Inspection on 10/07/07 for Bierley Court

This inspection was carried out on 10th July 2007.

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

Bierley Court 16/06/08

Bierley Court 15/08/06

Bierley Court 28/10/05

Bierley Court 06/05/05

Bierley Court 03/11/04

Bierley Court 03/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Bierley Court 49 Bierley Lane Dudley Hill Bradford BD4 6AD Lead Inspector Karen Westhead Key Unannounced Inspection 10th July 2007 09:00 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 Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 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. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bierley Court Address 49 Bierley Lane Dudley Hill Bradford BD4 6AD 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) 01274 680300 01274 680303 bierleycourt@schealthcare.co.uk Southern Cross Healthcare (Kent) Ltd Care Home 40 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (5), of places Physical disability over 65 years of age (25) Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 2006 Brief Description of the Service: Bierley Court is a purpose built care home. It is owned and run by Southern Cross Health Care Ltd. It is a care home, which does not provide nursing care and has room to care for up to forty older people. Within the total of forty, the home is registered to look after twenty five people who have a physical disability and ten who may have dementia or other memory loss disorder. The home is in a residential area in the Bierley district of Bradford. There is a good bus route nearby which runs into Bradford town centre. The bus stop is immediately outside the home. The home has forty single bedrooms which all have an ensuite. A married couple, who wish to share, use one room as their bedroom and the second bedroom as a sitting room. All rooms are furnished but residents can bring their own furniture and equipment if they want to. This can help them feel at home and go some way to keeping their independence. There are communal areas, which are comfortable and provide a venue for social activities to take place and for residents to meet. There is a passenger lift to the first floor. Smoking is allowed in a designated lounge by residents only. Bierley Court is well maintained throughout and there is a routine programme of refurbishment. There are safe and accessible garden areas with seating and there is ample car parking for staff and visitors. Access for the disabled is good. The fee charged is between £329 and £420 per week. This information was provided during the inspection. Residents are charged extra for hairdressing, newspapers, private chiropody treatments and some toiletries. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was done by one inspector and had not been prearranged with the Manager. The inspector arrived at 9.00am and left at 4pm. At the end of the visit the manager was told how well the home was being run and what was needed to make sure the home meets the standards. The reason for the visit was to make sure the home was being run for the benefit and well being of the residents and in line with requirements. The home was last inspected on 15th August 2006. Before the inspection information received about the home was reviewed. This included looking at a completed questionnaire from the home, the number of reported incidents and accidents, the action plan provided following the last inspection and reports from other agencies such as the fire safety officer’s report. This information was used to plan the inspection visit. The home gave the Commission for Social Care Inspection (CSCI) information about residents living in the home and some of their relatives and doctors were then asked by CSCI for their views. At the time of writing this report three replies had been received. In addition to this CSCI questionnaires and post-paid envelopes were handed out during the visit and some were left for residents and visitors to complete. Visitors and residents were spoken to during the visit. All of the views expressed are included in this report. A number of records were looked at which covered all aspects of the home and the care provided. All communal areas of the home were seen and some of the residents bedrooms. Most of the day was spent talking to residents, visitors, staff and the manager, to find out what it is like to live and work at Bierley Court. What the service does well: The home is well managed by a competent manager who is supported by a skilled group of staff. Residents, relatives and visitors spoke highly of the home; ‘it is the best place for my mum, she is very well cared for’, one relative said. Paperwork is comprehensive and therefore staff know what they need to do to meet residents needs. Southern Cross Healthcare is always looking at their recording systems and paperwork to find ways to improve them and make sure they are understood by the staff using them. Information available to residents is also reviewed on a regular basis. For example the complaints procedure has been reproduced in Braille and recorded onto tape to make sure Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 6 it is available to resident who may not be able to read the standard version. The Statement of Purpose is also on audio tape. The Plans of care for residents are user friendly and detailed enough to give an accurate picture of the care provided and what needs to be done to make sure the needs of each resident are met. The residents, their families and friends are actively encouraged to share their views about the home and how it should be run. This is one way staff can be sure the home is being run in a way which benefits those living there. Health and personal needs of each resident are fully met. Staff are given support and guidance by other health care professionals, including district nurses, the mental health team and social services. Staff know their own limitations and when to ask for additional support and advise. For example, the home does not provide nursing care, but this does not mean residents, who develop an illness or condition, cannot still live in the home. If there is agreement with the resident’s doctor and the home can continue to provide care with nursing support from other agencies then this is done. Health and safety is seen as important and risk assessments have been completed to make sure the home is fit for purpose and safe. The layout of the home means all residents have their own bedroom. They can furnish this themselves. Those residents, who were able to share their view, said they were glad they could bring their own things with them. This