Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 31/01/08 for Bankfield Manor Care Home

Also see our care home review for Bankfield Manor Care Home for more information

This inspection was carried out on 31st January 2008.

CSCI found this care home to be providing an Good service.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Anyone thinking of moving into Bankfield Manor can go and look around, have a meal and talk to staff and other people living there. If they decide to move in, staff from the home will carry out an assessment to make sure that they can meet that person`s needs and arrange a day for admission. People get a contract/statement of terms and conditions document, this means that they are given information about their rights and obligations. Staff are quick to involve GPs and other health care professionals to make sure people`s health care needs are met. The medication system is well managed. This means that people get their medication at the right times. People living at the home said that there are some activities on offer and that the meals are good. Relatives and friends are made to feel welcome and can visit at any time. People know about the home`s complaints procedure and who to talk to if they are unhappy about anything. People living in the home said that staff listen to them. This means that if people have any concerns they know how to get them sorted out. People said that the home is always clean and fresh. People living in the home like the staff. They said that they are kind and caring. People living in the home are consulted through staff meetings and surveys about how the home is run. This means that their views are taken into consideration and acted upon. The home is well managed. People living in the home, relatives and staff all find the manager and deputy manager approachable and helpful.

What has improved since the last inspection?

Two of the bathrooms have been refurbished and now provide Jacuzzi baths for people to enjoy. A weekend cook has been employed. This means that care staff no longer have to cook.

What the care home could do better:

There are areas of the home that need redecorating and general refurbishment. An audit of all of the bedrooms needs to be completed and a redecoration and refurbishment plan put together to show what is going to be done and when. This will make sure that the rooms are improved.The staffing levels need to be reviewed to make sure there are enough staff on duty to meet people`s needs and to supervise people in the lounges. This will make sure that people`s needs are met and that they are safe. New staff must be properly checked before they start working in the home. This will make sure that staff are suitable and safe to work with older people. More attention needs to be paid to health and safety issues to make sure these are identified and addressed. This will make sure that any potential risks to people living in the home or staff are sorted out.

CARE HOMES FOR OLDER PEOPLE Bankfield Manor Care Home Boothtown Road Halifax West Yorkshire HX3 6HG Lead Inspector Paula McCloy Key Unannounced Inspection 31st January 2008 09:10 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.V358681.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. Bankfield Manor Care Home DS0000030355.V358681.R01.S.doc Version 5.2 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 CastleVillas@aol.com Mrs Safia Bano Hussain Mrs Joan Philomena Berry 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.V358681.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration to revert back to 25 OP when service user with category PD has been discharged. 4th June 2007 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 older people. 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. The weekly scale of charges within the home range from £328.50 for a shared room to £347 for a single room. Additional charges are made for hairdressing, personal toiletries, newspapers and podiatry. Bankfield Manor Care Home DS0000030355.V358681.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The last key inspection took place in June 2007. We have not made any visits to the home since. This inspection was carried out to assess the quality of care provided to people living at the home. The inspection process included looking at the information we have received about the home since the last key inspection, as well as a visit to the home, which was carried out over one day and lasted approximately 6.5 hours. We were accompanied by an “expert by experience” from the organisation, Help the Aged. An “expert by experience” is a person who, because of their shared experience of using services, is able to help us get a better picture of what it is actually like for people living in the home. The “expert” who came with us looked around the home, had lunch and spoke to some of the people living there and to the staff. The feedback she gave us has been incorporated into this report. During the visit we spoke to seven people living in the home, the manager, 4 members of staff and 1 relative. We also observed care staff delivering care, looked at various records and looked around the home. The home completed a self assessment form which provided us with some information about the service. We have used some of that information in this report. Surveys were sent to 10 people living in the home, 10 relatives and 10 staff. These provide an opportunity for people to share their views of the service with us. Information received in this way is shared with the home without identifying who has provided it. Nine people living at the home and 