Inspection on 09/01/06 for Bartlett`s

This inspection was carried out on 9th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Bartlett`s 05/02/08

Bartlett`s 12/09/06

Bartlett`s 10/08/05

Bartlett`s 07/02/05

Bartlett`s 01/06/04

Bartlett`s 08/01/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Bartlett`s Peverel Court Portway Road Stone Aylesbury Bucks HP17 8RP Lead Inspector Chris Sidwell Unannounced Inspection 9th January 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 DS0000022953.V278259.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. DS0000022953.V278259.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bartlett`s Address Peverel Court Portway Road Stone Aylesbury Bucks HP17 8RP 01296 747000 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) Peverel Court Limited Gloria Ncube Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places DS0000022953.V278259.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 10th August 2005 Brief Description of the Service: Bartletts is registered to provide personal care and accommodation for twentyfour older people. The home is privately owned and is situated on the outskirts of Aylesbury and Stone. There are some amenities within the village of Stone and ample social and recreational facilities in the market town of Aylesbury. Bartletts is a large, Victorian country house, set in its own grounds. The home has been refurbished to meet the needs of residents, whilst maintaining many of the original characteristics of the house. All but one of the bedrooms provides single room accommodation. A married couple reside in the remaining double bedroom. All bedrooms are fitted with en-suite facilities and there are ample bathrooms and toilets within close proximity to all sleeping and communal areas. One lounge is situated on the ground floor adjacent to the dining room. There is a quiet lounge on the first floor. The home is well decorated. There is an experienced manager and care team. DS0000022953.V278259.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection undertaken on the 9th January 2006. The purpose of the inspection was to inspect the remaining core standards, which were not assessed at the inspection undertaken on 10th August 2005 and to assess compliance with the requirements arising from that inspection. Policies and procedures were examined. The manager and general manager were interviewed. All residents in the home were seen and a number were spoken to. This report should be read in conjunction with the report of the inspection undertaken on the 10th August 2005. What the service does well: What has improved since the last inspection? The staff now receive medication training. The hallways and front entrance have been redecorated since the last inspection. The outside areas have been tidied and the bin area is now enclosed. A staff room has been provided. DS0000022953.V278259.R01.S.doc Version 5.1 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. DS0000022953.V278259.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 DS0000022953.V278259.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): These standards were not assessed at this inspection. The core standards were assessed and met at the inspection undertaken on the 10th August 2005. EVIDENCE: DS0000022953.V278259.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): 9 The medication management at the home is good and residents receive their medication in a safe and timely way. EVIDENCE: There is a medication policy. A local pharmacist supplies medication in dosette boxes. Records are kept of medication entering and leaving the home. There are self-administration of medication policies and procedures which enable residents to maintain their independence if they wish. The supplying pharmacist visits the home on a three monthly basis to audit the medication management systems and offer advice to the staff. He has indicated that he may not be able to do this in the future. The manager must discuss this with him as it is a recommendation of The Commission for Social Care Inspection that care homes seek the advice of a registered pharmacist on a regular basis to ensure that that medication is managed well. The medication administration records were completed accurately. Records were seen to confirm that all staff who administer medication now have the required training. DS0000022953.V278259.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. They were assessed and met at the inspection undertaken on the 10th August 2005. EVIDENCE: DS0000022953.V278259.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. The core standards were assessed and met at the inspection undertaken on the 10th August 2005. EVIDENCE: DS0000022953.V278259.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Bartletts is a comfortable and well-maintained home for residents, who said that they enjoyed living there. The home is clean and tidy and free from offensive odours, protecting residents from infection. The kitchen is in need of upgrading if it is to remain fit for purpose and resident’s meals are to be prepared in a clean and safe environment. EVIDENCE: Bartletts is a large Victorian country house, set in extensive grounds. The grounds are well maintained and residents have access to them. There are plans to install additional ramps to facilitate access. There are beautiful views across the Vale of Aylesbury. The house has been adapted to meet the needs of older residents. The rooms are large and are well furnished, in keeping with the age of the home. There was evidence that residents are encouraged to bring in their own furniture and to personalise their rooms. The communal lounges and the dining room are pleasantly decorated and furnished. The residents spoken to said that they liked living at the home. One said that her only worry was that she might have DS0000022953.V278259.R01.S.doc Version 5.1 Page 13 to move if she became unwell. She was very happy at the home and had decorated her room to her liking. At the previous inspection a requirement was made that a large crack in the wall be surveyed and repaired. This has now been addressed. The main entrance and hallways have also been redecorated. There are no CCTV cameras. The electronic gates at the drive provide security. The fire safety officer last visited the home on the 25th October 2005 when