Inspection on 05/04/05 for Bath Lodge

This inspection was carried out on 5th April 2005.

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

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

Other inspections for this house

Bath Lodge 19/03/09

Bath Lodge 18/05/06

Bath Lodge 28/06/05

Bath Lodge 28/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Name BATH LODGE 8 Bath Road Reading Berks RG1 6NB Lead Inspector Debbie Willcox Unannounced 5TH April 2005 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. Name BATH LODGE Version 1.10 Page 3 SERVICE INFORMATION Name of service Bath Lodge Address 8 Bath Road, Reading, Berkshire, RG1 6NB 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) 011 89591901 Mr Michael John Bissell Mrs Jacqueline Foster Care Home, Older People 17 Category(ies) of Old age not falling within any other category registration, with number of places Name BATH LODGE Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. Statement of Purpose and Service User Guide to be produced. 2. Compliance with requirements of inspection report of 17/03/04 to be achieved. 3. Business and financial plan and financial projections to be produced. All above to be produced within 3 months of registration. Date of last inspection 28/07/04 Brief Description of the Service: Bath Lodge is a care home providing personal care and accomodation for 17 older people. The home is situated on the A4 Bath Road close to Reading town centre. It is located close to local amentities and is within reasy reach of the M4 Motorway. The home provides 8 single rooms and 4 double rooms. The home has extensive gardens, which are well maintained. Name BATH LODGE Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over a period of 4.5 hours and was carried out by one inspector. A partial tour of the building was conducted and records relating to care, employment and health and safety were viewed during this inspection. Time was spent observing life within the home and interactions between staff and service users. Feedback was given throughout this inspection to the registered provider and manager. It was difficult to ascertain service users views during this visit as the majority of service users were unable to coherently express their views mostly as a result of mental frailty. There is a high percentage of service users with dementia. The home is not registered to provide dementia care services. The registered person will need to ensure that the home does not admit service users with a primary diagnosis of dementia as this would result in the registered person operating outside of the category of the homes registration. One service user during the course of this inspection complained at the frustration experienced, as she was unable to communicate with other service users and enjoy conversations. An Immediate requirement was issued at this inspection for the removal of door wedges and a requirement for appropriate door opening devices to be provided. The use of door wedges poses a potential risk of harm to service users in the event of a fire. An immediate requirement was also issued for CRB and POVA checks to be undertaken when recruiting staff. This home was transferred to new ownership in March 2004. What the service does well: The manager and staff communicate well with service users and it was evident from observation of interactions between staff and service users that staff are warm and empathic in their manner. The home is clean and well maintained retaining a homely, domestic environment. Residents are enabled to personalise their rooms. Name BATH LODGE Version 1.10 Page 6 What has improved since the last inspection? What they could do better: There are 5 outstanding requirements from previous inspection visits. It was evident from the viewing of recruitment records that checks on the suitability of staff are still not being carried out as required by legislation. The files of 2 staff recently employed within the home since December 2004 were viewed. The files showed that the way staff are recruited without satisfactory checks prior to employment within the home, left the people living within the home potentially at risk. This is not acceptable and the matter has been brought to the attention of the proprietor and manager. Any further noncompliance may result in enforcement action. There is a need for the registered person to improve the system for induction of new staff and provide induction which is compliant with the TOPSS foundation standards to ensure that staff have training in principles of care practice, safe working practices and understanding the workers role and the particular needs of this service user group. The top floor flat of this registered home is leased to tenants who are not staff in the care home. These tenants access the flat through the care home as do their visitors. The proprietor has not assessed this potential risk. There is an outstanding requirement for all staff to receive training in manual handling. Name BATH LODGE Version 1.10 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Name BATH LODGE Version 1.10 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 Name BATH LODGE Version 1.10 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) 1,2,3,4,5, The home is failing to ensure that a proper assessment of care needs including provision of a care plan is provided prior to people moving into the service. Without this there is no assurance that the care needs of service users will be met. EVIDENCE: The homes statement of purpose and service user guide have been created since the last inspection as was a requirement from previous inspection visits. The inspector reviewed documents relating to two service users most recently admitted to the home within the last 3 months. There were no care plans provided by the home for either service user. A pre-admission assessment document was viewed for one service user provided by a local authority. No formal review had been undertaken since admission of this service user in December 2004. The inspector was informed that a conversation had occurred over the telephone with the social worker and the placement made permanent as a result. Pre-admission assessment documents had been completed by the manager prior admission to the home for both service users. It was noted that