Inspection on 29/12/06 for Bartholamew Lodge

This inspection was carried out on 29th December 2006.

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

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

Other inspections for this house

Bartholamew Lodge 31/01/06

Bartholamew Lodge 11/07/05

Bartholamew Lodge 22/02/05

Bartholamew Lodge 03/12/04

Bartholamew Lodge 22/03/04

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

CARE HOMES FOR OLDER PEOPLE Bartholamew Lodge 1 Trouse Lane Wednesbury West Midlands WS10 7HR Lead Inspector Mrs Mandy Beck Key Unannounced Inspection 29th December 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 Bartholamew Lodge DS0000004777.V324317.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. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bartholamew Lodge Address 1 Trouse Lane Wednesbury West Midlands WS10 7HR 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) 0121 502 1606 0121 502 1100 bearwood@btconnect.com Bartholamew Lodge Nursing Home Limited Ms Susan Parfitt Care Home 30 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (29) of places Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Bedroom 2 situated on the first floor must only be used to accommodate residents on a temporary basis (e.g. intermediate or short stay care). The home can accommodate the older person with dementia as detailed in the variation report dated 27 February 2006 for the length of their stay, at which point this condition will be removed from the certificate. The Registered Manager is required to notify the CSCI at the point the person concerned leaves the home. The home has 10 Intermediate care beds under the existing categories of registration. 31st January 2006 3. Date of last inspection Brief Description of the Service: Bartholomew Lodge is an adapted building sited opposite open parkland near the centre of Wednesbury and as a result within walking distance of the facilities on offer there. Transport links are supported by easy access to public transport and close proximity to the Black Country route and M6 motorway. The home provides personal care with nursing for up to 30 residents with ten beds allocated for intermediate care (short term intensive rehabilitation to enable service users to return to their own homes), this supported by the local Primary Care team (health authority). The home also has one bed available for respite care (for stays between 2 - 4 weeks). The bedrooms comprise single rooms, with some shared and the home has adaptations consistent with provision to a dependent resident group (including such as call system, hoists, shaft lift etc). The staff team is managed by a Registered nurse and there is a nurse on duty 24hours per day. The nurses supervise a range of care and ancillary staff. The home currently charges between £335 and £439 per week for residency, this fee is inclusive of the Registered Nurse Care Contribution (RNCC). Items that are not included in this fee are toiletries, newspapers, hairdressing services and chiropody, these services are available but service users will be expected to pay for them. The home does not currently charge a top up fee. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the service to complete a key inspection. The inspection took place over two days and involved talking with the manager and provider, service users and staff. Service users files were also examined as were staff files to ensure the home continues to recruit people in a safe manner. In addition to this a partial tour of the premises was undertaken. The information and judgments made in this report have been done so using all available evidence including a pre inspection questionnaire completed by the manager and service users comment cards completed by service users and their families. The inspector would like to thank the registered provider, manager and all the staff and service users for their hospitality throughout the inspection. What the service does well: What has improved since the last inspection? The home has taken steps to meet one of the two outstanding requirements. The other requirements regarding the quality assurance systems for the home remains only part met but there has been good progress in improving this system. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 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 Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. service users can be assured they will have their needs assessed in full and they can feel confident that the home can meet those needs. service users who are admitted to intermediate care will be encouraged to maintain their independence throughout their stay. EVIDENCE: The home provides good sources of information to service users to help them make a decision about moving into the home. The manager must consider providing this information in alternate formats such as large print and audio. Four service users were case tracked during this inspection, each of the service users had been given a contract that contains most of the required information, contracts need to be reviewed so that they contain the fees that service users are required to pay for their residency. Needs assessments are completed by the manager prior to service users being admitted to the home and this forms the basis for care planning once the service users has moved in. When the manager is confident that the home can meet their needs she writes to them confirming this. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 9 All prospective service users are encouraged to spend a day or half a day as a trial visit to ensure that they like it and to give them chance to talk to other service users about living at the home. The home also provides intermediate care services for ten service users. This means that service users move into the home for an agreed period of time to maximise their independence before returning to their own homes. Whilst service users are there they are supported by the care staff that have been trained by the local PCT intermediate care team and by specialist services such as Occupational Therapists and Physiotherapists. This means that staff enable service users to maximise their independence at all times. