Inspection on 14/09/05 for Bancroft Gardens

This inspection was carried out on 14th September 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

Bancroft Gardens 16/07/08

Bancroft Gardens 25/04/07

Bancroft Gardens 18/01/06

Bancroft Gardens 15/12/04

Bancroft Gardens 27/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bancroft Gardens Waterside Stratford On Avon Warwickshire CV37 6BA Lead Inspector Christy Wannop Unannounced Inspection 14th September 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 Bancroft Gardens DS0000004204.V249405.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. Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bancroft Gardens Address Waterside Stratford On Avon Warwickshire CV37 6BA 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) 01789 269196 01789 263455 Mr D Barnfield Mrs Jeannette Sandra Barnfield Mrs Jeannette Sandra Barnfield Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2005 Brief Description of the Service: Bancroft Gardens is situated in the centre of Stratford-upon-Avon, opposite the Royal Shakespeare Theatre, gardens and the river. All the facilities of the town are easily accessible for residents, either on foot or with the use of a wheelchair. Car parking can be difficult, but there are large public car parks within reasonable walking distance. Access to the home is at street level where the front door leads into a small lounge with a picture window onto the road. Apart from this all the accommodation is on the two upper floors. There is a shaft lift serving all levels, but there are a number of small flights of steps here and there. The home has two lounges and a dining room, a kitchen, two bathrooms, one separate lavatory and a small laundry area. There are ten single and three double bedrooms, all of which have en-suite facilities. Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on an autumn day. Two inspectors visited the home and spoke with staff, service users and one relative and both the manager and deputy. Some records were viewed. Inspectors ate lunch with residents. The Manager has taken action to improve those areas identified by the inspector at the last inspection. The inspection was positive and the inspectors confirmed the good standards of care that have been established at this small, town centre home. What the service does well: 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. Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 6 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 Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 7 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): We looked at the outcomes for standards 2 and 3. There is an assessment prior to people coming to live at the home to ensure that needs can be met. People staying for short periods, particularly where previously known to the Manager may not have such full assessment information. Each service user has a written contract and statement of terms and conditions. EVIDENCE: A detailed assessment process is in use to assess prospective residents needs. Two care plans were looked at, one of a person who had very recently moved to the home, the other of a person having a short stay. The assessment of the new resident had not been fully completed prior to admission and the staff were still in process of gathering all the information needed from family and from staff observations. One person staying for a short stay did not have adequate written information in an assessment for 24 hour care needs in the home, though there was a social services care management assessment. Information for this resident was specific to her service from the providers home care service in her own home. The service user guide contains much of the information usually found in a residents contract. All residents do have contracts. Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 8 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): We looked at outcomes for standards 7 and 9. Care plans are generally satisfactory, being full and informative; however those of short stay residents may not provide sufficient information to support staff in meeting the needs of residents. Medication is generally well managed. Residents are protected by the home’s policies procedures and practice in dealing with medicines. EVIDENCE: Two care plans were looked at, one was still being completed during the first week of admission; the other did not relate to care within the residential home but was the care plan from the provider’s home care service. Notably, continence and nighttime care needs were not addressed. This means that staff may not be able to meet these needs. There was evidence that one care plan had been written using information from the assessment tool. Other care plans in the home showed evidence of good and regular review, involving family and service user. One resident said that they would lie to have more input into their care plan. Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 9 Some elements of care planning were found to be excellent, i.e. mouth care plans. Some care needs were described as “need” and “problems” rather than as strengths and abilities. There was plenty of evidence that in practice staff and the manager promote independence and individuality and that residents were content and confident. Care plans reflected activities enjoyed by residents and how they liked to look and dress. Staff spoken to described the care and backgrounds of the people they were looking after. Medication procedures were observed to be satisfactory and the medication policy was accessible to staff. Staff administering medication had been trained to do so. Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 10 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): We looked at the outcomes for standard 12 and 15. The service has a lively atmosphere. Recreational, social, religious and cultural needs are met. Families and friends are encouraged and welcomed to maintain contact and play an active role in the daily life of the home to ensure that people have choice and control over their life. Meals are well cooked using a high proportion of fresh foods, provided a healthy and varied diet with an excellent vegetarian choice. The dignity and self-respect of residents are promoted through the home’s value of the meal times as a significant part of people’s daily lives. EVIDENCE: Bancroft Gardens provides a busy atmosphere with a mix of individual and group activities. It is ideally placed for spontaneous activity with the gardens and town of Stratford easily accessible. Staff and residents described both planned and impromptu activities. Visiting theatre groups, aromatherapy, mobility sessions, hand massage, hairdresser, and visits from farm animals! The inspector and manager spoke to one family member who shared a positive discussion about ways of promoting independence and dignity for people through leisure. Residents spoke positively of shopping trips, canal side walks and holidays. Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 11 The inspector joined the residents for lunch. Residents confirmed there was a good choice, that food and mealtimes were enjoyable and that staff knew their preferences. Some were delighted to be able to join in vegetable preparation. Table presentation was good with aids for eating being used where needed to aid independence. A choice of two fruit juices and water was available. The atmosphere at lunch was unhurried and jovial and there was evidence that meal times are happy and entertaining. Staff respect and affection for residents was visible. Bancroft Gardens DS0000004204.V249405.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): We looked at the outcome for standards 16 and 18. Here is an effective complaints policy and procedure for residents and their representatives to use. Complaints are taken seriously and acted upon promptly. The service has clear and comprehensive written information about how the prevent abuse of older people and local procedures for dealing with this with social services. EVIDENCE: Systems for managing both complaints and POVA are in place. Staff are trained in both procedures. The Manager talks with residents, holds meetings to ascertain their views and encourages early sorting out of issues. Staff were seen to be respectful, gently spoken and kind towards residents. There have been no complaints or reports of abuse in relation to the service made to the Commission for Social Care Inspection. Bancroft Gardens DS0000004204.V249405.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): We looked at the outcomes for standard 19 and 26 Whilst the home does not have a garden and is limited by unique architectural features, which do not allow for a large laundry or kitchen, the overall environment is very clean, safe and pleasant. The building is imaginatively used. Service users were free to move around the home and to personalise their own private rooms. The investment in the appearance of the home is one of its strengths. EVIDENCE: The laundry has been rebuilt, but remains small and without hand washing facilities or fully washable walls and floors. The manager has invested heavily in a high quality industrial washing machine and the housekeeper reported how she maintains hygiene through good infection control procedures. There was evidence of the rolling programme of maintenance and replacement of furnishing and fittings. There are new good quality beds, a walk in shower room has been created, and lounge chairs have “pressure relieving” seats. The physical environment is comfortable, homely and welcoming. A resident said she liked her room, it was personally decorated and she described her enjoyment of the good view of the town street below. Bancroft Gardens DS0000004204.V249405.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): 30 An ongoing programme of wide ranging training is provided to all staff by a privately commissioned health and social care trainer to ensure residents’ needs are met. Staff are encouraged to develop skills and pride in their job. EVIDENCE: There was evidence in staff certificates of a range of basic and advanced training for care staff, linked to the established NVQ and the governments’ Care for Skills programme. This included; infection control, moving and handling, food hygiene, nutrition, emergency first aid, fire prevention, dementia, protection from abuse, Parkinson’s and a formal induction programme called Introduction to Care. The manager maintains a matrix of training needed and undertaken by all staff. Staff clearly have a commitment to their work and a respect for the residents that is promoted through their close supervision and investment by the Manager in their professional development. Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 15 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): We looked at the outcomes for standard 31 and 33 and 38. The manager and her senior team are skilled and resourceful and operate each shift with clear leadership and direction. The ethos of the home supports the best interests of the residents and is inclusive of the views of residents and their families and staff. Residents, their families and visitors are involved in quality surveys and their opinions and views are sought to develop the service. There were insufficient safeguards to ensure the safety of some residents. EVIDENCE: The Manager trained as a nurse and has developed her skills over many years in the social care field. Both she and her deputy are appropriately qualified. Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 16 The management team supports the staff in their confident caring roles. The manager is also the owner of the business and operates a home care service also from the home. Quality surveys are conducted regularly and an example of the questionnaire used and the results of the survey are presented in the service user guide. There was evidence of some very positive feedback from users of the home, friends and families and health care professionals. Cleaning fluids were placed next to shampoos and soaps in a communal bathroom within easy reach of residents. The Manager explained that she wanted cleaning materials nearby in order that good immediate cleaning could be done after bathing in order to maintain good hygiene. The inspector advised that these could be stored safely and accessibly. The door to the upstairs roof garden, usually locked to residents, was open and should be risk assessed to ensure residents’ safety. The Manager was informed of these risks. Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 17 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 18 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 OP3 and 7 Regulation 14,15 Requirement All people staying at the home must have an assessment and a plan of care that details how their needs are to be met within the residential care home. Chemicals for cleaning must be stored safely and risk assessments cover all identified risks. Timescale for action 01/11/05 2 OP38 13 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Bancroft Gardens DS0000004204.V249405.R01.S.doc Version 5.0 Page 20 - 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. 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