is limited due to the amount of space available but such things as a bed, armchair, sideboard or occasional table had for some become a cherished item of furniture. Those rooms seen were highly personalised and residents said the maintenance man had helped to put pictures and shelves up. Residents are given ample opportunities to be involved in activities in the home. The home employs an activity organiser. Residents and relatives said this was an important aspect of the care provided at Bierley Court. There is a structured programme including ‘discussion groups’ which look at every day events in the news and local papers. Residents and their relatives have the chance to be involved in the writing of plans of care and are invited to reviews when the care provided is looked at. What has improved since the last inspection? A new manager has been appointed since the last inspection and is making a positive impact on the home and the quality of life for residents. The six requirements from the last inspection have been addressed by extra staff training; new floor coverings; improvements to cleanliness in the kitchen and employment checks have been done to make sure those staff working in the home are suitable to work with vulnerable people. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 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 Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 (Standard 6 - N/A, the home does not provide intermediate care) People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Residents have enough information about the home to decide if it will meet their needs. EVIDENCE: Seven residents told the inspector that they had been helped by their relatives or Social Services to move into Bierley Court because they couldn’t look after themselves at home. Five said they had visited the home before deciding to move in and felt the information available to them had been helpful. Two residents could not remember if they had but said their relative might have done that on their behalf. The home does not usually accept emergency admissions and has in fact got a waiting list in place. When a vacancy arises the room is allocated and taken up very quickly. All of the residents and relatives who filled out a questionnaire said that they had received enough information about the home and that a contract is provided on admission. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 10 Six plans of care were looked at in detail. These included the most recently admitted person, a resident with poor mobility, a resident who is being looked after in their bedroom and a resident who has high dependency needs. The inspector was told by staff that the format of the files worked well. All of the files seen included a pre admission assessment. Assessments are carried out by the manager or a senior member of staff. Residents are visited in their own home. This means the manager can get a good idea about the type of care needed. The prospective resident can also ask questions about the home and what moving in will mean to them. A judgement is then made about whether the home can provide the care needed. The admissions process gives prospective residents the opportunity to spend time in the home before moving in. On admission, where possible, an individual member of staff is allocated to give the resident information, special attention, help them to feel welcome and comfortable in their surroundings and ask any further questions. During the morning of the inspection a new resident was admitted. The residents arrival was expected and planned for. The allocated member of staff was available to welcome the resident and her family. She dealt with the resident and family in a calm and organised way. The resident was told exactly what to expect and was reassured. This was an example of good practice. The plans of care were looked at and cross-referenced with other records, including accident forms, medication sheets, risk assessments and daily diary sheets (which record what the resident has done during the day and night.) All residents receive a contract of terms and conditions on admission. The contract is clear and easy to understand. The Statement of Purpose and Service User Guide provides enough information for residents and their relatives about the home and what they can expect. Staff said they had read through the information with those residents who have sensory impairment or needed help with documentation. Residents also told the inspector this had happened. The information is also available on audio tape. All bedrooms are single. This means residents can have privacy whilst being attended to, by staff, in their own bedrooms and can have time alone if they choose, without being disturbed. Some residents spoke to the inspector in their bedrooms and shared their experiences about moving in to Bierley Court and what they thought about the care provided. They all said they were well looked after. One resident said ‘I feel well cared for and special. We aren’t forgotten because we are old’. The staff team are qualified and experienced to work with the resident group. Staff understand the cultural and diverse expectations of the residents and work within these. Residents have access to the advocacy service. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Health, personal and social care needs are met. The principles of respect, dignity and privacy are put into practice. However, practices around medication need improving. EVIDENCE: Residents at Bierley Court receive a good level of support with their personal and healthcare needs. Care is given in a way which is ‘person centred’. The Statement of Purpose and Service User Guide explain the type of care the home offers. The staff team are skilled and knowledgeable about the needs of the residents and deliver care in a professional, caring and competent way. Plans of care show the personal and healthcare needs of each resident and how staff will meet these. Staff work in partnership with other professionals to make sure residents are receiving the best possible care. For example, district nurses visit residents to carry out routine dressing changes and social workers Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 12 call into the home to review the care being provided to residents. The management of pressure sores is good. Residents who are at risk of developing pressure sores are identified early so that specialist mattresses and cushions can be used to prevent them developing. Residents who are showing signs of developing a pressure sore are referred to the district nurse immediately and appropriate action is taken. At the