Inspection on 03/06/05 for Bevan House

This inspection was carried out on 3rd June 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

Bevan House 21/08/07

Bevan House 25/07/06

Bevan House 28/10/05

Bevan House 19/10/04

Bevan House 26/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Bevan House Stackwood Avenue Barrow in Furness Cumbria LA13 9HQ Lead Inspector Marian Whittam Unannounced 03 June 2005 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. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bevan House Address Stackwood Avenue Barrow in Furness Cumbria LA13 9HQ 01229 894547 01229 894550 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) Cumbria Care Susan Balderstone Care Home 40 Category(ies) of DE(E) - Dementia, over 65 registration, with number OP - Old Age of places Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service must at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission 2. A maximum of forty older people (OP40) may be accommodated nine of whom may have dementia (DE(E)9). 3. The staffing levels in the home must meet the Residential Forum Care Staffing Formula for Older Adults. 4. When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available.. Date of last inspection 19 October 2004 Brief Description of the Service: Bevan House is a care home registered to care for 40 older people, 9 of whom may have dementia. The home is in a residential area of Barrow in Furness, close to a local bus route into Barrow, and to surrounding areas. The home has a car park to the rear of the building and there are lawn and patio areas for service users to use. All of the home’s 40 bedrooms are single rooms and the home is divided into five units for residents. On the first floor are Langdale, Abbey and Furness units and on the ground floor are Piel and Ramsden units. Piel cares for up to 9 people with dementia and Ramsden offers respite care for up to 6 people. Each unit has a non- smoking lounge and dining area with a small kitchen attached, a bathroom and 2 separate toilets. The home has a main kitchen, sluice facilities, a laundry, two staff rooms, a hairdressing room, day centre room and bathroom and a large room used for meetings and training purposes. The home has a large lounge for communal activities. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over 5 hours; the inspector looked at a number of records, care plans and medication records, looked around the home and spoke with 14 residents, 4 staff members and 1 visiting District Nurse. What the service does well: What has improved since the last inspection? Facilities for residents who smoke have been improved since the last inspection and it is planned to improve this further for residents. Improvements have been made to furnishings in resident’s bedrooms and in the communal lounges and residents were pleased with these. Formal staff supervision has been done more regularly and is better planned than previously. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 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. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 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 Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 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) 1,2,3 and 5 Information on services for prospective residents and trial visits are offered, so people can make an informed choice about coming to the home. Assessments had been done prior to residents coming into the home so residents could be confident that their assessed needs would be met. EVIDENCE: The home has a statement of purpose and service user guide for residents and families and the terms and conditions of residency that make it clear what services the home is offering to residents. Assessments done before and at admission were used to plan care on admission and particular needs were being catered for. Some were very detailed and gave a clear picture of what someone would need. Where needed other agencies or health care professionals were included in looking at needs. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 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 and 10 The health and personal care needs of residents were being identified in individual care plans and were being met for residents. However care plan reviews had not always been done to make sure staff knew that resident’s changing needs. Medication records needed some improvement to make sure that residents were not at risk. Care was being given in a way that respected resident’s privacy and dignity. EVIDENCE: Care plans are in place for all residents and gave a good indication of what individual needs were and their personal preferences. There were some plans that had not been reviewed for some time and one had unfinished sections. Discussions with staff and residents and observation of practices suggested that although some reviews had not been done staff were aware of needs because of their familiarity and knowledge of particular residents or because changes had been gradual. Residents spoken with felt their needs were being met. This approach depends on individual staff passing on information to Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 10 colleagues. Residents are at risk of changes being missed if this informal system breaks down and reviews must always be done to provide clear guidance for all staff. Healthcare needs were being identified and met with a good working relationship with local doctors, nurses and other agencies. A visiting district nurse commented positively on the homes early involvement of nursing services for pressure area care and continence needs of residents. Medication systems needed to be improved to make sure all medications administered were recorded such as the application of prescribed creams and lotions. The designated refrigerator for medications is not working and medications needing cold storage are being kept in the domestic refrigerators on the units and this practice must stop. Residents spoken with felt they were treated with respect and their privacy and dignity maintained. Good practice was observed in maintaining personal dignity during a moving and handling procedure using hoists. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 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) 12,13, 14 and 15. The home provides limited regular social activities but staff supported residents well in individual activities, in making choices in their daily lives and to maintain outside contacts. Food in the home offered variety and choice and catered for special dietary needs. EVIDENCE: The home provided some daily activities, recorded resident’s hobbies and interests and organised social and religious events. Residents said that they could come and go as they pleased and see who they wanted to. No one person has responsibility for coordinating activities with resident’s wishes and capabilities. Instead staff on each unit took on this role in addition to their other duties. Carers were helping residents with group activities, playing dominoes and doing a quiz on one unit and residents said they enjoyed these and looked forward to them. Residents enjoyed the evening bingo sessions. Residents spoken with made positive comments about the food in the home and those spoken with felt the food was “good” and “very good” and a vegetarian resident felt she was well catered for and had a “very good diet”. All agreed there was a choice of food each day and that there was plenty to eat Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 12 and drink. The menus provided showed a nutritious diet with fish, meat and vegetables, milk and cheese dishes and fresh fruit were available. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 13 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 and 18. The home has a satisfactory complaints system that was displayed in the home. Residents felt confident that the manager would listen to them and act to deal with their concerns. Staff were aware of Adult Protection processes, the procedures in place and had received training and information on this to safeguard residents from abuse. EVIDENCE: The home has a complaints procedure and logged formal complaints for investigation and the procedure was available to residents. Residents spoken to were confident that the manager would deal with any complaints they made. Advocacy services were available to residents and the home had information on this if they wanted someone to act on their behalf. Since the last inspection there had been one complaint made regarding personal and health care, privacy and dignity and staffing that was investigated by the CSCI and upheld. There were satisfactory procedures in place to protect vulnerable adults and for whistle blowing including multi agency guidance and these were easily available for staff in the home. Staff spoken with were clear what they would do if they suspected abuse and had received training on adult protection and dealing with aggression to promote residents safety and well being. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 14 The home did not deal with any resident’s personal finances only small amounts of spending money. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 15 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) 19,20,22,24 and 26. The standard of décor in the home was satisfactory overall with evidence of recent improvements and more planned. The home provided a clean, homely and adequately maintained environment for residents to live and had the equipment they need to promote mobility and independence. EVIDENCE: Some rooms in the home had been redecorated and new bedroom furniture, armchairs, dining tables and commodes had been provided for residents, improving their environment and comfort and the homely appearance of communal areas. The dining and lounge areas on the units were seen being used for activities and residents said they enjoyed being able to mix socially on the units. Residents were pleased with the improvements that had been made in their home. Further changes were planned to provide a separate room for smokers to further improve shared facilities for all residents. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 16 Resident’s bedrooms seen by the inspector had satisfactory standard of décor and many had new furnishings. Many rooms had residents own possessions and this made them more personal and homely for residents living there. The home was clean and tidy. There is a range of equipment and adaptations in the home to help residents make the most of their independence and to get about the home. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 17 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) 27, 29 and 30. The deployment and number of staff available on some shifts on the rota has not always been sufficient to safely meet the needs of the residents. There are shifts when a minimum level of staff has not been maintained and this has a potentially detrimental impact on providing a consistent and safe standard of care for residents. The procedures for the recruitment of staff are satisfactory and offer protection to people living in the home. Staff training was established in the home and induction and foundation training provided to promote a competent staff group to care for residents. EVIDENCE: There had been a lot of staff sickness over the last year and there has not always been full permanent senior team in place. The home had recruited new staff and was trying to recruit more. However, shifts could be identified when staff levels had been inadequate. The supervisors have to work as carers at times to cover staff shortages, which can lead to staff not being properly supervised and supported whilst on duty. If resident’s needs are to be properly and safely met then there must always be sufficient numbers of staff on duty with appropriate skills and experience to fulfil their roles. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 18 The home had satisfactory recruitment procedures in place and the inspector looked at the files. The home had followed procedure and undertaken the necessary checks for staff to protect residents. The home had individual training records for staff and was making good progress on developing these. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 19 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) 33,36 and 38 The home reviews aspects of its performance through reviews and quality surveys, however regular resident feedback and consultation would improve their involvement in the way the service is delivered. Although there are policies and procedures in place to protect residents, there are practices within the home that do not promote resident’s health and safety. EVIDENCE: Formal staff supervision was being done although not consistently. Regular staff meetings allowed staff feedback, along with internal reviews of policies and procedures. Residents said that they saw the manager most days and felt happy to raise issues with her. However regular residents meeting in the home had not been taking place and these must re start to ensure that resident’s views and opinions are formally sought and acted upon to affect the way the service is run. The satisfaction surveys the home does should be published and made available for people to see. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 20 Although there are health and safety procedures in place there was no evidence that Legionella and water temperature testing had been done for some months. During the visit old furniture from residents rooms was on the patio blocking a fire exit and general access onto the patio. This would seriously compromise any evacuation of frail and vulnerable residents. Residents could not use the door to get out onto the patio restricting their use of the outdoor space and it posed a fire hazard from the combustible material. An immediate requirement notice was issued to have all the furniture removed and ensure the fire exit was not blocked. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 21 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 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 x 3 x 3 STAFFING Standard No Score 27 2 28 x 29 3 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 2 x x 2 x 2 Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 22 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. 3. Standard OP7 OP9 OP9 Regulation 15 (2) 13 (2) 13 (2) Requirement The residents care plans must be kept under review to reflect changing needs. Prescribed creams and lotions must be recorded following administration. A separate, secure and dedicated refrigerator must be provided for the storage of medicines requiring cold storage. There must at all times be sufficient care and supervisory staff on duty as are appropriate for the health and welfare of residents. Regular residents meeting must be held to allow residents views and opinions to be put forward. Water temperature and Legionella testing must be done regularly and records kept. Items blocking the fire exit and posing a hazard must be removed. Timescale for action 30.6.05 30.6.05 15.7.05 4. OP27 18 (1) 30.6.05 5. 6. 7. OP33 OP38 OP38 24 (1) (3) 13 (3) (4) 13 (4) 30.6.05 30.6.05 9.6.05 Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 23 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 OP33 OP36 Good Practice Recommendations The results of satisfaction surveys should be published for residents and visitors to see. All care staff should be given regular supervision. Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith, Cumbria CA11 9BP 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 Bevan House F58 F10 s35555 bevan house v226905 030605 ui stage 4.doc Version 1.30 Page 25 - 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. 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