Name BATH LODGE Version 1.10 Page 10 information was brief and insufficient in informing staff on the actions to be taken to ensure that new residents are properly assessed and informed of an appropriate plan in meeting care needs. Care records did not evidence that trial visits had occurred. The inspector was informed by the manager that trial visits did occur for both service users recently admitted to the home and were brief in duration. These visits need to be documented. Contracts/Statement of terms and conditions are provided and were viewed. Name BATH LODGE Version 1.10 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) 7,9,10,11 Without provision of care plans it was difficult to assess whether or not care and health care needs of service users are being met by the home without these needs having been identified. This has the potential to put service users at risk. EVIDENCE: For the two service users most recently admitted to the home no care plans had been provided and so no written details of action which would be needed by care staff to ensure that all aspects of the health, personal and social care needs of the service users are met One care plan was viewed on another service users file which had been compiled in January 2004. There was no evidence of any further review since that date. The manager has taken on sole responsibility for the compiling and reviewing of care plans. It was evident that this is proving to be an onerous task for one person. The home does not operate a keyworker system and this was encouraged in conversation with the manager. Name BATH LODGE Version 1.10 Page 12 The storage and administration of the morning medication was viewed during this inspection. Staff were viewed to administer medication into their hands before administration to service users. This was highlighted as poor practice to the manager. Medication was administered from the dining room table in one lounge and was left whilst staff went off to administered to individuals in other rooms. Considering the mental frailty amongst this service user group this poses a risk to service users. Internal and external medication was found stored together and eye drops in use were found to be out of date. Staff have received training in administration of medicines via Newbury College. The home operates using the Boots Monitored Dosage System. The supplying pharmacy carries out regular 3-monthly audits in the home. This is commendable. Recording of weight charts were viewed on service user files. Of the 3 service user files viewed none contained evidence of service users wishes in event of terminal illness or death. Name BATH LODGE Version 1.10 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 Opportunities are available for stimulation and choice is offered in aspects of daily living. With the absence of care planning it was difficult to ascertain if service users needs and preferences in relation to social activities and opportunities for stimulation are considered, particularly service users with a mental frailty. EVIDENCE: The midday mealtime was observed. Toad in the hole with fresh vegetables followed by rice pudding was served. This was well presented and enjoyed by all. Service users are offered a glass of sherry prior to lunch being served. Outside entertainers had recently visited the home and the manager informed the inspector that activities such as Bingo, Reminiscence and manicures are provided weekly. A local minister provides monthly communion into the home and one service user attends church. It was evident from observation that choice is provided in routines of daily living. There is a need for the registered person to evidence within care planning documentation that consideration is given to opportunities for meeting the social, recreational needs for stimulation amongst service users, particularly those with dementia and other cognitive impairments. Name BATH LODGE Version 1.10 Page 14 Name BATH LODGE Version 1.10 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) 18 There is a potential for service users to be at risk.The home has a complaints policy in place. EVIDENCE: The manager informed the inspector that she has attended training in responding to abuse of vulnerable adults within the last year. Staff who are undertaking the NVQ qualification receive training in abuse awareness. There is a need for the registered person to ensure that all staff receive training in responding to abuse of vulnerable adults. The top floor flat of this registered building is leased to tenants who access this flat by the front door of the care home as do their visitors. A requirement from the previous inspection was for the registered person to undertake a risk assessment to highlight actions to be taken to ensure the safety and well being of service users has not been met. Name BATH LODGE Version 1.10 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) 19,21,22,24,25,26 The environment is clean, homely and the majority of the building well maintained. Consideration will need to be given to planning for refurbishment of the kitchen. EVIDENCE: The home was found to be clean and on the whole well maintained, decorating of bedrooms and communal areas has recently been carried out and carpets replaced. The kitchen is in need of refurbishment and decoration. An assessment of the premises has been carried out by a qualified occupational therapist and a copy of the report provided was viewed. A number of recommendations have been made within this report which would improve the safety of the environment and provision of disability equipment and environmental adaptations to meet the needs of service users. Name BATH LODGE Version 1.10 Page 17 Name BATH LODGE Version 1.10 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) 27,28,29, The procedures for the recruitment of staff are not robust and do not provide the safeguards that would ensure protection for people living within the home. The current induction process is not compliant with the TOPSS foundation standards which if followed would ensure evidence that staff have been trained in understanding good practice values, the workers role and the particular needs of this service user group. EVIDENCE: It was evident from the viewing of recruitment records that checks on the suitability of staff are