Inspection on 14/06/06 for Bascombe Court

This inspection was carried out on 14th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bascombe Court 18/10/07

Bascombe Court 13/12/05

Bascombe Court 08/06/05

Bascombe Court 23/11/04

Bascombe Court 28/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Bascombe Court Bascombe Road Churston Ferrers Brixham Devon TQ5 0JS Lead Inspector Judy Cooper Unannounced Inspection 14th June 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bascombe Court DS0000018322.V292227.R03.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. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bascombe Court Address Bascombe Road Churston Ferrers Brixham Devon TQ5 0JS 01803 842360 01803 842360 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) Manor Collection Ltd Vacancy Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31), Physical disability over 65 years of age of places (31) Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users over the age of 50 can be admitted within the category of PD Females over the age of 60 may be admitted within the category of OP Date of last inspection 13th December 2005 Brief Description of the Service: Bascombe Court is a large house situated between Paignton and Brixham with views over Torbay. The home provides care for up to 31 older people, some with physical disabilities. Entrance to the home is via a newly created large sweeping driveway, leading to a virtually level entrance into the home. There are mature gardens, and three patio areas. The bottom of the garden has been landscaped. The entrance hall now has a separate enclosed office and a large communal seating area is currently being finished within the hallway. The hallway subsequently leads into a large sun lounge, dining area and quiet area. There is level access onto a patio from this area. The lower ground floor is accessed by a chair lift. It has 6 en-suite bedrooms and each open onto a level patio area. There are 6 bedrooms on the ground floor. All bedrooms are en-suite, some with showers or baths. The ground floor also has a laundry and an assisted shower and separate toilet. There is a passenger lift to the first floor and second floors, which between them have 15 bedrooms, an assisted bath and a walk-in shower. There are also staff rooms and a staff toilet. The current fees range from £375.00 --- £470.00. The owner has now completed eleven close care units within the grounds of the home. These units operate totally separately from the home and therefore, do not form part of the current registered facility. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on a Tuesday (10.00-5.45 p.m) and a Wednesday (9.30-3.00p.m). Opportunity was taken to observe the general overall care given to residents. The individual care provided for four residents was also followed in specific detail, from the time they were admitted to the home, which involved checking that all elements of their identified care needs were being met appropriately. A tour of the premises, examination of some records and policies, discussions with the owner, acting manager, residents, staff, as well as several visitors and a visiting District Nurse and a visiting G.P. all formed part of this inspection. Staff on duty were also observed, in the course of undertaking their daily duties. Other information about the home, including the receipt of seven completed questionnaires from residents, four staff at the home and one from a District Nurse has provided further feedback as to how the home performs, and this collated information has been used in the overall writing of this report. All required core standards were inspected during the course of this inspection process. The acting manager, and both owners were present on the first day of the inspection and additionally the home’s newly appointed quality control officer was also present during the second day of the inspection. What the service does well: The home’s environment continues to provide residents with a very comfortable, excellently maintained, homely, bright place to live in. Residents continue to benefit from a “community spirit” within the home and are encouraged and enabled to socialise with each other as desired. The management and staff enable residents to maintain links with the nearby local community and visitors are both encouraged and welcomed into the home. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 6 The staff maintains residents’ lifestyles to good effect which facilitates residents to be able to pursue their own interests. What has improved since the last inspection? The Responsible Person has ensured that water temperature regulation is in place within the home, which therefore protects residents from the risk of scalding. General, on-going, routine maintenance work, within the home, continues to ensure that the physical environment of the building remains at a very high standard. Several bedrooms have been completely refurbished as well as the home’s communal areas, which are in the process of being completed. All work has been undertaken to an excellent standard. A privacy lock is in the process of being provided to each resident’s bedroom door. Since the last inspection a new self contained, private office area has been created at the entrance to the home. The previous open plan office area has been incorporated into the large, square, main entrance hall, thereby giving more room within this popular communal/meeting area. Improved, additional parking have been provided, with the access to the home also benefiting from new paving and therefore making access much easier for any person with mobility problems. Additionally some new garden furniture and a new commercial dishwasher has been provided. Residents are also benefiting from a new improved laundry system now operating within the home. The home’s filing/recording systems have been streamlined and all required records updated to ensure they are in compliance with those that need to kept by a registered care home. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 7 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. Bascombe Court DS0000018322.V292227.R03.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 Bascombe Court DS0000018322.V292227.R03.