Inspection on 23/01/07 for Bathampton Manor

This inspection was carried out on 23rd January 2007.

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 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

Bathampton Manor 06/03/06

Bathampton Manor 07/07/05

Bathampton Manor 07/02/05

Bathampton Manor 09/07/04

Bathampton Manor 30/12/03

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Bathampton Manor Mill Lane Bathampton Bath Bath & N E Somerset BA2 6TS Lead Inspector Jon Clarke Key Unannounced Inspection 23rd January 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bathampton Manor DS0000008147.V327143.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. Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bathampton Manor Address Mill Lane Bathampton Bath Bath & N E Somerset BA2 6TS 01225 466260 01225 466260 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) www.bcvs-homes.co.uk BCVS Homes Mrs Marilyn Evans Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 21 persons aged 65 years and over requiring personal care only. 6th March 2006 Date of last inspection Brief Description of the Service: Bathampton Manor is one of three homes owned and managed by B.C.V.S. a Bath based charity. The home is a converted older property set in extensive grounds. It is some distance from Bath the nearest facilities being in Bathampton which has pubs, church and small shop. The home offers care and accommodation for up to 21 older people over three floors with stair lift or lift access to all floors. Eleven of the rooms offer en-suite facilities. There are two communal lounges and dining room with plans for a conservatory to be built during this year. The gardens and grounds are particularly attractive with level access and a number of seating areas. The philosophy of the home is to look after the residents in a caring and sympathetic way so that their privacy and dignity are respected and to encourage active independence where possible. A resident said of the home if you cant live in your own home its the next best thing. Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over one day. As part of this inspection a number of records were examined including: pre-admission assessments, care plans, staffing records (recruitment and training) and health and safety. There was also an opportunity to speak with residents and staff about their experience of living and working in the home. What the service does well: What has improved since the last inspection? What they could do better: Two requirements have been made as a result of this inspection firstly around the recording of accidents in that there was poor practice identified in this area. Any incident which results in an injury must be recorded in the accident book. This information could then be used to make a judgement about any changes in moving and handling practice or to identify the need to refer the individual for assessment perhaps by an occupational therapist. Secondly Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 6 there needs to be a more formal approach to quality assurance questionnaires and the responses received from residents. A previous inspection recommendation to improve practice in this area has not been followed up and with new arrangements around inspection and providers providing such information to interested parties particularly residents and relatives but also CSCI this has now been made a requirement. Two recommendations have also been made about training and organising of activities in the home in that there should be identified members of staff who responsibility in these areas of the homes practice. 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. Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s arrangements for admission to the home are generally good in that assessments are obtained and completed by the home so they are able to make an informed decision about the capacity of the home to meet the individual’s health and social care needs. However the home’s assessment could be more through and person centred in its approach to gathering information. EVIDENCE: Local authority assessments completed by a social worker with contribution from the individual gave information about the health and social care needs. The home also completes a “Resident Assessment Form” this provides information about personal care tasks, mobility. This assessment could be developed to provide information about health needs, physical or medical conditions, mental health and importantly give a picture of the individual’s Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 9 social and personal circumstances. This was discussed with the manager and whilst it is recognised this information is sometimes discussed with the individual there remains no structure or prompts in the form to obtain these details. Copies of BCVS Agreement of Terms and Conditions of Residence were also examined and sample of residents showed that these had been completed. New regulations are now in place relating to contracts and amendment need to be made showing additional costs if any such as health services. Where a contribution is made to an individual’s fee is made by a third party such as local authority this needs to be shown. Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 10 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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care Planning and arrangements for meeting health care are good providing staff with the necessary information so that the health and social care needs of residents are met. The home has good policy and procedures in place for making sure resident’s medication and health needs are protected. The practice of staff and policies of the home help to make sure that residents are treated with respect and their dignity is upheld EVIDENCE: A number of care plans were examined and showed that there is good practice in this area. There is good information about personal care tasks and support that the individual needs. Risk assessments are completed and regularly reviews. Moving and handling assessments were completed. Care plans are reviewed regularly and of note are keyworker comments that provided an overview of any particular changes or events in the individual’s life. Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 11 Medication administering records were examined and recorded accurately where medication had been given to individuals. One resident is currently selfadministering their medication a risk assessment had been completed. A pharmacist inspection took place on 8/1/07 and had found good practice in storage and administration. In talking with resident and from observation of staff there was evidence of staff interacting with residents in a sensitive and respectful manner. One resident spoke of how she always “felt comfortable with staff” another “they always treat us well”. In talking with staff there was a real sense that they had understanding of the differing needs of individuals and the importance of respecting the “differences of residents”. Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for meeting the social and recreational needs of residents are good and there are opportunities for residents to maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable residents to exercise choice and have control over their lives. The home provides meals, which are balanced and meet the dietary needs of individuals in the home. EVIDENCE: In talking with residents about activities available in the home they spoke of “there’s enough for me” “sometimes could be more” “suits me I do what I want to do” “not a lot going on”. One resident said they would like to see more exercise sessions. In response to the pre-inspection questionnaire 4 respondents said there were “always” activities arranged by the home they could take part in and 10 usually. Activities organised in the home include Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 13 musical sessions, quizzes, reminiscence, and video afternoons. There are also occasional trips out. Where able residents are encouraged to go out four resident attends a local luncheon club. In talking with staff about activities in the home they spoke of at times it is difficult to motivate residents but recognised this was an important area of the home’s life. There are also times when work pressures make it difficult to make sure there are activities. Visitors are welcomed in the home and this was confirmed by a resident who said that whenever she had visitors “they are always made to feel welcome by the staff”. A relative commented that they “have been made most welcome”. There were a number of positive comments about the food provided in the home “its always good” “they give you a choice” “always enjoy the meals”. In response to questionnaire “Do you like the meals at the home” 4 responded always, 8 usually and 1 sometimes. Menus examined showed a good range of meals provided with variety and the meal on the day of the inspection was appetising and well presented. There was a relaxed and unhurried atmosphere during the meal with staff available to give assistance and support if needed. Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place and this enables individuals to make a complaint and voice their views about the service they receive and to know that they will be listened to and actions taken where necessary. The home makes sure that as far as possible residents are protected from harm by having policy and procedures about the Protection of Vulnerable Adults and providing training to staff in this area. EVIDENCE: Copies of the complaints procedure forms part of resident’s information. When asked residents said that they were aware that they could make a complaint comments about this included “I would always say and tell someone” “I’ve never needed to make a complaint” “will say if something’s wrong”. A complaint had been made to the home and the complainant had contacted the CSCI though had not made the complaint to the CSCI. Copies of the home’s response were looked at as were records relating to the individual. In the inspectors view the complaint had been dealt with appropriately and there was no substantial evidence that the home had acted un-professionally. The Inspector wrote to the complainant that this was our view. When asked residents said that they felt safe in the home. The Adult Protection policy sets out in a clear way the action to take if an allegation of Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 15 abuse is made. A copy of the B&NES Multi-Agency Vulnerable Adult policy is available in the home. Staff have completed Adult protection training, training records showed there remain 5 members of staff who need to complete this training. The manager has completed Investigator Adult protection training. Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and hygienic environment for the residents and staff. EVIDENCE: The home is well maintained with ongoing improvement in decoration. The garden is well maintained, paths and seating in good condition. Residents’ rooms are decorated to a good standard. Residents spoke of the home always being clean and tidy. There are procedures in place to make sure that risk of infection is alleviated and staff are provided with the necessary protective clothing and measures to maintain good hygiene. Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 17 Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements in the home are good and the needs of residents are met in an efficient way with care being provided by skilled and competent staff. The recruitment and selection of staff is undertaken to make sure that as far as possible the health and welfare of resident is protected. EVIDENCE: Staffing rotas showed that there are generally 3 staff including senior care on duty in the mornings, 2 evening and 2 during the night. A duty manager is available throughout the 24-hour period. The home has been able to retain staff over long periods and there is a relatively stable staff group. Currently there is one vacancy for deputy which the home is in the process of recruiting. (Following this inspection the inspector learnt this post had been filled) Respondents to the pre-inspection questionnaire said that Staff “always” available when you need them (7) “usually (6) “sometimes (1) all respondents said they received the care and support they needed. When talking with residents typical comments about staff included “staff always help me if I need it” “nothing too much trouble for them only have to ask and they help me” “staff all so caring” “very kind”. Recruitment records were examined and showed that all necessary checks had been undertaken e.g. Criminal Record/POVA checks, two references and Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 19 application forms showed full employment history. Medical declarations and questionnaire are completed as part of recruitment process. Training records showed that staff had completed the required mandatory areas of training: moving and handling, food hygiene, infection control, health and safety and first aid. Where staff have responsibilities relating to medication training in this area is also undertaken. Over 50 of staff have NVQ 2 or 3 qualifications. Staff would benefit from undertaking more specialised training such as Mental Health and this was something staff thought would be of help to them in that there are a number of residents in the home who have some level of mental health impairment or degree of dementia. The inspector was informed that this training is planned for all staff. There was no one individual who has responsibility for having an overview of training needs and where the gaps are in individuals training. Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 33,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are good opportunities for residents and others to express their views about the service they receive. Recording of accidents must be improved so that there is a clear record of incidents which affect the health and welfare of residents. The practices of the home are generally good so that the health, safety and welfare of residents and staff are protected. EVIDENCE: Residents meeting are regularly held providing an opportunity for residents to comment on life in the home and make suggestions about the quality of care they receive. Minutes of meetings were looked at and showed that residents Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 21 had made suggestions about the meals provided in the home, outings and activities. Questionnaires had been sent to residents and gave positive feedback about the care they receive. There was no summary available of the outcome of these questionnaires or actions that had been taken as to the comments received. In looking at daily records and tracking records of accidents in the home and recordings in the accident book the last record of incident was 20/05/06. One resident had fallen and sustained an injury this had not been recorded. Another resident had had frequent falls again these had not been recorded. Records relating to health and safety were examined and showed good practice in this area other then the area identified relating to accidents. Fire equipment is serviced regularly last being 04/01/07. Fire alarms tests are undertaken weekly and emergency lighting monthly. Lift last serviced 21/12/06. Equipment such as hoists and mechanical baths had all been serviced since the last inspection. Records showed staff undertake regular fire drills. Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X 2 3 Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 23 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. 1 Standard OP33 Regulation 24 (2) Requirement A report in respect of any review of services to residents to be made available to residents and a copy supplied to the Commission. (This refers to Quality Assurance questionnaire and report about the results of the questionnaire and any actions that have been taken in response to the questionnaire.) A record to be kept of any accident affecting residents that is detrimental to the health & welfare of the individual. (This refers to record being made in Accident book) Timescale for action 30/04/07 2 OP37 17 (1) (a) Schedule 3 (j) 23/01/07 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 OP30 Good Practice Recommendations Identify member of staff who has overview of individual staff training and training needs of the home. DS0000008147.V327143.R01.S.doc Version 5.2 Page 24 Bathampton Manor Bathampton Manor DS0000008147.V327143.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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. 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