CARE HOMES FOR OLDER PEOPLE
Bempton Old Rectory Vicarage Lane Bempton Bridlington East Riding Of Yorks YO15 1HF Lead Inspector
Karen Ritson Unannounced Inspection 18th October 2005 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 Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 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.V255366.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bempton Old Rectory Address Vicarage Lane Bempton Bridlington East Riding Of Yorks YO15 1HF 01262 850072 01262 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 Mrs Valerie Sykes 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.V255366.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th March 2005 Brief Description of the Service: Bempton Old Rectory is situated within the small village of Bempton, near the costal resort of Bridlington. The home is registered to care for a maximum of 17 older people some of whom may experience some memory impairment. The home is a grade two listed building, which has been extended and refurbished for its purpose and thus provides service users with a homely and comfortable environment. The village has a number of local amenities including pub, village shops as well as a bus service to nearby Bridlington. Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection took place on November 9th 2005. The manager was unavoidably absent and was not available for the duration of the inspection. However, a senior carer was present throughout and provided assistance. There was a calm and relaxed atmosphere on arrival at the home. Three service users and three members of staff were spoken to. Their comments are detailed within the body of the report but all service users without exception expressed great confidence in the staff teams’ ability to provide quality care. This inspection took ten hours to complete which includes time for preparation and writing the report. What the service does well: What has improved since the last inspection?
Quality assurance audits continue to highlight areas which service users and staff feel are important and these are acted upon as part of the regular running of the home. The acting manager had carried out work regarding standard eleven, which covers service users wishes at the latter part of their lives, unfortunately this could not be discussed as the manager was not available. Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 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. Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 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 Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Service users are assured that their care needs will be met. EVIDENCE: Conversation with the acting manager prior to the inspection confirmed that service users remain at the centre of the homes procedure for assessment of care needs. A pre admission assessment is followed by a full assessment on admission to the home. Risk assessments are included with particular reference to falls. All other areas of potential risk are also included. Assessments are detailed and provide a thorough base upon which to develop the care plan. All nursing input is recorded in daily notes. Intermediate care is not usually offered by this home. Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Service users health care needs are fully met. EVIDENCE: The home’s care plans continue to be detailed, informative and linked to a comprehensive assessment. Plans are drawn up with the involvement of service users and their families who signed where possible. All aspects of health, personal and social care needs are addressed. There are comprehensive risk assessments on file and risk management plans in place. Care plans are reviewed on a monthly basis. The home continues to meet service users’ health care needs well. All residents are registered with a GP of their choosing. Dental, chiropody, hearing and sight visits were logged in a separate document to the file. District nurses are consulted regarding continence promotion. Service users’ psychological health is reviewed on a regular basis and detailed in care plans. Opportunities were provided for the service users’ physical needs to be met and risk assessments on falling were in place. A record of nutrition and weight is maintained by the home. The home has a detailed policy on the handling of medication, which includes selfmedication. Records of all medication received, administered and disposed of
Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 Page 10 were available. Records checked by the inspector on the day were accurate. No controlled medication is prescribed at present. Staff who are responsible for the administration of medication have been provided with training by the pharmacist and have been supervised on an individual basis. Quality assurance documentation provided evidence that the service users are treated with particular regard to dignity and respect. Written responses from service users, relatives, friends, health care practitioners were all very positive. Service users said that care staff could not be faulted on their attitude and all were without exception kind and thoughtful. Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Service users have choice and control over the way they live their lives. EVIDENCE: Service users said that the staff spent time with them to find out their preferences and interests. Individuals are encouraged to develop their own interests. There is an emphasis upon developing stimulating activities for service users based on a thorough knowledge of each individual. Time is spent each day in engaging those service users in conversation or activity who might have difficulty with concentration or who have a deteriorating condition. Those service users who were reasonably independent said that sometimes they found it difficult to enthuse sufficient residents to join in any activity which required a level of involvement and that at times they felt a little isolated. A visitor said that the staff were very patient and were creative regarding how they worked with service users who have a limited memory span. Visitors may call at any reasonable time and all service users said they had considerable control over the way in which they lived their lives. The meals continue to be of a high standard. All food preferences, allergies and medical dietary needs are recorded on file. All said they found the meals to be excellent and questionnaires confirmed this. A midday meal was observed. Each person was treated with great care and all who required assistance were offered this in a calm unhurried way.
Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Service users are protected from abuse and complaints are acted upon. EVIDENCE: The quality assurance feedback confirmed that all complaints are handled in an efficient and professional manner. Any complaint is responded to in writing and the written procedure is followed. Service users all said that any concern was listened to, acted upon and taken seriously by the staff. There had been no formal or internal complaints since the last inspection. Service users are protected from abuse through well -trained staff. All staff understood the abuse policy and procedure and were aware of the procedure for the Protection of Vulnerable Adults. Service users said they felt safe and well cared for. Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home is well maintained and clean. EVIDENCE: The home is well maintained and redecorated on a regular basis. There are sufficient toilet and bathing facilities and communal space is pleasantly laid out. The home is clean and the living environment very pleasant. All service users said they enjoyed their surroundings and that they had been kept informed regarding any changes planned. There are no reported difficulties with the laundry service. Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Service users’ welfare is protected by well trained and recruited staff in adequate numbers. EVIDENCE: The home is well staffed. An emphasis is placed upon recreation time with staff being employed specifically to spend time with service users in this way. Service users said there were plenty of staff to carry out their duties without having to rush. Staff are recruited according to policy and procedure. All service users and visitors said that the staff were patient, kind and suitable for the role of carer. Staff receive thorough training. All staff administering medication had just completed a ‘Safe Handling of Medication’ course at York University and a dementia course was planned for the following week. Staff said there was provision for them to receive training in areas of particular interest and this was discussed in regular supervision meetings. Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 The home is run in the best interests of the service users. EVIDENCE: The acting manager is not yet registered with CSCI. An application is now recommended. The home continues with a detailed and thorough quality assurance system based on regular questionnaires distributed to service users, friends, relatives, health care professionals and all others coming into contact with the home. Quality assurance audits are regularly carried out by the acting manager. All information is collated and fed back to service users and staff in regular meetings. Staff and service users said that management took on board suggestions and many had been acted upon. Service users also commented that they felt encouraged to mention any quality issue at any time and all concerns or comments were listened to and acted upon appropriately. The results of the quality assurance surveys are published and available for
Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 Page 16 any interested party to examine. The home has a policy of continual self monitoring and has a proactive approach to improving the quality of service through consultation and regular review. The home does not become involved in service users finances. All health and safety documentation was up to date, with all certificates in place for systems and appliances. The Landlords’ gas safety certificate was forwarded following the inspection. Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 Page 17 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 4 8 X 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 Page 18 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. Standard Regulation Requirement Timescale for action 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 OP31 Good Practice Recommendations Recommend application to CSCI by Diane Beevers for manager of home. Bempton Old Rectory DS0000019648.V255366.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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