Inspection on 19/07/07 for Bayford House

This inspection was carried out on 19th July 2007.

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 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

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 Bayford House Rookwood Stockcross Newbury Berkshire RG20 8LB Lead Inspector Yvonne Souden Unannounced Inspection 11:30 19th July 2007 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 Bayford House DS0000069032.V340567.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. Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bayford House Address Rookwood Stockcross Newbury Berkshire RG20 8LB 01488 608632 01488 658606 bayfordhouseeveryone@bupa.com 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) ANS Homes Limited Mrs Jennifer Madeline Dawkins Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (53) of places Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Bayford House provides residential/nursing care and accommodation for 53 older people. The registered provider is ANS Homes Limited, a subsidiary of BUPA Care Homes. The home is located in the rural village of Stockcross, four miles from the market town of Newbury, and is surrounded by extensive grounds with walkways and seating provided. The home was built at the turn of the 20th century and has been extended and modernised over recent years to provide care for older people. There are three floors that can be accessed by lift. Rooms are mainly single and have en-suite facilities. Bayford House has an information pack available on application to the home. Email dawkinsj@bupa.com. Information CSCI received 19/07/07 confirms that weekly fees start from £532.84 for a shared room facility to £975 for a single room, dependant on assessed needs. There are additional charges for hairdressing, daily newspapers, chiropody, taxi fares, opticians andP pysiotherapy. Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information gathered to support this report includes inspection records, documentation received from the home, returned CSCI surveys ‘Have Your Say About Bayford House’, and an 8.5 hour site visit to the home. The site visit enabled the inspector to observe care practice within the home and hear the views of the service from residents, staff and management. The site visit also gave the inspector an opportunity to view further documentation, and view the care plans of five residents. From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals of various religion, race, or culture. The home follows the organisation’s policy and guidelines to manage issues relating to equality and diversity. What the service does well: What has improved since the last inspection? N/A Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 6 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. Bayford House DS0000069032.V340567.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 Bayford House DS0000069032.V340567.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Bayford House enables prospective service users and their representatives to make an informed choice when considering the home as their new home. Service users’ care needs are assessed prior to a placement offer. The home does not provide intermediate care. EVIDENCE: On entering the home the inspector observed information on the range of facilities and services offered within the home that included a previous inspection report (prior to the registration of the new provider), Statement of Purpose, BUPA brochures and copies of the minutes from residents’ and relatives’ meetings. Prospective service users receive a detailed pack containing information about Bayford House and the services provided that include information on the fees. Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 9 The home has introduced a new format of assessment and care planning as developed by BUPA, known within the organisation as ‘QUEST’. The inspector viewed the needs assessments of two recently admitted service users. The needs assessments were user friendly, enabling the reader to quickly identify the individual needs of the service user, and had a scoring system that determined whether the identified need, for example communication, was to be added to the service user’s personal plan of care. Service users’ files viewed demonstrate that the home works closely with external health and social care professionals within the assessment and review of their needs. Bayford House DS0000069032.V340567.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home works closely with health and social care services to ensure service users’ health and social care needs are met with dignity and respect. EVIDENCE: Care plans viewed were person-centred and gave clear information on how to support and meet the individual needs of the service user and minimise identified risk. Service users or their representatives are encouraged to be involved in the development of the plan of care and their signatures are obtained in support of the plan, with review dates set. It was evident that information gathered to support individual care plans included the initial needs assessment, a map of the service user’s life (detailed information about the service user’s childhood memories, relatives, work history, hobbies and interests) and risk assessments that include, for example, nutritional screening, pressure care and manual handling. Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 11 Records identify that service users have access to external health and social care services. As quoted by a service user, “They are very caring, if you are not well they get you a doctor”. Daily records identify the daily life of the service user and therefore quickly identify changing need. The home has a contract for the disposal of drugs and sharps and complies with policies and procedures for the control, storage, disposal, recording and administration of medication. The inspector observed that only trained staff administer service users’ medication from a monitored dosage system, and observed that medication in stock matches records kept. The inspector observed that staff treat service users with dignity and respect as they knocked on the service users’ doors before entering, and responded to service users’ requests for assistance in a caring and pleasant manner. As quoted by a service user, “They make sure personal care is in private, they are not rude, we have male nurses and they are as nice as the female nurses”, and as quoted by another service user, “Staff help me with a bath, but they encourage me to do as much as I can”. Call bells were observed to be readily available, as quoted by a service user, “They come straight away if I use my bell”. Bayford House DS0000069032.V340567.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 adequate. This judgement has been made using available evidence including a visit to this service. Activity plans do not support the diverse needs of the service users. Service users enjoy choice and are involved in menu planning. Service users are enabled to maintain links with family and friends. EVIDENCE: In general service users said they were happy with their lifestyle and could choose to participate in activities or not. Quotes from service users included, “We have a rector who comes from next door, I don’t like to participate in activities”, and, “We went to another home, we went by coach to a place like this, we all had a sing song”. The manager confirmed that the home does not have their own transport and has to hire transport to enable service users to access community events. Some service users said they felt lonely, and most said staff were nice and met their needs with dignity and respect, but were too busy to spend a lot of time with them. Staff said, as quoted, “We could do with a bit more quality time with the service users, as a bit of a rush in the morning”. Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 13 The home has a full time activity organiser and arranges activities from one week to the next, with a routine coffee morning Monday-Friday. It was evident from discussions with the activity organiser, staff, management and service users that the coffee morning is aimed at those service users who are physically/mentally able to attend/participate in the chosen topic of conversation. The activity organiser spoke of afternoon activities ranging from crafts, gardening, film shows, playing cards and games. The activity organiser confirmed that visits would be made to those service users who, through choice or frailty, remain in their rooms, and that chapters from a book are read to them. On the day of the site visit the home was busy preparing to participate in a BUPA ‘Themed Cruise of the Mediterranean’, and planning the home’s garden fete to be held that Saturday. It was evident from the range and delivery of activities that those service users who are less able are excluded from a structured activity programme that would meet their individual needs; the registered manager agreed that this must improve. The home has a menu plan that delivers choice and is received well by the service users, as quoted, “On the whole food good, usually come round today and ask for tomorrow, it was lamb stew and rice today”. Meals served at lunch and teatime looked appetising and, when asked, all service users said they had enjoyed their meal, as quoted, “Meals quite alright, may not be the Ritz, but OK”. The information gathered within the service users’ personal plan and the home’s diet directory/fact sheets equips the home to meet the needs of service users from various religious and cultural backgrounds, for example Chinese, Islamic, Jewish, Hindu and Sikh. Discussions and records viewed identify that most service users are of a Christian faith; a Church of England service is held within the home and a Catholic priest visits on request. The inspector did not have the opportunity to speak with visitors, but observed visitors coming into the home and frequent visitor signatures within the home’s visitor book. As quoted by a service user, “I have visitors and often go into the garden to chat”. Bayford House DS0000069032.V340567.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’s complaints procedure is readily available to service users and their representatives, and service users are safeguarded from abuse. EVIDENCE: No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. Service users and their representatives have a copy of the home’s complaint procedure. The home has responded appropriately to complaints made. Discussions with staff identify that they are aware and have knowledge of multi-agency policy and procedures to safeguard service users, and are aware of the home’s whistle blowing policy. Staff spoke of training received, and staff training records confirm that staff have attended safeguarding adults training. Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 15 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. Service users live in a comfortable, clean and safe environment. EVIDENCE: Bayford House has three floors accessible by stairs or by a passenger lift. Each floor was observed to provide a warm, comfortable, homely and clean environment. However, one area had the presence of a strong unpleasant odour; the manager identified the cause of the odour that was quickly rectified. Service users have personalised their rooms and most service users have been provided with a new profiling bed and mattress. As quoted by a service user, “They gave us all new beds last week”. The home has a maintenance report book on each floor that details maintenance repair requests made by staff. It was evident from observation that some redecoration and replacement of carpets has taken place and this has enhanced the homeliness of the home. Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 16 Staff have attended infection control training, and were observed to use protective clothing. Arrangements are in place for the disposal of continence waste. Contingency plans are in place to cope with the laundering needs of the service users whilst the home’s laundry is refurbished. Fire records viewed show that weekly checks of fire equipment are maintained, and discussions with staff and records viewed confirm that staff attend regular fire safety training. Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 17 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. Bayford House has a staff team who are competent, trained and sufficient in numbers to meet the health and social care needs of the service users. EVIDENCE: It was evident from the provision of care observed at the site visit that staff were able to meet the personal care needs of the service users in an unhurried and attentive manner, and that the staff rota was compiled to maintain sufficient staffing levels to meet those needs. As quoted by a service user, “Staff very good, they like a bit of fun, but if you had a problem they would help you”. As discussed within the daily life and social activities section of this report, improvements must be made to ensure that all service users have equal opportunity in social/recreational activities that would meet their individual needs. This could be achieved by an increase in activity staffing hours, or by restructuring the home’s activity programme. The home has policies on equal opportunities, diversity, anti-oppressive practice and recruitment and employment. Records identify that recruitment procedures are followed with references and security checks obtained prior to an offer of employment. Records and discussions with staff confirm that new staff are allocated a mentor to assist them through their three-month probationary period, and that staff have regular one to one supervision. Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 18 A full programme of external and internal staff training is in place, for example understanding dementia, palliative care and mandatory health and safety training. 48 of care staff have a National Vocational Qualification in Care. Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 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 31, 33, 35 and 38 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 is managed by a competent and qualified manager whose leadership and management skills ensure that service users’ needs are met in a relaxed and safe environment. EVIDENCE: The manager has been in post since October 2005 and has qualifications and experience in meeting the care needs of older people, and is working towards completing the Registered Managers Award. Surveys, discussions with staff and service users confirm that the manager is approachable and has made changes to the home that benefit the service user. Records identify that annual, bi-monthly and monthly audits are undertaken, and that the home undertakes customer satisfaction surveys to ensure that service users have their say. Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 20 There was a positive and relaxed friendly atmosphere as the inspector walked around the home, and records identify that regular staff and resident/relative meetings take place. However, some staff reported low morale that the manager acknowledged, confirming that it was due to changes made, and the sense of insecurity staff have had due to low occupancy levels that are now improving. The provider and manager of the home do not act as appointee for handling financial affairs of the service users. Service users can choose to have a small amount of money held in safe keeping by the home. Service users’ money is kept within a pooled bank account with accrued interest split equally between the service users. It was evident throughout the home that the health and safety of service users, staff and visitors is paramount. The home has policies and procedures on safe working practice and staff receive regular training within health & safety, fire prevention, moving and handling, COSHH and food hygiene. The kitchen was observed to be clean, with safety audits maintained to ensure a safe working environment, and ensure that food hygiene standards are met. Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 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. 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 4 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 3 X 3 X 3 X X 3 Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 22 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 OP12 Regulation 16 (2) (m) (N) Requirement The manager must review the home’s staffing hours and activity plan, to establish which of the two is failing to provide an equal amount of social and recreational activities for the service users. On reviewing the staffing hours and activity plan, the manager must develop ways to ensure that service users have equal opportunity to participate in social and recreational activity that would meet their diverse needs. Timescale for action 19/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Bayford House DS0000069032.V340567.R01.S.doc Version 5.2 Page 24 - 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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