CARE HOMES FOR OLDER PEOPLE
Bhajan Kaur Rai Hall Epinal Way Care Centre Hospital Way Loughborough Leicestershire LE11 3GD Lead Inspector
Mrs C A Burgess Unannounced Inspection 10th May 2006 10:00 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 Bhajan Kaur Rai Hall DS0000001655.V293885.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. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Bhajan Kaur Rai Hall Address Epinal Way Care Centre Hospital Way Loughborough Leicestershire LE11 3GD 01509 216616 01509 262710 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) Rushcliffe Care Limited Mrs Karen Joy Wragg Care Home 43 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (12), Old age, not falling within any other category (43), Physical disability (43), Physical disability over 65 years of age (43), Sensory Impairment over 65 years of age (6) Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. No person under the age of 55 years may be admitted into the home under category PD. No one falling within category SI (E) may be admitted into the home where there are 6 persons of category SI (E) already accommodated within the home. Service Users: No person to be admitted to the home in categories MD(E) or DE(E) when 12 persons in total of these categories/combined categories are already accommodated in the home. 16th August 2005 Date of last inspection Brief Description of the Service: It is purpose built with all the necessary adaptations to support the specific needs of the residents. The home is situated on two floors with a lift servicing the first floor, and is fully accessible to wheelchair users. The first floor is seperated into two zones - one being a safe environment for residents with dementia. It has a high standard of décor throughout. All rooms have en-suite shower facilities. The home has spacious dining rooms, and comfortable and well-appointed sitting rooms with televisions, videos and books on both floors. There is an on site laundry and industrial kitchen which services all three units. Situated adjacent to the Loughborough Hospital, and approximately one mile from the centre of Loughborough, it is accessible by public transport or car. There is ample parking for visitors. The Statement of Purpose, Service Users’ Guide & Inpection Report are available on request. The Statement of Purpose, Service Users’ Guide are provided for all new residents. At the time of the site visit the Registered Manager stated that weekly fees were: £319 - £500. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over one day. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive through review of their records, discussion with them (where possible), and the care staff and observation of care practices. An opportunity was taken to look around the home, view records, policies and care plans and to talk to staff and residents. Many of the residents were seen during the inspection and four residents gave the Inspector their impressions of the home. What the service does well: What has improved since the last inspection?
Since the previous inspection in August 2005 the Registered Manager has worked hard and has addressed the requirements and recommendations which were made and there have been significant improvements in all aspects of management and care for which the Registered Manager should be commended. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 6 BKR Hall provides a well-managed, safe and supportive environment for the residents. The home has many adaptations to assist with care and to help residents achieve their optimum independence, and exercise personal choice within their capacity to do so. Assessments, care planning and risk assessment are good to ensure that the residents’ health and welfare needs are met. The Registered Manager has introduced entertainment every Wednesday evening in the lounge such as a film evening, bingo, or pub night. This has recently been introduced by the Registered Manager and is proving to be popular with both residents and staff. The home also has a new television DVD/video player and a karaoke machine. The home is in the process of providing access to a safe area outside, accessible to wheelchair users, and with the help of the residents, is planning to plant tubs of flowers to make it into a pleasant garden. Staff relationships with specific relatives has improved (sharing information on an individual basis) demonstrating an understanding of relatives concerns and feelings, whilst supporting residents to make choices regarding their preferred lifestyle. Staff now undergo regular supervision to ensure that they are equipped to provide the best care for the residents. What they could do better:
There were no requirements made and only one recommendation following this inspection: Although the Registered Manager stated that regular fire drills had been undertaken it was noted that the last recorded fire drill was in February 2005. The Registered Manager stated that they had been done (the last one only about a week ago), but that it had not been recorded on the form provided. Fire drills should be formally recorded and followed up as necessary to ensure the safety of residents and staff. NB. A copy of the most recent satisfactory fire drill, dated 22nd April 2006, was provided to the CSCI prior to publication of the final report. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 7 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. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 8 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 Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 9 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 & 6. Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process is well managed to ensure that the residents’ health and welfare needs are fully met. EVIDENCE: The assessment process is sound. Three residents were case tracked. One resident had been living in the home for five years and the pre-assessment documentation had been archived. A second resident had been admitted for emergency respite and therefore had not had a pre-admission assessment but subsequent care plans and risk assessments were satisfactory. The third resident had a comprehensive pre-admission assessment to ensure that their health and welfare needs prior to admission were identified. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 10 Following admission the home undertakes a 72-hour assessment to fully evaluate the resident’s needs. From this a detailed care plan and risk assessments are produced to ensure that resident’s needs are fully met. BKR Hall does not provide intermediate care. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 11 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. Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well looked after in respect of their health to ensure that resident’s health and personal care is fully met. EVIDENCE: Residents are well looked after in respect of their health and personal care. Care plans and risk assessments were detailed and reflective of resident’s specific healthcare needs. Care plans had been regularly reviewed, updated and signed by the resident or the resident’s relatives/representatives, to demonstrate agreement with the care plan. Healthcare professionals visits i.e. GP, District Nurse, Podiatrist, Nutritionist etc were recorded with outcomes and changes required to the residents care. Residents said that they were consulted about their specific healthcare needs and staff were prompt in calling the GP if they felt unwell. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 12 Medication policies, procedures and medication training for staff are sound and ensure that residents receive medication in a safe and timely manner. Observation during the inspection showed that staff have a good awareness of how to protect residents privacy and dignity. They were seen to be kind, and patient, and treated the residents in a respectful, friendly and supportive manner. Three residents spoken with said that staff were respectful, patient, very caring and kind. One resident was particularly complementary about the supportive care, respect and consideration by the staff towards the residents. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 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. Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff work hard to ensure that residents experience a safe and homely life style. EVIDENCE: The home has a routine, which includes specific meal times and activity timetables. Most (if not all) residents have their own television. Residents are encouraged to socialise in the lounge and join in with any activities but individual preferences to spend quiet time in their own room is respected. Entertainment is arranged every Wednesday evening in the lounge such as a film evening, bingo, or pub night. This has recently been introduced by the Registered Manager and is proving to be popular with both residents and staff. There are celebrations throughout the year at Christmas, Valentines Day, and Easter etc and residents’ birthdays are celebrated. This enables residents and their relatives to enjoy seasonal and community activities. The Registered Manager said that she hoped to have an activities organiser in the near future. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 14 Residents’ religious and cultural needs are discussed, recorded and supported such as special dietary requirements and specific religious days or festivals to be celebrated, and the priest visits Roman Catholic residents about every two weeks. One resident had very specific religious requirements, which the Registered Manager had sensitively addressed to ensure these were met without isolating the resident. Menus are balanced and appealing with choices at each mealtime, and are flexible enough to accommodate individual needs and preferences. They are freshly prepared and are of a good standard. Lunch looked appetising and well presented and three residents said that the meals were usually good. One resident said that staff always ask what her preference were and that the chef would provide her with something else if she did not like what was on the menu. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 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. Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for receiving and responding to complaints are sound. EVIDENCE: The home’s complaints process reflects the government’s adult protection guidelines, set out in the local Multi Agency Policy & Procedure For The Protection of Vulnerable Adults from Abuse, No Secrets’ publication, 2004. Staff are aware of these procedures and receive relevant training. Complaints and concerns made to the home are dealt with appropriately. The home has received one complaint since the previous inspection that was satisfactorily resolved. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 16 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. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, homely, clean and safe standard of accommodation for the residents. EVIDENCE: The home is safe and well maintained with many adaptations to suit residents’ specific needs. It is decorated and furnished to a high standard that creates a comfortable and homely environment, and there is a system of maintenance and refurbishment. On the day of the site visit the home was clean, pleasant and hygienic throughout.
Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 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 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. Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff at the home are well trained and caring and staffing was sufficient for the numbers and dependency of the residents at the time of the site visit. EVIDENCE: Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 18 At the time of the site visit there were 35 residents. Staffing levels were in accordance with those suggested by the Department of Health Residential Forum Guidelines and appeared to be sufficient to meet the residents’ needs. There are four care staff on duty throughout the day and the Registered Manager who is supernumerary, and three care staff at night. In addition there are domestic staff, catering and caretaking staff. A Senior Manager is always available. However, it was noted by a member of staff and two residents that, staffing was ‘thin’ in the morning and evening when residents required assistance getting up and dressed and again in the evening when residents required assistance going to bed, and on occasions around lunchtime when residents required help getting to and from the dining room; particularly as there are two floors and three zones, one of which is separate and cares for people with dementia. It was noted that the Registered Manager has posted notices to advise visitors to press call bells should they require staff as staff may be busy assisting residents and therefore not noticeably visible at all times. Training for staff and extensive ‘in house’ training supports staff in meeting the residents’ health and welfare needs. Rushcliffe Care Limited, Epinal Way Care Centre undertakes the recruitment process centrally and this appears to be robust. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 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 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. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Registered Manager manages the home well and ensures that the residents’ rights are protected. EVIDENCE: The Registered Manager has many years of experience in care and manages the home well for the benefit of the residents and their relatives and the staff. There is an ethos of openness in the home that demonstrates an inclusive, open and constructive management style, which is well supported by senior management.
Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 20 Residents’ personal allowances are appropriately managed and recorded to ensure that residents’ financial interests are safeguarded. Staff receive annual appraisals and the Registered Manager stated that she has commenced regular staff supervision - all staff having received one or two supervision session this year. All new care staff receive a comprehensive induction with additional mandatory, specific ‘in house’, and well supported National Vocational Qualification (NVQ) in Care training and support to ensure that staff maintain the standard of care expected throughout Rushcliffe Care Limited. Health and Safety Policy and Procedures, such as regular recorded fire alarm tests and fire drills are completed to ensure the health and safety of the residents and staff. It was noted that the last recorded fire drill was in February 2005. However, a copy of the most recent satisfactory fire drill, dated 22nd April 2006, was provided to the CSCI prior to publication of the final report. Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 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 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bhajan Kaur Rai Hall DS0000001655.V293885.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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