time of the visit one resident was receiving treatment from district nurses. There are fixed hoists in two of the four bathrooms, these are seats which lift residents in and out of the bath. This can encourage residents to retain their independence and at the same time make sure they are comfortably helped in and out of the bath without staff having to lift them manually. Staff have received training in the use of the equipment. Two of the four bathrooms are not used, as there is only a step in bath, which residents find hard to use. Despite this, residents spoken to said they were able to have a bath when they wanted. Residents also have access to a shower room, which is not used often. At the time of the visit the manager was waiting for a new seal to be fitted to the bottom of the shower door as it was leaking. Residents who have moved in from the area keep their own doctor. Others are automatically registered with one of the three local surgeries. There is a team of district nurses who know the residents and the residents trust. Regular reviews and health appointments are seen as important and systems are in place to make sure these happen, including optical, dental and chiropody treatments. Staff are alert to any changes in mood, behaviour and general wellbeing of each resident. Plans around health are in place and records are carefully updated to give an accurate account of what is required and what has been done. Examples of good practice were seen with regard to residents who are prone to falling, developing pressure sores or may need specialist equipment. Risk assessments are carried out to identify what the risk is and how this is minimised. Falls are monitored and preventative measures are taken to make sure residents are protected, specialist equipment is in place and staff receive adequate training to use it. Moving and handling procedures are designed to safeguard residents and staff. However it was noted that the home does not have enough lifting belts available for staff to use and that some residents are in need of an assessment by a physiotherapist to make sure staff are using the correct methods of transfer and to be given advice if necessary about other equipment available. There is a good medication policy in place. Staff understand the procedures however a random audit of medication by the inspector showed that some items were being overstocked; unused medication was not being returned to the chemist and there was a risk that residents were not getting medicines as prescribed because of a failure to document the medication onto new records and therefore could be missed. It is important that residents are given what is Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 13 prescribed. This was discussed with the manager. Some of the residents take care of their own medication such as inhalers and creams. However this is discussed with the resident beforehand and the level of risk is assessed. The manager and staff team take a common sense approach to risk and look at ways to minimise this, without taking away a residents choice and independence. An example of this could be where a resident wishes to keep medication in their own bedroom which needs to be kept in a fridge. The home has a fridge for medication but this is on the ground floor, in a locked treatment room. This can prevent a resident being able to make choices and maintain their independence. The manager and staff use imaginative ways to overcome such situations without ignoring their duty of care. An example of good practice was seen when medication was to be given out at lunchtime. Residents were given the chance to finish their meal without being disturbed when being given medication. The home does not provide nursing care, however admissions are seen as long term for as long as the staff team can provide the care needed. The wishes of each resident about terminal care and the arrangements they want after death is sensitively discussed with residents or their relatives. Their wishes are then recorded. All relatives and residents who filled out a questionnaire or were spoken to said health care in the home was very good. Relatives said they were kept well informed of any events which might affect their relative and if the resident was not able to make decisions, they where involved in planning for the future. This means that decisions are not being made by staff without the residents relative being able to speak on the residents behalf and putting what they think is the residents wishes. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Residents at Bierley Court make choices about their lifestyle. Social, cultural and recreational activities meet the resident’s expectations. EVIDENCE: The manager and staff team focus on the residents right to live the life they choose. Staff do not impose their views on residents but take time to listen to what residents want and try to support them in ways to improve their quality of life. Staff make sure residents rights are protected. For example residents are treated with respect and dignity and have access to community resources. Residents said they are able to do what they wish, when they wish. The manager has had a residents meeting since her appointment in May 2007. The minutes showed that this was used to formally introduce herself but also talk about staff changes and to listen to their views on what they thought about the home and how it could be improved. Five main points were highlighted and an action plan was put in place. All the points have now been addressed: chiropody treatments; serving of meals; outings; hot flasks for serving drinks and introduction of specific activities. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 15 Routines are very flexible and residents make choices about their lives. For example residents have control over when they get up and go to bed, who they spend time with and whether they join in activities. A main meal is provided at lunchtime and there are always two choices. Meals are served in the two main dining rooms. However if residents wish, they can sit else where in the home to dine. If residents have any difficulties with their meals staff discuss this and come up with solutions. For example, residents who may be unwell or sleep a lot are given assistance to eat and staff will stay with a resident to make sure they are able to finish a meal and receive the nutrition required. Staff need to be careful about where they sit when assisting residents. For example, if a member of staff is not at the same level as the resident they are helping this can affect the outcome for residents and be undignified. All residents said they enjoyed the meals provided. There is a varied menu available and residents have a choice at each mealtime. Snacks and drinks are provided throughout the day and night. Staff try to encourage residents to eat a healthy diet and monitor weight loss and gain. Staff complete a ‘nutritional screening’ form for residents to assess if they are at risk of being undernourished and if so steps are taken to make sure they receive high calorie foods and snacks. If necessary food and drink intake is recorded. A drinks trolley was being taken round and residents were being given a choice of hot or cold drinks, fresh fruit and biscuits. The inspector watched the main meal being served and talked to residents after the meal. The presentation and delivery of the food was good. Staff need to take care that residents have the correct crockery during their meal. Soup was served as a starter and residents having bread did not have a side plate. Visiting is unrestricted and relatives were seen coming and going throughout the inspection. They are asked to sign in and out for fire safety reasons and said they understood why this was important. All the visitors said they always made to feel welcome. Activities and recreation are a main feature in the home. An ‘activity organiser’ is employed. All organised activities are recorded and monitored to make sure residents have access to things they enjoy, that activities are age appropriate and that they cover a wide variety of themes to give everyone an opportunity to take part. Activities and trips are discussed with residents. For residents who prefer not to join in staff record any activity they have been involved in. This is monitored to make sure no one is left out or may become isolated. Staff are sensitive to residents wishes and this is also considered when reviewing the social aspects of each residents care. One resident said she was ‘lucky to still be able to read and enjoy things on her own and not rely on others to provide activities for her’. One relative said they thought residents should go out more and use the garden. One resident, who had filled in a questionnaire, said there were ‘never’ any activities they could take part in and that they ‘didn’t like to join in most things, like dominoes’. Residents and Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 16 visitors spoken with said they thought the activities were good and that staff played an active role in promoting things in the home. Some activities involved people coming into the home and residents going out which added to community involvement. One resident said the activities were ‘fun’ and that they were given a choice about taking part or not. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Residents are able to raise complaints and have access to a complaints procedure. Their rights are protected and they feel safe. EVIDENCE: There had been one complaint to the manager since the last inspection. This had been from a staff member about her wages and did not affect resident care or practices in the home. Residents said they knew who to complain to if they were unhappy. The complaints procedure is available for residents and relatives in Braille and audio tape in addition to the standard written version. All the residents and relatives spoken with said they had not had reason to make a complaint. A number of training dates have been confirmed for staff to attend courses on adult protection procedures. There is a written policy in the home for staff to refer to. Despite staff not having had formal training they showed a good level of awareness of what they should do if they thought residents might have been subject to any form of abuse and were able to identify the different types of abuse possible. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 18 The home employs an administrator who deals with residents personal money and other office procedures. The arrangements around residents money provide safe guards and residents can be sure that their money is handled properly when it is being looked after on their behalf. The homes computer system is backed up and the information is checked by internal systems within the company. All transactions are recorded and receipts are kept showing what the residents money has been used for. All falls and incidents are recorded in full, including diagrams showing where marks, an injury has occurred or bruising is seen. These forms are then audited for things such as recurring trends or high numbers of falls. This can pick up any problems which need to be addressed, for example if falls are occurring at a particular time of day, which might indicate there are not enough staff or that a residents mobility is deteriorating and that they need a moving and handling assessment. Unexplained bruising is not missed and therefore residents are protected against possible abuse. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The design and layout of the home allows residents to live in a safe, well maintained and comfortable home. EVIDENCE: There is a car park for staff and visitors. Smoking is allowed by residents only, in a designated lounge. The home is well maintained and the standard of decoration and furnishings is good. Bedrooms are highly personalised and reflect the tastes of the resident using it. Many of the residents had brought cherished items of furniture, photographs and ornaments with them to make their room feel like their own. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 20 One resident said ‘It is important for me to have my own things and furniture with me’. The layout of the building means groups of residents can meet together in one of four communal lounge areas. Residents meet with friends and relatives in their bedrooms if they wish. Some visitors said they always met with their relative in their bedroom and staff always knocked before entering, which they appreciated. Bathrooms and toilets are located around the home. These were found to be clean and tidy. Two of the four baths are assisted. Residents said there is enough hot water. Water temperatures are monitored daily to make sure temperatures do not exceed safe limits and to protect residents from the risk of scalding. The home is well lit, clean and tidy. There were no unpleasant odours. This shows that staff are alert to the needs of residents and attend to personal care in a prompt and effective way. Relatives and residents said they appreciated the fact that the home was clean and tidy and well decorated. Outside, the home is surrounded by mature gardens with some seating areas for residents and visitors. Work has started to improve these areas and make it easier for residents to become involved in gardening and planting flowers. All safety certificates and evidence of servicing was seen. Information provided by the home also showed that regular maintenance was being done by staff in the home and where necessary private contractors. Staff have received the necessary training to make sure they know what to do in case of fire and many have been trained in health and safety procedures. