Inspection on 08/06/05 for Bascombe Court

This inspection was carried out on 8th June 2005.

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

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

Other inspections for this house

Bascombe Court 18/10/07

Bascombe Court 14/06/06

Bascombe Court 13/12/05

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 TQ5 0JS Lead Inspector Judy Cooper Announced 08/06/05 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 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 D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bascombe Court Address Bascombe Road, Churston Ferrers, Brixham, Devon, TQ5 0JS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of registration, with number of places 01803 842360 01803 842360 Manor Collection Ltd Care Home 31 Old age, not falling within any other category (31), Physical disability over 65 years of age Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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 23/11/04 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 through a large parking area with a step into the porch area. There are mature gardens, and three patio areas. The bottom of the garden has been landscaped. The entrance hall has an enclosed office and leads into a large sun lounge, dining area and quiet area. There is level access onto a patio. 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 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 lower ground floor is accessed by a chair lift. It has 6 en-suite bedrooms that all open onto a level patio area. The owner is in the process of completing twelve “close care” units within the grounds of the home. The units, when completed, will operate totally separately from the home and therefore, will not form part of the current registered facility. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day. Unfortunately, as the owner had not distributed any standard feedback forms to residents or their relatives, written feedback was not received prior to the inspection. However, opportunity was taken during the inspection, to tour the premises, examine appropriate records and policies, talk with the owner and manager, staff on duty and meet with the majority of residents. Staff on duty were also observed, whilst in the course of undertaking their daily duties. A visiting G.P was available to give some verbal feedback as was a District Nurse. Several visitors were also happy to speak with the inspector during the inspection as was a training officer, who was undertaking staff training on the day of the inspection. All of the information obtained from these sources was used in the inspection process. What the service does well: The home’s environment provides residents with a very comfortable, excellently maintained, homely, bright, environment. Residents 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. The result of this is that residents benefit from companionship with each other and continue to feel a valued part of the local community. A core group of staff have stayed in post for a number of years, thus ensuring that residents continue to have a sense of security and continuity. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: All hot radiators and pipe work in the house must be guarded, in order of priority, according to the risk assessment, to ensure that residents are protected form the risk of sustaining a burn. A permanent ramp should be provided to the front door area to allow level access for any resident who may have mobility problems. Please contact the provider for advice of actions taken in response to this Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 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 standard(s) 3, (6 is not applicable). The admission process is appropriately managed with residents’ needs explored and known, prior to admission to the home. EVIDENCE: The owner and manager continue to maintain the home’s statement of purpose and service user’s guide appropriately. By looking at the records for a resident, who had recently been admitted to the home it was noted that a full and detailed admission procedure was undertaken. Some residents who had recently come to live at the home were spoken with and they were able to confirm that they had been made to feel comfortable, both on admission and since, and that their needs were being met. One new resident’s relative was also happy to confirm that their relative who, had only recently come to live at Bascombe Court had been assessed at the resident’s previous home, prior to admission, and that the resident and the family had been informed as to both the care and facilities that would be provided. The relative felt the home was fully meeting all the assessed needs of the resident. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 10 It was also pleasing to note that a resident who was in the home for a short stay had also had their needs fully assessed, and as the resident had regular short stays, these notes had been updated on each stay. This resident was able to confirm that they enjoyed their stays at Bascombe Court and felt all their needs were well met. The home does not provide for intermediate care. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 7,8,9,10 Residents are looked after well in respect of their health and personal care needs. Residents are treated with dignity and respect and their individuality and independence maintained. EVIDENCE: Care plans contain all relevant details appertaining to providing for each individual resident’s care. The care plans had been reviewed monthly. They were concise and contained full details of any medical needs of the resident, as well as any visits made by District Nurses, G.P’s or any other health professionals. The manager and staff liaise with other professionals as required and, during this inspection, it was noted that a G.P and District Nurse visited. Both were spoken with and gave positive feedback as to the way they felt those residents they were involved with, were cared for, in relation to their physical and health care needs. It was also noted that the continence advisor was being contacted in relation to one resident whom the home felt would benefit from her specialised in-put. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 12 A relative of a resident at the home, wanted it noted that her relative had been treated very kindly when ill and that the relative had been kept fully informed as to the resident’s progress. She felt very confident with the home’s ability to meet the resident’s, now complex, care needs. The home’s medication systems were noted as being in order with medication being administered correctly, by appropriately trained staff, (one staff member confirmed that they had just attended an update on safe medication), whilst the storage and recording of medications were also in order. There are good links with the local pharmacist and there were records of her visits to inspect the medication systems operating within the home. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 12,13,14,15 Residents enjoy a peaceful, pleasant yet varied life at the home, with visitors very much encouraged and links encouraged and maintained with the local community. Various informal activities such as gentle exercise, clothes parties etc are made available whilst residents also benefit from nutritious, well planned and varied meals. EVIDENCE: Staff undertake activities with residents and there are other planned activities provided by outside entertainers. (On the day of inspection a clothes party was taking place, followed by a gentle exercise class, led by the manager and a member of staff). Several of the current residents are still independent and as such come and go as they so choose. Many residents and their families used the words “happy and satisfied” to describe the overall standard of their daily life. The home operates an open visiting policy and, during the day of inspection, many visitors came and went, whilst the visitor’s book clearly showed that the residents had many visitors at varying times throughout the day, and many Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 14 were spoken with. All confirmed that they were always made very welcome when visiting at the home. The routines within the home are flexible to ensure that residents can choose how they spend their time. Several had chosen to spend their time in the communal lounges, enjoying each others company, or later in the day the activities on offer, whilst others had chosen to spend their time in their rooms, or outside the home, enjoying the homes’ patio areas. Residents’ individuality and respect were noted as being maintained by the staff, and residents verbally confirmed this. Examples seen include the fact that one resident is enabled to have a dog stay with her, for periods of time, and greatly appreciated this. Another resident was noted as enjoying a glass of wine with their lunch, whilst another was enjoying the exercise class along with her sister who was visiting her at the time. Residents confirmed that they enjoyed the meals provided and that there was always choice made available. On the day of inspection the meal was roast beef or pork, new and roast potatoes, vegetables followed by rhubarb crumble and custard. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 16,18 Arrangements for protecting residents and responding to their concerns are satisfactory. EVIDENCE: The home’s complaint procedure was clear and easily available to all residents and/or their families/carer. Two recent separate complaints, made about different issues within the home, are in the process of being investigated. CSCI are aware of the content of the complaints, and are to be kept informed of any action taken and conclusions made. The outcome to both complaints has not yet been finalised. There are appropriate adult protection policies which staff have easy access to. The manager holds some monies for some residents in a safe, as agreed with the resident/their family, and there were detailed receipts etc in respect of these, ensuring that those residents that do use this service can be reassured that their monies are being handled and kept appropriately and securely. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19,26 Bascombe Court is very comfortable, clean, well maintained and provides a safe standard of accommodation for the residents. EVIDENCE: The tour of the building showed that the home maintains an upgrading programme that ensures the home always provides a very high standard of accommodation. The accommodation presented as comfortable, very well maintained, clean and welcoming and residents agreed that they enjoyed living in the home’s pleasant environment. Bedrooms have been personalised as desired and residents can bring in personal items with them if they wish to. The owner stated that the home would provide a suitable lock if requested by a resident, and has already done so for those that have requested this, but they are not provided as standard on admission. This is documented within the home’s statement of purpose. The lounge and dining areas are both very spacious and well appointed. The manager maintains the home’s fire precautions in line with the requirements of the local fire department. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 17 There is an infection control policy and all areas of the home were odour free with infection control training being provided regularly, therefore ensuring that staff maintain practices within the home which minimises any risk of cross infection. The home’s laundry area is satisfactory, if a little small, however the owner advised that a new laundry area is to be provided by November this year. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Staff at the home are well trained. They presented well in both appearance and manner. Staff are employed in sufficient numbers to meet the current resident groups’ needs. EVIDENCE: Staffing levels were noted as being sufficient to allow residents’ needs to be met both during the day the day and at night. Residents said that they felt well looked after and that staff were always available if needed. Some very positive verbal feedback was received from the residents and their relatives as to the standard of care received, and the manner the care was delivered. Training continues to be well planned and supports the staff in providing for the varied needs of the residents. During the inspection a recently recruited night staff member visited the home and was able to confirm that she had been given sufficient induction training and support to allow her to undertake her duties with confidence. The home has recently been awarded its “Investors In People” award and as such has ensured that all staff receive appropriate and relevant training. During the inspection two NVQ assessors were present, undertaking some assessment work with the staff and one staff member was clearly delighted to have been awarded her NVQ level 2 in care at the same time. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 19 Three staff files were inspected which evidenced that a full staff recruitment programme operates within the home. Residents stated that they were happy at Bascombe Court and were benefiting from the care they received and staff stated that they continued to feel supported in their caring role and from observing the verbal communications that took place during the day, it was noted that the management of the home is available if necessary to support both residents and staff. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,38 The home is managed satisfactorily. The home is providing a mostly safe environment for the residents, however all hot surfaces, to which a resident has access need to be guarded to ensure that residents are fully protected from the risk of sustaining a burn from a hot surfaces. Hot water, provided to residents’ facilities, should be regulated to a safe temperature if a resident is assessed as being at risk of scalding if using non regulated hot water. EVIDENCE: The acting manager has been in post for approximately eight months. Previously she was the home’s deputy manager. She has recently completed her NVQ level 4 in care and is now undertaking the Registered Manager’s Award. Several residents and staff members confirmed that they felt able to speak to the manager if necessary. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 21 The owner is providing support and training to the manager to ensure that she becomes confident and aware of the requirements of her post and to this end visits the home very regularly. As the manager is currently not registered with this Commission, the owner is to put forward the manager’s application to this Commission to allow the manager, if successful, to become the registered manager for the home. The home operates satisfactory internal quality monitoring systems with residents’ feedback invited as part of the overall process. A member from the senior management team of the Court Group, of which the home is a part, undertakes a monthly in depth quality audit visit where all aspects of the running of the home are examined and reported on, including consultations with the residents. This ensures that the practices within the home are regularly reviewed and that the care provided is of the standard the residents would expect/want. Health and safety issues are well managed within the home with the required records being made available with all being seen to be up to date, which confirms that residents are cared for in a mostly safe and secure environment. The home’s hot water supply is regulated where there are full bathing facilities. Risk assessments are in place for any other areas i.e. hand washbasins. Not all hot surfaces, accessed by residents, are protected although there are risk assessments in place. Although these measures ensure, to some extent, that current (less dependent) residents are free from the risk of scalding, the manager needs to continually risk assess for any newly identified risks as residents’ needs either change or increase to ensure that the risk remains minimal. The owner has not yet minimised the risk of a resident sustaining a burn from a hot surface by covering all such surfaces. The home is registered to be able to offer care for physically frail residents as well as elderly only residents, and this former resident group could be considered to be at a high risk of sustaining a scald/burn from non-regulated hot water or non-protected hot surfaces. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION 4 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 4 x 3 x x 2 Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 23 yes Are there any outstanding requirements from the last inspection? 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 25 Regulation OP15 Requirement The registered provider must continue to ensure that all pipe work and radiators to which service users have access must be risk assessed and guarded or have low temperature services to minimise the risk of a resident sustaining a burn.(This is a previous requirement with a timescale of 12/11/05 which has not yet expired). Timescale for action 12/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP22 OP25 Good Practice Recommendations The Register Provider should ensure that service users are provided with permanent level access to the front door of the home. The registered provider should continue to ensure that all water outlets, including hand basins within the home, are risk assessed and the hot water regulated to 43 degrees Centigrade as required to minimise the risk of residents sustaining a scald, where necessary. Bascombe Court D54-D07 S18322 Bascombe Court V222092 080605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 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. 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