CARE HOMES FOR OLDER PEOPLE
Bancroft Gardens Waterside Stratford On Avon Warwickshire CV37 6BA Lead Inspector
Lesley Beadsworth Key Announced Inspection 10:00 16 & 17th July 2008
th 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.V367104.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. Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 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.V367104.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th April 2007 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. The registered manager advised that the current fees are £475.00 to £595.00 per week for a single room and £450.00 a week if sharing a room. Additional charges are made for hairdressing, chiropody, aromatherapy and dry cleaning. Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes.
The inspection included a visit to Bancroft Gardens. As part of the inspection process the registered manager of the home completed and returned an Annual Quality Assurance Assessment (AQAA), which is a self-assessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service. Information contained within this, from previous reports and any other information received about the home has been used in assessing actions taken by the home to meet the care standards. Three residents were ‘case tracked’. This involves establishing an individual’s experience of living in the care home by meeting or observing them, talking to their families (where possible) about their experiences, looking at resident’s care files and focusing on outcomes. Additional care records were viewed where issues relating to a resident’s care needed to be confirmed. Other records examined during this inspection included, care files, staff recruitment, training, social activities, staff duty rotas, health and safety and medication records. The inspection process also consisted of a review of policies and procedures, discussions with the manager, staff, visitors and residents. The inspection visit took place over two days on 16th July between 10:00am and 5:45pm; 17th July between 10:00am and 7:35pm. What the service does well:
Bancroft Gardens offers comfortable, homely and generally well-maintained surroundings for the people living at the home. The home’s Statement of Purpose and Service User Guide were looked at and contained detailed information that would enable a person to make a choice about moving into the home. Apart from evidence related to orthoptic care residents on going health care needs were being met with evidence of visits made by other health care personnel. Records for falls, pressure areas and weight were in place within the files looked at. Completed risk assessments for nutritional screening, use of bedrails
Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 6 and a manual handling risk assessment were also in place. These would help to minimise any risks. One file looked at showed that the appropriate steps were taken for a resident who had lost weight thereby protecting that person’s well being. Terms of preferred address were on the residents care plan and heard to be used by staff. Residents were seen to be cared for in a respectful manner ensuring that their dignity and self-esteem are maintained. Residents spoken with confirmed that they were treated respectfully. All care plans and daily records within the files looked at of deceased residents at the home showed that the staff had given appropriate and good care and that all levels of staff had showed compassion and in most cases continued to care for the residents in the home amid familiar surroundings and people as they and/or their relatives had wished. There was a good range of activities included in the programme provided and residents said that they were occupied during the day. Observations made and discussion with residents showed that people living and staying at the home have the opportunity to make choices in their daily lives. Visiting was unrestricted and visitors were seen to be welcomed and to have comfortable rapport with the manager and staff. All relatives spoken with felt that a good standard of care was being provided and had no concerns or complaints about the care provided. There were positive comments made by residents about the food at Bancroft Gardens, such as “there is plenty to eat” and “the food is very good”. Meals were well presented, looked appetising and nourishing and appropriate plates, glasses and cutlery were used. One resident said, “the staff are very patient”. Another resident described staying at the home as to like staying at a “hotel”. Throughout the meal taken with residents comments made were positive about the care at the home and that they felt their needs were being met. In a survey returned to us a visitor commented, “the meals are excellent and prepared from fresh ingredients (on more than one occasion whilst visiting we have held the door open for the local butcher and grocer)”. The complaints procedure was displayed on notice boards in the corridors and was in hand books provided in each resident’s room. All recruitment practices safeguard residents from the employment of unsuitable people. Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 7 Bedrooms were personalised and presented as clean and tidy and well furnished. One resident visited in their bedroom had a tracking hoist over their bed to assist safe transfers between bed/armchair/commode. This person also had an electric reclining/rising chair, which provided increased independence. There are sufficient staff available to meet the needs of the residents. The importance of training is recognised. All but recently appointed care staff had achieved National Vocational Qualification (NVQ) Level 2 in Care, which shows that they have been assessed as competent to carry out their role. Satisfactory recruitment practice protects residents from the employment of unsuitable people. The rota showed, and the manager said, that if a resident was poorly there were two waking night staff and that if a resident was at the end of life then the manager would support the staff and residents throughout the night. There was evidence to show that if a person had been appointed after receipt of a Protection of Vulnerable Adults First clearance but before a Criminal Records Bureau clearance had been received they did not work unsupervised and undertook induction training during this period. The manager confirmed that a risk assessment related to this has since been produced to demonstrate what action is put in place to protect residents. The registered manager is a registered nurse and has the Registered Managers Award qualification. She and all staff were helpful and cooperative throughout the two days of the meeting and showed an intention to meet all requirements and comply with regulations. Several issues raised during the visits were addressed immediately and a comprehensive action plan was forwarded to us soon after the inspection detailing how other issues had been, or would be addressed. The home has had the Investors in People Award for approximately twelve years. There was evidence from a random check of records, that equipment was regularly serviced and maintained, health and safety checks were carried out and that in house checks on the fire system were up to date. What has improved since the last inspection?
