Inspection on 15/10/08 for Bempton Old Rectory

This inspection was carried out on 15th October 2008.

CSCI found this care home to be providing an Adequate service.

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

Bempton Old Rectory 13/10/09

Bempton Old Rectory 28/09/06

Bempton Old Rectory 20/01/06

Bempton Old Rectory 18/10/05

Bempton Old Rectory 08/03/05

Bempton Old Rectory 27/10/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/02/2009.

CARE HOMES FOR OLDER PEOPLE Bempton Old Rectory Vicarage Lane Bempton Bridlington East Riding Of Yorks YO15 1HF Lead Inspector Anne Prankitt Key Unannounced Inspection 15th and 23rd October 2008 09:45 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 Bempton Old Rectory DS0000019648.V372161.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. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bempton Old Rectory Address Vicarage Lane Bempton Bridlington East Riding Of Yorks YO15 1HF 01262 850072 F/P01262 850072 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) Mrs Dorothy Hunter Care Home 17 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (17) of places Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th September 2006 Brief Description of the Service: Bempton Old Rectory is situated within the small village of Bempton, near the coastal resort of Bridlington. The village has a number of local amenities including pub and village shops, as well as limited public transport to Bridlington. The premises, a grade two listed building is set in its own grounds and has been extended and refurbished to provide people with a homely and comfortable environment. The home has lounges and dining rooms which are large enough to accommodate everyone who lives there. The home is registered to care for a maximum of 17 older people who may or may not have a dementia type illness. Some people’s private accommodation is on the first floor and a chair lift is provided. One room on the first floor requires the person to be able to manage a small set of stairs in order to reach it. We were unable to find out what the current weekly fees are, and what people pay extra for. People should approach the registered provider for this information. Information about the services provided are made available in the home’s Statement of Purpose, Service Users Guide and through published inspection reports available from the home. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The key inspection included a review of the following information to provide evidence for this report: Information that has been received about the home since the last inspection. A self assessment called an Annual Quality Assurance Assessment (AQAA). This assessment told us how the registered manager thinks outcomes are being met for people using the service. It also gave us some numerical information about the service. Completed comment cards from seven people living at the home. A visit to the home by one inspector. The visit took place over two days. On the first day, the registered provider could not be available. After speaking to her on the telephone, a decision was made that it would be better to return when all of the information needed to complete the inspection could be seen. Our visits are unannounced. Due to circumstances beyond the registered provider’s control, she was not able to be present at the second visit either. During the visit to the home, several people who live there and three staff were spoken with. Three people’s care plans were looked at in detail, and one in less detail. We were unable to see staff recruitment files, policies and procedures or records about health and safety in the home, because the registered provider had these at her home. Care practices were observed, where appropriate. Some time was also spent watching the general activity to get an idea about what it is like to live at Bempton Old Rectory. Feedback was given to the two care staff on duty after the visits were completed so they could pass on our findings to the registered provider. What the service does well: People are assessed before they are admitted to the home to check what their needs are, and whether the home will be able to meet them. People are normally involved in this assessment, and staff get information about this assessment so they know what care will be needed when they arrive. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 6 People say that staff know well what their needs are, and are satisfied that they get their care the way they want it, in a homely environment which meets their needs and comfort. They know the registered provider, and feel confident that she would sort out any problems they may encounter during their stay. People enjoy a flexible lifestyle, which means that they are not ruled by routine. This means that one day does not have to be the same as the next. They can enjoy visits from their family, and can enjoy their company in their own room, or in the communal areas if they prefer. Staff know that they must report any concerns they have about people’s welfare, so that action can be taken to protect them from harm and abuse. Staff told us they get a range of training, which is updated, so that they know how to give good, safe care. What has improved since the last inspection? What they could do better: All of the written information about the care and support people need could be available for staff to refer to on a daily basis. This would help to keep people’s care consistent, and would remind staff about areas of people’s health where risk to them needs to be monitored. Some medication practices with regard to storage and recording could be improved to reduce any potential risk to people. Records about the management and administration of the home could be kept at the home so that at any time a sound judgement can be made that people are protected by sound procedures, and good health and safety practice. This is so they are available for authorised people to look at. People could be asked about what activities they would like to see at the home, and their views collected about how it runs could be fed back to them, so they can see what is being done in response to their collective comments. Staff could be provided with formal training on safeguarding, so that it can be assured that they all have up to date information about what to do, and who to report to, should they ever believe that a person living at the home was not being properly treated. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 7 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. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People who use the service experience good outcomes in this area. People are assessed, and are consulted before their admission to the home. This helps to keep them involved in decisions made which will affect their life. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People’s pre admission assessments are not kept with their care plans. The registered provider keeps these separately once their care plan has been written, because she has tried to keep the day to day paperwork for staff to refer to easy to follow. The most recent pre admission assessment was seen. It contained basic information about the person’s needs. This information was collected by the registered provider when she visited the person before they were admitted. The registered provider also collects information from the person’s care manager where applicable. This will help to make sure she has all the information she needs to decide whether the person’s care can be provided at Bempton Old Rectory. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 10 Staff said that they get enough information from the registered provider to know what needs people will have before they arrive. This puts them in a better position to offer the right care straight away. Everyone who returned their surveys said that they received enough information before they moved in to the home. One person confirmed that the registered provider had come to see them before they came in, to check what care they would need when they arrived. One person commented ‘Warm, friendly and homely as soon as I stepped inside’. The home does not provide intermediate care. It does however provide occasional short stay care when people come in for a period of respite. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People who use the service experience good outcomes in this area. The care people get is not fully reflected in their care plan, although they get this care in an individual way, from staff who respect them. Some improvements could be made to the medication practice to reduce the risk to people from avoidable error. We have made this judgement using a range of evidence including a visit to this service EVIDENCE: The care plans gave some details about people’s general care, and how it should be provided to help people to remain independent. They also gave a good summary about people’s mental capacity, and when they would need help in making daily decisions. However, not all of the information staff need, to understand about people’s overall needs, risks and choices, were kept together in the care files used by them on a daily basis. We were told that the registered provider keeps some of this information separately. This sort of information needs to be put back into people’s care plans so that it is all held together. For instance: One person did not have a care plan available for staff to refer to. Staff found this care plan in the registered provider’s office, because she had been adding Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 12 to it. However, she is not at the home all the time, and this information should be readily available for staff to refer to at all times. When we told staff we thought that more information about people’s social needs and interests could be included in their file, a very good ‘potted social history’ was retrieved from the registered provider’s office. The care staff spoken with said they always complete one, because they believed it gave staff a good starting point to get to know the person. This is very good practice, and would form the basis of a good care plan about people’s social needs. People’s wishes about death and dying were not included in their plan. This is an aspect of a person’s life that they may want to talk to staff about. By having knowledge of their current wishes, staff could anticipate the person’s needs better when discussing their care with them. We were told that specific risk assessments are completed if problems are identified with, for instance, nutrition, mobility and pressure sores. Some care plans told us that these problems were still an issue for the person, and referred staff to their risk assessment which had again been separated from the person’s file, so were not available for staff, or for us, to look at. One plan asked staff to refer to such an assessment for a person at high risk from pressure sores. The equipment needed to minimise risk to them had been provided, and there were no problems reported in their daily records. But the risk assessment itself was not available for staff to refer to when providing daily care. In another case, the location of a person’s bedroom could impact upon risks identified prior to their admission. Although staff knew how to keep this risk to a minimum, the details of how they achieved this was not written down and formally assessed in their plan. Some of the care plans had been signed by the person to whom they belonged, when they were first written. People said that they were not involved in the subsequent monthly review of their plan, which is carried out by