Inspection on 18/10/07 for Bascombe Court

This inspection was carried out on 18th October 2007.

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 14/06/06

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 Douglas Endean Unannounced Inspection 09:00 18 & 24th October 2007 th 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.V344860.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bascombe Court DS0000018322.V344860.R01.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 Mrs Jill Wakeham 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.V344860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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 Named male service user to be admitted under the DE(E) category Date of last inspection 14th June 2006 Brief Description of the Service: Bascombe Court is a large well presented house, overlooking the sea, situated at Churston Ferrers, an area between Paignton and Brixham in South Devon. It provides personal care for up to 31 people, some with physical disabilities. It is a short walk, almost level walk, from shops and a post office at Broadsands. The entrance to the home is via a large sweeping driveway with ample parking for the home and adjoined flats, leading to a virtually level entrance into the home. There are mature landscaped gardens to the rear of the home, a large water garden and three patio areas at different levels and easily accessed from the home. The main office is immediately inside the front door off the reception area where information about the home is displayed. Stairs lead to the lower ground floor, and a stair lift is present. This floor has 6 en-suite bedrooms and each open onto a level patio area. The two upper floors can be reached by either stairs, or the shaft lift. A door leads into the main lounge that has magnificent views over the grounds to the sea beyond. There is a spacious dining area sharing the same space as the lounge being gently separated by the design of the building and placement of chairs. An inner lounge off the dining room provides space for the library books, and the television, and has no natural light from windows but is comfortably furnished. There is level access onto a patio from the lounge/dining area All the bedrooms have an en-suite with showers or baths. The lower ground floor also has a small laundry, an assisted shower and separate toilet. The upper floors have an assisted bath and a walk-in shower. There are also staff rooms and a staff toilet on the second floor. The current fees commence from £395. Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 5 There are eleven close care units within the grounds of the home. The units operate totally separately from the home and do not form part of the current registered facility. Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection commenced at 09:00 hours on the 18th October 2007 and a second visit was made on the 24th October 2007. The total inspection time was 6.5 hours. The homes Registered Manager was not available on the 18th October due to sickness, however, the Deputy Manager and Quality Assurance Officer gave their full cooperation on that day and were joined by the Group Trainer/Health & Safety Officer during the afternoon. The Registered Manager was at the home on the 24th October 2007. During the inspection we made a tour of the home and spoke to 5 of the people who live there. We also spoke to 5 members of staff through the course of the inspection. The records of three people who live in the home were read as part of tracking care. A sample group of three staff records were also read to establish recruitment and training at the home. No relatives were interviewed, however, six relatives survey forms were returned, seven staff survey forms and five survey forms were received from health care professionals who visit the home. What the service does well: What has improved since the last inspection? Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 7 The general management of the home has improved with the appointment of the new Registered Manager. This has had a domino effect in improving the general functioning of the home. The Manager had made arrangements for a more appropriate medicines trolley but this had not arrived at the time of this inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home uses a well laid out format for the pre-assessment of prospective admissions. The information that is gathered about individuals is comprehensive giving a good picture of them and their care needs. The format that is used should enable the home to always make good decisions about whom they choose to admit. EVIDENCE: The procedure for admission is that the manager visits the person being referred to the home at their home, or wherever they may be, such as in hospital. They assess their needs with them or their advocate. They are encouraged to visit the home prior to admission for a trial period if it is felt Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 10 that they meet the criteria for admission. A statement of purpose, including the complaints procedure, and brochure are given to them at this time and the fees discussed. We looked at the format used for gathering information about people who may be admitted to the home. The home has introduced new documentation that includes what is to be known about someone before there is a decision to admit them. The forms include gathering a personal history, dietary needs, daily routine including the bedtime routine, and what the care needs of individual’s are. The interviewer is prompted to explain that the purpose of gathering the information is to help staff providing care to better understand the individual’s needs. There are prompts for the person carrying out the assessment so that import