CARE HOMES FOR OLDER PEOPLE
Bankfield Manor Care Home Boothtown Road Halifax West Yorkshire HX3 6HG Lead Inspector
Liz Cuddington Unannounced Inspection 30th November 2005 12:00 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 Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bankfield Manor Care Home Address Boothtown Road Halifax West Yorkshire HX3 6HG 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) 01422 352398 Mrs Safia Bano Hussain Mrs Safia Bano Hussain Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (24), Physical disability (1) of places Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Registration to revert back to 25 OP when service user with category PD has been discharged. 28th June 2005 Date of last inspection 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 24 people over the age of 65 years and one adult with a physical disability. 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 DS0000030355.V254668.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One statutory requirement, concerning the lack of secure storage for some of the confidential records, has been brought forward from the last inspection in June 2005. This must be addressed without further delay. Two good practice recommendations have also been brought forward from that inspection. One new requirement and two new recommendations have been made. I spent time during the inspection talking to some of the ladies and gentlemen about their experience of living at Bankfield Manor. I also spoke with some members of staff to gain their views about the home. I examined a number of personal plans of care, some staff files and other documentation. Before the inspection I received a phone call from the relative of a service user who praised the home and the staff for the excellent care of her relative. I was told they looked after the person ‘wonderfully’. I would like to thank the service users, staff and management for their welcome and hospitality during the inspection. What the service does well: What has improved since the last inspection?
An improved system has been put in place for recording quantities of medicines received and passed on to service users who look after their own medication. Staff who administer medicines have now received additional training in handling controlled drugs, should the need arise. Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 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 DS0000030355.V254668.R01.S.doc Version 5.0 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 Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 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): 3&5 Standard 6 does not apply The admission procedures cover the necessary areas and form the basis for the individual plans of care. EVIDENCE: In addition to the Social Services’ assessment of needs either the Manager or the Deputy Manager of the home also meet prospective service users to carry out their own assessment. This is to make certain they can meet the person’s needs at Bankfield Manor. The emergency admission procedure was described to me in detail by the Deputy Manager. This includes making the person welcome, ensuring they have no injuries, checking their medication and finding out information to form the basis of a care plan. Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 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): 9 & 10 The administration of medicines appears to be carried out accurately. The storage of some medicines is unsafe and must be improved. Service users privacy and dignity were seen to be respected. EVIDENCE: Staff who administer medication have now received additional training in administering controlled drugs, to make sure they are prepared if a service user is prescribed this type of medication. An improved system has been put in place for recording quantities of medicines which are passed on to any service user who handles their own medication. The Medicine Administration Record (MAR) sheets were examined and were seen to be accurately completed. Containers of medicines, received from the pharmacy and waiting to be checked and put away, were being stored in an open box under the manager’s desk. Medicines were also seen left out on top of the medicines trolley. These are unsafe practices and must cease. For the safety of service users, all medicines must be securely stored at all times.
Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 Page 10 Staff were seen to treat the ladies and gentlemen who live at Bankfield Manor with respect and consideration. Those people who commented said how kind and helpful the staff are. People’s individual choices and their wish for privacy are respected. Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 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): 13, 14 & 15 Service users visitors are welcomed. There are suitable arrangements for handling service users finances. Independent advocacy services are available. The meals are varied and there is always a choice of dishes. EVIDENCE: Visitors were seen to be made welcome and service users receive their visitors either in one of the lounges, or in their own bedroom. Except for small amounts of money which the home assists some people to look after, service users individual finances are managed by their families when the person concerned is no longer able to deal with them. Age Concern provide an advocacy service, should anyone wish to use it. The people who commented said they enjoyed their meals. I looked at some of the menus. There is a choice of main course each lunchtime and a choice of dishes at teatime. All the meals are well presented and appetising and the mealtimes appeared to be relaxed and unhurried. Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The complaints handling and adult protection procedures are comprehensive. EVIDENCE: The home has a suitable complaints procedure detailing how any complaints will be handled. A record is kept of the complaints that are received; this includes notes of any concerns or complaints that are made verbally. The home has a ‘Whistle Blowing’ policy and procedures to enable staff to safely approach the manager, or whoever they prefer to contact, if they have concerns about the safety and protection of a service user. The procedure to be followed in the event of an allegation of abuse being made was discussed with the home’s management. It includes consulting with Social Services’ Adult Protection Officer and the Commission for Social Care Inspection. Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 26 Torn and damaged floor coverings should not be left. For the safety of service users they need to be repaired or replaced without delay. Testing and recording hot water temperatures needs to be started. The service users who agree not to have privacy screening need to confirm this in writing in their plans of care. EVIDENCE: A full tour of the house was not made at this inspection, although I did notice that the floor covering in one bedroom was badly torn and could cause someone to trip. The manager said that replacement flooring had been arranged. When two people who share a room have chosen not to have privacy screening, their agreement needs to be recorded in their care plans. The hot water temperatures are not being checked regularly. The manager said this would be done and records kept.
Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 Page 14 These last two points are recommendations brought forward from the last inspection and which have still not been done. Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 Page 15 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): 28, 29 & 30 The staff team are well on their way to being a well-qualified group of people. Recruitment and selection procedures cover all the necessary areas. Staff training records show a commitment to having a well-trained workforce. EVIDENCE: One member of staff already has NVQ level 3 in care. The Deputy Manager and two senior carers are qualified nurses. At present seven of the care staff are working towards achieving their NVQ level 2 in care. They expect to complete the course in March 2006. When these staff have achieved this the home will have more than exceeded the minimum standard expected. I examined a number of staff files and discussed the recruitment procedures. The files show that all the necessary pre-employment checks are carried out to ensure the protection of the service users. The staff training records show evidence that staff receive the training they need which is appropriate to their role. All the mandatory training, such as health & safety, fire drills and infection control are taken by staff. Adult protection training is also provided. Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 Page 16 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): 31, 33, 35 & 37 The management of the home and the quality assurance systems meet the necessary standards. Any monies handled on behalf of service users are dealt with accurately. Some personal files are still not stored securely. EVIDENCE: The home’s owner/manager has the necessary qualifications and experience to manage the home. He home’s quality assurance systems were discussed with the Manager and Deputy Manager. Residents’ meetings are held and service users and their families are consulted individually. Anonymous surveys are carried out and a nutritional preference questionnaire is planned. The Manager reviews the results of the surveys and tells me that she then discusses the outcomes with the Deputy Manager to decide on a course of action. I saw examples of quality assurance questionnaires and analysis of the results.
Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 Page 17 Where the home keeps all or part of an individual’s personal allowance on behalf of the service user, for them to use when they need to, the records were seen to be accurate and the monies balanced. This money and the records are stored securely. There are still individual, personal records being kept in unlocked cupboards and cabinets in a public area of the home. It was a requirement of the last inspection report that this is changed and the situation remains unaltered. All personal information must be stored securely. Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 Page 18 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X 2 X 2 STAFFING Standard No Score 27 X 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 1 X Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 Page 19 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. 2. Standard OP9 OP37 Regulation 13(2) 17(1)(b) Requirement All medications must be securely stored at all times. All confidential information must be stored in securely locked cabinets or rooms. This requirement has been carried forward from the last inspection. Final revised timescale: 31/01/06 Timescale for action 31/12/05 30/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP24 OP24 OP26 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. Torn floor coverings need to be replaced without delay. The hot water temperature regulators should be checked for accuracy and adjusted where necessary, and records
DS0000030355.V254668.R01.S.doc Version 5.0 Page 20 Bankfield Manor Care Home 4. OP28 kept. More staff need to complete an NVQ in care qualification in order for the home to meet the standard. Bankfield Manor Care Home DS0000030355.V254668.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Brighouse Area Office 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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