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Staff are trained, skilled and enough staff are on duty to support the residents who live at the home. EVIDENCE: All the residents, relatives and visitors, who talked with the inspector or filled in a questionnaire, spoke positively about the manager and staff team. • • • • • • ‘They can’t do enough for you here those girls’. ‘They’re always busy but have time to talk to me and my family’. ‘The new manager seems to know what it is all about’. ‘My mum was in another care home but it was no way as good as this one. I know she is looked after very well.’ ‘I’ll fill in a questionnaire but I am highly satisfied with the home, you only have to look at the residents to know they are happy here’. ‘I think they do very well, it takes a Saint to look after my mother’. There are enough staff on duty throughout the day and night to meet the needs of the current group of residents. The home is carrying three vacancies for care staff, one full time and two part time. The staff are managing to cover the shortfall in hours by working flexible hours and overtime. The manager Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 22 and staff team feel this is better for residents as they are not having to use agency staff, who residents do not know. Common phrases used by residents and relatives, when talking about the manager and staff were ‘approachable, willing to help, patient, hardworking, committed and motivated, always busy and caring’. Staff have the skills and knowledge to deal with the needs of the resident group. All staff have an accurate job description, which sets out their roles and responsibilities. Residents knew the names of staff and seemed to value the relationships they had with them. The staffing structure and duty roster are based around the needs of the residents and not led by staff requirements. There is a good recruitment procedure that makes sure only staff who are suitable to work with vulnerable people are appointed. The manager confirmed that all staff employed in the home had been through a criminal records bureau check. All staff are recruited subject to a probationary period. This is extended if necessary until the manager is confident they are the right person for the job. Two staff files were looked at in detail. All the necessary checks had been carried out. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The management of the home is based on openness, respect and commitment. The manager is competent and has the necessary skills and qualifications to run the home. EVIDENCE: The manager is qualified to do the job and has a significant amount of experience. She was appointed in May this year and has yet to be registered with CSCI as the manager of Bierley Court. The registration process includes the manager completing a CSCI application form, having an interview and supplying satisfactory references and a criminal records bureau check. This is Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 24 to make sure she is the right person to manage the home and is suitable to work with vulnerable people. The manager has a clear vision of what the home provides and what they want to do to further develop the home and the quality of life experienced by the residents. Policies and procedures are written in a way, which follows ‘best practice’. Equality and diversity issues are considered when staff are working with residents and a statement about this is included in the information provided on admission. The way people are treated supports the idea that everyone who comes into the home is treated as an individual and is respected irrespective of their age, gender, sexual preference, colour, religious beliefs, culture, ability or social background. The home monitors the care they provide by self-assessing the service on a monthly basis, asking residents to complete surveys, supervision of managers and staff meetings. Residents told the inspector that their views are listened to, valued and acted upon. They said they understood the difficulty in ‘pleasing all of the people all of the time’ but felt the staff tried their best to make sure the majority of the residents were receiving the level of care they thought they needed. There are safeguards in place for the correct management of resident’s money. Record keeping relating to resident care and maintenance of the home are good; therefore staff know what they are doing. These are kept securely and staff know what they have to do to comply with the requirements of the Data Protection Act. The plans of care are written with involvement of residents and their relatives as appropriate. The manager and staff team have a good understanding of the risk assessment process and this is taken into account in the day-to-day running of the home. A common sense approach is used to minimise risk without restricting the movements of residents. Health and safety systems are regularly reviewed and are kept up to date. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 25 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 4 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 26 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. 1 Standard OP9 Regulation 13(2) and 17(1)(a) Schedule 3 3(i) 13(5) Requirement The registered person must make sure drugs no longer in use are returned to the pharmacy for disposal; that overstocking does not occur and that medication is correctly recorded as prescribed. The registered person must make sure there are sufficient lifting belts and equipment for staff to be able to handle residents in a safe way. Residents with mobility problems must be assessed by a physiotherapist to make sure staff are using the correct techniques to transfer them. Timescale for action 12/08/07 2 OP8 12/08/07 Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 27 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 OP15 Good Practice Recommendations Staff should take care at mealtimes to make sure they are sat in the correct position when assisting residents and that there is enough crockery on the table. Bierley Court DS0000034010.V340034.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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