The team had obviously worked hard to improve care plans and had devised and implemented a new format for these. Care plans to prevent the incidence of pressure sores were provided in care plans looked at.
Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 8 There was a big improvement in the medication system. The manager and acting deputy manager had carried out daily or weekly audits and staff had been assessed with regard to their competence. Copies of prescriptions were being made and kept in order to check the medicine received against the medicines ordered. The manager had ordered a new controlled drug cabinet two months previously and was awaiting delivery. This would be in line with new guidelines. It was apparent that the manager had given a great deal of thought to how medication could be transported around the home in a safe manner and had tried several different methods but none of these maintained medication security in the event of an emergency whilst they were being administered. This was resolved after discussion at the visit by the home purchasing a locked metal box that could be transported around the home. All chains had been removed from doorways thereby removing the risk of them being used as a form of restraint. Residents and/or their representatives were being involved in the drawing up of their care plans to ensure that they were in agreement with the plan and that it matched their wishes. The home no longer used the term ‘pocket money’ and used the more age appropriate ‘personal allowance’. A new policy and procedure had been implemented regarding money held on behalf of residents. Gravy and sauceboats were on the tables in order that residents could help themselves and offering choice. The policy and procedure for security and management of money belonging to residents had been rewritten in line with recommendations made at the previous inspections. Staff supervision was taking place and evidence of this was seen in staff files. The manager advised that this was on target to be undertaken six times a year. Records related to hot water temperatures were in good order. What they could do better:
Pre admission assessments did not contain sufficient information to show that the home had sufficient information to make a decision as to whether they could meet the needs of the prospective resident. this assessment must take place before it is agreed that the person will move into the home. There was information absent from several of the care plans viewed, mainly in relation to challenging behaviour. To ensure that people living at the home receive person centred support that meets their needs all relevant information regarding care requirements must be included in their individual care plan.
Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 9 Staff did not have the information they needed to ensure that two people with specific dietary needs had the appropriate diet to maintain their well being. There was no record of residents having had any vision testing. Whilst staff had undertaken training related to adult abuse (safeguarding) some of this was not in line with Local Authority policy and procedures, in particular what action should be taken if abuse is alleged or suspected. Staff must undertake appropriate training related to safeguarding in order to respond appropriately to protect residents. Complaints received by the home were recorded briefly in the same folder as residents’ meetings and did not discuss any investigation or what action was taken in any detail. More formal and detailed recording was discussed and the manager provided us with an appropriate format during the visit. There was no adequate or appropriate hand washing facilities to maintain infection control. The manager was taking steps to address this. Some soiled items were being rinsed in residents’ wash hand basin prior to being taken to the laundry. Visitors and residents have always had full access to the kitchen area and meals for the community are made and delivered from there. It was seen to be quite a busy thoroughfare and therefore could create the risk of cross infection. A gift card was found in the file of financial records viewed but there was no record of where this came from or when it was received. In order to protect the financial interests of people living at the home a record must be kept of all valuables received on their behalf for safe keeping. Although addressed promptly during or immediately after the inspection visits, there were several concerns regarding health and safety. A resident who had been assessed to require bedrails had these in place but the bumpers assessed to be needed to prevent the trapping of head or limbs were missing. The hairdresser’s equipment, which included ammonia based products and hair dye were found in the small lounge on the second day of the visit. These were in reach of any resident and a hazard to residents with limited understanding. Alcohol was in an unlocked cupboard in the room also accessible to residents. As far as practicable an environment that is free from hazards must be provided for the people living at the home. This will safeguard their health and well-being. Summaries of several residents’ reviews were recorded on the same page. As these notes had not been copied to individual care files they created concerns related to the Data Protection Act and residents having access to their own information. Individual records must be maintained in accordance with the Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 10 Data protection Act 1998. this will ensure the confidentiality of individuals whilst enabling them to have access to their own information. The rota was not easy to follow and did not show the designation of the members of staff. In some cases a code was used rather than the hours worked. Rotas should show the capacity in which the members of staff worked and the hours each member of staff worked, with a key for any code or abbreviation used. 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. Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 11 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.V367104.R01.S.doc Version 5.2 Page 12 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): 1,3 Quality in this outcome area is adequate. Information required to make a decision about choice of home is available when needed. Pre-admission assessments are not recorded in sufficient detail to show if the needs of prospective residents can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s Statement of Purpose and Service User Guide were looked at and contained detailed information that would enable a person to make a choice about moving into the home. The fees for living there were not included in the Service User Guide but there was a brochure given to prospective residents at the same time and included these fees. The manager advised that a contract is given to a resident after the four-week trial period. However this should be provided on the first day of a person’s admission to the home.
Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 13 Pre admission assessments were available in all care files looked at. Although these covered all the required areas of assessment they were fairly brief. The Assessment of Daily Living completed following admission were in much more detail and would be more useful to demonstrate whether a person’ needs could be met at the home. Two pre admission assessments looked at showed that the person had a diagnosis of dementia prior to admission. The home is not registered with us to care for people with dementia and therefore the home must not agree to admit anyone with dementia. Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 14 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. There are some shortfalls in the information contained in care plans that may carry the risk of residents’ needs not being met. Residents have access to health care professionals and are cared for in a respectful manner. The medication process safeguarded residents’ well-being. People living at the home are cared for in a respectful manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care files of three residents were examined as part of the case tracking process. Other care files were looked at to provide further information. It was evident that the manager and deputy manger have made efforts to improve the quality of the care plans and had implemented new forms of short and long-term care plans. The manager said that consultation with staff regarding the care plans had taken place and feedback from staff has guided management in the development of the care plans. Residents and/or their representatives had been involved in drawing them up. Care plans were consistent with the assessment of daily living that were completed one week
Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 15 after admission but were brief and mainly only gave an outline of the care required to meet the needs of each person. There was information absent from some care plans. For example in one care plan details relating to ‘aggressive behaviour’ had not been clearly recorded. There was little information informing staff of the triggers identified that could lead to the person displaying ‘aggressive behaviour’. There was no risk assessment in place to advise staff how to minimise the risks of this behaviour occurring or for how staff needed to respond when such behaviours were seen nor any information available on how staff protect the resident or other residents and staff when these behaviours occur. On the second day of the inspection visit the resident was seen to hit a member of staff on the face. Another care plan showed that a resident had diabetes and although their name was included in the kitchen plan there were no specific “do’s and don’ts” required for the diets either on this or in the care plan. The care file for this person did not advise on any mental health needs even though there was a diagnosis of dementia. General care needs are met by care staff as was confirmed by observations made, discussion with staff, visitors and the people living at the home. A good care plan viewed of a resident without specific or complex needs included the information needed to provide support to this resident and had been signed by them, showing their involvement and agreement. However there was evidence that challenging behaviours were not met in a consistent way and good care planning would assist staff so that the residents receive the support they need. One care file recorded two room numbers, which could be confusing to new or temporary staff. The care plan Residents on going health care needs were being met with evidence of visits to or visits by the GP, District Nurse, chiropodist and Community Psychiatric Nurse being identified in discussion and in the care files looked at. There was no evidence of optician support in any of the care plans viewed including those with specific concerns regarding vision. Records for falls, pressure areas and weight were in place within the files looked at. Completed risk assessments for nutritional screening, use of bedrails and a manual handling risk assessment were also in place. These would help to minimise any risks. Another file showed that the appropriate steps were taken for a resident who had lost weight. One file of a resident with diabetes included a chart measuring blood sugar levels on a weekly basis and these had remained within normal limits. One resident with bedrails had a risk assessment in place that claimed ‘bumper’ pads were in use to prevent head or limb entrapment but on the second day of the visit these were not being used. They were replaced
Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 16 promptly after the manager was alerted to their absence. A member of staff advised us that the bumpers had been in the laundry. Preventative measures such as pressure relieving mattresses and cushions were seen to be in use for several residents. There was a big improvement in the medication system. The manager and acting deputy manager had carried out daily or weekly audits and staff had been assessed with regard to their competence. Copies of prescriptions were being made and kept in order to check the medicine received against the medicines ordered. The manager had ordered a new controlled drug cabinet two months previously and was awaiting delivery. This would be in line with new regulation related to safe storage of medication. It was apparent that the manager had given a great deal of thought to how medication could be transported around the home in a safe manner and had tried several different methods but none of these maintained medication security in the event of an emergency whilst they were being administered. This was resolved after discussion during the visit. We were later advised that the home had purchased a locked metal box that could be transported around the home, and if staff needed to attend to an emergency the box could be locked to keep the contents secure. Medication Administration Record Sheets were looked at and there were no unexplained gaps or inappropriate codes. The home had introduced a code to identify if one or two tablets had been given when the instructions gave that choice. A protocol for PRN (as required) medication was included in the Medication Administration Record Sheets folder. The home had a homely remedy policy that suggests residents purchase any over the counter medications and take responsibility for this themselves. However this does not protect residents with limited understanding and could mean that a doctor needs to be consulted for treatment of minor ailments such as occasional aches and pains. Despite this one resident regularly took a branded painkiller and a letter from the GP was on file to confirm that the GP was in agreement with this. An audit of some medication of residents that were case tracked was looked at and all were accurate and tallied with the Medication Administration Record Sheets. All staff responsible for medication had undertaken training in the safe handling of medication. Terms of preferred address were on the residents care plan and heard to be used by staff. Residents were seen to be cared for in a respectful manner Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 17 ensuring that their dignity and self-esteem are maintained. Residents spoken with confirmed that they were treated respectfully. The home no longer used the term ‘pocket money’ and used the more age appropriate ‘personal allowance’. Due to there having been a high number of deaths at the home during the last two years a large number of care files of late residents from the home were viewed. All care plans and daily records within these files showed that the staff at the home had given appropriate and good care and that all levels of staff had showed compassion and in most cases continued to care for the residents in the home amid familiar surroundings and people as they and/or their relatives had wished. Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 18 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. Residents are occupied and stimulated. Visitors were made welcome and their needs considered. Residents had choices and control over many aspects of their daily lives. Residents enjoy the nutritious and varied meals provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was a good range of activities included in the programme provided and residents said that they were occupied during the day. The programme included walks in the adjacent public gardens, visits from 6th form students to play board games or cards; Roman Catholic services on Sundays and monthly Baptist church services; weekly visits to the local market in the summer; monthly exchange of library books. One resident was unable to continue to be active in a previous pursuit but was supported in maintaining an interest. Two residents spoken with said that their faith was important to them and that their families supported them to attend church when they wished. Some residents were watching television in the lounge; one resident was knitting; the hairdresser was in attendance on the morning of the first day; a member of staff member of staff was seen to be playing cards and chatting with a resident on one occasion and there several visitors during the two days. No other organised activity was observed during the two visits. The manager said that
Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 19 she had cancelled the weekly aromatherapy session that was due on the first day as she thought it might disrupt the inspection visit. Observations made and discussion with residents showed that people living and staying at the home have the opportunity to make choices in their daily lives, such as when to get up and go to bed, what to eat, whether to join in activities or not and where to spend their time. Visiting was unrestricted and visitors were seen to be welcomed and to have comfortable rapport with the manager and staff. Three relatives were spoken with over the two day period. All relatives spoken with felt that a good standard of care was being provided and had no concerns or complaints about the care provided. Those asked said that they knew who to contact if they had any concerns and felt that they would be listened to. Two weeks of menus were seen and show a varied and balanced diet with a choice of two meals offered each day. With a note stating that other dishes e.g. poached / boiled eggs are available for supper each day on request. Breakfast choice included the option of a cooked breakfast. We joined residents for lunch on the first day of the inspection. There was meal choice of gammon, potatoes and vegetables or vegetable lasagne, potatoes and salad. Appetising choices of pudding were offered. None of the residents spoken with knew what to expect for lunch although some of them were asked what their choice was whilst we were sitting with them. There were positive comments made by them about the food at Bancroft Gardens, such as “there is plenty to eat” and “the food is very good”. All of the meal was well presented, looked appetising and nourishing and appropriate plates, glasses and cutlery were used. Sauces to accompany the meal were provided separately to the meal to offer choice. A choice of two fruit juices was offered during the meal and tea or coffee after the meal. During lunch the people we joined spoke about the care they received at the home and one said, “the staff are very patient”. Another resident described staying at the home as to like staying at a “hotel”. Through the meal all comments were positive about the care at the home and that they felt their needs were being met. In a survey returned to us a visitor commented, “the meals are excellent and prepared from fresh ingredients (on more than one occasion whilst visiting we have held the door open for the local butcher and grocer)”. Two residents who prefer to have their lunch in the lounge were observed. They both sat with their meals on trays on their laps and food was seen to fall off their plates. This was discussed with the manager who explained that staff have made continuous efforts to encourage them to use tables or bean cushion Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 20 trays, however they have refused. The two residents also told us that they were happy with the way they were served their meal. The kitchen was viewed and apart from a small area of worktop trim, which was missing and which could have been a source of infection, the area was clean and well maintained. Two items of food in the fridge were not dated to ensure that they were used or disposed of by their use by date. Both these shortfalls were addressed as soon as they were pointed out to the manager. Visitors and residents have always had full access to the kitchen area and meals for the community are made and delivered from there. It was seen to be quite a busy thoroughfare and therefore could create the risk of cross infection. In order to maintain the advantages of residents and visitors having access to the kitchen, for example for the tea making facilities or for access to the rear part of the home, and following consultation with the Environmental Services, the manager might consider creating a separate zone in the kitchen for this purpose with an off-limits zone where food is prepared and cooked. Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 21 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. The home has some shortfalls in the complaints record keeping but has the policies, procedures and practices to safeguard residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure was displayed on notice boards in the corridors and was in hand books provided in each resident’s room. Complaints received by the home were recorded briefly in the same folder as residents’ meetings and did not discuss any investigation or what action was taken in any detail. The manager advised that concerns and minor complaints were dealt with informally and as they arose. Discussion took place regarding the differences between complaints and concerns. There is a need for more formal and detailed recording for complaints, and the manager provided us with an appropriate format during the visit. Following the visit an improved version was forwarded to us and the manager advised that these were now in use. Staff had attended Protection of Vulnerable Adults training carried out by outside contractors but some of the content of the course and a flow chart provided by the trainers was not in line with the Local Authority procedure for how to follow up any safeguarding allegations, incidents or suspicions. The manager said that she would contact the Local Authority safeguarding team to discuss this.
Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 22 A safeguarding allegation made last year was currently under investigation. All recruitment practices safeguard residents from the employment of unsuitable people. Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 23 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): 19,20,21,22,24,26 Quality in this outcome area is adequate. The home offers the people living there comfortable surroundings, which are clean, free of offensive odour and generally safe and well maintained but with some shortfalls in infection control and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Bancroft Gardens offers comfortable, homely and generally well-maintained surroundings for the people living at the home. These surroundings are free of offensive odour apart from an empty bedroom used by the inspectors during the two days. This room had a distinct smell of urine, which will need to be addressed before a resident can use it. The rest of home did not have such odours; however there were smells in some areas of the home that arose from the cooking in the Indian and fish and chip restaurants over which the home is built.
Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 24 We carried out a tour of the home including case tracked residents’ and other residents’ bedrooms. Rooms were personalised and presented as clean and tidy. Staff provided personal care to residents in their bedrooms but the only hand washing facilities available for staff in close proximity to the bedrooms or the laundry area were in the residents’ ensuite rooms but as there were no disposable towels or soap dispensers provided this could be a source of cross infection. Discussion with the manager in relation to this promptly led to soap dispensers being provided by the manager in each ensuite and the manager stating that residents would be asked if they are happy for disposable towels/dispenser to be in these areas. The manager also said that she would seek advice regarding a wash hand basin being fitted in the shower room for care staff and for the housekeeper when using the laundry next door. This facility should also be pursued for the bathroom to enable staff to wash their hands if personal care has been provided in this room. One resident visited in their bedroom had a tracking hoist over their bed to assist safe transfers between bed/armchair/commode. This person also had an electric reclining/rising chair that provided increased independence. There were no bumpers on the bedrails used by the occupant of one bedroom viewed. These are needed to minimise the risk of the person trapping their head or a limb in the rail gaps and the subsequent risk of injury. The bumpers were replaced whilst the inspectors were still in the building. Staff said that they had been taken to the laundry. All chains had been removed from doorways thereby removing the risk of them being used as a form of restraint. The home had two lounges, one in the centre of the home and a smaller, brighter room at the front of the premises. Only the centre lounge was being uses as a sitting room during the visit with the smaller room being used by the hairdresser on the first day. This is an attractive room, which benefits from windows across the front. The main lounge was clean, well furnished and decorated and had a small attractive stained glass window but no other natural light. The hairdresser’s equipment, which included ammonia based products and hair dye were found in the small lounge on the second day of the visit. These were in reach of any resident and a hazard to residents with limited understanding. Alcohol was in an unlocked cupboard in the room also accessible to residents. The manager later advised that the hairdresser claimed she had left them behind in error and that she collected them the following day. However it would seem that either no one had noticed that they were there and/or had put them in a secure location. Bottles of alcohol were also stored in an unlocked cupboard in this room, which could also be a hazard to those residents with limited understanding. The manager attended to this promptly when it was pointed out to her but all staff need to be more aware of such safety issues.
Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 25 There is no garden at Bancroft Gardens but a roof terrace is available for residents’ use. The door to this was unlocked at the time of the visit. It was considered by us that this was not a safe space for resident with dementia/limited understanding to have unsupervised access. The manager said that this was usually locked with the key left on a high hook by the door but it had been left open to hang clothes to dry. This practice changed as a result and the manager advised that the housekeeper now has a key to this door on the key ring so that it can be locked after attending to the washing. The laundry was visited. This is a very small area/large cupboard but contains the appropriate equipment. Walls and the floor are washable in order to maintain infection control. Care staff bring soiled clothing to the laundry room in red disposable plastic bags and the housekeeper, who does all the laundry, puts them into the washing machine on a soiled wash programme. One member of staff informed that there are occasions when staff use residents’ sinks to wash off excess soiled garments before placing garments in the red bag. This creates an infection control concern. As previously mentioned the laundry area does not have any hand washing facilities and the housekeeper uses residents’ ensuites for this purpose. The housekeeper does not wear a protective apron or disposable gloves when carrying out laundry tasks, which may also be an infection control risk. Following the inspection visits the manager advised that the gloves were not worn as they cause skin irritation to the person and kitchen rubber gloves would be provided. The manager needs to check with infection control personnel about the appropriateness of this and an alternative to vinyl gloves but which are still disposable, may need to be considered. Disposable gloves were seen to be readily accessible with each member of staff having their own named supply. Products used for cleaning are stored away safely in a locked room. Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 26 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. There are sufficient care staff available to meet the needs of the residents. Satisfactory recruitment practice protects residents from the employment of unsuitable people. The importance of training is recognised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Comments about staff made by residents and visitors were positive and in a survey returned to us a relative said, “Have nothing but praise for all of the staff at the home who are kind and compassionate and can be seen to have genuine affection for all of the residents.” A letter received by us from an outside contractor commented that when seeing staff and the manager “not under inspection” had “always witnessed nothing other than the highest levels of care, love, respect and compassion shown to all residents”. There were sufficient care staff available to meet the needs of the residents. Staff rotas were looked at and showed that the number of care staff during the day was three in the morning and afternoon, two in the evening and one during the night with a member of staff sleeping in for if they were needed. in addition there was a senior member of staff on duty for each shift apart from night duty. The rota showed, and the manager said, that if a resident was poorly there were two waking night staff and that if a resident was at the end of life then the manager would support the staff and residents throughout the
Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 27 night. Sufficient domestic, catering staff and administrative staff were also provided throughout the day. Observation and discussion with management and other staff confirmed that these were the normal staff numbers. The rota was not easy to follow and did not show the designation of the members of staff. In some cases a code was used rather than the hours worked. Rotas should show the capacity in which the members of staff worked and the hours each member of staff worked, with a key for any code or abbreviation used. All care staff apart from those recently appointed have achieved National Vocational Qualification Level 2 in Care. This qualification shows that staff have taken appropriate training and that they have been assessed to be competent in their role. Staff files showed evidence of induction training taking place with all new staff. All staff have undertaken training related to dementia care. Other training undertaken by staff during this year includes mandatory training related to health and safety processes and training related to conditions common in care for older people. Staff have undertaken training related to adult abuse but the registered manager needs to confirm that this training is up to date and in line with the Local Authority policies and procedures. Three staff records were looked at, all of which had the appropriate documentation and information required to safeguard residents from the employment of unsuitable people. There was evidence to show that if a person had been appointed after receipt of a Protection of Vulnerable Adults First clearance but before a Criminal Records Bureau clearance had been received they did not work unsupervised and undertook induction training during this period. The manager confirmed that a risk assessment related to this has since been produced to demonstrate what action is put in place to protect residents. Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 28 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): 31,33,35,36,38 Quality in this outcome area is good. A person with the appropriate qualifications and who has extensive management experience manages the home. There are shortfalls in the monitoring and auditing of the service and practices to ensure that all services operate in the best interests of residents and shortfalls in health and safety practice thereby not protecting residents and staff at the home. There are minor shortfalls in safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is a registered nurse and has the Registered Managers Award qualification. She is also the registered manager of a domiciliary service that is managed from the same premises and she and her husband are registered providers of the services. A service for cooking and delivering meals
Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 29 in the community is also provided from the home. This is not a registerable service and therefore is not inspected by us. This also applies to day care for one person that has been provided by Bancroft Gardens although there were no day care service users at the time of the visit. The manager should continue to consider the practicalities of managing all three services. The deputy manager had left the home some months previously and a temporary deputy manager had been appointed. She was present on the morning of day one of the inspection visit and had been working with the manager to comply with requirements from the previous inspection. The manager was helpful and cooperative throughout the two days of the meeting and showed an intention to meet all requirements and comply with regulations. Several issues raised during the visits were addressed immediately and a comprehensive action plan was forwarded to us soon after the inspection detailing how other issues had been, or would be addressed. The manager indicated that one ancillary member of staff was not willing to be included in training sessions but discussion took place as to how this could be addressed on a one to one basis in order to ensure the member of staff had the appropriate information to carry out their role safely and in a way that protects residents. A new policy and procedure had been implemented regarding money held on behalf of residents. Case tracked residents finances were viewed. Two pages did not record the year of transactions, otherwise all monies were correct. Receipts were available, however not all transactions had been debited from individual accounts. The manager informed us that this was in relation to hairdressing, which is accumulated and debited over a period. A gift card for £10 was in the folder for one resident but when it was received and from whom was not recorded. Records of any valuables received on behalf of residents must be maintained showing the date it was received, the purpose the money or valuables were used returned or a written acknowledgment of their return to the owner. Not all transactions were recorded in chronological order by the bookkeeper, which could make reconciliation of records and receipts more difficult. The home carried out resident surveys in August 2007 and April 2008. Some surveys were completed by residents and some by families. The comments were mainly positive and indicated that the home was monitoring the service in order to enable growth and improvement. Areas of the service, such as medication, were being audited but this needs to extend to all areas. The home has had the Investors in People Award for approximately twelve years. Staff meeting records and residents review summaries were located in the same folder. Summaries of several residents’ reviews were recorded on the same page. As these notes had not been copied to individual care files they
Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 30 created concerns related to the Data Protection Act and residents having access to their own information. Guidance was given regarding this and the manager said that the information would be added to individual residents’ care files promptly. Staff supervision was taking place and evidence of this was seen in staff files. The manager advised that this was on target to be undertaken six times a year. There was evidence from a random check of records, that equipment was regularly serviced and maintained, health and safety checks were carried out and that in house checks on the fire system were up to date. Records related to hot water temperatures were also in good order. There were some hazards to the safety of residents with limited understanding seen during the visits with regard to alcohol and hairdressing products being accessible to them. Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 3 3 3 X 3 X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 32 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 Regulation 14 Requirement Pre-admission assessments must be carried out in sufficient detail to demonstrate the service can meet the needs of anyone before agreement is made to admit that person. Care and catering staff must be provided with sufficient detail regarding special diets. This will ensure that the relevant people receive the appropriate diet to maintain their well being. All relevant information regarding care requirements of people living at the home must be included in their individual care plan. This will ensure that they receive person centred support that meets their needs. Staff must undertake training related to safeguarding that is up to date and in line with the Local Authority policy and procedures. This will ensure that staff are able to identify abuse and to respond appropriately to protect residents. The home must have adequate infection control measures in
DS0000004204.V367104.R01.S.doc Timescale for action 15/09/08 2. OP7 12 15/09/08 3. OP7 12 15/09/08 4. OP18 13 15/10/08 5. OP26 16 15/09/08 Bancroft Gardens Version 5.2 Page 33 6. OP35 17 7. OP37 17 8. OP38 13 place. This will protect the welfare of residents and staff. A record must be kept of all 30/08/08 valuables received on behalf of people living at the home for safe keeping. This will protect the financial interests of people living at the home. Individual records must be 30/08/08 maintained in accordance with the Data protection Act 1998. This will ensure the confidentiality of individuals whilst enabling them to have access to their own information. As far as practicable an 30/08/08 environment that is free from hazards must be provided for the people living at the home. This will safeguard their health and well-being. 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. 2. 3. 4. 5. Refer to Standard OP2 OP8 OP9 OP16 OP27 Good Practice Recommendations Residents should receive a statement of terms and conditions on the day of their admission. The home should demonstrate that the optical needs of people living at the home are met. The home should consider introducing a homely remedy policy that is approved by the GPs for each resident. Records related to complaints should include details of the complaint, the investigations carried out and the outcome. The staff rota should show the actual hours worked by staff and the capacity in which they worked. Bancroft Gardens DS0000004204.V367104.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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