their key worker and the registered provider. Those spoken with were happy for this to be done on their behalf. One person said ‘Staff know exactly what they are doing so I don’t need to be involved’. We were told that the registered provider records separately when the person’s review is completed. Because this is not recorded on their files, it gave the impression that the review had not been done, because some of the information in their plan had not been updated as needs had changed. For instance: Where a person now has problems with continence, their care plan still stated that they do not, as was the case when it was first written. The fact that they now need assistance with their meals was not recorded. The plan still said that they could manage on their own. The action taken when someone had lost a lot of weight was not recorded. When raised with the staff, they told us the reason why, and the fact that professional advice had been sought and Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 13 followed. Again, this information was not recorded so until explained it looked as if this had not been acted upon. Four of the five people who returned their surveys said that they always get the care they need. One said this is usually the case. They made comments like ‘I am very happy and comfortable here’. Everyone said staff listen and act on what they say, although one added ‘Usually – some are a little forgetful’. Another anonymous comment that more baths would be appreciated was discussed with staff, who said that they try to assist people with a bath whenever they ask. People asked confirmed that this was the case. On the day, people said that they were very satisfied with their care. They made comments like ‘I’m fine here. It’s very good. I look after myself and can suit myself what I do’, ‘It’s very nice here. We are very fortunate’, ‘Staff are kind and respectful’. A visitor commented on the ‘good care’. They said when they visit, people always look ‘well dressed and cared for’. All but one person, who said it was usually the case, said in their surveys that they always get the medical support they need. Staff said that they consult with the doctor as needed or requested, and that the nurse practitioner attached to the surgery is always available for advice if necessary. A record was kept in people’s files which showed regular contact with such professionals. Staff on the site visits were extremely polite, kind and respectful to people. People appreciated this, and it was obvious that everyone knew each other very well. This made the service feel very homely and welcoming. Staff look after people’s medication on their behalf. They told us that they have completed a training course so that they know how to do this safely. The medication was locked away, and the records that staff keep were kept up to date. Some areas, which need to be acted upon to make the system better and safer, were discussed with care staff: When it is necessary for staff to write out people’s medication by hand on the administration records, they should have another member of staff check what they have written, and sign and date this check. Such records made by staff must always include the number of tablets to be given, and not just the strength of the medication, so it is clear from the record how many tablets are to be given at each dose. Staff said they would check people’s records and put this right on the day. When medication is received into the home from the pharmacist, rather than ticking to say that it has been received, staff should record on people’s charts how much of each drug has arrived. This makes it easier to check the stock balance over the course of the month, including any remaining stock which is being stored in the home. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 14 Medication which needs to be kept cold was stored in a refrigerator in the kitchen stores. The fridge is used solely for this purpose, but it cannot be locked. The pharmacist should be contacted for advice to see if suitable lockable equipment can be provided. A controlled drug was being stored in the same cupboard as other items such as bandages and other non controlled medication. And there was evidence that other controlled medication had been prescribed for people at the home in the past. Controlled medication must be stored in a separate cupboard used only for this purpose. Again, advice should be sought from the pharmacist to decide how this will be achieved. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People who use the service experience good outcomes in this area. People enjoy a flexible lifestyle and can maintain important links with people who are important to them. By asking their views about activities, a better idea about what people would like to happen to improve their social life further could be achieved. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Some people who are able and independent said they sometimes arrange their own activities, such as scrabble games or dominoes. One person said they enjoyed walking out in the grounds when the weather was nice. The registered provider told us that she takes small groups of people out for lunch sometimes, that there is a religious service held at the home monthly, and that some people are involved in the local church activities. One person said they ‘appreciate monthly services/communion’. They continued ‘my condition prevents from more interactive activities’. Another was very pleased that their spiritual needs were still being met since moving in. People had mixed views about the activities that are available to them. Some were perfectly happy with the informal arrangements in place. Others said it would be nice to have more going on. One said ‘I choose not to do activities, but I can always go down for a game of dominoes if I