CARE HOMES FOR OLDER PEOPLE
Bankfield Manor Care Home Boothtown Road Halifax West Yorkshire HX3 6HG Lead Inspector
Liz Cuddington Announced 28 June 2005 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 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. Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Bankfield Manor Care Home Address Boothtown Road Halifax West Yorkshire HX3 6HG 01422 352398 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Safia Bano Hussain Mrs Safia Bano Hussain Care Home 25 Category(ies) of 24 x Old Age (over 65 years) registration, with number 1 x Physical Disability of places Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 3/11/2004 Brief Description of the Service: Bankfield Manor is a residential care home situated in Boothtown, near to Bankfield Museum. There are some shops within walking distance and Halifax town centre is easily accessible. The home is set back from the main road in its own grounds and there is car parking available. Bankfield Manor offers personal care and accommodation for up to 25 people over the age of 65 years. The house is a former convent which has been adapted and extended to provide suitable accommodation. In the original part of the building there is a passenger lift between the ground and first floors, the extension has a stair lift between the floors. Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took a full day and during that time a tour of the premises was undertaken and time was spent talking with six service users, two visiting relatives and three members of staff. Time was also spent discussing the running of the home with Mrs Hussain, the owner/manager, and examining individual plans of care and other documentation. The comments made by the service users, relatives and staff contribute greatly to the inspection and give a fuller picture of the care and support offered at Bankfield Manor. The information from the comment cards is also very useful and thanks go to the people who took the time to complete the cards and to those who gave their time to talk with the inspector. What the service does well: What has improved since the last inspection?
The three requirements and most of the good practice recommendations, made after the last inspection, have been satisfactorily addressed. This included some maintenance matters, which have now been completed, and the environmental standards in the home have improved as a result. The general documentation has improved and the staff rotas show more clearly the staff who are on duty at each shift. Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 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 standard(s) 2 EVIDENCE: The home’s statement of the terms and conditions of an individual’s stay at Bankfield Manor was examined. Following consultation with Calderdale Social Services’ contracting staff the document has been amended and now includes all the necessary information. Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 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 standard(s) 7, 8 & 9 EVIDENCE: A number of service users personal plans of care were examined. There was evidence that showed the plans had been drawn up with the agreement of the service user and/or their representative. The plans showed that risk assessments, nutritional screening and other health and care assessments are carried out and that a range of visiting healthcare professionals are involved where necessary. The medication system was examined. The Medication Administration Record (MAR) sheets were seen to be accurately completed. Where the GP’s instructions are not specific enough the home will contact the surgery to ensure that all medicines come with clear and accurate directions. Where a service user administers their own medication the home is to change the way they record this to a more accurate system showing only which staff member hands medication to the service user, and the quantities. The home’s pharmacist provides training in medication administration for the relevant staff. It would be good practice to include training for administering controlled drugs, to ensure the home is prepared. Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 13 EVIDENCE: Service users were seen sitting outside enjoying the sunshine and assisting a member of staff to water the bedding plants. One service user commented that it would be nice to have some more stimulating activities, although each service users file contained a record sheet showing when and what activities the individual had enjoyed. Some service users went out for a walk during the inspection, which they said they enjoyed, one person was seen helping to plant some bedding plants. Service users visitors were seen to come and go freely and local choirs come into the home to provide entertainment. Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 Page 11 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 standard(s) EVIDENCE: None of these standards were inspected on this occasion. Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 Page 12 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 standard(s) 19, 21, 24 & 26 EVIDENCE: The house and grounds are attractive and appeared to be well maintained. The wash hand basin, which was needed in one of the bedrooms, has now been fitted. The most recent Environmental Health Officer’s inspection did not result in any requirements. Since the last inspection a new washing machine with an integral sluice programme has been installed and the laundry floor has been painted to make it impermeable and hygienic. The temperature regulators on the hot water taps need checking and adjusting as the water temperatures were erratic. Generally the furnishings provided in service users bedrooms were seen to be satisfactory, although one armchair was badly marked and should not be used in someone’s room. One of the twin rooms did not have privacy screening. The manager said the service users had chosen not to have a screen and would ensure agreement to this was documented in their plans of care. Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 EVIDENCE: Staff rotas were examined and showed satisfactory staffing levels, with sufficient staff on duty to meet the needs of the service users. At night there are two waking night staff with a senior member of staff ‘on call’. At the time of the inspection the home was using 2 agency staff to help cover shifts during the holiday period. Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 37 & 38 EVIDENCE: The home’s manager appeared to give a clear sense of direction to the staff about the way the home is run. The records of staff meetings reflected the staff’s input. Confidential records were not all being kept securely locked, in accordance with the requirements of the Data Protection Act 1998. The manager said this would be remedied without delay. The fire safety practices are now being carried out regularly and additional fire safety training has been undertaken. All staff have basic emergency aid training and four staff have a full First Aid certificate. Moving and handling training, including refresher training, is also delivered regularly. The windows in the home which need them now all have window restrictors fitted. Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x
COMPLAINTS AND PROTECTION 3 x 3 x x 2 x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 3 x x x x 1 3 Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 Page 16 No Are there any outstanding requirements from the last inspection? 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 OP 9 Regulation 13(2) Requirement Timescale for action 30/09/05 2. OP 37 17(1)(b) When a service user selfadministers their own medication the records must show the quantities and the date on which the medicine was handed over to the service user. The staff member involved must sign to confirm this transaction. All confidential information must 30/09/05 be stored in securely locked cabinets or rooms. 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. Refer to Standard OP 24 OP 9 OP 26 Good Practice Recommendations Where service users have chosen not to have privacy screening in their bedroom agreement to this needs to be documented in the individuals plans of care. It would be good practice for staff to have training in the administration of controlled drugs, to ensure the home is prepared should this type of medication be prescribed. The hot water temperature regulators should be checked for accuracy and adjusted where necessary. Bankfield Manor Care Home J52J01_s30355_Bankfield Manor_v227927_280605.doc Version 1.30 Page 17 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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