all fire matters were deemed satisfactory. The kitchen is old and although the staff work hard to keep it clean, the cupboards were in poor state of repair and the floor is not non-slip. The worktops, cupboards and fascias are showing signs of wear and are no longer impervious. At the last inspection a recommendation was made that the proprietor consider replacing the kitchen. The general manager said that this was under consideration and that a decision would be made shortly. The laundry facilities are situated in a building in the grounds near to the home. The washing machines wash at the required temperature to control infection and the laundress described the manner in which soiled laundry would be handled. The floor is impermeable. The dryer is gas fuelled and the room has to be vented. The result was that on the day of the inspection it was very cold to work in. The proprietor should seek advice as to how the room could be safely vented but kept at an acceptable working temperature for the staff working there. The bin area at the rear of the building has been enclosed and was tidy on the day of the inspection. DS0000022953.V278259.R01.S.doc Version 5.1 Page 14 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, 28 and 29 There are sufficient care staff to meet resident’s needs. There are sufficient ancillary staff to ensure the smooth running of the home and to ensure that carers are not diverted from assisting residents by the need to undertake other duties. The training programmes give staff the knowledge and skills to meet resident’s needs. The recruitment policies and procedures are in general satisfactory although there is room for some improvement if residents are to be fully protected from the potential employment of unsuitable carers. EVIDENCE: There is a staff rota, which shows the staff on duty at any time. The rota shows that additional staff are on duty at times of peak activity. There are five carers on duty in the morning, four in the afternoon and evening and two at night. The ancillary staff include the chef, domestic assistant, cleaning staff, laundress and handyman. There is a vacancy for an assistant chef at present. The residents spoken to said that the care staff had time to help them and that they did not have to wait for attention. A newly appointed general manager supports the three homes in the group. No staff are under the age of 18 and nobody under the age of 21 is left in charge. On the day of the inspection there were twenty-two residents, two of whom had high, eleven medium and nine low care needs. The manager stated that the home provides approximately 529 care hours per week. This meets the recommendations of the Department of Health. DS0000022953.V278259.R01.S.doc Version 5.1 Page 15 There is an active training programme. There are eighteen carers in total. Five hold the National Vocational Qualification in Care at Level 3 and a further two are undertaking the course. Three carers hold the National Vocational Qualification at Level 2 and a further two are undertaking the course. The home has almost met the target that 50 of staff hold this qualification and has a clear plan to do so. Two recruitment files were examined. Both had application forms, two references, one of which was from the previous employer and copies of passports and work permits. For one the Criminal Records Bureau check had not been received before the employee commenced work and there was no evidence that a POVA first check had been undertaken. This must be addressed and the home must be sure that POVA first checks are undertaken before a staff member starts work and that they are supervised until the full Criminal Records Bureau check is received. It is recommended that the home audit all recruitment files to ensure that they contain the required documentation. DS0000022953.V278259.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 The proprietor does not have systems in place to assure himself that the quality of care offered to residents is of a consistently high standard. EVIDENCE: At the last inspection a requirement was made that the proprietor undertakes monthly quality assurance visits to the home and supplies the Commission for Social Care Inspection with a report detailing the outcome of these visits. This is still not in place. One report has been received since April 2005. It is a requirement of this report that the proprietor makes arrangements for these visits to be undertaken on a monthly basis and that the reports are sent to the Commission for Social Care Inspection on a monthly basis. DS0000022953.V278259.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 X 8 x 9 3 10 X 11 X 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 1 x x x x x DS0000022953.V278259.R01.S.doc Version 5.1 Page 18 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 OP19 Regulation 23 Requirement Timescale for action 30/06/06 2 OP28 18 3 OP29 19 4 OP33 26(1) The kitchen should be upgraded to ensure that the surfaces, cupboards and fascias are impermeable. A non-slip floor should be fitted. The progress that the home has 31/03/06 made towards meeting the standard that 50 of care staff hold the National Vocational Qualification in Care at Level 2 or above should be maintained and a date by which this will be achieved should be set. All staff files should be reviewed 31/03/06 to ensure that they all contain the information required Regulation 19, Schedules 2 and 4 of the Care Homes Regulations 2001. The proprietor must make 31/01/06 arrangements to ensure that monthly quality assurance visits are undertaken and that reports of these visits are sent to the Commission for Social Care Inspection on a monthly basis. This is an unmet requirement of previous inspections and a new timescale has been set. DS0000022953.V278259.R01.S.doc Version 5.1 Page 19 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 Refer to Standard OP26 Good Practice Recommendations It is recommended that the ventilation be reviewed in the laundry to ensure that the laundry is adequately ventilated and that the temperature is adequate for staff to work in the laundry. DS0000022953.V278259.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 DS0000022953.V278259.R01.S.doc Version 5.1 Page 21 - 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. 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