for this. Arrangements were made immediately to ensure that choices of drinks were offered between meals. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 13 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): 16 & 18 Service users, their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. The policies procedures and practise in the home protected service users from abuse. EVIDENCE: The home has a written complaints procedure, which is distributed to service users and their representatives as part of a pack of information on admission to the home. Providing them with the procedures to follow if they had a complaint. Service users said they did know how to make a complaint and they did have someone to talk to if they were unhappy. Since the last inspection the CSCI has received one complaint about the home regarding record keeping, access to the nurse call system and responding to the needs of service users. The CSCi carried out an investigation. The complaint was upheld and the manager was issued with requirements to address the issues. Records were kept at the home of all complaints, the issues raised the outcome of any investigation and of the action taken. This ensured that appropriate records were kept in line with the regulations. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 14 The staff spoken to were able to verbalise the action they would take if an allegation of abuse was reported to them. They said the home had a policy, which they were aware of, but felt that refresher training was necessary. The manager said training had been booked for key staff on the Protection of vulnerable adults. This will ensure that staff receive up to date information regarding procedures, ultimately reducing the risk of harm to service users. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 15 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 & 26 Service users live in a safe clean pleasant and hygienic environment. Some areas of the home were not maintained to the standard required. EVIDENCE: Service users said they were happy with their bedrooms and they were able to bring personal items into the home with them. This provided service users with the opportunity to personalise their bedrooms. The majority of the bedrooms were single, double rooms were available. This provided choice for couples and individuals who wanted to share. Relatives spoken to said the home was always clean and they observed staff arranging times with service users for cleaning bedrooms. Service users said they were comfortable, able to get around the home and the gardens if they wished and felt safe at all times. This promoted a feeling of wellbeing. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 16 Since the last inspection some replacement of furniture had taken place. Some carpets, furniture and décor remain in a poor state of repair, and failed to meet the National Minimum Standards. The manager said that there was a programme of replacement and refurbishment in place, which was being actioned. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 17 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 & 30 The number and skill mix of the staff met Service users needs. Staff are competent to do their job. 50 of the care staff are not yet trained to NVQ level 2. EVIDENCE: The service users said they had confidence in the staff and felt that the staff were competent and knew how to do their job. They said there always seemed to be enough staff on duty and that calls for assistance was usually provided without delay. They added, staff did not “over fuss”. This promoted service users freedom of choice and independence. On the morning of the inspection (due to staff sickness) the staffing levels were below that which was required for the number and needs of the service users. Cover arrangements were made ASAP to ensure that service users needs were met. The manager said there had been a delay on NVQ training for care staff. She added that three staff had now been registered for the training with a rolling programme in place to for remaining staff. This will ensure that 50 of the care staff are trained to NVQ level 2 in care. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 18 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): 37 & 38 Service users records were insecurely stored. In the main the health safety and welfare of the service users and staff are promoted and protected. EVIDENCE: Service users files were kept in a cupboard this was not locked and files were accessible to unauthorised persons. Staff said they had received health and safety training, which included safe moving and handling and fire training. They said appropriate equipment was provided eg hoist, wheelchairs, gloves, aprons etc. Records of accidents were kept and a system was in place for monitoring accidents, with the aim of reducing risk of harm to service users. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 19 Hazards were observed which included heated food trolleys being left unattended creating a risk of burning, as they were very hot inside. Setting lotion insecurely stored, uncovered loft space, creating fire hazard. These issues were brought to the attention of the manager. One service user was seen sitting in a wheelchair labelled with another service users name. When asked about this the staff said that the service user could weight bare but was unable to walk, but did not have his own wheelchair. This was reported to the manager. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 20 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 2 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x 2 2 Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 21 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 OP2 Regulation 5 Requirement Each service user must be provided with a written contract/statement of terms and conditions with the home. (previous timesale of,10/1/05 not met) Each service user must have a care plan that includes all the information detailed in the, Natianal Minimum Standars and the Care Homes Regulations. The care plan must be kept under review and contain up to date information. Arrangements must be in place for the recording, handling, safekeeping and safe administration of medicines received into the home. Service users must be offered a choice of drinks and snacks in between meals. Staff must receive training on the protection of vulnerable adults. All areas of the home used by service users,including floor coverings and décor must be well maintained and in a good DS0000021767.V251186.R01.S.doc Timescale for action 01/12/05 2 OP7 15 01/12/05 3 OP9 13 10/10/05 4 5 6 OP15 OP18 OP19 16 13 16 10/10/05 10/01/06 01/12/05 Balmoral Nursing Home Version 5.0 Page 22 7 8 OP37 OP38 17 13 state of repair. Previous timescale of, 10/1/05 not met. Service users records must be securly stored. All parts of the home used by service users must be, as far as possible free from hazards. The service user identified must be reffered for assessment to establish wether or not he requires a wheelchair. 10/10/05 22/09/05 9 OP38 13 10/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 1 OP9 The approach to care plan development should be consistent. Information regarding the needs of service users and of the care provided should be recorded in the service user file. Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. Extracts may not be used or reproduced without the express permission of CSCI Balmoral Nursing Home DS0000021767.V251186.R01.S.doc Version 5.0 Page 24 - 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. 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