not being carried out as required by legislation despite previous requirements with timescales. The files of 2 staff recently employed within the home since December 2004 were viewed. An immediate requirement was issued at this inspection as no CRB disclosure checks neither POVA checks had been carried out on these 2 staff. One file contained 2 written references and the other only one. There was evidence of an induction check list on staff files which related to the environment and health and safety. The current induction is not compliant with the TOPSS foundation standards which would guide staff in the principles of good care, safe working practices, the workers role and understanding the particular needs of this service user group. Due to movement of staff since the last inspection there are now no staff NVQ qualified at the present time, 7 staff are currently working towards the NVQ qualification. Name BATH LODGE Version 1.10 Page 19 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) 31,32,34,35,37,38 Staff are confident and positive regarding the change of ownership. There are shortfalls in providing care planning records, health and safety checks relating to hot water and fire doors does not fully promote and safeguard health, safety and welfare of the people using this service. EVIDENCE: The manager has obtained an NVQ level 4 qualification including the registered managers award. Staff were positive about the change of ownership of the home that has occurred within the last year. Staff expressed confidence in the managers approachability and dependability. Name BATH LODGE Version 1.10 Page 20 There is an outstanding requirement from the last 2 inspections for a robust system for recording service users valuables held for safe keeping and inventory records to be maintained. A book to record items brought into the home by service users has been implemented but did not contain signatures and receipts were not given. A previous requirement to remove personal information found sited on shelving within a corridor has been met and a locked cupboard has been provided. A variety of records relating to health and safety were viewed at this inspection including fire records. Staff have recently attended training in fire safety. General risk assessments including a fire risk assessment for the building have recently been undertaken by contractors. Weekly recording of water temperatures were viewed. There is an outstanding requirement for six monthly servicing of thermostatic water valves to be undertaken by a qualified person. This has been outstanding from the last 3 inspections. An immediate requirement was issued at this inspection for the removal of door wedges and appropriate door opening devices to be provided. This has been an outstanding requirement from the previous inspection with no extension of timescale requested by the registered person. Several fire doors throughout the home were seen not to close fully posing a risk to all living and working within the home in the event of a fire. Name BATH LODGE Version 1.10 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 2 1 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 2 2 3 2 3 STAFFING Standard No Score 27 3 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 x x 2 2 2 2 Name BATH LODGE Version 1.10 Page 22 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 3 Regulation 14(2)(a)( b) Requirement The registred person to ensure that a comprehensive assessment of service users needs is provided prior to admission and kept under review. The registered person to provide a care plan detailing how service users needs in respect of health and welfare are to be met and kept under review.ORIGINAL TIMESCALE FOR COMPLIANCE 01/05/04. The registered person to ensure that Internal and external medication is stored separately. The registered person to ensure that medication is not to be dispensed into staff hands but appropriate containers used to ensure safe handling. Service users wishes in the event of terminal illness and death to be assessed and recorded within care plans. An action plan responding to recommendations within occupational therapists report following assessment of the premises to be provided and sent to the CSCI. Version 1.10 Timescale for action 01/06/05 2. 7 15 01/06/05 3. 4. 8 8 13 13 01/06/05 Immediate and ongoing 01/06/05 5. 11 15 6. 22 23 01/07/05 Name BATH LODGE Page 23 7. 8. 18 19 18 13 9. 25 13 10. 29 19 Schedule 2&4 11. 35 17 Schedule 4 12. 38 13 13. 14. 38 38 18 13,23 All staff to receive training in repsonding to abuse of vulnerable adults. The registered person to remove door wedges and provide appropriate door open devices. ORIGINAL TIMESCALE FOR COMPLIANCE WAS 28/07/04 Six monthly servicing of thermostatic water valves to be undertaken by a qualified person. ORIGINAL TIMESCALE FOR COMPLIANCE 01/05/04 The registered person to ensure that no staff are employed to work within the home unless full and satisfactory information has been obtained including CRB and POVA checks undertaken. ORIGINAL TIMESCALE FOR COMPLIANCE 17/03/04. An inventory record to be maintained of furniture and valuables brought into the home by service users and a written acknowledgement of return. ORIGINAL TIMESCALE FOR COMPLIANCE WAS 01/05/04. Fire doors throughout the building must be able to close fully in the event of the fire alarm sounding. All staff to be trained in manual handling. A risk assessment to be undertaken highlighting the risks to service users in the renting of the upstairs flat to tenants with access to this flat through the registered care home with actions as to how risks will be reduced and eliminated. ORIGINAL TIMESCALE FOR COMPLIANCE 28/10/04 01/07/05 Immediate. 01/05/05 Immediatel y and ongoing. 01/06/05 01/06/05 01/07/05 01/06/05 15. Name BATH LODGE Version 1.10 Page 24 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 7 Good Practice Recommendations As a recognised good practice model a keyworker system to be implemented within the home to ensure that the care and health needs of service users are regularly reviewed and monitored. Name BATH LODGE Version 1.10 Page 25 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 Name BATH LODGE Version 1.10 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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