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The quality in this outcome area is good. The admission process is managed appropriately and residents and/or their next of kin/advocate are given the necessary information regarding the service prior to admission so that they can make an informed decision. EVIDENCE: Since the last inspection the home has admitted several new residents. In the majority of cases the admission was a privately arranged admission, although there was evidence of Social Service involvement in some instances. Whilst at the inspection, it was noted that a resident who had enjoyed many separate breaks of respite care had now, along with their family, made the decision to move into the home permanently and there was full care management involvement in this particular instance. Another permanent resident, spoken with, was able to confirm that they had been facilitated to have a respite stay and then go back home to see if they wished to make a permanent move into the home. After a short while this is what they had chosen, fully aware of what services the home could offer. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 10 Four relatively new residents were chosen as part of the case tracking exercise, which involved looking in depth at their admission process as well as other areas of care in relation to these residents. In all four cases the admission documentation was fully inspected. In respect of the one of the newly admitted residents their relative was also available to speak with. Verbal feedback from the relative concluded that the home had been initially chosen, based on information contained with the home’s previous report. The family was then given information about the home from the home’s managment, which they were able to take and discuss with the prospective resident whilst she was in hospital. The acting manger was unable to visit due to the resident being “out of county”, but the daughter confirmed that she was able to give all required information to allow the manger to be aware of the residents’ needs and consequently undertake a pre admission assessment which then informed the acting manager as to whether the resident’s needs could be met at Bascombe Court. The daughter and the resident, who has been at the home since March this year, both confirmed that the resident’s need were being well met and that the resident had been made welcome and enabled to settle comfortably in at Bascombe Court. For two other residents a similar process had taken place. Regarding the final resident the admission had been undertaken as an emergency admission, however it was noted that the relative had been also given information about the home and that correct admission procedures had been carried out. In the case of all four there were up to date signed contracts and detailed admission assessments and relevant risk assessments. The Court Group, overall, have recently introduced an initial risk assessment based on the admission process. This includes such areas as ensuring glasses and other personal necessary items arrive with the resident and that information noted within the pre-assessment continues to be valid. It also determines whether there is a need to contact other professionals to inform of new resident’s admission. This is to ensure that the resident will “feel at home” as quickly as possible and will ensure that all required care can be made available at the commencement of the stay. The Court Group are also in the process of issuing feedback questionnaires to all newly admitted residents to try to build up a true picture of how each new resident felt and to see if the admission process can be improved on. This is a positive move and should be commended. After observing all of the documentation in relation to the admission process, it was concluded that the admissions had been undertaken in such a manner as to allow the residents and/or their next of kin/ advocate to be aware of what services the home could offer and therefore allow an informed choice. Random selected residents also gave written feedback indicating that they had been given sufficient details to enable them to make an informed choice. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 11 The home does not provide an intermediate care service. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 12 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): 7,8,9,10 The quality in this outcome area is good. All residents are looked after well in respect of their health and personal care needs. Residents’ privacy and dignity is upheld and their life style choices respected. EVIDENCE: Care plans were seen in respect of the four permanent residents who were case tracked. The care plans examined were thorough and covered all required care needs. There were appropriate risk assessments in place including a moving and handling assessment, a pressure area risk assessment and a self medication assessment (where appropriate). One resident’s relative, who wishes to, has chosen to be involved in the drawing up of their care plan and the regular monthly review process and the home were waiting for the relative to visit to initiate this process. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 13 In respect of the other three residents, they had requested the management of the home to undertake this role on their behalf. One of the four residents stated that since she had moved into the home she had felt more confident in mobilising and felt much more able to get around than she had at home. Another said that “She couldn’t be treated any better than if I was in my own home. The staff are kind and nice”. A visiting relative (not connected with those residents whose care was looked at in detail) confirmed that they were always made aware of their relative’s changing needs and were always involved in any change to the resident’s care. They valued this involvement and felt it kept them in touch with the care being provided. The relative also stated that they felt confident to be able go away on holiday as they knew the home would contact them if required and allow them to have a say on any treatment that needed to be made available. All of the residents’ health care needs were known and were noted as being appropriately provided for. Professional advise is asked for as required. During the inspection a visiting District Nurse was spoken with who confirmed that the staff try their best to follow any instruction given regarding clinical issues within the home. A visiting G.P was also asked for feedback and was able to confirm that he felt the home called for help whenever they were concerned, which the G.P felt was the best way, rather than the management not calling for advise early on. On the second day of the inspection, it was noted that another G.P visit was requested for a resident who was not well and that there were good and helpful communications with the G.P during the visit. The home maintains a comprehensive list of any health care visits which ensures all staff are easily able to be aware of what each professional may have prescribed/suggested. The home’s medication cupboard was inspected and the home’s medication procedures were noted as mostly being in order. There are also plans in hand to move the medication cupboard to larger more, easily accessible space. However it was noted that the carer, in charge of administering medication on the first day of inspection, had not signed for the medications as they were administered, choosing instead to record the medication given some time later and in a collective manner. Discussion took place with the owner and acting manager as to the risk involved of subsequently recording medication given/refused etc wrongly using this method as it relied on memory. The acting manager and owner were, themselves, aware of the need for immediate recording and, following this inspection spoke with the carer responsible to ensure that the practice was immediately discontinued. The home receives regular visits and advise from its supplying pharmacist and medication training is provided to the staff. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 14 This information evidenced that the management of the home are aware of how best to handle residents’ medications and therefore ensure residents are protected. The home’s accident book was inspected and details were noted as being in order, in relation to an accident that had recently happened which had involved a resident falling out of bed. Residents’ individuality and dignity were noted as being upheld throughout the days of inspection and those residents spoken to confirmed that this is always the case. There were also several comments made by residents and their visitors, about how well the staff cared for the residents to ensure their needs were provided for. The home operates a key worker system, which the acting manger has upgraded to ensure that both the residents are fully aware who their key worker is and what the key worker’s role will be and that staff are also aware of their responsibilities for their named residents. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 15 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): 12,13,14,15 The quality in this outcome area is excellent. Residents continue to enjoy a peaceful, pleasant yet varied life at the home, with visitors encouraged and welcomed, whilst links are maintained with the local community. Various daily activities are made available. Excellent nutritious, well planned and presented meals are provided. EVIDENCE: Residents spoken with stated that they were happy living at Bascombe Court. Two more recently admitted residents were still getting used to communal living but overall felt comfortable with the home’s routine. Both had regular visitors at times, which were convenient to them, or their visitors, which they valued. All visitors were noted as being welcomed and able to come and go as they wish. There were many visiors during the inspection. If desired a meal is provided for any visitor, free of charge. Some visitors were spoken with and all confirmed that they were always made very welcome, could visit at any time and found the management and staff helpful. Residents are encouraged/enabled to be as independent as possible with help available if required. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 16 Individuality is upheld by the staff and it was noted that residents chose exactly how they spent their time, with some coming and going quite independently. The home’s regular hairdresser was doing several residents’ hair during the inspection and she also confirmed that residents she saw always said that they happy with the care and facilities provided. Arm chair activities were being provided in the afternoon, whilst in the morning a community coffee morning had taken place within the home involving a local G.P’s support group, which residents can choose to join in with if they wish to. On the second day of the inspection there was a mini bus trip out to a local beauty spot, followed by a cream tea, which many of the residents had chosen to go on. Some of those that had remained at home were spoken with and they confirmed that they themselves had taken the choice not to go on the trip and said that they were enjoying the peace and quiet of the communal lounge, with it being a very hot day and the staff were arranging a game of bingo for those that wanted to participate. The management of the home have recently asked all residents for ideas as to what activities they would like to see. Following on from this a new activities programme has been provided which is based on the residents in-put whilst feed back from residents and staff confirmed that the activities provided were those the residents enjoyed. The Court Group have also just introduced a three monthly quality auditing of all activities that are being made available, to ensure that they remain as residents want and to allow for residents to have a say on what is put in place within their home. Meals provided are very good. On the first day of inspection the meal was roast lamb with roast potatoes and fresh vegetables, followed by crème caramel. There was also a choice offered. All residents spoken with stated that they enjoyed their meals and confirmed that there was always choice available if they wanted to have something different. One resident particularly wanted to state that the quality of the meal that day was always upheld and that “it hadn’t been for show”. The home’s chef was spoken with and has been at the home for approximately a year now. He was enthusiastic about his role and tried to involve residents as far as possible as to what meals they wanted to see served. He said that a lot of residents will pop into the kitchen for a general chat about their dietary needs and he welcomes this interaction. He was aware of residents’ individual needs, likes and dislikes including the one diabetic resident’s needs who is currently at the home. Those residents that required some additional support with feeding were provided with this help in a sensitive and gentle manner. In fact one able resident was noted as helping another frailer resident. When asked why she was doing this she said she wanted to, as the resident was her friend. Staff were noted as also discreetly supporting her in this to ensure the frailer resident did receive her meal appropriately. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 17 The relative of a resident who was case tracked stated that the resident had put on weight since coming to live at the home due to the good food, something which had been viewed very positively by all concerned. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality in this outcome area is good. Arrangements for protecting residents and responding to their concerns are satisfactory. EVIDENCE: The home’s complaint policy remains communally displayed (although in the days of inspection it had been removed due to re-decorating of the hallway) and is also contained within the home’s statement of purpose. It was particularly pleasing to note the detailed way any in-house complaints are both treated and recorded, clearly evidencing what action has been taken to resolve them to the resident’s satisfaction. An example of a complaint dealt with involved a resident hearing a carer using some inappropriate language and reporting it. This was eventually dealt with through the home’s disciplinary procedures and the member of staff was dismissed. The seriousness with which each complaint is treated allows residents to have confidence that, should they make a complaint, it will be addressed correctly. Residents spoken with were clear as to how to complain and felt they could easily approach the acting manager or any staff member should they have any cause to. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 19 A direct complaint was made to the CSCI in February this year in connection with a mix up of medication being given to two residents going home for a period of time over Christmas. The complaint was investigated by the provider and was upheld. The Responsible Person has since provided a new amended policy in relation to two staff now having to ensure the correct medication is given out. This was considered to be appropriate action and the complaint is now closed. Returned questionnaires from some randomly selected residents indicated that they would feel confident to speak to the acting manager of staff if necessary over any concern they may have. Staff confirmed they receive vulnerable adult training on a regular basis and there was an updated list kept of when this training was both given and when it needed to be renewed. A new staff member stated that one of the reasons they enjoyed working at the home was that all residents “are treated well” and they “had never heard any resident being spoken to in a bullying or disrespectful manner”. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 20 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): 19,26 The quality in this outcome area is excellent. Bascombe Court is very comfortable, clean, well maintained and provides a safe standard of accommodation for the residents. EVIDENCE: The tour of the home confirmed that the Responsible Person maintains excellent environmental standards within the home, which makes Bascombe Court a very pleasant place to live in. Routine general upgrading continues to take place, including re-decorating, refurbishment and re-carpeting etc. During the days of the visit upgrading work was on-going in the form of redecorating the home’s communal lounge and enlarging the home’s communal hallway. The manager maintains the home’s fire precautions in line with the requirements of the local fire department whilst a member of the Court group staff is employed specifically to ensure this, and all other areas associated with Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 21 the health and safety of the residents, are maintained in accordance with the requirements associated with each area. The home’s fire log book was inspected and found to be in order. Privacy locks to residents’ bedroom doors are in the process of being fitted. Each resident has had a room risk assessment undertaken. These have now been amended to include the hot water regulation to each resident’s bedroom and the covering of any hot surfaces (i.e. radiators), which are now in place. The home presented as very clean and feedback given from various parties, during the visit, indicated that this was normal. Feedback contained within a resident’s questionnaire included the statement: “the cleanliness is excellent”. During the inspection the home’s domestic member of staff was spoken with. She has been at the home for four years and it was obvious she takes pride in her work. There were no unpleasant odours what so ever throughout the home and the home presented overall as clean and tidy. The laundering needs of the residents are met appropriately with new improved laundry equipment ensuring that all residents’ laundry needs are undertaken as effectively as possible. Staff receive regular cross infection training as part of the Court Group’s statutory training programme and during the visit staff were noted as observing routine health and safety procedures, to help prevent any unnecessary cross infection within the home. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 22 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): 27,28,29,30 The quality in this outcome area is adequate. The home’s recruitment policies are in order and protects residents. Staff at the home are appropriately trained and employed in adequate numbers so as to meet the residents’ needs. EVIDENCE: All residents and visitors spoken with during the site visit confirmed that the staff are caring and kind. Staff were also noted as being well presented and polite towards the residents. The staffing rota was inspected. Although one comment received from a resident stated that on occasions the home could be short of staff, those spoken with during the inspection confirmed that when all rotered staff are present there are sufficient staff to meet the residents’ needs. On the day of inspection there were twenty-seven residents in the home. The number of carers on duty was four in the morning and three in the afternoon and evening. The acting manager also works from 8.00a.m until 6.00pm.as well and her role incorporates some element of “hands-on” care. The acting manager is currently also working every other weekend, and when she is on days off or finishes at 6.00p.m a duty officer covers the management of the home as well as providing for care needs as required. Additionally there is a cleaner five mornings a week and a weekday chef. