CARE HOMES FOR OLDER PEOPLE
Bank Hall Residential Home Colne Road Burnley Lancashire BB11 2AA Lead Inspector
Mr Jeff Pearson Unannounced Inspection 2nd February 2006 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.V281283.R01.S.doc Version 5.1 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.V281283.R01.S.doc Version 5.1 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 Mrs Karen Idle Care Home 36 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (34) of places Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 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 29th September 2005 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 and two dining rooms. 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. Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took 8 ½ hours and was carried over one day by one inspector. There were 34 residents accommodated. The files/records of 3 residents were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of residents. During the inspection, the residents, registered manager, deputy manager, relatives and staff were spoken with. Policies, records and documents were looked at. A tour of the premises was carried out. Comment cards were received from relatives. What the service does well: What has improved since the last inspection?
The residents were being more involved when their care plans were reviewed, some had signed in agreement with them. The carpets on the corridors had been cleaned. The floor covering in one shower room had been replaced and a new seat had been obtained. Some
Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 6 parts of the home had been decorated to provide a more pleasant environment for the residents. Guidelines on protection and abuse, for managers and staff had been updated to provide more suitable information. Some parts of the home had been decorated to provide a more pleasant environment for the residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were assessed at this inspection; please refer to the previous inspection report dated 29th September 2005. EVIDENCE: Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 The residents had satisfactory individual care plans, but they were not accurate in providing up to date, detailed instructions for staff. Medication management practices were in need of improvement for the protection of the residents and staff. EVIDENCE: The care plans looked at included information about the residents’ needs and wishes, including personal care needs and daily living activities. Reviews were being carried out, but ongoing changing needs and staff instructions in response, had not been entered into the care plans. Staff said they had been involved with the care planning process, and expressed an awareness of individual residents needs and abilities. Residents spoken with had an awareness of the care plans some had signed in agreement with them. There were no specific individual moving and handling risk assessments. A separate record/plan was being kept of social needs and activities.
Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 10 Medication storage facilities were good. Medication policies were available. The self administering policy did not refer to risk assessing and their were no individual protocols for ‘when necessary’ medication. There were several errors in medication records. There were gaps in MAR (medication administration record) with no reason given. One residents’ medication was self administered, with prompt, but this was not indicated as such on the MAR sheet, another had been prescribed Gaviscon this had not been entered on the MAR sheet. A homely remedy had not been entered on the MAR sheet. Several residents had been prescribed medication on a ‘when necessary’ but there were not instructions on when this was to be offered. Written entries on MAR sheets had not been signed and countersigned. One GTN pump spray was without a label. Eye drops had not been dated when opened. Selfadministered medication had not been booked in. Not all senior staff with responsibilities for medication had attended accredited training, but this had been arranged. Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15 Interesting and flexible lifestyles were being positively promoted in response to individual and group needs, abilities and wishes. The catering arrangements were generally good, offering choice and variety, but some attention was needed to improve the meals service for the residents. EVIDENCE: The routines in the home were flexible, residents said they were able to go to bed and get up, whenever they wished, and were seen spending time in their rooms. Meals could be provided at different times. A full time activity organiser was employed at the home. The residents spoken with appreciated the various activities available, including craft sessions, bingo, DVDs and visiting entertainers. Residents meetings were being held regularly to provide opportunity for discussion and consultation. The activity organiser said she had been involved with new residents assessments, to find out about peoples interests before they came to Bank Hall. Various outings were being arranged each week. Holidays were being planned for. Records showed the residents involvement with activities and outings. Links had been developed with a local Church, some residents went out to a tea party on the afternoon of the inspection. Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 12 The residents spoken with said they liked the quality, variety and choice of meals provided. Three full meals were being offered daily. A four-week menu system was in place, the cook said the residents could have whatever they wanted, whenever they wished. On resident had a cooked breakfast at 11 am. Choice menus were available, the options being discussed with residents each day. Diets such as diabetic and low fat were being catered for. At lunchtime the service was good meals were served sensitively with attention being given to individual preferences. The menu was not on display in the dining room, so options, particularly for breakfast were not widely made known; arrangements had been made to address this matter. There was no blender or electric food mixer in the kitchen. Vegetables were being cooked over an hour before lunch. Several staff were seen to enter the kitchen, to make drinks for the residents without additional protective clothing. Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Systems and procedures were in place to provide for the management of complaints. Protection procedures had been updated, to include more appropriate referral instructions, but the reporting bad practice policy needed developing to provide further details and assurances. EVIDENCE: The residents spoken with indicated they were aware of the action to take should they wish to make a complaint or raises concerns. The home had a complaints policy, which provided guidance for responding to any issues raised. The complaints procedure was included in the service user guide and on display in the entrance hallway. The procedure provided suitable instructions on making a complaint, including expected timescales. There had not been any complaints made. It was suggested a compliments, comments complaints form be introduced and made available to residents, relatives and others. Staff spoken with were aware of how to respond to complaints from residents. Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 14 The protection and abuse policy included the referral details for Social Services and the police as appropriate. Records showed training on protection and abuse matters had been held at the home. The staff ‘whistle blowing’ policy was lacking in specific reassurances to staff, if they report bad practice. Staff disciplinary procedures did not make reference to the possibility of being referred to POVA (protection of vulnerable adults register) Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 The standard of the accommodation was good; providing the residents with an attractive and homely place to live, some matters needed attention to ensure the residents have safe, pleasant surroundings. EVIDENCE: The programme of redecoration was ongoing, some bedrooms had been decorated. The corridor carpets had been cleaned and arrangements had been made to clean them periodically. The lounges and dining room were appropriately furnished and provided pleasant living areas. The residents spoken with appreciated the accommodation provided. The shower room/toilet floor had been repaired, and a more appropriate shower seat was had been obtained and was due to be fitted. The home was clean and free from unpleasant odours. Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 16 Work to extend the home was in progress; the front driveway was very muddy with some rubble. the debris presented as a tripping hazard for residents, staff and visitors. Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 Staffing arrangements were sufficient in aiming to ensure the resident’s needs are effectively and safely met. Recruitment practices, showed appropriate attention was being given to protecting the service users. EVIDENCE: The required numbers of staff were on duty. Staff rotas and records of hours worked, indicated that appropriate staffing levels were being kept with extra staff also being on duty. Residents spoken with were complimentary about the staff team. There were sufficient numbers of catering; cleaning, laundry and maintenance staff employed. An admin assistant provided assistance with office duties. At night three waking watch night staff were on duty, one designated as senior. Staff records checked were found to have all the required information and clearance checks had been carried out. New application forms had been introduced. Equal opportunities and recruitment procedures were available. Some residents spoken with explained they had been involved with recruiting the new cook.
Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35, 38 Appropriate systems were in place to manage residents’ monies, charges and payments. Arrangements had been made to maintain health and safety; some further safeguards were needed to promote the well being of residents and staff. EVIDENCE: The homes’ guide included information about financial matters. Records seen indicated accountable systems were in place to manage residents’ monies, property and charges and payments. Secure storage was available. Documents were available to show the servicing of installations and equipment. Fire Safety risk assessments had been completed, records indicated fire systems were being tested and a fire drill had been carried out. A
Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 19 satisfactory report following a recent Fire Safety Officer visit was available. Records showed staff had received training in safe working practices, or this was ongoing or had been arranged. All senior staff had attended First Aid training. The debris and mud to the front outside area presented as a tripping hazard for residents, staff and visitors, residents were being supported when leaving the home and some action was taken to improve this situation at the time of the inspection. Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 3 X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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. (Timescale of 27/01/06 not fully met) Individual moving and handling risk assessments must be completed in respect of residents requiring this type of assistance. Full and accurate records must be kept of all medicines received and administered. There must be a full record of all medication currently prescribed for each resident. The shower must be fitted with an appropriate shower seat. (Timescale of 31/12/05 not fully met) As far as practicable, the front access to the home must be kept clear from mud and debris. Timescale for action 28/04/06 2. OP7 13 28/04/06 3. OP9 13,17 03/03/06 4. OP21 13 28/04/06 5. OP38 13 02/02/06 Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The care plan format should ensure all needs/abilities/wishes are identified and responded to. The care plan should be as used as an ongoing working document. Care plans should make reference to any additional plans and records, such as those relating to social needs and activities. Individual criteria for the administration of when required and variable dose medication should be clearly defined and recorded for all residents prescribed such items. A second member of staff should witness all hand written annotations on Medication Administration Record charts. The opening date should be recorded on eye drops and other items with a short shelf-life Medication should be checked for an appropriate label on the item itself and returned to the pharmacist if no label is present. 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. 3. OP15 Catering practices should ensure food retains as much nutritional value as possible during the cooking process. A food blender and suitable food mixer should be available in the kitchen. To promote good food hygiene/health safety, accessing the food preparation kitchen should be reviewed and revised accordingly. Catering staff should be supported to receive training/guidance on the provision of a nutritional diet for older people. 2 OP9 Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 23 4. OP18 The staff whistle blowing policies and procedures should provide assurances to staff when reporting bad practice. Staff disciplinary procedures should make reference to the possibility of being referred to POVA (protection of vulnerable adults register) 5. OP19 The corridor carpets and some bathroom floor coverings should be replaced. Bank Hall Residential Home DS0000009652.V281283.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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