Inspection on 06/05/05 for Bierley Court

This inspection was carried out on 6th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bierley Court 16/06/08

Bierley Court 10/07/07

Bierley Court 15/08/06

Bierley Court 28/10/05

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 Court Dudley Hill Bradford BD4 6AD Lead Inspector Barbara Grell Unannounced 11 05 05 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. Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bierley Court Address 49 Bierley Lane Dudley Hill Bradford BD 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) 01274 680300 01274 680303 Southern Cross Healthcare Mrs A Leyland Care home 40 Category(ies) of Old age (5) Dementia - over 65 (10) Physical dis registration, with number - over 65 (25) of places Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11/11/04 Brief Description of the Service: Bierley Court was designed as a care home and provides a service to older people. There is level access, a passenger lift and secure garden. There are a variety of communal rooms, assisted bathrooms and communal toilets to both floors. The bedrooms are single and all are provided with an en-suite WC. Bierley Court is situated three miles from Bradford city centre. Public transport can be accessed close by and parking is provided within the grounds. The home is registered to provide care to a maximum of 40 service users. The home is able to provide for up to twenty-five older people with a physical dissability and up to ten with dementia. Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by one inspector on 11 May 2005. The following methods were used in collecting information. Four service users care documentation was case tracked including inspection of assessments, care planning and monitoring. Three visitors were able to make comment to the inspector. Nineteen service users had discussions and made comment to the inspector about the services and care at the home. All staff on duty were observed in undertaking their duties and had discussions with the inspector. All communal rooms and a small number of bedrooms were inspected including the laundry and gardens. The policies, practices, recording and storage systems pertaining to the administration of medicines were inspected. The residents opted for the term resident in preference to service user and hence this term was used through out this report. The inspector joined the residents for lunch. What the service does well: Residents and visitors are satisfied with the care and services provided at the home. Staff are seen as friendly, helpful and competent. Residents chose their routine and are free to use communal facilities or their own rooms. Involvement from residents and relatives allows them to have good input in the assessments and care planning. This results in person centred care practices that take account of individual preferences and choices. The staff team are committed toward meeting the needs of the residents and aim to improve their well-being and health with their input. Residents appreciated their friendly and helpful attitudes. Regular staff and resident and relative meetings are held to ensure ongoing feedback to management about the service. Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 6 Whilst there were some gaps in monitoring and care planning, staff knew the residents well enough and were ensuring care even though the care need was not yet recorded. Staff were aware of gaps. The environment at the home is bright, clean and provides for good facilities. Residents enjoy their own rooms and appreciate the en-suite facilities. Residents rights are protected through policy and practice and good practices are observed in protecting vulnerable adults. What has improved since the last inspection? 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. Bierley Court J52 S34010 Bierley Court V225743 060505 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 Bierley Court J52 S34010 Bierley Court V225743 060505 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, 3, 4 and 6 Residents and visitors were provided with a good amount of information in respect of services, aims and procedures of the home. An appropriate assessment gave opportunity to the prospective resident to state their expectations and preferences. Pre-admission documentation was of good quality and ensured that the residents assessed needs can be met on admission. EVIDENCE: Information about to the home such as brochures, statement of purpose and service user guide was available in a prominent position in the entrance. There are a variety of pictures displayed in the entrance showing life in the home, celebrations and parties for example. Visitors and many of the service users were aware that this information was accessible here including the complaint procedure. One case-tracking example was concerned with a new admission. A core assessment was available and had been undertaken by the representative Social Worker and this gave good information. A member of staff visited the Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 9 prospective resident and assessed and discussed the care needs. The assessment record was signed and dated and included good information. It also gave clear evidence that the prospective resident had been fully involved in the process and was able to state any expectations and preferences. The deputy manager said that a pre-admission assessment was always undertaken to ensure that the prospective residents needs can be fully met on admission. Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 10 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 Care plans must be improved to include all the assessed needs as omission may lead to residents needs remaining unmet. However, the involvement of service users and their representatives in the assessment and care planning is good and leads to a good level of satisfaction with the care and services provided. A safe system of medical administration and recording is ensured. The residents are treated as individuals and their preferences ascertained, recorded and underpin the care and services provided. EVIDENCE: The staff continued with the assessment on admission by completing the organisations assessment record. This included skin viability, falls, handling and nutritional assessments. A care plan was then established showing how staff will meet the assessed needs. The case tracking undertaken showed that there are some gaps in transferring assessed needs to the care plan. The examples seen included pain management, monitoring of dietary intake and in another case the dementia care needs/challenging behaviour had not been entered into the care plan. In all three cases staff were aware of the need and able to state what input was needed. Some assessments were out of date and needed review. The senior staff were aware and had started reviewing these. Staff reviewed care plans monthly. Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 11 The resident’s social needs, personalities and histories were well recorded in the examples seen. The staff knew the residents well and honoured individual preferences. Most residents and visitors stated that they had been involved in the assessment, care planning and review process. Care plans seen had been discussed with residents and signed by the resident or a representative. Periodic review meetings ensured ongoing formal input from residents and their representatives. Minutes are kept. The service users health care needs were assessed and details included in the care plan. Health care professionals were involved in providing advice, monitoring and treatment. The residents were provided with a choice of local GP’s on moving into the home. NHS services were accessed via GP referral and NHS staff provided for any nursing input at times required. A monitored dosage and recording system was provided. Staff whose role it is to administer medicines had been trained to do so. The blister packs in use ensure a safe system and administration records were well completed by staff. There was appropriate storage. Some residents administered part or all of their medication within a system of risk management. Administration records show receipt of medicines and when they had been provided to the resident. Service users and visitors spoken to were clear that staff listened and tried to do their best. All stated that the en-suite facilities in the home and single rooms ensured a good level of privacy. Residents stated that personal care and treatments were always undertaken in private. Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 12 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) 13, 14 &15 Residents were enabled to choose their own routine and are assisted by staff that take account of the residents wishes and preferences. The visiting times and arrangements were good and ensured that visitors and residents can meet in private if they wished. The meals are good and provide for choices. EVIDENCE: Residents and visitors spoken to were able to say that the visiting times and arrangements were open and visitors were able to use communal rooms or bedrooms. Visitors were offered refreshments by staff and informal discussions and information giving were observed. Residents meetings were held and minutes recorded periodically allowing for input on a broader scale. Residents stated that they went out with relatives at times. Residents said they followed their own routine and staff assisted at times appropriate and chosen by the individual. This included times to rise and retire. Residents also liked spending time in their rooms and were allowed to use the rooms of their choice. Staff spoke to service users with respect asking permission prior to providing care and assisting residents. Staff ensured the residents comfort whilst assisting them and chatted with the residents showing good relations were maintained. Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 13 The lunchtime meal consisted of three courses and provided for choices that were offered at the time of serving. The meal was well prepared and presented and staff provided assistance to those who needed it. Residents said that the meals were good and they enjoyed the social opportunities for chats with each other after the meals. A resident who had suffered with poor appetite was able to say that staff had gone out of their way by providing requested cooked items at breakfast. Generally the meals were good and tasty with ample choices residents thought. Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 14 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) 17 &18 Practices and policies at the home ensured that the resident’s civil and legal rights are protected. The staff team are aware of how to detect, report and protect vulnerable adults from abuse. EVIDENCE: The residents stated their civic and legal rights are protected. Many of the residents had made arrangement to complete their postal votes with help for relatives and friends or staff. The case records seen showed if anyone was responsible for resident’s finances for example showing a transparent system of recording any advocacy formally. Many residents stated and were confident that the deputy manager is reliable and will provide any assistance or information. The home has got adult protection policies including local policies provided by the Social Services Department and how to access help locally and how to link in with the local adult protection department. The whistle blowing policy had been tested recently leading to appropriate investigations and prompt actions. All staff members spoken to had good knowledge and were clear how and to whom any concerns must be reported. Staff were also able to discuss different scenarios and were clear what their duties would be. Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20, 21, 22, 26 The environment provides for good indoor and outdoor space and facilities that are well maintained and kept clean. The management must review their decision for the use and layout of the ground floor communal rooms in the view of resident’s opinions. EVIDENCE: Flower borders to the front of the building have improved this area to become welcoming and provides for focal points. The main garden can be accessed from the communal rooms situated on the ground floor. This was being tidied up and garden furniture was provided. The deputy manager stated that she had plans to purchase some additional garden tables and chairs this year. The building works continue on the site next to the home. Many of the residents looked out on this site. Residents hope that when a new fence is fitted and landscaping done after completion will improve the current noise level and outlook. Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 16 The residents discussed a number of concerns with the inspector. The residents did not like that their dining room/lounges to the ground floor had been changed to provide for a separate lounge and dining room. Residents felt that this stopped them from chatting after the meal, as they could not move to their comfortable chairs as they did previously. Residents had not been consulted with regard to the changes made. The deputy manager was on holiday at the time of the changes but was able to clarify that senior management within the organisation had made and implemented the decision without consulting the residents. This situation must be resolved taking full account of the resident’s views. Secondly there was concern that residents and relatives had been told that they would have to purchase their own door retainers to hold open heavy fire doors fitted to bedrooms. As discussed with the Southern Cross Operations Manager this type of adaptation/equipment must be provided for by the home and not charged to the resident’s accounts. Eight residents have requested such door retainers to be fitted in order to meet their needs. Doors must not be wedged or otherwise held in the open position. The home provides for a variety of assisted bathrooms and ample communal toilets that are positioned close to communal rooms and bedrooms. All bedrooms are provided with an en-suite toilet and bathroom. The home was clean, bright and provided adequate space meeting the current room size standards. The laundry rooms are well-organised meeting current hygiene standards. The registered person has provided an action plan showing how the requirements of the recent fire safety report had been met. Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 28 There were sufficient staff on duty in meeting the needs of the residents. The relationships between staff and residents were good and resident centred practices observed. EVIDENCE: A staff duty rota was provided during the inspection. levels to be in line with current requirements. This showed staffing The home does not meet the current requirement for 50 of staff to be qualified to NVQ level 2 or above. The deputy manager discussed the training plans and was able to say that all staff that have not yet completed this training are booked onto a suitable training course to complete level 2 or 3 during this year. The residents and visitors commented that there were sufficient staff on duty. Residents felt that staff tried their best were generally friendly and helpful. Bierley Court J52 S34010 Bierley Court V225743 060505 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 & 35 The leadership was well managed in the absence of a registered manager. The deputy was supported with her extended role providing good continuity of management. The financial procedures and practices ensure transparency and security. EVIDENCE: The deputy manager was currently in change of the home and assisted by the operations manager and another registered manager from another Southern Cross home. This arrangement was working well and residents had a good and trusting relationship with the deputy. Staff and residents reported to be well supported within the current arrangements. The deputy manager and mangers seen were clear about their own and others role. The deputy manager showed resident centred practices that provided for a good role model for other team members. Staff supervision and staff and residents Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 19 meetings were planned in line with procedures ensuring continued input in decision-making. The financial procedures at the home have recently been fully audited leading to a tightening of systems in use. Residents had made arrangements for the safekeeping of their money and can leave small amounts in the care of the home. The records seen were well recorded and receipts kept for any purchases made on behalf of residents. Bierley Court J52 S34010 Bierley Court V225743 060505 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 x 3 3 x x 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 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 2 x x x 3 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 3 3 3 x x 3 x x x Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement The service users plan must set out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs of the service user can be met. Suitable retainers must be fitted to bedroom doors where residents want these fire doors to be held open for their comfort and conveniance. Regulation 23 (2)(n) requires for the registered person to provide such equipment and residents must not be charged in this respect. fire doors must not be wedged in the open position. 9This item is outstanding form the previous report.) The registered person must consult with the service users about the lay out and use of communal rooms and include the residents wishes in the decision making process. 50 of care staff must hold an NVQ level 2 or above. (Item outstanding from previous inspection.) Timescale for action 1 August 2005 2. 19 & 22 23 1 August 2005 3. 19 23 & 15 1 July 2005 4. 28 18 1 December 2005 Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 22 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 Good Practice Recommendations Bierley Court J52 S34010 Bierley Court V225743 060505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP 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 Bierley Court J52 S34010 Bierley Court V225743 060505 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!