want’. Another Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 16 commented that overall, this was the only area where there were ‘downfalls’. They said there is ‘not enough going on’. The registered provider told us in the information provided before the site visit that she realises that activities is an area that need to be improved upon, and this is part of her plan for the coming year. In order to find out what activities would suit people, they could be surveyed so their collective views can be considered when making improvements. People are happy that they can make their own decisions and choices in their daily lives. One commented ‘I can keep my room nice, and can come down when I want. I’m very happy’. People can see their relatives where and when they want, and can spend time in their room when they want. On the morning of the first site visit, the communal areas were still empty at 9.45am. Staff said it is important that people get up at their own pace, and that they are not rushed. This is good practice. People were pleased with these flexible arrangements, which mean that one day does not have to be the same as the next. The cook was not at work on either site visit. Therefore the meal was being prepared by the care staff. They said that fresh meat, fish and vegetables are delivered to the home regularly, and that people get a choice of meal each day. In between meals people are offered hot drinks, and they have cold drinks in their room, which are topped up as needed. Some people choose to eat in their room. Those who want to eat communally have their meal delivered to their table, and are able to select their own vegetables from serving dishes. Gravy was served separately, so people could choose how much they wanted. In their surveys, two people said they always like the food. Three said they usually do. One of these said ‘Food is a topic of conversation. Teas could be improved’. There were no complaints on the day about the food, and people were seen enjoying a mealtime which was not rushed, and which was quite a social occasion. Special diets are catered for. For instance, one person said they are always provided with a good vegetarian meal to meet their choice. We were told that the dietician had advised staff that one person needed to have their meals enriched so they got lots of calories to help them put on weight. Staff had achieved this, and said that the dietician was pleased with the result. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 17 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): 16 and 18 People who use the service experience good outcomes in this area. People are confident that the home will always try to put right their complaints and concerns. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Everyone who returned their surveys said they know how to complain, although one added ‘But I’ve not had any (complaints) so far’. People said they ‘always’ or ‘usually’ know who to complain to. Others made comments like ‘All staff and Mrs Hunter (the registered provider) very approachable’, ‘I have no complaints but I’m certain they would be sorted if I did’. The complaints book was not available, because it is kept by the registered provider. However, she has told us that there have been no complaints received by the home in the last year. Staff were clear about what they should do if they ever suspected that someone living at the home was being abused. They knew that they could not keep secrets, and that they must pass information on straight away if they suspected anything. Although staff have covered abuse awareness in their National Vocational Qualification studies in care, they have not received formal training in safeguarding adults which would link closely to the role of the local authority as lead investigators. It is recommended that this be provided, so that people can be assured that all staff would be confident about the right action to take, and who they must tell, should an incident happen, or be suspected. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 18 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): 19 and 26 People who use the service experience good outcomes in this area. People live in a warm, comfortable home, which meets their needs. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home is situated in the village of Bempton. It is a warm and comfortable home, which provides a variety of communal areas for people to choose from. It is nicely decorated, and free of unpleasant smells. Some of the communal areas look out onto the gardens, which are well maintained and enjoyed by the people who live there. The first floor is reached by stair lift. There is one room on the first floor which can only be reached by a small final flight of steps. The care staff spoken with said that this is considered as part of people’s assessment before they move in. People have their own single accommodation. They said they like their rooms very much, and have been able to bring in personal belongings to make them Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 19 feel more homely. One person said ‘I love my room. I have lovely views of the garden’. Although the house was warm, one person’s room felt cold. This was rectified at the time, and the radiator switched back on. The heating in this room needs to be monitored by staff, as the person is not able to operate the heating control themselves. The registered provider told us that there is an ongoing programme of decoration at the home. This includes the refurbishment of both bathrooms, one of which smelt a little damp following a recent leak, which has now been attended to. In the first floor bathroom, some of the tiles had come loose around the bath. This makes it more difficult to keep clean. They need to be reattached. Also, the door closer had come away from the frame. The staff member who deals with maintenance within the home was told that this needs repairing so that it is safe, and in full working order. He agreed to do this forthwith. The laundry facilities provide washers, driers and sluicing facilities, so staff can choose from a range of temperatures to ensure people’s clothing and linen is washed correctly. Staff have disposable gloves and aprons to wear when they are handling soiled linen, which is delivered in separate sealed bags. This reduced the risk from cross infection. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 20 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): 27,28,29 and 30 People who use the service experience good outcomes in this area. People are cared for by staff who have regular training which tells them how to give good care. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: In their surveys, people said that staff were ‘always’ or ‘usually’ available when they were needed. One person said ‘I ring this bell, and staff come straight away’. Another commented that staff were good, and that the number of staff available was sufficient to provide people with the right care. It was felt however that more staff would allow for more walks out, which were sometimes not possible, because staff were busy providing care. Staff spoken with said that they work well together and like their job very much. They work flexibly to make sure that people get a consistent service if their colleagues are not on duty. For instance, on the day of the site visit, a member of the care staff prepared the meal for people in the absence of the cook. People knew that this was the case, and said that the meal was still very nice, and that it still provided them with a choice. It was not possible to look at the staff recruitment files, because the registered provider keeps these at her home. So it was difficult to assess the quality of the recruitment process, and whether all necessary checks are made to protect people, before staff are allowed to provide care. However, one member of staff spoken with was able to recall the checks that were made before they started Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 21 working with people. These were satisfactory. Whether staff get a full induction to current minimum standards could not be confirmed. However, the staff member spoken with stated that they were told about paperwork used at the home, and were not expected to carry out any tasks alone until they felt fully confident to do so. Staff get training to assist them with their work in providing good care. One member of staff said ‘If ever I want to do anything I just tell Mrs Hunter (the registered provider). They said recent training includes the safe handling of medication, dementia awareness, continence management and bereavement training. There is also ongoing training provided for staff to achieve National Vocational Qualifications in Care at Levels 2 and 3. Staff training files were not available. The registered provider said that she was updating these at home. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 22 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): 31,33,35,37 and 38 People who use the service experience adequate outcomes in this area. People are satisfied that the home is run in their best interests. But the administration systems are adequate only, because they are not sufficiently robust to confirm this. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The registered provider also manages the service. She works at the weekend, and is normally in the home Thursdays and Fridays as well. She often cooks for people on a Monday and Tuesday when the cook is having days off. She previously worked as a nurse, but has owned Bempton Old Rectory since 1993. Staff spoke highly of her. They keep her updated about what is going on in the home when she is not there, so that she knows what is going on, and whether she needs to visit. Staff said ‘With Mrs Hunter (the registered provider), the residents always come first’. A person living at the home agreed, Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 23 saying ‘Mrs Hunter is clear that the ethos of the home is that it runs around the residents’. The home was awarded ‘Investor In People’ status in 2005. This shows the commitment to staff members working there. It has also been quality assessed by the local authority, and has achieved their quality award at level 1. This shows that the quality of the service has been recognised by those professionals who refer people to the home. Staff were aware that the registered provider gives people a survey periodically to seek their views about the service they get. We were not able to establish whether the views of people’s relatives, and professionals who support them, were also sought. A staff member said they do not get feedback about the results, and they were not sure about how this information was fed back to people at the home. Two people living there said they could remember completing surveys. Neither of these were sure about what was done with their comments, and both agreed that they had not received any feedback from them. We could not see this information because the registered provider keeps it. However, people spoken with were clear that in their view the home was run in their best interests. One said ‘It’s marvellous – I have no complaints’. Another commended the home and said ‘We have very few rules and regulations’. The home does not look after anyone’s money. People look after this themselves, or relatives help them where they need assistance. The staff member responsible for minor maintenance jobs at the home showed us that they check the fire alarm weekly to make sure it would work properly in the event of a fire, and explained how, every three months, staff and people living at the