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can feel confident that their health needs will be met, that they will have prompt medical attention and at all times be treated with respect and dignity. Medication practices within the home are good and service users can feel sure that their medication will be administered at the appropriate times. EVIDENCE: Four service users files were seen as part of the case tracking process, it was pleasing to see that all of the files contained an assessment that formed the basis for their individual care planning. All of the plans seen had been reviewed at least on a monthly basis and wherever possible the service user had been included in this process. Each service user is assessed for their risk of falls, developing pressure sores, malnutrition and moving and handling, where an increased risk had been identified a management plan was in place to show how the care staff aimed to reduce or manage this risk to service users. All service users have access to specialist medical; nursing services, as they require them, there was also evidence to show that service users receive visits from the optician, chiropodist and the dentist. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 11 Medication practices within the home are very good, there are robust systems in place for the ordering, receipt and storage of medication. Controlled drugs are stored appropriately and again there are good systems in place to ensure that these drugs are not mishandled. Trained nurses are responsible for all medication administration. At present none of the service users administer their own medication but the manager stated that if service users wanted to do this, this could be arranged. This is particularly relevant for those service users who are using the intermediate care services, as they will need to get used to administering their own medication before they return home. Service users indicated in their questionnaires that they felt staff always listened to them and that they were treated well. Staff were seen talking to service users in a friendly and polite manner throughout the inspection and were seen to be knocking doors before entering when service users were receiving personal care, for instance when using the toilet. All staff are instructed through their induction programme how to treat service users with respect and dignity. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that they will be encouraged to take part in activity and to maintain their social contacts. Meals are provided in sufficient portions to meet service users needs. EVIDENCE: The home has a senior supervisor who coordinates the activity throughout the home. There is a varied activity programme although the manager reported that at times it can be difficult to motivate service users to take part. There are outside trips organised such as shopping, going to the pub and gardening. The manager also informed the inspector that they also have visits from the local clergy. On the day of this inspection service users were playing bingo and snakes and ladders, one commented “I haven’t played this for years I forgotten how much I like it”, All visitors are encouraged whenever they want to but are asked to give consideration to service users needs when visiting early in the morning or late at night. The home provides service users with hot and cold meals throughout the day, all of which are freshly prepared on the premises. The kitchen was seen and found to be very clean and well equipped. The kitchen staff are recording all Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 13 required temperature to ensure that food is stored at the correct temperature. The home operates a three-week menu that offers service users two hot choices daily, if service users want something different they are more than welcome to ask for it. Menus are reviewed as service user needs change, the home is also working with the local Food Team in their “Five for Life” campaign to produce highly nutritious food for service users. There are two dining rooms in the home both of which were pleasantly decorated and all of the tables were laid with condiments and sauces for service users to use. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured they their concerns and views will be listened to and acted upon, furthermore service users will be protected from abuse. EVIDENCE: The manager has received two complaints since the last inspection both of which were investigated and as a result changes in practice have occurred. There is a clear and simple complaints policy available for service users to access, although the manager should consider making this available in different formats to meet service users needs such as large print or audio versions. Most of the staff have now completed their adult protection training further safeguarding service users. All of the staff files seen had relevant PoVA and CRB disclosures. The home also has good systems in place for dealing with service users financial affairs. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a well maintained and clean environment EVIDENCE: A partial tour of the building was undertaken, some service users bedrooms were seen and contain all the required furniture, although some of the vanity units in some of the rooms require replacing as the chipboard has blown and is now exposed. There is an odour in one of the bedrooms on the ground floor that needs to be addressed. The registered provider stated that there are new vanity units and wardrobes on order for all of the rooms and steps will be taken to mend the minor shortfalls identified during the tour such as the bathroom 3 extractor fan that needs repairing and the small dents in the floor that need to be made good as they pose a trip hazard. There are limited height adjustable beds for service users although the registered provider is aware that these need to be provided. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 16 The home is well maintained and very pleasant and cosy, service users appeared contented as we walk around and stated that they “liked it very much”. The laundry facilities include systems that allow soiled laundry to be put straight into the machines, the laundry staff do not have to sort through the soiled clothing, there are hand washing facilities, washing machines meet sluicing and disinfecting guidelines, and a cleaning schedule is in place. Staff have also recently completed infection control training. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that staff are recruited safely and are provided in sufficient numbers to meet the needs of the service users. All new workers take part in an induction programme that meets recognised standards. EVIDENCE: The home employs sufficient staff to meet the needs of the service users. The nursing team are supported by domestic staff who complete the cleaning and laundry, maintenance and cooking in the home. the managers hours are supernumery, this means that she is not included in the care hours provided to service users. The care staff who work at Bartholamew Lodge have all worked very hard and they now have 9 care staff who have completed their NVQ level 2, 3 care staff currently working towards this qualification and a further 3 staff ready to commence their NVQ’s once they have completed their induction. All of the staff should be congratulated on this achievement. New workers are recruited safely and of those staff files that were examined all of the required information was available, there were very minor shortfalls for the manager to address such as ensuring all new workers give a full employment history and where workers provide references titled “to whom it may concern” the manager must take steps to authenticate this. The Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 18 registered provider has stated that there are systems being put into place that will address these shortfalls. All new workers are supported through their induction, the home keeps clear records of what is involved in this process and the programme meets the skills for care standards. Each new worker is supported through their induction by a suitably experienced supervisor. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can feel confident that the home is well managed and well run. The home generally acts in the best interests of service users. Service users financial interests are safeguarded. The home actively promotes the health and welfare of both service users and staff. EVIDENCE: The home is managed by Mrs Sue Parfitt, she is both qualified and competent to run the home. Her hours are supernumery this means that she is free to manage the home and any issues that arise without affecting the care that service users receive. Since the last inspection there has been some progress in moving forward the quality assurance system, the manager has begun assessing the home’s own progress in meeting the National Minimum Standards and has identified at Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 20 least one area where some changes/improvements could be made. In order to be sure that the home is acting in the best interests of the service users the manager needs to develop ways in finding out their views. Service users monies were also checked to ensure that the home has good systems in place for dealing with money and keeping it safe. Three service users monies were checked and found to be in order. There was one area of confusion regarding the receipt of money for one service user, the manager was encouraged to seek the advice of social services to ensure that both the home and service user are protected. There are robust systems in place for maintaining the health and safety of service users and staff. Maintenance certificates for the home were spot checked and found to be in order, the manager also has a training matrix that identifies when staff are due to take part in their mandatory training such as, food hygiene, infection control and first aid. There has recently been a fire drill for staff to take part in however the manager must ensure that all staff, this must include all night staff take part in a fire drill so that they are all clear of what to do in case of fire. Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 21 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 2 3 3 3 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 3 Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 22 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 OP2 Regulation 5A Requirement The registered provider must review service user contracts and term and conditions to ensure they contain all details of fees, this must include the registered nurse care contribution (RNCC) where appropriate. The registered manager must seek individual GP agreement for service users and homely remedies The registered provider must take appropriate action to make sure that the uneven areas of flooring on the ground floor are level. The registered manager must ensure the new employees provide a full employment history with a written explanation of any gaps. All references must be authenticated, this must include those references for overseas workers entitled “to whom it may concern” Timescale for action 01/03/07 2 OP9 13(2) 01/03/07 3 OP19 23 01/03/07 3 OP29 19 01/02/07 Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 23 5 OP33 24 To develop the homes systems 01/04/07 for quality assurance in accordance with the expectations of the National Minimum Standards and comments within this report. (Previous timescale of 30/06/06 part met) The registered manager must ensure that all staff take part in fire drills, this must include night staff. 01/03/07 6 OP38 23 (4) 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 4 Refer to Standard OP19 OP24 OP26 OP33 Good Practice Recommendations To develop a formal plan for maintenance of the premises that shows forward planning. It is recommended that the registered provider purchase height adjustable beds for service users where nursing is provided. It is recommended that the manager obtain a copy of the Department of Health publication “infection control guidance in care homes” June 2006. To consult all stakeholders in respect of the quality of the homes service provision (for example PCT, G.Ps, Social workers etc), and to ensure that all returned questionnaires are dated, with findings collated into an overview/report in a format for public consumption. It is strongly recommended that the manager seeks advice from a social worker in respect of the service user identified during inspection and their financial situation. 5 OP35 Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Bartholamew Lodge DS0000004777.V324317.R01.S.doc Version 5.2 Page 25 - 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!