Inspection on 03/01/06 for Bernadette House

This inspection was carried out on 3rd January 2006.

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 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 10/07/06

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 Unannounced Inspection 3rd January 2006 10:20 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.V275341.R01.S.doc Version 5.1 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.V275341.R01.S.doc Version 5.1 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), Learning disability (1), Old age, registration, with number not falling within any other category (23) of places Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 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 registered 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 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. Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. The main method of inspection used was called case tracking, which involved looking at policies and procedures relating to maintaining the safety and general welfare of residents. Two residents were spoken to as well as a visitor and a visiting community nurse, the manager and care staff and observations were made of care practices. A partial tour of the home took place. What the service does well: What has improved since the last inspection? What they could do better: 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. There is no evidence that reviews are undertaken with a record made of who attended and what decisions were made regarding a residents ongoing plan of care. The home does not have a form for recording monthly or annual reviews of residents care. Accidents to Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 Page 6 residents are not recording appropriately as per the homes policies and procedures. 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.V275341.R01.S.doc Version 5.1 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.V275341.R01.S.doc Version 5.1 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 The home undertakes a full care needs assessment of residents prior to admission. The home writes to prospective residents confirming 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 she had visited the home prior to her mothers admission. The homes template for letters to be sent to residents was seen which confirms whether the home can meet their needs or not. One senior care worker knew about the care needs of residents and explained that the seniors or manager undertake admission assessments, which is an ongoing process once the resident is admitted to the home. Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 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 & 10 The home does not record the outcomes of monthly or annual reviews. Residents care plans do not show how their dignity and privacy are to be maintained. The home does not follow its own procedures in the recording of accidents to residents. The administration of medication is undertaken as per the homes policies and procedures. 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 and yearly basis. However, there was no evidence that a recording is made of any review being undertaken or changes to residents care plans from their reviews. The home does not have a review form to record monthly or annual reviews. Two files seen showed that care plans had been signed by residents or their representative. One visitor said that she has seen her relatives care plan and was aware of its contents. Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 Page 10 Individual care plans and the homes accident book did not evidenced that the homes policies and procedures are always followed in relation to the recording of bruises or abrasions to residents through accidents. Two accident forms were checked through the homes accident procedures and it was found that a fall had been recorded in the night book but not in the residents daily contact sheet or on the body map. 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 maintained. Care plans need to be more prescriptive regarding information to carers about maintaining individual residents privacy. A visitor said that she felt that her relative was well looked after. The visiting community nurse stated ‘that residents are very well looked after and that the home has a very nice atmosphere’. At the last visit on 09/12/05 the pharmacist report showed that administration records were good and storage and stock control was good. 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 has also 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 DS0000002324.V275341.R01.S.doc Version 5.1 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 The home provides a programme of social and leisure activities. Relatives and friends of residents are made welcome in this home. EVIDENCE: The home has an activities worker who works sixteen hours per week split between two days. Visitors seen said that they had seen activities taking place in the homes on a regular basis when they visit. One visitor commented that her mother does not like to join in activities and is allowed to stay in her own room if she so wishes. It was noted that the hairdresser had visited the home on the day of the inspection and was busy with a number of residents. The homes newsletter was seen which included diary dates for the visit of a clothing company, keyboard entertainments and a visiting hospital band. Christmas activities were also undertaken with a local school picking up residents (12) to take them to their school for entertainments and refreshments. A touring pantomime visited the home as well as a church choir. 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 she visits and refreshment is always offered. Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 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): The key outcomes were assessed at the last inspection. EVIDENCE: Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 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): The home is clean and free of unpleasant odours. EVIDENCE: A tour of the home found that it was clean with a pleasant odour throughout. Two residents showed the inspector their rooms, which had been personalised with their memorabilia. They stated that the home was always clean and tidy. Two visitors also commented that the home always smells fresh. Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 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 & 30 Recruitment practices need to be more robust to protect residents. Residents benefit from a staff team who are well trained and work well together and compliment each others skills. EVIDENCE: Two personnel files were seen and contained CRB checks (Criminal Record Bureau), references, current photographs, identification and contracts. However, the home does not record interviews for those prospective carers who apply for posts at this home. All care workers have been given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. The homes training record was seen which showed that, six care workers had NVQ (National Vocational Qualifications) level 2, six have NVQ level 3 with two workers nearly completing level 2. Two workers started NVQ level 2 training in November 05. The manager is awaiting confirmation for her completion NVQ level 4 in care and has completed the registered managers award. Statutory training such as fire training, moving and handling and first aid are undertaken at this home. Other training undertaken included; administration of medication, food hygiene, adult protection, working in care and TOPPS induction training for all new staff. Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 Page 15 Comments received by the community nurse were ‘ I am not aware of a high turnover of care staff at this home’ and ‘very impressed with the home it’s a lovely place and they work as a team’. The duty rota showed that adequate staff numbers are on duty to meet the needs of residents in this home. There are two waking night staff, with a senior who can be contacted if required. A visitor stated that she felt ‘that there are enough staff on duty and has not seen anybody not attended to’. Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 Page 16 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): 38 Appropriate checks are not carried out to ensure the safety of residents. EVIDENCE: There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was also evidence 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. Certificates were available showing that bath hoists and wheelchairs had been serviced/cleaned. All wheelchairs seen on the day of the inspection had footplates, which were in use. Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 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 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x 3 Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 Page 18 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 Standard OP7 Regulation 15(2) Requirement The home must undertake monthly and annual reviews and record the outcome and how this will affect the residents plan of care. The home must record all accidents to residents as per the homes policies and procedures. The home must record in the residents care plans how they are going to maintain their privacy and dignity whilst carrying out personal care. (Timescale of 25/10/05 not met). The home must ensure that interview notes are made and kept of those care staff applying for a post at this home to help ensure the safety of residents. Timescale for action 25/02/06 2. 3. OP8 OP10 12 12(4)(a) 25/02/06 25/02/06 4 OP29 19 25/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 Page 19 No. Refer to Standard Good Practice Recommendations Bernadette House DS0000002324.V275341.R01.S.doc Version 5.1 Page 20 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.V275341.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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