Inspection on 10/07/06 for Bernadette House

This inspection was carried out on 10th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Bernadette House 03/01/06

Bernadette House 19/07/05

Bernadette House 14/03/05

Bernadette House 14/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Bernadette House The Old Vicarage South Park Lincoln Lincolnshire LN5 8EW Lead Inspector Mr Doug Tunmore Key Unannounced Inspection 10th July 2006 7:50 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 Bernadette House DS0000002324.V301700.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. Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bernadette House Address The Old Vicarage South Park Lincoln Lincolnshire LN5 8EW 01522 521926 01522 543963 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 Beullah Bernadette Brown Mrs Beullah Bernadette Brown Care Home 30 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (24) of places Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2006 Brief Description of the Service: Bernadette House was originally an old vicarage that has been subject to a change of use. The home is registered to provide personal care for 24 people over the age of 65 years and six with a diagnosis of dementia; accommodating 30 residents in total. The home stands in approximately one acre of secluded landscaped grounds, surrounded by large trees and it is situated on the edge of South Common, close to local facilities. Care parking is available to the front of the premises. The home has four double rooms, twenty single rooms, fourteen of these rooms are en-suite and there are five lounges. The home has a conservatory that offers the opportunity of privacy for meetings and visits. The majority of the single bedrooms are located in an extension that was built approximately five years ago. The homes service users guide states that, our continuing aim is to provide a professional and efficient service to meet requirements of care and enhance the quality of life of residents by helping them lead a full and active life as possible. The current scale of charges at this home is from £335.00 to £415.00. Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took into account any previous information held by CSCI including the homes previous inspection reports, their service history, the homes pre-inspection questionnaire and residents questionnaires sent to the home by the Commission prior to this inspection. The site inspection consisted of case tracking a sample of three resident’s records and assessing their care. The inspector spoke with two of the residents who was being case tracked and joined three other residents for lunch. The inspector also spent time with the administrator, the deputy manager and the registered manager. Two visitors were also seen during the inspection and one carer. A partial tour of the home and a review of a sample of the records was also included. What the service does well: What has improved since the last inspection? The home continues to look for ways to improve its service to residents in the home. This has been seen in the continuing upgrading of the residents care plans and pre-admission forms. The home continues to maintain the fabric of the home to a high standard as well as the grounds in which residents were seen to use during this inspection. Bernadette House DS0000002324.V301700.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. Bernadette House DS0000002324.V301700.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 Bernadette House DS0000002324.V301700.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 6 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents are admitted into the home only after a full needs assessment has been carried out either by the home and or health care or social care agencies. Written confirmation that the home can meet a prospective residents needs is also undertaken prior to admission. All residents have current contracts. This home does not provide intermediate care. EVIDENCE: A review of all information available prior to this inspection including previous inspection reports dated 03/01/06 and evidence seen at this inspection in residents files and care plans showed that the home does not admit residents without a care needs assessment being undertaken. Prospective residents are also written to by the home confirming that they can meet the residents care needs or not. Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 9 The Commission sent resident’s questionnaire forms to the home prior to this inspection and twenty five were returned, not all questions were completed by residents who had the support of either relatives or carers. Twenty two questionnaires confirmed that residents had information about the home prior to admission and the same number also agreed that they had received a contract. A relatives written comments was that ‘additionally we were given the opportunity to view the home and talk to the staff prior to making a decision of suitability. This was much appreciated’. Two visitors seen said that their relative was assessed for her care needs at the hospital by one of the senior staff from the home. A sample of a contract was sent to the Commission and the two residents who were being case tracked had a contract in their files setting out the terms and condition of their stay. Bernadette House DS0000002324.V301700.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The homes policies and procedures provide guidance for the care practices of care staff. Residents or their representatives are involved in the care plans. The home administers medication appropriately to all residents. Pre-admission care assessments and care plans do not always address the intimate care needs of residents. EVIDENCE: This inspection found that residents who were being case tracked have individual care plans, which evidenced that health care professionals in relation to their health care needs have seen residents. Resident’s files also describe their health and welfare needs. Care plans outlined risk assessments, nutritional and dependency assessments. Care plans also evidenced that they have been reviewed on a monthly basis or sooner depending on changing needs. The reviews and care plans of residents had been signed and dated by the carer the resident or a relative. Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 11 The homes notifiable incidents record was seen and corresponded with the Commissions service history of the home relating to accidents/deaths to residents. Resident’s questionnaires showed that twenty four felt that they received the support that they need and staff listened to them and acted on what they said. Twenty one residents commented that residents felt that staff are always available when they need them and three residents felt that staff are usually available when they need them. One resident felt that staff are sometimes or never available. A relative completing a questionnaire on behalf of her mother, wrote that ‘it does not matter how busy the staff are, they always make themselves available to discus any concerns’. Two relatives stated that ‘there is always somebody that you can talk to and mum is a bit spoilt at this home’. One resident commented that ‘I am very happy and satisfied here and staff are very nice I couldn’t have a better home’. Two care plans were seen and it was found that limited information is available regarding resident’s likes and dislikes. This area of care planning is centred around food preferences and not those aspects of residents daily living requirements and residents expectations. If an holistic care package is to be delivered it must reflect that a meaningful dialogue as been undertaken with the prospective resident and their families. Care plans were also seen not to have established the intimate care needs of residents and what help they require as individuals when bathing or toileting or how their privacy and dignity can be maintained. Two relatives confirmed that their mother was ‘bed ridden’ and that ‘ she is kept lovely and clean, she has a special mattress and staff ask us to go out while they wash her’. Residents comments made in questionnaires were; ‘Attitude of staff is exemplary’, ‘ staff very pleasant and caring’. The Commission has received copies of written accolades concerning the home from relatives voicing praise for the services provided. One relative commented ‘thank you for your care and compassion over the last fifteen years it has been greatly appreciated by all the family’ ‘thank you for looking after my Aunt, I know she was very happy and comfortable with you’. The pharmacist inspected the home on the 24/03/06 and recorded that storage and stock control is carried out appropriately and medication sheets correctly filled in. Due to this no inspection by the regulator of medication was undertaken. Residents questionnaires received back from the home showed that twenty four felt that they always get the medical support that they need and one felt Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 12 that they usually did. The homes pre-inspection questionnaire also showed that managing and safe handling of medication training had been undertaken in August 05 and May 06. Those residents seen do not self medicate. Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Relatives/friends of service users are made welcome in this home. A range of stimulating activities are made available to residents. A choice of meals are available at this home. EVIDENCE: Eighteen residents questionnaires showed that there are activities and they are available to residents always, five resident commented that activities are usually available and two said sometimes. The minutes of the residents meeting held on the 06/01/06 evidenced that residents are asked about which activities they would like in the year ahead. A number asked for outside entertainers to come into the home, sing a longs in the afternoon and a Karaoke machine so residents and staff could join in together. The recorded outcomes from the home was that monthly entertainers would visit, the Karaoke was machine was purchased and armchair activities was commenced with ten pin bowling. The homes news letter also evidenced planned activities for 2006. The inspection undertaken in January 06 found that the home had an activities worker who works sixteen Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 14 hours per week split between two days. The registered manager confirmed that the home still employs an activities organiser. The deputy manager confirmed that residents go to the seaside for a holiday and the provider brought down three residents for a day out. The deputy manger also stated that coffee mornings are held and trips are to be organised to the local garden centre. Two visitors commented that their relative was not really interested in activities ‘but likes to read the newspapers and watch television in her room’. The two visitors confirmed that ‘the home is great, they are made to feel welcome and are given food and drinks during the day and said that staff told them to ring anytime if you are worried about your mum’. One of the three residents who the regulator joined for lunch made complimentary comments about the food that was served ‘saying that you get plenty here and it is very good’. Resident’s questionnaires evidenced that twenty-three always liked the meals and two usually liked their meals. One written comment received stated that ‘The meals are varied and well prepared’. Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The home has in place policies and procedures for addressing and monitoring complaints. Service users feel safe and confident in approaching care staff regarding any concerns that they might have. Staff have undertaken safeguarding vulnerable adults training. EVIDENCE: The home has displayed the service users guide, which contains the homes complaint procedures in the main entrance. The home has a detailed complaints procedure. The home did not have a complaints format for the logging of complaints or providing a space for a potential complaint to sign confirming that they agree or otherwise with the outcome of their complaint. However, before the inspection was completed the homes administer had created a complaints document and added it to the homes complaints policies and procedures. The homes pre-inspection questionnaire evidenced that no complaints had been made since the last inspection. Resident’s questionnaires recorded overwhelmingly that they were aware of how to make a complaint and knew who to speak to if they were unhappy. Other comments were ‘If I went around the world I would not find a better place’. A residents stated that ‘ staff are very nice couldn’t have a better home’. Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 16 The homes pre-inspection questionnaire showed that safeguarding vulnerable adults training has been undertaken in May 05 and November 05. The deputy manager confirmed that all staff have now undertaken safeguarding vulnerable adults training. The Provider confirmed that the adult protection issue that she raised at a previous inspection is ongoing and that no residents are at risk. Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 17 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): 19,26 The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well maintained, the standard of the environment and its facilities are appropriate to the needs of residents. The home is clean and free of unpleasant odours. EVIDENCE: Previous inspection reports dated July 05 and January 06 and this inspection showed that improvements to the homes fabric both internal and external are continually undertaken. The home has a maintenance book setting out what work has been undertaken within the home and the rolling programme for the coming year. The home has undertaken risk assessments, which highlighted risks to residents posed by the homes environment and action to be taken. The home employs three domestic workers, one of which works full time and the others work part time. A tour of the home found that it was clean and no Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 18 unpleasant odours were detected. One resident showed the inspector her room, which had been personalised with her memorabilia. Her room was found to be clean and tidy. The residents survey was overwhelming in that they confirmed that the home always smells nice and is clean and tidy. Two visitors commented that ‘ staff are always cleaning, washing pegged out on line just like home, never any unpleasant smells, smells lovely’. Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 19 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 & 30 The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. Appropriate recruitment practices are in place. Staffing level meets the needs of residents. The home provides adequate training for care staff. Staff were seen to be competent in carrying out their care tasks. EVIDENCE: A review of all information available prior to this inspection including the homes pre-inspection questionnaire and last inspection carried out in January 2005, showed that; personnel files evidenced that thorough recruitment practices are undertaken to ensure the safety of residents. The deputy manager confirmed that no new staff have been recruited in the last year and was able to give a good account of how she would recruit new staff safely, ensuring that they had a satisfactory CRB (Criminal record Bureau Checks). She also confirmed that interview notes are kept on file for possible future reference. The homes pre-inspection questionnaire evidenced that the home operates a set training pattern for the year. Mandatory training has been identified as being undertaken and certificates seen at this inspection confirmed that professional trainers had undertaken training. Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 20 The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. The homes preinspection questionnaires evidences that 60 of carers have NVQ (National Vocational Qualifications) which means that the home meets the ratio of 50 of care staff trained to level 2. The questionnaire completed by residents showed that twenty one felt that staff are available when they needs them. Three felt that staff are usually available when residents need them. The two visitors said that staff ‘check on their mother and there seems to be enough staff always popping into mums room’. The homes pre-inspection questionnaire and the rota evidenced that there are twenty three care staff, four ancillary workers and a gardener. The duty rota showed that adequate staff numbers are on duty to meet the needs of residents during the day and night shift. The deputy manager was of the opinion that there are adequate staff on duty. A carer confirmed that she had undertaken mandatory training and had NVQ level 3. Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 21 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, & 38 The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. The registered manager and deputy manager are suitably qualified and experienced to carryout their her tasks. Records seen show that residents’ health and general welfare and safety are promoted. The home ensures that the residents have the opportunity to voice their views and opinions. Accurate records are kept of residents’ monies. EVIDENCE: The registered manager who is also the provider and deputy manager have worked in the home for a number of years. The deputy manager has The Registered Managers Award and NVQ level 4 in care. Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 22 Two visitors said that The provider Mrs Brown ‘is very good and told us that when our relative was admitted that ‘this is her home now please treat it as such’. The home conducts a quality assurance report. The quality assurance report is posted for the information of residents and visitors, as is the last Commission for Social Care Inspection report. However, it was felt that this document needs to be in large print and also modified to ensure easy reading for residents and visitors. Two visitors confirmed that they had completed the homes questionnaires. The deputy manager said that home only deals with a small number of residents personal allowances. Two residents allowances were checked and an accurate record was kept, with signatures and receipts available for monies spent. Two visitors confirmed that the family deals with their relatives monies. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. The homes pre-inspection questioner evidenced that fire alarm, fire drills and emergency lighting checks have been undertaken. Care staff also receive fire training as part of the homes initial training and as a regular training event. The homes pre-inspection questionnaire has evidenced that maintenance and service histories of all aids and adaptations are carried out as required by law. Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 23 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 3 3 x x X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 4 4 x x x x x x 4 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 Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bernadette House DS0000002324.V301700.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!