information is gathered about the care needs such as mobility, continence and communication issues. The pre-admission information that is gathered helps to inform any future care planning. We read the files of three people who now live at the home. One file was in the old format and two used the new format. The old format still provided the information now obtained but in a less user-friendly way than the new colour coded format that is part of just one file. Each file commenced with photographic identification of the individual. This was followed by the assessment check list that included if the General Practitioner or District Nurse are presently involved in the care that is needed with an area for a description of what this care is. Subsequent information formed the pre-assessment is entered on sheets that record issues specifically about nutrition including the persons likes and dislikes of food items, oral health, foot care, communication, and any risk assessments that have been made such as tissue viability and moving and handling. The risk assessments included one for self-medication that is followed by a clear agreement that is signed by the resident, their representative and the person in charge of the home. There is a clear reference to the two standards that raise the need for pre-assessment information, and also the care plan that follows. It then lists the areas to be commented upon in the assessment. Where an individual was involved with other services prior to the referral for admission their were letters and assessments that provided more insight into the individuals present state of health, medical and psychological, that help to guide the home to a decision about the suitability of the placement. Prior to an admission taking place the records also have a full checklist to be completed that covers the property being brought in including electrical items with a record of the Health & Safety portable electrical appliance test. There is also a full checklist for the environment that the person is moving into with action points where work is needed. Finally the home have a quality assurance questionnaire to obtain the views of newly admitted individuals about the move and the welcome they had. It also Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 11 asks about any concerns they hold. Completed copies of the questionnaire were seen during the inspection of the three records sampled of people living at the home. Bascombe Court DS0000018322.V344860.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standards 7, 8, 9 & 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans were very good in that they gave clear identification of assessed needs and how they were to be met. The home does encourage people who live there to maintain their identity and independence whilst providing safe levels of care. People are treated with dignity and respect. EVIDENCE: The construction of care plans was guided by the reference to standards 3 and 7 on the homes documentation. This has guided the assessors of care to look at each area and make comments about the individual needs of the person being assessed. We looked at a sample of three files written about people who had been admitted within one week, three months and then a longer stay. It Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 13 was found that each did have well written care plans that could be followed by the person delivering care. The first care plans were drawn up from the information gathered at the time of the pre-admission assessment and the supporting risk assessments, such as for mobility, nutrition and medication arrangements. There was also a form signed by the person living at the home, or their advocate, agreeing to the care plan. It also allows them to record if they wish to be involved in the monthly reviews of care or trust the judgement of the manager and care team during reviews. We saw the proof that the home does carry out monthly reviews, and records the outcomes of reviews and also acts upon more regular changes in someone’s health that may need a change in the care plan. The care plans do cover the basic care needs such as oral hygiene as well as more specialist needs that require the intervention of people such as the General Practitioner, District Nurse or Chiropodist. We saw the deputy manager deal appropriately with General Practitioner who visited the home during this inspection. People can choose to see the health care professionals in the home or to make their own arrangements to visit the General Practitioner, dentist or chiropodist of their choice. Medications are stored in a locked cupboard. The home uses a monitored does system that allows for a visual check on what has been given, or nor given. This visual check was supported by the administration sheets, which filled in at the time of administration as a medication round was observed during the inspection. The sheets had photographic identification of the people who were receiving medication. The procurement and administration records were good although someone had used pencil to record their signature during one round in the last week. We did comment that a more secure trolley would improve the security of medications during a drug round. The deputy manager told us that a MDS drug trolley had been ordered. The home has established a six monthly audit of the medication process. We saw that people had been assessed for there safety to self medicate. A self-medicating agreement is available to be signed by the person and their advocate if they are safe to self-administer and wish to do so. Safe storage arrangements are provided in bedrooms if there is a self-administration agreement. No one was self-administering medication at the time of the inspection. During the inspection we saw