Inspection on 31/01/06 for Bartholamew Lodge

This inspection was carried out on 31st January 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 29/12/06

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 Mr Jon Potts Announced Inspection 31st January 2006 09:45 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.V274922.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 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 505 3607 Bartholamew Lodge Nursing Home Limited Ms Susan Boot 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.V274922.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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). 8/7/05 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 of the beds allocated for intermediate care (short term intensive rehabilitation to enable service users to return to their own homes), this supported by the local PCT (Primary care Trust). The home also has one bed available for respite care (for stays between 2 – 4 weeks). The bedrooms comprise single and some shared rooms with the home having adaptations consistent with provision to a dependent elderly resident group (including such as call system, hoists, shaft lift etc). A Registered Nurse (who is also the registered manager) manages the staff team and there is a nurse on duty 24 hours per day. The nurses supervise a range of care and ancillary staff. Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out between 9.45am to 4.10pm and focussed primarily on case tracking service users admitted for long stay care, this involving comparison of the individual users records with the actual practice that was carried out, the evidence including discussion with residents where practicable. Other documentation was also explored including staffing rotas, training records, staff files, and health and safety documentation. Further information was also gained from a pre inspection questionnaire completed by the manager and feedback cards from residents and relatives. There was a part tour of the premises centred on the case tracking exercise carried out. The residents and staff are to be thanked for their assistance with this inspection. What the service does well: What has improved since the last inspection? What they could do better: There are only a few areas identified where improvement is needed this including the need to ensure that residents or their representatives consistently sign care plans and the work to continue development of the homes quality assurance system is continued. Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 6 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. Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Each resident has a written contract/statement of terms and conditions with the home. No service user moves into the home without have his/her needs assessed and been assured in writing that these will be met. EVIDENCE: All those residents case tracked were in receipt of a contract from the home in addition to those supplied by the funding authorities. The contracts supplied by the home to the resident/representative were all signed by the former. There was evidence that the home receives social work assessments in respect of residents needs prior to their admission to the home this building on the assessments carried out by the home’s staff. The primary care team have developed the way in which information is recorded for resident’s receiving intermediate care prior to their admission to the home so that goals in respect of the service users care are clearer. There was evidence of the home confirming its ability to meet resident’s needs prior to admission. Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,10 Service user plans that set out resident’s health, personal and social care needs are in place. Residents feel that they are treated with respect and their right to privacy is respected. EVIDENCE: All the case files examined contained care plans that were clearly laid out and easy to follow, with information in the majority of cases drawn from pre admission assessments and covering the majority of the individual residents health and most social care needs. All issues identified from the previous inspection were found to have been addressed with the exception of these documents been consistently signed by the resident or their representative. Eleven comments cards were received from residents prior to the inspection of which all stated that the resident’s privacy was respected by staff, and that staff treated them well. It was noted that residents choices in respect of a number of areas including preferred title were documented in their case files, these found to be accurate in discussion with some of the residents. Other examples given by residents as to the way staff respected residents privacy Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 10 and dignity included, staff knocking doors (this also observed), privacy given whilst using toilet, in respect of the clothing worn and the way they are addressed by staff. Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15 Residents felt that the lifestyle experienced within the home matches their expectations, satisfying their social, cultural and recreational interests, with help from staff to exercise choice and control over their lives. Residents receive a wholesome and appealing balanced diet in pleasant surroundings at times that are acceptable to them. EVIDENCE: The residents spoken to confirmed that they did have some choices in regard to their daily routines, in respect of such as times they rise and retire, the number of pillows on their beds and how their individual care was to be provided, which were as recorded in the care documentation for those residents with whom this information was discussed. Questionnaires returned by 11 residents indicated that out of this number 9 felt there was suitable activities available at the home, the other two stating there was sometimes. Those residents spoken to stated they were satisfied with the activities available. It was evident from discussion with the home’s activity co-ordinator (appointed to this post since the last inspection) that much work had been done to try and stimulate the residents with appropriate activities. An activities programme has been developed although this was said to be open to change based on the wishes of the residents on a day-to-day basis. Group activities on offer included Bingo, chair exercises, reminiscence and arts and crafts with Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 12 plans to develop some outdoor activities when the whether improves. The enthusiasm of the activity co-ordinator was evident in discussion with the inspector, and recording of the activities was seen to be much improved. The home has a three week menu that indicated a well balanced and nutritional variety of meals was available to residents, this confirmed by sight of the midday meal which was well presented and available in portions in accordance with individual choices. Discussion with residents indicated satisfaction with the food available with statements such as, ‘ The food is lovely, all nice, too much though, very filling’ ‘Can have a choice of foods, is available only need to ask’ ‘Food good’. The comment cards returned from 11 residents all stated that they liked the food. The dining areas were seen to be well presented (with napkins and condiments available on the tables) making for a pleasant and comfortable eating environment. Staff were seen to give individual attention to those residents that needed assistance with eating, and any special requirements were documented in an individual resident’s case file (i.e. for diabetics). Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for these standards were not fully assessed at the time of this inspection. EVIDENCE: Whilst these standard were not fully assessed in the responses within comment cards returned to the CSCI by relatives and residents 5 of the relatives (out of 8) stated they were aware of the homes complaints procedures whilst all the residents that responded stated they knew who to speak to if unhappy with anything. Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24, 26 Residents live in an environment that overall is safe and well maintained. Residents have access to safe and comfortable communal facilities and their own rooms suit their needs. The home is clean, pleasant and hygienic. EVIDENCE: The home is ideally situated for access to the centre of Wednesbury by foot and the local bus station. The building itself was seen to be maintained to a good standard of décor (this judgement drawn from a tour of the premises including sight of the communal living areas, some bedrooms and bathrooms/toilets). It would however be of benefit if the provider was to produce a general maintenance programme for the upkeep of the premises, this to be available at times of inspection. There were not any areas that required attention identified at the time of this inspection however. Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 15 Residents were seen to have access to a number of communal rooms these comfortable, well presented and maintained. There is an enclosed patio/garden area to the side of the building. Discussion with residents indicated that they were satisfied with their bedrooms, these inspected as part of the case tracking process. Residents are able to bring their possessions in to the home (within space and safety requirements) if they so wish. The home from a tour of the building was seen to be clean and hygienic with staff having access to liquid soap; paper towels and personal protective wear as required. The homes laundry meets the required standards. Policies and procedures in respect of infection control were accessible these reinforced by provision of training for staff in the same area. Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 Resident’s needs are met by the numbers and skill mix of staff. Residents are supported and protected by the homes recruitment policy and practice. EVIDENCE: Based on the required allocation of care staffing hours per week against the residential forum-staffing tool (as recommended by the department of health) the home has almost sufficient care hours without the inclusion of any nursing hours, this based on the dependency levels at the time of the inspection. There were some beds vacant at this time. This translates into 4 care staff during the morning, 3 in the afternoon and 2 at night. Again these figures do not include nurses or ancillary staff (with one nurse available on every shift throughout the day and night). The manager’s hours are supernumerary to any nursing or care hours. An audit of the files for those 3 staff employed since the last inspection showed that the home was following good recruitment practice with a risk assessment completed and discussed with the CSCI when taking staff on without a disclosure, but with all other checks and POVA 1st. Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 17 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): 33,35 The home is run in the best interests of the residents although the way the home evidences this could be better. Resident’s financial interests are safeguarded. EVIDENCE: There was evidence of on going work in respect of a self monitoring tool for the home with a Quality manual seen that laid out audit sheets in respect of the homes health and safety procedures but not to date other areas of practice. The home has developed a policy on internal audits but there was comment as to the need to date the audits carried out (some were) and organise the folder in an easier to follow layout with use of such as dividers. There was evidence that the home does consult with residents and relatives through questionnaire, meetings, reviews etc although the most recent returns were not dated. Questionnaires also need to be submitted to stakeholders of the service (i.e. Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 18 PCT, G.Ps, Social services etc) with the findings from all of the feedback made available publicly. There is also need to develop an annual development plan on a more formal basis. The home was seen to have appropriate policy and procedures in place in respect of safeguarding resident’s finances and valuables. A spot check was carried out on monies in safekeeping these found to balance with well kept records. Inventories of resident’s property were seen to be recorded within case files and all bedrooms seen had a lockable draw available if needed by the resident. Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 19 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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 4 X X 3 3 X 3 STAFFING Standard No Score 27 4 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X X Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 20 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 OP8 Regulation 12 Requirement Care plans must be consistently signed by the resident or their representative. Timescale for action 31/03/06 2. OP33 24 This is a repeated requirement that was to have been met by the 30.10.05. To develop the homes systems 30/06/06 for quality assurance in accordance with the expectations of the National Minimum Standards and comments within this report. 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. Refer to Standard OP19 OP33 Good Practice Recommendations To develop a formal plan for maintenance of the premises that shows forward planning. 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 DS0000004777.V274922.R01.S.doc Version 5.1 Page 21 Bartholamew Lodge overview/report in a format for public consumption. Bartholamew Lodge DS0000004777.V274922.R01.S.doc Version 5.1 Page 22 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: 0845 015 0120 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.V274922.R01.S.doc Version 5.1 Page 23 - 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!