home are involved in a full fire evacuation. He also does a series of daily health and safety checks around the home, to make sure that there are no obvious problems that need attention. Both the fire officer and the Environmental Health officer have visited since the last key inspection. The fire officer reported to us that they were satisfied with the systems at the home to control fire. Staff told us that the registered provider dealt with one minor recommendation raised by the Environmental Health Officer straight away. Before the site visit, the registered provider did not give us some of the information we asked for in her Annual Quality Assurance Assessment. This included omissions about when major equipment in the home, such as the gas appliances and fire alarm system, had last been serviced. Again, this information was not available on the day. We were able to get some of the information in other ways. For example, we were not able to see how the registered provider makes sure hot water temperatures accessible to people Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 24 are checked to make sure they remain safe. But staff told us instead that they check the temperature is right, before people get into the bath, to make sure it is not too hot. We could also see that the registered provider looks at accident records to see what can be done to stop the same accident from happening again. However, we need to know this information so we can be sure that the premises are maintained to keep people safe. The registered provider has assured us that these service checks are up to date, and has agreed to send details of this information to the commission so we can look at how she keeps the premises safe for people who live there. We are awaiting this information to date. Information about compulsory training that staff have completed was not available. Staff said they had received some training in the last year on fire safety and infection control. And all said they had received training in Food Hygiene. We were told by them that there was always a first aider on duty to deal with emergency situations. However, one thought that moving and handling had not been completed in the last year, and another said they have not yet received any training about safe moving and handling. As explained throughout this report, some of the information we needed to see to complete this key inspection was not available to look at. More importantly, some of this information should be readily available to staff at all times. For instance, some care plan documentation, and policies and procedures that they might need to refer to when the registered provider is not in the building. Staff recruitment and training records, information collected to assess the quality of the service, and also health and safety certificates to show the home is kept safe for people need to be kept at the home, so they are available for inspection at any time. As our inspections are usually unannounced to meet people’s wishes, it is important that this information is available in the future so we are able to make a proper assessment about how the service is managed, and how necessary checks are administered. Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 25 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 2 8 3 9 2 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 2 X N/A X 2 3 Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15 Requirement The information needed for staff to get a full picture about people’s current health, social and psychological care needs, and any risks relating to this care, must be included in their care plan. This is so that all of the information can be considered and updated each time the person’s care is reviewed, and adjustments made to their plan of care accordingly. Advice must be sought from the pharmacist, and followed, to establish what equipment is needed for the correct, safe storage of controlled drugs, and medication which needs to be kept cold. This will ensure that such medication is safely stored in line with current law. Timescale for action 31/12/08 2 OP9 13 30/11/08 3 OP37 17 Records relating to the running DS0000019648.V372161.R01.S.doc 30/11/08 Page 27 Bempton Old Rectory Version 5.2 Schedule 4 of the home must be kept on the premises and available at any time for inspection, so confirmation can be seen that people are protected by sound management and administration procedures relating to any activity at the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations Hand written medication records completed by staff should always be completed fully, checked, countersigned and dated. This will reduce the risk from avoidable errors being made, and will help to monitor stock control. People’s views about the activities provided should be sought and acted upon, so that planned improvements in this area consider their collective views. Training should be provided for staff in safeguarding adults. This would help to make sure that all staff understand the current guidelines about who to report to, and what action to take, should they suspect abuse, or have an allegation made to them. The collective results of surveys should be published to show what the home does well, and what the registered provider intends to do where suggestions about improvements are made. A check must be made to make sure that all staff have up to date compulsory training in safe moving and handling. This will make sure that they are fully competent and confident when helping people with their care, and managing their own health and safety. 2 3 OP12 OP18 4 OP33 5 OP38 Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Bempton Old Rectory DS0000019648.V372161.R01.S.doc Version 5.2 Page 29 - 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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