that people received care in the privacy of their rooms, bathrooms or toilets. Staff addressed individuals in a manner that appeared to agree with them, and they were responded to politely by the care staff when communicating. Everyone seemed appropriately dressed and there had been much attention to their personal appearance. None of the people living in the home responded to the Commission for Social Care Inspection using the survey forms. We spoke to 5 people who live at the home during course of the inspection. One said that she did not wish to be in the home but Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 14 they did manage her care well. Another who had recently arrived was very pleased with the total arrangement for her care. She liked her room that was already personalised, the staff were polite and helpful and the food was good. There were 6 relatives/advocates who responded in the relatives survey to the question “Does the care service support people to live the life they choose?” 4 stating always whilst 1 said sometimes and 1 said usually. Comments were written about encouraging people and helping them along side statements such as “He also likes his privacy, this is very much respected”. Another commented, “Obviously, most of the residents would prefer not to be in a home, but my relative gets out whenever she wants and she is encouraged to have visitors”. Bascombe Court DS0000018322.V344860.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standards 12, 13, 14 & 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The level of choice that people are given helps to maintain their independence and self-respect. The meals are well planned to meet the preferences and nutritional needs of the people who live in the home. EVIDENCE: During the admission of individuals the home does record information about the persons likes and dislikes relating to food, activities and in what they wish to be involved in the planning of their own care. The records file is entitled “My Life Now” and this has sections that record a persons personal history, medical history, who they are best able to communicate, what their own daily routine is and their food preferences. We read 3 of these files and spoke to a total of 7 people who live in the home who were able to give a comment on the establishment. The records indicated that people did make their personal choices known. The people that were spoken to also indicated that their Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 16 personal choices were met to an acceptable degree. Choices included how much time they spent in their own room and how much in the company of others who live in the home. They could choose who provide them with assistance during their times of need such as when bathing or moving about the home. Many people had their own private telephone line and most had personalised their rooms to their own liking, some being “just like home”. Where it is safe to do so people can also manage their own medication if they wish. The home tries to engage the people who live there in how it is run from day to day. We saw the minutes of the quarterly residents meetings that were displayed on the notice board in the dining area. Food was mentioned and this is a regular focus of the people who attend the meetings. The people are given a daily choice of menu taking into account personal preferences, and special needs. Activities are arranged by the home such as bingo, quizzes and weekly piano playing. There is a quarterly cloths show that benefits those who do not leave the home. Every four weeks the home has Holy Communion for those who do not visit their own church. There is also a library in the quiet lounge and the books are changed quarterly. We saw people leaving the home with and without staff and relatives to pursue their own interests. Some people also have their own pets in the home. We saw a small number of people enjoying the open views from the patio just off the lounge whilst others were watching television in their rooms or taking some exercise on a rowing machine. Staff spent time with individuals in conversation and we were told that more formal “one to one” afternoons happen giving staff time to complete the person centred forms that the home uses. One relative did comment that they felt that there was not enough done to stimulate the residents and therefore they get bored. We did see some people sitting apart from the main groups of people in the lounge, and we spoke to them whilst the other people were happily involved in conversation. The individuals spoken to were happy with the home and the food although one was not entirely happy that she had to move into the home. She said she does retire to her own room in the evening to watch her own television and did not mix much with the other residents out of choice. She did comment that the food was acceptable but she did miss the small of a roast cooking as the modern kitchen extracts the smell to the outside rather than through the lounge. The 6 relative who responded to the Commission for Social Care Inspection survey were asked, “Does the care service support people to live the life they choose?” 4 said always with one writing “My relative loves to be outside in the air as much as possible, despite being very immobile. They have been encouraged and helped on numerous occasions. They also like their privacy. This is very much respected. Another said usually and 1 said sometimes qualifying this with, “Obviously, most of the residents would prefer not to be in a home, but my relative gets out whenever she wants and is encouraged to have visitors. Visitors are given refreshments and can even request a meal at the home if they wish. Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 17 The home has recently purchased a mini bus to share between other homes in the group but it is being converted for wheel chair access and has not yet been delivered for use by the home. The home does not manage the financial affairs of the people who live there. They do hold small amounts of pocket money and we saw clear accounting for how that money has been used, such as for hairdressing and toiletries. The Quality Assurance Officer for the group said that she carries out a monthly audit of the records selecting records at random. The kitchen is located just off the dining room and prepares fresh meals for everyone having obtained their preference from the day’s menu. The meals that were served on the day of the inspection were nicely prepared and presented. Some people were given some assistance during the meal and this was done in a respectful way. The portions were good and the people who we spoke to said that they enjoyed the food they receive. The kitchen is managed well and the recordings were satisfactory. Bascombe Court DS0000018322.V344860.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standards 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for informing people how to make a complaint and the procedure for handling a complaint are good. The home provides good arrangements for the protection of people from any form of abuse. EVIDENCE: The home has a complaint procedure that meets the requirements of the regulations. It provides information on how to make a complaint, who to speak or write to and who to contact if they are not satisfied with the outcome. The procedure is on the notice board in the foyer outside the manager’s office. It is also in the Statement of Purpose that is available for anyone to read as it is in the foyer next to the signing in book. The Statement of Purpose is given to everyone who is interested in moving into the home. However 2 of the 6 relatives that responded to the Commission for Social Care Inspection survey did not know how to make a complaint. Of the 4 that did 1 said that, “Generally complaints are acted upon”. In-house complaints are both treated and recorded clearly with information about how they resolve them to the resident’s satisfaction. Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 19 The home provides several ways to protect the people who live in the home from abuse. The staff receive training to recognise the signs of abuse and have how to report concerns as early as the induction period that is enhanced by a second training session by the group training officer. They also have access to the policies and procedures on the subject that are kept in the manager’s office, including the Local authorities “Alerters Guide”. We saw evidence of this training in the 3 staff files that were read. Also we saw that staff have to tick a list of all the policies that they are required to read. Further Safeguarding People training is planned for December 2007. The home also has a whistle blowing policy and disciplinary policy and procedure. Staff receive this information in their handbook and reviews of all policies are discussed during supervision that is carried out as a formal agreement on a 2 monthly basis. The records for management of pocket money are clear and regularly audited by the Quality Assurance Officer. We saw that the home manages the safety of people through good maintenance of the building, good records relating to the use of hazardous substances, and regular Health & Safety inspections of the premise, the last one taking place in July 2007. Staff recruitment and training will be dealt with in the “Staffing” section of this report. Bascombe Court DS0000018322.V344860.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standards 19, 20, 21, 22, 23, 24, 25 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides excellent accommodation for the people who live in it. The premises risk assessment is of a high standard, The result of this is that the environment is safe and well maintained. EVIDENCE: The home is located in an area between Paignton and Brixham in Devon. It is close to a small shopping area called Broadsands that is on the main bus route. The shops include a small late opening supermarket, post office and hairdressers. The shops are about a ten-minute walk from the home on an almost level road. The home shares a large car park with an adjoining group of Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 21 11 close care apartments. The layout of the home is good with ample communal space laid out as lounge, quiet lounge and dining room. There is a well-tended good-sized outdoor space including paved patios and lawns. One patio is accessed immediately off the lower ground rooms. A shaft lift from provides access to the ground floor to the two upper floors that can also be reached by stairs. There is a stair lift to the lower ground floor. The home is very well presented with quality furnishings and some beautiful views over Torbay from the rear of the home. We saw proof that there is a regular 8 weekly Health & Safety check of the premises that includes maintenance of the building and equipment, such as the shaft and stair lifts and portable electrical equipment. If people bring electrical equipment to the home with them they do have to pay a fee to have it tested when it initially enters the home. We saw information about this that the home provides to all new people who move into the home. We also saw proof that the home has undergone fire inspection by the local fire service and also by a competent person and outside contractor who is experienced in fire systems and fire safety. Checks on fire alarms and emergency lighting, fire doors and extinguishers were made at the required intervals. The home possesses an up to date fire risk assessment of the premises that is