4 relatives wrote to us with their comments. Their comments have been used in this report. What the service does well: Anyone thinking of moving into Bankfield Manor can go and look around, have a meal and talk to staff and other people living there. If they decide to move in, staff from the home will carry out an assessment to make sure that they can meet that person’s needs and arrange a day for admission. Bankfield Manor Care Home DS0000030355.V358681.R01.S.doc Version 5.2 Page 6 People get a contract/statement of terms and conditions document, this means that they are given information about their rights and obligations. Staff are quick to involve GPs and other health care professionals to make sure people’s health care needs are met. The medication system is well managed. This means that people get their medication at the right times. People living at the home said that there are some activities on offer and that the meals are good. Relatives and friends are made to feel welcome and can visit at any time. People know about the home’s complaints procedure and who to talk to if they are unhappy about anything. People living in the home said that staff listen to them. This means that if people have any concerns they know how to get them sorted out. People said that the home is always clean and fresh. People living in the home like the staff. They said that they are kind and caring. People living in the home are consulted through staff meetings and surveys about how the home is run. This means that their views are taken into consideration and acted upon. The home is well managed. People living in the home, relatives and staff all find the manager and deputy manager approachable and helpful. What has improved since the last inspection? What they could do better: There are areas of the home that need redecorating and general refurbishment. An audit of all of the bedrooms needs to be completed and a redecoration and refurbishment plan put together to show what is going to be done and when. This will make sure that the rooms are improved. Bankfield Manor Care Home DS0000030355.V358681.R01.S.doc Version 5.2 Page 7 The staffing levels need to be reviewed to make sure there are enough staff on duty to meet people’s needs and to supervise people in the lounges. This will make sure that people’s needs are met and that they are safe. New staff must be properly checked before they start working in the home. This will make sure that staff are suitable and safe to work with older people. More attention needs to be paid to health and safety issues to make sure these are identified and addressed. This will make sure that any potential risks to people living in the home or staff are sorted out. 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. Bankfield Manor Care Home DS0000030355.V358681.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 Bankfield Manor Care Home DS0000030355.V358681.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): 1, 2, 3, 4 & 5 (Standard 6 does not apply) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are assessed before they move in to make sure their needs can be met and they can visit to see if they think the service is suitable for them. People are given terms and conditions of residence, this means they get written information about the fees payable or their rights and responsibilities. EVIDENCE: We asked people living in the home if they had enough information about the home before they moved in. Everyone said that they did. The home has a service user guide and a copy is available in the entrance. Some of the information in the guide is out of date. For example the survey information about meals and activities. This was discussed with the manager who agreed that she would update the guide with the results of the most recent surveys. Bankfield Manor Care Home DS0000030355.V358681.R01.S.doc Version 5.2 Page 10 The manager also said that she would make sure there were copies of the service user guide available to give to people when they come to look around. We asked people living at the home if they have a contract or terms and conditions of residence document. Everyone told us that they did. We look at the terms and conditions document for the person that was most recently admitted. This showed us that he had been given this information on the day he moved into the home. This means that people are aware of their rights, fees payable and their responsibilities. The home’s admission procedures are good. The records for the most recent admission to the home showed that staff had completed the necessary assessment before she moved in. This means that staff are sure they can meet people’s needs before they move in. Staff said that they encourage people to come and look around the home, although sometimes it is the relatives that do this. This gives people the opportunity to see the home for themselves and decide if it is suitable. Staff told us that recently two people have been to look around the home, they stayed for lunch and had the opportunity to ask staff questions. Following this visit they have decided to move into the home. The home does not provide intermediate care. Bankfield Manor Care Home DS0000030355.V358681.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s health and personal care needs are being met. EVIDENCE: We looked at a selection of care plans because we wanted to see what individual needs had been identified and what action staff are expected to take to meet these needs. We asked people in the surveys if they get the care and medical support they need. People said that they did. One relative said ‘when my mother first entered the care home she hadn’t been eating or taking care of personal hygiene, thanks to the care and kindness of the staff my mother has regular baths, has her hair done and is putting on weight, she also seems very happy.’ We looked at four care plans. We could see from these plans that people are receiving health care from a range of people such as doctors, district nurses, Bankfield Manor Care Home DS0000030355.V358681.R01.S.doc Version 5.2 Page 12 dentists and chiropodists. Details of any visits are clearly documented in the care plan together with any advice given. The care plans are detailed and set out what staff need to do to make sure that people’s needs are met. Risk assessments are in place and clearly show what action staff have taken in order to minimise any identified risks. For example, one person was identified as being at risk of developing pressure sores. The care plan tells staff that they must check his skin condition for any signs of deterioration. There was evidence in two of the care plans we looked at of people or their relatives being involved in the planning process. One relative said that she has been told that she can read her mother’s care plan any time she wishes. Care plans are reviewed every month and updated as necessary. Relatives told us that staff keep them up to date about their relatives care and support. Whilst we were in the lounge there was a verbal altercation between two of the people living there. There were no staff present. We were concerned that if we had not intervened the incident may have become worse. We discussed with the manager the need to review the risk assessments for the two people concerned and the need for greater staff supervision in the lounge area. She agreed to do this. People all looked smart and well cared for. The hairdresser was visiting when we were there and people were having their hair washed and set. We did not observe a medication round. We looked at the medication records, which showed that people are receiving their medication at the right times. There is a photograph of people with their medication record. This means that it is easy to identify the person the medication is for. Bankfield Manor Care Home DS0000030355.V358681.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are some activities on offer to keep people stimulated. Meals at the home are good. EVIDENCE: We looked at four care plans. There were detailed life histories on each one, which give staff valuable information about them. There was also information on the care plans about how people like to spend their time and what they enjoy doing. This helps staff to provide appropriate activities. For example one man has always been a Newcastle United supporter. Staff said that he enjoys watching football on the television on Saturdays. Another man enjoys playing cards. On the afternoon of our visit a member of staff was sat with him having a game of cards. We asked people living in the home if activities are arranged in the home for them to take part in. Everyone said that there were activities for them to take part in if they wanted to. One person living in the home and one relative said that they thought more activities would be good. We spoke to the manager Bankfield Manor Care Home DS0000030355.V358681.R01.S.doc Version 5.2 Page 14 about the activities. She told us that she is looking at recruiting an activities organiser so that more activities and stimulation can be provided. At mid morning and mid afternoon drink time people are encouraged to use the dining room. This encourages people to move around and also encourages conversation between them. We spoke to one relative who was visiting. She said that she is always made to feel welcome and has coffee with her mother in her bedroom. In the self assessment document we were told that relatives are also encouraged to come and have a meal at the home. People living in the home told us that the meals are good. One person said ‘I enjoy all of them.’ In the mornings the cook asks people what they want for their lunch. People living in the home are asked at meetings and in surveys about the meals and if they like them. This information is then used to plan the menus. One of us had lunch. We were not offered a choice of meal. The food included frozen vegetables, but the potatoes were fresh, not powdered and the tender cooked ham was very good. This was followed by a substantial sweet. Bankfield Manor Care Home DS0000030355.V358681.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 & 19 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living in the home know who to talk to if they are unhappy or want to make a complaint. Staff know how to use the adult protection procedures which means that people are kept safe. EVIDENCE: We asked people living in the home, and their relatives, if they knew who to speak to if they were not happy and if they knew how to make a complaint. Everyone said that they did. The complaints procedure is on display and is also in the service users guide. We have received three complaints since the last inspection. These were all passed on to the adult protection team. There is a complaints log in place where details of any complaint that is made can be recorded together with the action taken and outcome. The home told us that they have involved the advocacy service for people living in the home who need someone to make sure their best interests are being looked after. Bankfield Manor Care Home DS0000030355.V358681.R01.S.doc Version 5.2 Page 16 The home has notified us and adult protection when they have needed to. Staff are aware of the adult protection procedures and are using these properly. This means that people living in the home are being kept safe. Bankfield Manor Care Home DS0000030355.V358681.