Inspection on 18/04/07 for Bank Hall Residential Home

This inspection was carried out on 18th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bank Hall Residential Home 02/02/06

Bank Hall Residential Home 29/09/05

Bank Hall Residential Home 08/03/05

Bank Hall Residential Home 01/09/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Bank Hall Residential Home Colne Road Burnley Lancashire BB11 2AA Lead Inspector Mr Jeff Pearson Unannounced Inspection 18th April 2007 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 Bank Hall Residential Home DS0000009652.V331919.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. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bank Hall Residential Home Address Colne Road Burnley Lancashire BB11 2AA 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) 01282 838909 01282 448855 bank-hall@tiscali.co.uk Rochecare Limited Vacant post Care Home 36 Category(ies) of Dementia - over 65 years of age (2), Learning registration, with number disability (1), Old age, not falling within any of places other category (33) Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home must, at all times, employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection When named service users no longer reside at the home, application must be made to vary the registration back to the original status of Old age, not falling within any other category (OP)36 The home is registered for a maximum of 36 service users to include: Up to 33 service users in the category of OP (over 65 years of age, not falling into any other category) requiring personal care. Up to 3 service users in the category of DE(E) Dementia over 65 years) requiring personal care. 1 service user in the category of LD (learning disability under 65 years of age) requiring personal care. 2nd February 2006 Date of last inspection Brief Description of the Service: Bank Hall a single story building is a former maternity hospital, which has a purpose built extension. Set in it’s own grounds, Bank Hall is close to a retail park and there are smaller shops quite close to the home. A driveway fronts the building with car parking spaces being available. Lawns and wooded areas surround the home. Garden furniture is provided to the front of the home and upon the rear decking area. Bank Hall is on a bus route with Burnley town centre being a fairly short distance away. There are 3 double bedrooms and 30 single bedrooms. All shared bedrooms and 8 of the single bedrooms have en suite toilets. There are three lounges, two with conservatories and a separate dining room. Various aides and adaptations are provided to assist with mobility and independence. Staff are available, to provide assistance with personal care and support, in response to individual needs/wishes. In house recreational activities are provided and various outings are occasionally arranged. Written information about Bank Hall, including the homes guide and previous inspection reports; was displayed in the reception area. At the time of this inspection visit, the range of fees charged were between £430 and £450 per week, there were additional charges for hairdressing and toiletries, also contributions for outings. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Bank Hall on the 18th April 2007. The visit took 15 hours and was carried out over two days by one inspector. Since the last inspection a new manager had been recruited. Information was gathered from various sources, 15 residents completed and returned questionnaire/surveys and 1 relative completed and returned a questionnaire/survey. Information was obtained from a pre-inspection questionnaire completed by the manager. The files/records of three residents were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of residents. The residents were also spoken with during the inspection. Discussion took place with residents, manager and staff. Various documents, including policies, procedures and records were looked at. Some of the accommodation and facilities were viewed. At the time of the key inspection visit there were 31 residents living in the home. What the service does well: Bank Hall had a welcoming and supportive atmosphere. The staff were friendly and enthusiastic. One resident said she loved living at Bank Hall and liked the friendliness of the staff, “they are very helpful”. Another wrote about staff“They are all kind and helpful to me” There were some good care practices at Bank Hall, including the arrangements for finding out about peoples’ needs, abilities, likes and dislikes before they moved into the home, so that there care could be considered and planned for. One relative explained “We came to look around, spent an hour with the manager, asking questions” The residents personal privacy needs were being dealt with sensitively and they were being treated with respect and as individuals. Residents said “Oh yes they treat me with respect” and “they let me be myself” Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 6 Routines in the home were fairly flexible, so people had some freedom in how they spent their time. “I think I do what I want when I want,” explained one resident. Residents meetings were being held to give people the opportunity to make comments and suggestions. An activity coordinator worked at the home arranging various activities and events, some residents said they preferred to “do there own thing” which was respected. Most residents expressed an appreciation of the food one saying “the food is lovely” Choice menus were available and specific diets could be catered for, another resident said “the food is very good, sometimes not always to my liking, but there’s a choice available, the menus is now on display which is better” Visiting times were flexible so friends and relatives could call at different times, the residents could see people in private, one resident explained “My daughters can visit whenever they wish.” Visitors spoken with indicated they were always made to feel welcome at the home. Staff recruitment practices made sure people were properly checked out and interviewed. To make sure the residents were being well cared for, staff training and development was being given high priority, various training courses had been planned for. Inwardly the home was clean, warm and generally in good order. The residents had been encouraged to personalise their rooms, by bringing with them their own belongings, such as pictures and ornaments this had help create a sense of home and belonging. “I’m very happy with my room” commented one person. Some residents also appreciated the homes grounds and wild life. What has improved since the last inspection? What they could do better: The resident’s individual care plans still needed to include full details of all their health and social needs and how they are to be met, to ensure staff know exactly what to do for each person. Any changes in care needs must be Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 7 written in care plans, to provide clear up to date instructions for staff. The residents should be more involved when their care plans written and reviewed they should where possible, sign in agreement with them. Medication management, policies and practices, needed further attention for the protection of residents and staff. The management of complaints needed some attention to make sure any concerns are more effectively dealt with. To make sure there are always enough staff to sufficiently and safely care for the residents, action needed to be taken to make sure all shifts are covered and that staffing arrangements are kept under review. To promote better accountability of residents’ fee payments, individual records needed to be kept showing all amounts. 