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 23 Discussion took place as to the fact that should there be any unexpected absences due to such things as sickness extra staff can be called on to cover from one of the other Court Group homes. The owner and acting manager were both aware of the fact that there had been a higher than normal staff turn-over, but were working towards ensuring that new staff employed are experienced and therefore able to meet the residents’ needs. The home has previously employed several members of overseas staff, however this has recently changed with only one overseas worker now employed. Training is provided regularly. Recent training provided has included updated statutory training which included such areas as fire safety, moving and handling, health and safety, and food hygiene. Due to the home having recently experienced a fairly high degree of staff changes the current ratio of trained staff is less than 50 , as several staff who moved on were qualified staff, however the owner is aware of the need to meet this requirement and has already registered several of the new staff members for the NVQ levels 2/3 training in care, commencing in September 2006 (they would have commenced earlier, however government funding ceased in April, but is due to re-commence in September). New members of staff are currently being taken through the induction programme and various in-house training packages. Staff on duty were able to confirm that they had received a lot of in house training since their appointments and were happy to take advantage of the further training opportunities being presented. This level of training helps ensure that staff are appropriately trained and consequently able to provide suitable care for the residents at the home. Staff records for three staff members, employed since the last inspection, were looked at in detail. The recruitment procedures within the home, including receipt of completed application forms, two written references, an enhanced CRB check, ensure that there are suitable staff working within the home and that residents are protected. All staff receive regular supervision and annual appraisals to allow them to fully understand their role/performance within the home. Staff on duty were spoken with and it was pleasing to note that those spoken with felt comfortable working at the home. Staff stated that they felt both the owner and acting manager were approachable. Two new members of staff also said that, although they had worked in several care homes in different parts of the country, they felt that “Bascombe Court had a lovely vibe” and that “the staff really cared for the residents and that the whole team pulls together”. Another staff comment received was “I feel that each resident is treated as an individual and made to feel special and this is carried through from the time Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 24 they come into the home until the time they leave. I am committed to the care of my residents throughout”. During the inspection it was noted that staff took pride in their role and tried to ensure that all residents had a good quality of life, irrespective of need or diversity i.e. it was noted that frailer residents were given choice and respect as a matter of course and that the male carer on duty was very aware that not all female residents may want him to provide personal care. If this was the case other arrangements were made to ensure a female carer was available instead. There are regular staff meetings held with minutes kept. Information that may be useful to staff, including the Court Group’s corporate strategies are also made available to all staff, with the staff having their own notice board. This allows them to have an awareness of all issues surrounding their roles. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. The quality in this outcome area is adequate. The management of the home, although not yet formally registered, provides the necessary support to staff and residents. Excellent quality auditing takes place to ensure that the home is run in the best interests of the residents. The home provides a safe, secure environment where residents’ safety and well being is maintained. EVIDENCE: Following this inspection it was confirmed that the recently appointed acting manager will remain in training for the immediate future. This is to allow her to gain further confidence and a greater awareness of the requirements of the registered manager’s role. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 26 During this period the Responsible Person will apply to become the registered manager for the home and will further support and train the acting manager. The responsible Person has many years experience in the setting up and running of care homes for the elderly within the local area. In turn the Court Group’s recently appointed Quality Assurance Officer will support both the owner and the acting manager. During the inspection several residents and visitors fed back how approachable they found the owner and how she is available within the home when the want to speak to her. Records inspected were up to date, concise and contained appropriate information. The residents or the residents’ families/advocates mostly deal with any financial matter although the home does hold small amounts as requested by residents or their families. There were detailed records in respect of these and the Court group senior management team undertake a monthly review of all monies held. This ensures residents’ monies are secure. A member of the Court group senior management team undertakes a formal monthly in-depth review of the service and provides both the manager and the Commission with a written record of this visit as required under regulation twenty-six. The acting manager holds three monthly residents’ meetings with the last one being held early in May this year. The Court Group Senior Management team are in the process of further improving their quality auditing approach to ensure that residents’ views are taken into account at all times. An example of this is the recently introduced auditing of the admission process for the residents, where newly admitted residents are invited to feed back on how they felt their admission went. The appointment of the newly created quality audit officer also evidences that the Court Group are working towards ensuring that all of its homes are run in such a way as to be in the best interests of the residents. The acting manager and the Responsible Person both confirmed that health and safety issues continue to be well managed within the home and records inspected supported this. The home’s hot water supply has now been regulated throughout the home. This measure further helps maintain residents’ safety at all times. Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 4 x 3 x x 3 Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations The Responsible person/manager should ensure that medications are individually signed for, as they are given out. The responsible Person/manager should ensure that the Commission is informed of any incident that appertains to the welfare of any resident. 2 OP37 Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Bascombe Court DS0000018322.V292227.R03.S.doc Version 5.2 Page 30 - 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. 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