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, 21, 24 & 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People live in a clean and comfortable home. There are some areas of the home that need to be redecorated and refurbished to bring them up to a good standard. EVIDENCE: 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 Care Home DS0000030355.V358681.R01.S.doc Version 5.2 Page 18 The home has been awarded 4 stars by environmental health for hygiene in the kitchen. Since the last inspection in June 2007 two of the bathrooms have been totally refurbished and have Jacuzzi baths. One of the lounge carpets and the stair carpet in the main house have also been replaced. We looked around the home. People’s bedrooms were very personalised and people are encouraged to bring any items of furniture, ornaments and pictures with them when they move in. We found that there are two bedrooms that are in need of redecoration and general refurbishment to bring them up to standard. The manager is aware of this. It would be helpful in planning the redecoration and refurbishment programme if an audit of all of the rooms was completed that identifies what needs to be done in each room. Work can then be prioritised and timescales set for the completion of any work needed. This will make sure that rooms are kept up to a good standard. There is a glass panel in one bedroom door, which means that people can see into the room and this does not give the person occupying the room any privacy. This was discussed with the manager who agreed to arrange for the glass panel to be obscured. In the newer extension there is a stairlift between the ground and first floor. The carpet on the stairs is very dark brown and the lighting in this area is poor. Our observation was that it was difficult to determine the edge of each stair. We both found ourselves hanging on to the banister for safety. The lighting levels need to be improved, or the carpet changed, so that people are able to use these stairs safely. People told us in the surveys that the home is kept fresh and clean. We did notice that the ground floor bathroom was in need of a good clean, but apart from this we found the home clean and tidy. In the self assessment we were told that all staff have completed infection control training. We saw staff wearing gloves and plastic aprons at appropriate times. We did not see any disposable wipes. Staff told us that they were using dark coloured face cloths to wash people’s private areas. Disposable wipes must be available to lessen the risk of any cross infection. Bankfield Manor Care Home DS0000030355.V358681.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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Staff are well qualified and experienced and people using the service like them. Staffing levels need to be reviewed to make sure there are enough staff on duty to meet people’s needs. The home’s recruitment process is poor. This is leaving people at risk of being cared for by staff who are not suitable and safe to work with older people. EVIDENCE: At the time of this visit, there were 20 people living in the home. The duty rotas showed that, during the day, there are 3 care assistants on duty until 4pm and then 2 care assistants on duty from 4pm until 8pm. At night there are 2 care assistants. In the surveys two relatives felt that the home needed more staff. Staff we spoke to also felt that they could provide a better service if there was more of them. The cook prepares the teatime meal before she leaves after lunch. At teatime the care staff are responsible for serving the meal and washing up. This takes them away from their caring duties. This was discussed with the manager who Bankfield Manor Care Home DS0000030355.V358681.R01.S.doc Version 5.2 Page 20 recognised this and said that she will recruit a kitchen assistant to help at teatime. We consider that the staffing levels must be reviewed and increased to make sure there are enough staff on duty to meet people’s needs. This is because the incident we observed in the lounge shows there needs to be greater supervision of communal areas. The layout of the home is complex and there are two new people due to move into the home. When we looked at the duty rota we found that 2 members of staff were working excessive hours. One person was rostered to work 79 hours and another 76 hours in one week. This is not safe practice and leaves people living at the home at risk of being cared for by staff who are tired and not at their best. The manager said that there were particular problems as one member of staff was on holiday and she was waiting for some new staff to start work at the home. If there are difficulties covering the rota agency staff should be used rather than existing staff working excessive hours. People living at the home and relatives said that they like the staff and find them helpful and caring. One relative said ‘very good staff (but not enough staff), the staff are lovely to my mum, which in care homes is hard to find a good one, people that care for the elderly.’ We looked at the recruitment files for 5 members of staff to make sure all of the necessary checks were being completed. We found that one person had brought a criminal records bureau check that had been done at their college, but the home had not completed their own check. One person only had one reference on file and another had brought two references with her. At the very least staff must have a POVA (protection of vulnerable adults) check and two written references that the home have obtained themselves before they start work. They may then only work if supervised until their full CRB check is received. Without a robust recruitment procedure there is no guarantee that people in the home are cared for by staff who are suitable and safe to work with older people. In the self assessment we were told that 80 of the care staff have completed their NVQ (National Vocational Training) level 2 in care. This means that staff are qualified and competent to do their job. Bankfield Manor Care Home DS0000030355.V358681.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is well managed and run in the best interest of the people living there. EVIDENCE: There is a registered manager at the home who works 6 days every week. The manager is aware that she needs to complete the registered managers award and is hoping to start this in March 2008. People living at the home, relatives and staff all said that the manager and deputy are very approachable and it is easy to discuss any issues with them. Bankfield Manor Care Home DS0000030355.V358681.R01.S.doc Version 5.2 Page 22 The annual quality assurance assessment (AQAA) was fully completed and gave us clear information about what changes have been made. It also told us about how they intend to make improvements over the next 12 months. There are quality monitoring systems in place. In December questionnaires were sent out about meals and activities. The results from these need to added to the service user guide so that people know what people living in the home said. The owner is completing the required monthly reports and is talking to people living in the home, relatives and staff. This means that she is checking that the home is being run properly and in the best interests of the people living there. Residents meetings are held and people’s views about the meals, activities and staff are asked for. At the last meeting in January people said that they had enjoyed the Christmas festivities. The manager holds money for safekeeping for some people. We looked at the records and found them accurate. This means that people are protected from any financial abuse. In relation to health and safety we did identify one problem. One person living in the home spends most of her time in her bedroom. The only time she goes downstairs is to see the hairdresser. This person needs a wheelchair and to get her from her room to the lift staff have been lifting her in the chair down 3 steps to get to the lift. We spoke to the manager about this. There is a bathroom that she can get to in the wheelchair that the hairdresser could use. Otherwise a portable ramp will be needed for the three steps. The manager completed a risk assessment and will get the hairdresser to use the bathroom, until a ramp can be made available. Staff must be aware of health and safety issues and make sure that all risks are identified and risk assessments are in place so that people living in the home and staff are not at risk of injury. We noticed that some of the fire doors were not closing properly. Staff must make sure that they check these when the fire alarms are tested and get them adjusted to ensure they are closing tightly. This will make sure that the fire precautions are effective. The self assessment document showed that equipment is serviced regularly. We looked at the fire test records and found these were up to date. This means that the system is working properly. Bankfield Manor Care Home DS0000030355.V358681.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 17 X 18 3 2 X 3 X X 2 x 2 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Bankfield Manor Care Home DS0000030355.V358681.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 OP24 Regulation 16 Requirement Timescale for action 31/03/08 2 OP26 13 3 OP27 18 4 OP29 19 An audit of the bedrooms must take place to identify which rooms need redecoration and refurbishment. A plan must then be put in place with timescales for achieving improvements. This will make sure that the rooms are brought up to a good standard. A copy of this plan must be sent to us. Disposable wipes must be 28/02/08 available in the home for staff to use. This will minimise any possible spread of infection. Staffing levels must be reviewed 28/02/08 and increased. Staff must be available at all times in sufficient numbers to meet the assessed needs of people who live at the home. This will make sure that the needs of each person are met. Pre-employment CRB and POVA 28/02/08 disclosures must be received and two written references obtained for all new staff. This makes sure that people in the home are cared for by staff who are suitable and safe to work with DS0000030355.V358681.R01.S.doc Version 5.2 Bankfield Manor Care Home Page 25 5. OP38 13 older people. Fire doors to bedrooms must be adjusted to enable them to shut properly to keep people safe. 28/02/08 6 OP38 13 (This remains outstanding from the previous two inspections) Risk assessments must be 28/02/08 completed in relation to the stairway in the newer part of the building and access to the lift in the old building for wheelchair users where three stairs have to be negotiated. Following these risk assessments any necessary action must be completed. This will make sure any potential risks to people living in the home or staff are sorted out. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bankfield Manor Care Home DS0000030355.V358681.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Bankfield Manor Care Home DS0000030355.V358681.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!