reviewed every 8 to 10 weeks. We carried out a full tour of the home looking into bedrooms, bathrooms, communal space, staff rooms and the service facilities such as the laundry rooms. The private bedrooms provide excellent facilities with en-suites with various levels of bathing facilities. Several rooms had two parts to them creating a lounge and bedroom and were decorated to a high standard with people’s own furnishings in many cases and good floor coverings. Where specialist equipment was needed it was provided. Only one person at the home was being hoisted at the time of the inspection. A well-maintained hoist was provided. The views from bedrooms were good, with excellent views from bedrooms at the rear of the home for those who like sea views. People also had their own televisions and their own private phone lines. The home has a nurse call system that is wireless and can be carried about the home by each person. It will raise the alarm if activated but will not show the location of an individual within the home if they are not in their own room. One staff member commented in the survey form that the bells couldn’t be heard from some locations in the home, but did not specify where. Bathrooms, wet rooms and toilets had handrails and raised seats where these were needed and all sinks had thermostatic mixer valves to prevent scalding. The radiators were provided with attractive guards to avoid burns from hot surfaces and it was possible for people to adjust the temperature if they wished. The premises were clean and very well presented. The home does employ cleaning staff in addition to the care staff. One relative wrote, “Bascombe Court has a very fresh and friendly feel to it. The staff are always friendly though seem to be overworked. Having looked at other places, I would say this Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 22 home comes out very well”. Another said that, “Food, entertainment, décor and furnishings create a pleasant homely atmosphere”. The home has its own laundry with the washing carried out by new equipment that has a sluicing cycle and dried in a commercial dryer. This room provides the basic services. The clothes are then taken to another room within the home where clothes are ironed and placed in named baskets for delivery to people’s bedrooms. Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standards 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a workforce in sufficient numbers who are suitably trained to meet the needs of the people living at Bascombe Court. The staff support arrangements are good with well organised training and supervision. EVIDENCE: During the inspection we discussed the staffing levels, looked at rota’s and also asked the people who live in the home about the response from staff when they need them. People felt that the staff respond to them within a reasonable time frame and are always polite and helpful. Professional Health Care staff that visit the home commented in the 5 survey replies that they felt that the home provides good care, staff are sufficiently skilled and that they do consider the privacy and dignity when being seen by them. We therefore consider that the staffing levels are sufficient, and that the staff are sufficiently trained for the tasks required of them. Two staff survey forms did comment on the duties that some day’s staff do need to cover the needs of people in the flats. We discussed this at the time of the inspection and saw that one person, Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 24 not on the duty rota for the home, was working in the flats as a private arrangement. We met this person during the inspection. The management team provided an Annual Quality Assurance Assessment that has given the Commission information about how they have viewed their own performance against the standards. It has also provided information about the training that the home provides for the staff using the Group Trainer and external trainers. Staff files, training records, discussion with the Group Trainer and also with the staff on duty showed that the induction of staff and subsequent training is of a good standard. Such training as Adult Protection (done in 2 parts, the first part being during the induction period), Dealing with Dementia, Emergency First Aid, and the safe handling of medication have been carried out in the last 12 months in addition to fire and moving and handling training. The induction package follows the Skills For Care Common Induction Standards and checklists provided evidence of all the induction training received by individual staff who must sign each part as they have worked through the workbook verifying they have understood what has been taught. Staff are involved in National Vocational Qualification training with an external service. They attend the home, provide training and then observe practice. The Group Trainer is also a National Vocational Qualification Assessor. Over 80 of the care staff have a National Vocational Qualification at level 2 or above. There performance is monitored through 2 monthly supervision that they have signed an agreement to attend. A sample of these agreements and supervision notes were seen during the inspection alongside records of annual appraisals. The homes approach to regular and appropriate training is good. The home has its own policies and procedures that have been developed by the group of homes. They have those that deal with staff recruitment, discipline and whistle blowing. The recruitment procedure was tested when we looked at staff records. These were well constructed and held proof that the home had made suitable check on staff before they commenced work. There was evidence that POVA firsts had been done and Criminal Records Bureau checks made. References were available