Inspection on 19/07/05 for Bernadette House

This inspection was carried out on 19th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bernadette House 10/07/06

Bernadette House 03/01/06

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 LN5 8EW Lead Inspector Doug Tunmore Unannounced 19 July 2005 09:30 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 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 C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bernadette House Address The Old Vicarage South Park Lincoln LN5 8EW 01522 521926 01522 543963 Telephone number Fax number Email 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 (DE) - 6 registration, with number Learning disability (LD) - 1 of places Old age, not falling within any other category (OP) - 23 Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14 March 2005 Brief Description of the Service: Bernadette House was originally an old vicarage that has been subject to a change of use. The home is registred to provide personal care for 23 people over the age of 65 years. One person with a learning disability 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 efficent 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. Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 10.30 am. The main method of inspection used was called case tracking, which involved selecting two residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observations of care practice. A partial tour of the premises took place. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that all prospective residents are informed in writing that the home can meet their care needs. Care plans must be signed by residents or their representatives agreeing or otherwise to the care provided by the home. Care plans seen need to be more prescriptive regarding the personal care given to residents. The care plans need to reflect how privacy and dignity are maintained when undertaking personal care. The homes medication files should be organised with file dividers and photographs of individual residents on the front of their medication sheet to help ensure that no errors are made. Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 Page 6 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 C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 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 standard(s) 3 The home undertakes a full care needs assessment of residents prior to admission. However, they do not confirm in writing to prospective residents that the home can meet their needs. EVIDENCE: Two residents files showed that a full assessment is carried out of residents needs prior to admission. The admission form documented the needs of new residents relating to likes and dislikes, mobility, dietary needs and hobbies. A relative of a resident who was being case tracked confirmed that they had been visited by someone from the home prior to admission but they had not received a letter to their knowledge confirming that the home could meet his wife’s needs. Files seen did not contain copies of letters sent to prospective residents. One senior care worker knew about the care needs of residents and explained that the seniors or manager undertaken admission assessments, which is an ongoing process once the resident is admitted to the home. Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 & 10 There is good care planning in this home, which helps ensure that the general health and welfare of residents is addressed. The signing and dating of documentation relating to the care of residents is not always undertaken. On the day of the inspection medication was administered appropriately. EVIDENCE: All residents have detailed care plans, which 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. Two files showed that care plans had been signed by one of the residents or their representative. One relative said that his daughter visits and she may have signed the care plan of behalf of my wife. The visitor also said ‘that his wife has adapted well to the home and people are very good to her and me’. The commission received one comment card from a resident and one from a relative. The residents comment cards confirmed that she felt well looked after here. The relatives comment card showed that he felt that he is kept informed of important matters affecting his wife. Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 Page 10 Individual care plans evidenced that accidents are recorded in the home’s accident book and in the resident daily notes. However, the home does not use body maps for the mapping of any cuts or abrasions to residents. One accident form was checked through the homes accident procedures and it was found that the fall had been recorded appropriately. Files seen confirmed that health care professionals visit the home when required by the residents. A senior carer stated that she was aware of the intimate care needs of residents and had undertaken national vocational training levels 2 and 3 in which personal care issues was addressed. Care plans seen did not record how residents dignity and privacy was to be mainatained. Care plans need to be more prescriptive regarding information to carers about maintaining individual residents privacy. A residents comment card showed that she felt her privacy was respected. At the last visit on 17/06/05 the pharmacist report showed that administration records were good and storage and stock control was good. One resident looks after their own medication and a lockable facility is available to them for its safekeeping. Risk assessments were seen and had been signed by the resident acknowledging that they can look after their own medication needs. The senior carer stated that she had undertaken two medication courses, which were in house and managed by Boots the Chemist and Lincoln College. The home may wish to organise the medication files with file dividers and photographs of individual residents on the front of their medication sheet so as to help ensure no medication errors occur. Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 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 standard(s) 13 & 15 Relatives and friends of residents are made welcome in this home. Meals are well managed and reflect resident’s likes and dislikes. EVIDENCE: The homes visitors signing in book was seen and showed that numbers of visitors attend this home on a daily basis at differing times of the day. A visitor confirmed that he is always made welcome when he visits and refreshment is always offered. One visitors commented card showed that he can visit his relative in private and that the staff welcome him in the home at any time. The inspector joined three residents for lunch and found the meal provided to be hot and delicious. Residents said that they have a choice of meals. The cook commented that she has access to residents files and is aware of the dietary needs of residents as well as their likes and dislikes. A residents comment cards showed that she liked the food at the home. The homes kitchen is in the process of being refitted with new cupboards and another oven. Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 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 standard(s) 16 & 18 The home takes the issue of addressing complaints very seriously and has a comprehensive complaints policy. Staff are aware of how to respond to a complaint or an adult protection allegation. 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 homes complaints log was seen; no complaints had been made since the last inspection. The acting manager said they are happy to receive complaints if this lead to improvements in the service. Staff are aware of the homes ‘Whistle Blowing’ policy and spoke knowledgeably about abusive practices and what action she would take if this came to their attention. All staff received adult protection training, undertaken in March and May 23rd 2005. A relative said that he felt that his wife was safe in this home. The Provider asked for advice concerning a possible adult protection issue. The Inspector informed the Provider what steps were required given the nature of the allegation. Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 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 standard(s) 19 & 26 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: The home has a rolling maintenance programme which highlights minor and major work undertaken. Since the last inspection the kitchen has been re-fitted with new cupboards, tiles and a second oven, the hallway has been painted and a new carpet will be laid when other work has been completed. The hairdressers room has been changed into a residents bedroom. Files showed that risk assessments were available which highlighted risks to residents posed by the homes environment and action to be taken. A tour of the home found that it was clean and no unpleasant odours were detected. One resident showed the inspector her room, which had been personalised with her memorabilia. She stated that the home was always clean and tidy. Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These outcomes were not looked at. EVIDENCE: Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These outcomes were not looked at. EVIDENCE: Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x x Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 Page 17 yes 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. 1. 2. Standard 3 7 Regulation 14(d) 15(2)(c ) Requirement All prospective residents must be written to confirming that the home can meet their needs. The home must ensure that care plans are signed by the resident or their representative confiriming that they agree with the plan of care. The home must record in the residents care plans how they are going to mainatian their privacy and dignity whilst carrying out personal care. Timescale for action 25/10/05 25/10/05 3. 10 12(4)(a) 25/10/05 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. 2. Refer to Standard 8 9 Good Practice Recommendations The home should consider using body maps to record all cuts or bruises to residents. The home should organising the medication sheet file with dividers and photographs or residents on the front cover of the dividers to help ensure no errors are made. Bernadette House C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection 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 C53 CO4 S2324 Bernadette House V240075 190705 Stage 4.doc Version 1.40 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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