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. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 8 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 Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 9 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): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process ensured peoples needs and wishes were properly considered prior to moving into the home. EVIDENCE: The records of the most recently admitted residents showed assessments had been carried out. Social services assessment information had been obtained as appropriate. The document used by the home for assessing people covered various health and social care needs and abilities, along with personal preferences about daily living. Records showed the residents and their relatives had been involved with the assessment process. One relative spoken with said staff had carried out an assessment when her mother came to look around the home. The manager and staff said people were also visited in their own location. Some residents had previously stayed at the home on a short stay Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 10 basis this had helped them to become familiar with the home and had enabled staff to get to know their needs. Residents surveys indicated they had received enough information about the home before they decided to move in, also that they had a contract of residence. The homes guide was displayed in reception area. It was advised the guide be reviewed and updated as appropriate, to include the requirements of the amended regulations and changes in management. Intermediate care was not provided at Bank Hall. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. The residents care plans lacked detail, which meant staff were not always provided with sufficient instructions. Medication management procedures and practices did not fully protect the residents. Support with health and personal care was provided sensitively in a way which promoted the resident’s privacy and dignity. EVIDENCE: Residents spoken with were generally satisfied with the care provided and felt their needs were known and being met. Care staff spoken with expressed an awareness of peoples care needs. Two relatives spoken with were happy with the care and attention their mother received, they visited the home almost every day. The care plans seen as part of ‘case tracking’ included some directions for staff to follow, but specific details of how to provide assistance, for example, with Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 12 personal care such as washing and dressing had not been fully noted. One plan mentioned a history of falls, but there were no details about the circumstances or support needs. This lack of precise directions to staff meant that continuity of care is largely dependant upon staff memory and good communication systems, with a potential for care needs not being properly met and care being reactively, rather than proactively planned. Care reviews were been carried out, however, care plans were not always being properly updated to reflect changing needs. Risk assessments were seen in relation to identified risk situations. Dietary needs and preferences were recorded. Records showed when bathing was being carried out, attention to hair, nails and weight was being recorded and monitored. Arrangements were in place for ensuring the residents receive attention from opticians, dentists and chiropodists. Records were seen of residents receiving attention of medical professionals. Senior staff had undertaken medication training, the deputy manager said training in this area was ongoing and being planned for. Medication storage was seen to be secure and clean. The residents’ consent for the home to manage their medication had been obtained. Medication recording sheets were completed appropriately. Each residents’ item of medication had an information fact sheet from the pharmacist. All residents had been risk assessed regarding to their ability or inability to manage their medication, however, the risk assessments did not show all matters had been considered such as ability to keep items safe. ‘When necessary’ medication had been highlighted, but here were no clearly defined indicators on administering or offering this type of medication. It was suggested the expectations of the home about over the counter medication and herbal remedies, be included in the service user guide and discussed at residents meetings. Residents spoken with considered they were treated with dignity and respect. Peoples preferred term of address was noted on care plans. Observations of care practices during the inspection indicated peoples privacy needs were being respected, doors were being closed and staff wee seen knocking on bedroom and toilet doors. Staff were seen to offer assistance with reading letters, consideration being given to confidentiality. The staff induction process covered the ‘principles of care’ including dignity and privacy. Staff spoken with explained how they promote dignity and privacy in their work practice. Promoting individuality was reflected in care planning and practices. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents had a degree of independence, opportunity to take part in activities, make choices and decisions and keep in touch with families and friends. The catering arrangements were sufficient in providing for the residents tastes, choices and diet. EVIDENCE: Residents spoken with and surveyed were generally satisfied with activities provided at Bank Hall. Separate plans and records were being kept of social activities which provided good information and showed this aspect of care was being given appropriate attention, it was advised these plans be linked to the main care plan to ensure social care needs are given proper attention. The activity coordinator described the various activities on offer, which included bingo and dominoes, crafts, sing a longs, quizzes, shopping, movement to music to feeding the birds each day. She had a box of items for discussion, which included and old iron and a weavers shuttle. Residents meetings were being held and entertainers had visited the home. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 14 The homes visiting arrangements were noted within the homes guide. Residents spoken with said they could see people at any time, in the privacy of their rooms if they wished. Relatives spoken with said they were made welcome at the home. Residents meetings and the care planning process enabled people to make group and individual choices. Some service users were handling their own monies others were being supported by their families or the homes arrangements. The residents had brought with them personal items such as ornaments, televisions, radios and small items of furniture. Details of advocacy agencies were displayed in the home. The days’ menu was now being displayed outside the dining room; choices were offered. In the dining room was large pictorial display of the choices available for breakfast; which include bacon and eggs, cereals and toast. The residents surveyed and spoken with; were generally satisfied with the quality, quantity and variety of meals available. Specific diets were being catered for and likes and dislikes were known. Home made cakes and biscuits were provided and fresh fruit was available. Various drinks were being offered throughout the day and fruit squash was available in the lounges. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems and procedures for managing complaints were inefficient in ensuring all complaints are effectively managed. Arrangements for safeguarding people; were robust in aiming to protect the residents. EVIDENCE: Residents spoken with said they had no complaints but expressed an awareness of the home complaints procedure and who to raise any concerns with. The acting manager said she considered complaints an important aspect in improving practice. All but one resident surveyed, indicated they were aware of how to make a complaint. The procedure for making complaints was in the homes guide and was displayed in the entrance hallway and included appropriate details for making and referring complaints. The home had recently received two complaints which had initially been referred to the Commission; this provided an indication that people felt at ease raising their concerns and were aware of the procedures to follow. The complaints were in the process of being dealt with, however, records and discussions showed some matters in relation to the complaints, had not been effectively managed. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 16 It was noted the home had several formats in use for recording complaints, it was advised one form be agreed and used, to establish one clear process of managing and recording complaints. Residents spoken with said they felt safe in the home. The document ‘No secrets in Lancashire’ was seen to be available in the entrance hallway. The staff whistle blowing procedure appeared to include appropriate details, including measures and assurances for staff raising concerns. It was advised each staff member be given a copy of the procedure. The ‘abuse’ policies seen provided information on indicators of abuse and dealing with such issues. The pre inspection questionnaire completed by the acting manager, indicated the home had policies and procedures in relation to physical intervention, restraint, staff disciplinary and grievances. Disciplinary procedures made reference to the possibility that staff may be referred for consideration of inclusion on the POVA register (Protection Of Vulnerable Adults). Safeguarding adults training had been arranged for July 2007. Staff spoken with expressed an awareness of protection matters. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation provided the residents with a comfortable, attractive, clean and safe place to live. EVIDENCE: The residents spoken with expressed an appreciation of the accommodation provided, including their bedrooms, communal rooms and garden areas, block paving had been laid to the front of the building. The residents had been encouraged to personalise their bedrooms by bringing with them, pictures, ornaments, pictures and other items. The lounges and dining areas were pleasantly decorated; furnishings were ‘homely’ in style and of a good standard. Some decorating had been completed, new carpets had been fitted on the corridors; others were due to be replaced. One conservatory, which was being used as a smoking area was quite warm, although electric fans were Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 18 available. It was therefore recommend blinds be fitted to the windows. Some floor coverings in bathrooms and toilets were badly marked, the manager said these areas had been professionally cleaned, but the marks had not been removed. There was an electric socket on the wall near the bath in one bathroom; the acting manager took steps to attend to this matter during the course of the inspection. Records showed systems were in place to deal with on going maintenance matters. The home was found to be clean and tidy. Residents’ surveys indicated the home was ‘always’ or ‘usually’ kept clean fresh and clean. The residents spoken with, considered the cleaning staff did a good job, one said “the home is kept very clean” Suitable laundry equipment and facilities were available. Designated cleaners, laundry staff and a handy person were employed at the home. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements were generally sufficient in aiming to ensure the resident’s needs are effectively and safely met. Staff recruitment practices, showed attention was being given to protecting the residents. Induction training and ongoing staff development, promoted effective care for the residents. EVIDENCE: Residents spoken with were complimentary about the staff team. The majority of residents’ surveys indicated staff were ‘usually’ available when they needed, but comments were made about staff being “very busy” and the home being short staffed on occasion. Staff spoken with considered, although some days were busier than others, they had enough time to care for the residents. Staffing levels were generally sufficient for the number of residents living at the home. However, records and discussion showed that on occasion some evening shifts were not always being covered which meant the well-being and safety of the residents may be compromised. The acting manager said that efforts had been made to cover the shifts and that staff are routinely given the option to cover extra duties, however, the procedures for ensuring sufficient staffing levels were not clear. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 20 The recruitment records of the three newest employed care staff showed the required information had been obtained and initial clearance checks carried out. Gaps in employment had been explored, however, the application forms did not request, or make provision for a full employment history, it was therefore advised the forms be updated. Staff had been provided with contracts of employment. Staff spoken with confirmed appropriate recruitment practices had been carried out. Residents had previously been involved in staff recruitment, this practice should continue. Records were seen of staff induction training, was suggested that all staff be offered a one to one supervision session on completion of their induction training. New staff were being supported to undertake NVQ and mandatory training courses. Staff were being supported to complete a recognised induction training programme followed by NVQ (National Vocational Qualifications) training. A training matrix was seen showing planned and undertaken training. Due to staff turnover only 39 of the carers had NVQ level 2, in care or above, however, five staff were due to commence NVQ level 2, five were starting NVQ level 3 and three were starting NVQ level 4 in care. Staff spoken with said training was encouraged at the Bank Hall, they were enthusiastic about their work and expressed a good understanding of their role in caring for the residents. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration arrangements, promoted the smooth running of the home for the benefit of the residents, staff and visitors. EVIDENCE: The atmosphere at Bank Hall was found to be relaxed, supportive and welcoming. The residents, visitors and staff spoken with expressed an appreciation of the management team; everyone seemed to get on well together. Lines of accountability were reflected upon the staff rota and within job descriptions. Records showed staff meetings were being held. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 22 The acting manager had been in post since September 2006, she had 9 years experience in care management, and had attained the Registered Managers award, a Certificate in care Management and NVQ (National Vocational Qualification) level 3 in care. She was due to commence NVQ level 4 in care. An application to be Registered with the Commission had been submitted. The manager had made several positive changes since being in post, staff rotas had been changed and communication systems improved. The deputy manager had been in post since December 2006 and had a number of years experience in a variety of care settings. Quality assurance surveys had been given out to the residents in March 2007 the activity coordinator had been given responsibility for this task, to promote objectivity. A computer programme was to be utilised to collate the information. Some matters had already been picked up and were to be responded to, for example, some residents had said they never see the manager; therefore this matter was to be addressed. Relatives were yet to be consulted and a questionnaire had been devised for other agencies such as social workers and GPs. The various methods of fee payment were said to be discussed during the admission process and were highlighted in the homes’ guide. Accountable systems and practices were in place for managing the residents’ monies. Records were seen of fee payments and charges. The recording method was not individual to each person and therefore did not promote confidentiality of information. The records did not include all payment amounts, such as the contributions paid by the local authority for funded residents; this meant the record did not provide an accurate account all fees paid. The pre-inspection questionnaire showed equipment had been serviced and that installations and maintenance checks were ongoing. Records were seen of various checks. Health and Safety policies were available and some health and safety risk assessments had been completed. The last recorded fire drill was September 2006 therefore a drill was just overdue, the acting manager said she would take action in response to this matter. Training in safe working practices had been undertaken, was ongoing, or being arranged. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans must include all identified needs and be in sufficient detail to provide clear guidance to staff, of the actions to be taken, to meet the residents health and welfare needs. Timescales of 28/04/06 not fully met) Care plans must be updated to reflect changing needs. Staffing arrangements must ensure sufficient numbers of suitably qualified, competent persons are always on duty to meet the needs of the residents. Individual records must be kept of the care home’s charges to residents, including all amounts paid by or in respect of each person. Timescale for action 22/06/07 2. OP27 18 (1)(a) 25/05/07 3. OP35 17(2) 16/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 25 No. 1. Refer to Standard OP7 Good Practice Recommendations The care plan process should be ‘person centred’ The care plan format should ensure all needs/abilities/wishes are identified and responded to. Staff should be guided to use the care plan as an ongoing working document. Care plans should make clear reference to any additional plans and records, such as those relating to social needs and activities. The risk assessment process for self administration of medication should be further developed to carefully consider all aspects of ability and safe practice. The medication management policies and procedures should be reviewed and updated, in line with current guidance. The self-administration of medication policy should guide staff to complete a risk assessment in respect of the resident concerned. The ‘when necessary’ medication policy should guide staff to define/refer to individual criteria for when necessary and variable dose medication. The criteria for the administration of when required and variable dose medication must be clearly defined and recorded for all residents prescribed such items. The manager and senior staff should undertake training/develop skills in relation to the effective management of complaints. Some bathroom and toilet floor coverings should be replaced. Suitable blinds/curtains should be fitted in the conservatory areas. Staffing levels should be regularly reviewed and amended accordingly, in response to the needs and abilities of the residents accommodated. Clear policies and procedures should be defined and implemented in relation to covering staff absences. 2. OP9 3. 4. OP16 OP19 5. OP27 Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 © 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 Bank Hall Residential Home DS0000009652.V331919.R01.S.doc Version 5.2 Page 27 - 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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