Inspection on 31/05/05 for Bhajan Kaur Rai Hall

This inspection was carried out on 31st May 2005.

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

Bhajan Kaur Rai Hall 17/05/07

Bhajan Kaur Rai Hall 10/05/06

Bhajan Kaur Rai Hall 16/08/05

Bhajan Kaur Rai Hall 02/02/05

Bhajan Kaur Rai Hall 15/09/04

Bhajan Kaur Rai Hall 19/03/04

Similar services:

Applegarth

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

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 31 May 2005 09:30 am st 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. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 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 surgit@rushcliffecare.co.uk Rushcliffe Care Limited 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) Vacant Care Home (CRH) 43 Category(ies) of Physical disability over 65 years of age (PD(E)) registration, with number 43 both. Old age, not falling within any other of places category (OP) 43 both. Physical disability (PD) 43 both. Sensory Impairment over 65 years of age (SI(E)) 6 both. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 No person under the age of 55 years may be admitted to the home under catgory PD. 2 To be able to admit the peron of category MD or DE as identified in correspondence with the previous registration authority dated 30/03/01. 3. No one falling within category SI(E) may be admitted to the home where there are 6 persons SI(E) already accommodated within the home. 4. Service Users: No person to be admitted to the home in catagories MD(E) or DE(E) when 12 persons in total of these catagories/combined catagories are already accommodated in the home. Date of last inspection 2nd February 2005 Brief Description of the Service: Bhajan Kaur Rai Hall is one of three units owned by Rushcliffe Care Limited within the Epinal Way Care Centre in Loughborough, Leicestershire, which opened in March 2000. The home is registered for forty-three residents of both sexes, and provides a safe and caring environment. 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. It is bright and clean with a high standard of décor throughout. All rooms have en-suite shower facilities. The home has a 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. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 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, 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 five residents, a resident’s relative and a district nurse gave the inspector their impressions of the home. What the service does well: What has improved since the last inspection? New care plans are being implemented to reduce paperwork but will focus more effectively on residents’ specific health and welfare care needs. Rushcliffe Care Limited are working towards implementing regular, formal clinical supervision in all of their care and nursing homes to ensure that staff are fully competent to meet the needs of the residents. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 6 Rushcliffe Care Limited have applied to the CSCI, and been approved, to provide accommodation for older persons with dementia. Separate, safe facilities and additional staff training have been implemented to ensure that the specific care needs of these residents will be met. 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. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 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 Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 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, 4, 5 & 6. The admission process is well managed and residents and their relatives/representatives are given clear and detailed information regarding the service; thereby ensuring that the residents’ health and welfare needs are being met. EVIDENCE: There is a comprehensive Statement of Purpose & Service Users’ Guide and a signed copy of the Terms and Conditions in residents’ files. The Statement of Purpose & Service Users’ Guide has been updated to reflect the care provided for older people with dementia. The pre-assessment process is detailed and robust and reflective of the health and welfare needs of the residents. Residents and/or their relatives are able to visit the home prior to taking up residence to assess the suitability of the home. Intermediate care is not provided. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 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 & 10. Residents are well looked after in respect of their health and personal care. However, relatives or the resident’s representative could be encouraged to take a more participative role in drawing up and reviewing the resident’s care plan to ensure that residents who are unable to do this for themselves have their individual preferences clarified. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 10 EVIDENCE: The introduction of new care plans is in progress. The new care plans are more focused and specific in identifying and meeting the residents’ particular health and welfare requirements. Healthcare professionals visits and instructions are well documented to ensure that residents’ healthcare needs are met. Medication administration is managed effectively within the home’s robust medication policy and procedural guidelines to ensure the safe and timely delivery of residents’ prescribed medicines. Residents are able to self-medicate, following a recorded assessment, and in accordance with the home’s medication policy, to ensure that they are able to do so effectively and safely. A relative stated, in their Relatives’/Visitors’ Comment Card that they had not been satisfied with the standard of personal hygiene afforded to their relative, and had complained to the home – and some improvements had been made. A relative spoken with on the day of inspection stated that her relative was sometimes given food he did not like. However, the resident said that he enjoyed his meals. Likes and dislikes for this resident had not been recorded. Residents said that they were well cared for and that the staff were polite and respectful. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 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 & 15. The staff work hard to ensure that residents experience a safe, homely life style but attention to detail within the care plans would ensure that all care needs are met. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 12 EVIDENCE: The home provides daily activities, detailed on the notice board, which are arranged by a carer who has dedicated time in the afternoon for this purpose. Visitors came and went throughout the day and the home has a lively, busy atmosphere. Menus are balanced, freshly prepared, are of a good standard and are served in attractive dining rooms. One resident said that the meat was sometimes ‘tough’; and this had been discussed at a residents’ meeting. A manager stated that this had been noted and was being addressed with the chef. A relative said that the soft diet was not always appealing and that her relative was, sometimes, given food he did not like, although the resident said that he enjoyed his food. Other residents said that they enjoyed their meals, particularly breakfast and were very satisfied with the food. It was noted by two relatives, in the Relatives’/Visitors’ Comment Card, and by one of the residents that more walks in the fresh air would be appreciated. One relative said that she felt that there were insufficient activities to ‘stimulate’ the residents. Management are to discuss this with the activities person to ensure that the residents’ preferences are met. It was also noted that information regarding a resident’s self-management of a related medical condition - through diet- was missing from the nutritional care plan. Residents are supported in maintaining their independence as much as possible; risk assessments are completed for residents who are able to go out without assistance. Residents are provided with laminated contact, cards with the home’s details, to enable them to contact the home if they need to and to help them maintain autonomy and independence. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 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, 17 & 18. 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 No Secrets’ publication. Staff are aware of these procedures and receive relevant training. The home’s guidelines require updating to reflect the most recent advice provided by the Department of Health. However, management are aware and have this in hand. Complaints and concerns made to the home are dealt with appropriately. A recent complaint, made by a resident to a carer was reported promptly to senior management and dealt with appropriately, in a timely manner and to the resident’s satisfaction. (Also see Health & Personal Care, standards 7 – 11). Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 14 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, 21, 22, 23, 24, 25 & 26. A comfortable, homely, clean and safe standard of accommodation is provided for the residents. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 15 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. Residents’ rooms are clean and well decorated, and residents are able to bring items of their own furniture and possessions with them to personalise their rooms. There are sufficient toilet, bathing and assisted bathing facilities. Hot water temperatures are checked to ensure they comply with Health and Safety legislation and were satisfactory when checked during the inspection. All areas of the home were cleaned and maintain to a high standard and residents said that they were satisfied with the general care and maintenance of the home. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 16 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, 28, 29 & 30. Staff at the home are well trained and supported. Staffing appears to be ‘thin’ for the numbers and dependency of the residents particularly during the early part of the morning and could, therefore, compromise the care provision for the residents. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 17 EVIDENCE: The Senior Manager and Acting Manager maintain direct responsibility for the home. Staffing levels, at the point of inspection, were low when compared with the Department of Health Residential Forum Guidelines. There are three staff on each day shift, morning and afternoon, (two on night duty) to cover two floors and 31 residents – 10 of whom are highly dependent. The Acting Manager stated that she is, sometimes, included in the numbers and not always suparnumery. A senior manager was reviewing staffing levels on the day of inspection. Staff said that they felt that extra staff were needed, particularly in the morning, to assist residents to get up and have breakfast. Relatives said that they felt staff were capable and caring, and that there were sufficient staff on duty to meet the needs of the residents most of the time, but that there were ‘thin’ times. Extensive ‘in house’ training supports staff in meeting the residents’ health and welfare needs. Two of the care staff hold National Vocational Qualification (NVQ) in Care, Level 2. The recruitment process is robust. Staff recruited, on entry to the UK, from abroad are not PoVA First or Criminal Record Bureau checked when taking up employment but the providers do ensure that all overseas staff have health checks, police checks (from their country of origin) and Work Permits (UK). Staff are then CRB checked before the end of their first twelve month period of employment. Current advice from the CSCI is that all staff should have a PoVA First & CRB check, when appointed, regardless of status. For further information contact www.crb.gov.uk or T. 08709090811. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 18 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) 31, 32, 33, 34, 35, 36, 37 & 38. The acting manager, who is applying for Registered Manager status, manages the home effectively and ensures that the residents’ rights are protected. Staff are well organised to ensure that the quality of care is maintained. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 19 EVIDENCE: There is no Registered Manager at present but the acting manager stated that she is applying for Registered Manager status. She is currently undertaking NVQ Level 3 and will be applying to undertake the Registered Managers Award. Good interaction between staff and residents ensures that there is an ethos of openness in the home. Staff support the residents to make decisions in their everyday life, which promote independence. Residents’ personal allowances are managed and recorded appropriately. Records demonstrate that staff receive annual appraisals but do not currently receive regular, formal supervision. However, as discussed with the acting manager, the home is in the process of introducing supervision (a regular review of staff performance and training needs) to ensure that staff maintain the standards of care expected throughout Rushcliffe Care Limited. Health and Safety Policy and Procedures, such as regular recorded fire drills and fire alarm tests are completed, to ensure the health and safety of the residents and staff. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 20 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 4 3 4 3 3 4 4 4 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 2 3 3 Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 21 NO 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 7 (6) Regulation 15 (1) Requirement The Registered Person is required to ensure that residents care plans are drawn up with the involvement of the residents or their representative Timescale for action 30/06/05 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. Refer to Standard 7.6 & 14. 1 8.9 18.2 27.1 29.3 Good Practice Recommendations The Registered Providers are recommended to involve residents and/or their representatives in drawing up care plans to ensure that they fully reflect the needs, likes and dislikes of the resident. The Registered Providers are recommended to ensure that where residents are not weighed, as per care plan, the reason why this is not done is recorded. The Registered Providers are recommended to update the No Secrets documentation to ensure that staff are fully aware of current practice. The Registered Providers are strongly recommended to revisit staffing levels to ensure that residents care needs are fully met. The Registered Providers are recommended to CRB check all employees at the point of employment. C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 22 2. 3. 4. 5. Bhajan Kaur Rai Hall 6. 7. 36.3 The Registered Providers are recommended to experdite the implementation of clinical supervision. Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection The Pavilions 5 Smith Way Grove Park, Enderby, Leicestershire LE19 1SX 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 Bhajan Kaur Rai Hall C51 C01 S1655 Bhajan Kaur Rai Hall V226792 310505 Stage 4.doc Version 1.30 Page 24 - 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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