and various proofs of identity. Employees are given a copy of the General Social Care Council code of practice and the Group Staff Handbook that provided them with their own policies and procedures relating to recruitment, discipline, job description and their entitlements. The Commission for Social Care Inspection surveyed staff at the home and 6 replied. Of these 5 made positive comments about the home providing good care and achieving a homely environment for the people who lived at Bascombe Court. One made derogatory comments about the management of the home not supported by her colleagues, the people who live at the home, or the findings at this inspection. One comment was that there are “many poor English speaking staff who struggle to understand service users and vice versa”. The homes Annual Quality Assurance Assessment informed us that Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 25 they employ 13 care staff, of these 2 were from overseas. At the time of the inspection one more person of overseas origins has been employed who has lived in the country for several years. We spoke to 2 overseas staff and they spoke good English, no person living at the home raised comment about communication difficulties. One of the 7 relative surveys commented on the standard of English but said that staff are efficient and helpful. Staff turnover has not been high, as the Annual Quality Assurance Assessment has informed the Commission that 4 full time and three part time staff have left since the last inspection that took place in June 2006. The manager said that 2 care staff left recently following performance and behaviour issues. In addition to the care staff we saw that the home does employ ancillary staff to clean, cook and maintain the home as part of the whole team who work towards achieving the homes aims and objectives. Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standards 31, 33, 35 & 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed using the skills of the management team and the resources of the group of homes that it is a part of. The Quality Assurance practices are very good. The environment is a safe and comfortable place for people to live in and staff to work in. Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 27 EVIDENCE: The home has a Registered Manager with many years of experience of management of homes in the independent healthcare sector. She became the Registered Manager for this home in October 2006 having been found to possess the necessary skills for the role. Under her direction, and with the assistance of the Groups Management team, which includes the homes Deputy Manager, the Group Quality Assurance Office and Training/Health & Safety Officer, the home runs well following their Annual Development Plan. We found that collectively they understand the problems experienced by people who live in the home, and how to utilise the staff teams skills to respond appropriately to them. The Quality Assurance methods that are used to establish the homes level of success are very good and the results of surveys are clearly displayed in the front foyer of the home for anyone to see. Questionnaires are used from the point of admission and regularly afterwards for people to comment on their care and surroundings. There are unannounced monthly audits carried out by the Quality Assurance Officer who looks at of the day-to-day running of the home including admission procedure, records and the environment. Regular monthly Residents Meetings take place where views are aired and minutes taken and again displayed for people to read. Action that is taken to address any issues is easy to evidence as was found to be the case during this inspection. The home does not manage the financial affairs of any of the people living at the home. However where pocket money is held we saw clear accounting records that showed how the money is spent and receipts held as evidence. The small amounts of money are securely stored on behalf of some people who live in the home. A full property list is taken when people are admitted to the home and held in their records. Safety checks are made on any electrical items that people might bring into the home with them as part of the homes overall Health & Safety operation. We saw proof of regular risk assessment of the premises with 8 to 10 weekly reviews that included checking water temperatures and COSHH. There was evidence of maintenance of the building and equipment including the hoist and stair lift. The level of staff training is high and covers subjects of importance from the induction phase of employment and beyond such as Adult Protection, Health & Safety, medication management and moving & Handling. Further information given in the Annual Quality Assurance Assessment supported that collected during the inspection to show that the home is, overall, very well managed. Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 28 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 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 3 4 4 4 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 4 Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 29 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 in ink, as they are given out. A locking drugs trolley will provide greater security of medicines during a drugs round. The call system, which is wireless, would be more effective if it showed the actual location of an individual in the home when they use it. The actual laundry room housing the washer and dryer needs some improvement. 2 3 4 OP9 OP22 OP26 Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bascombe Court DS0000018322.V344860.R01.S.doc Version 5.2 Page 31 - 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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