Inspection on 25/02/08 for Bilton Court

This inspection was carried out on 25th February 2008.

CSCI found this care home to be providing an Adequate service.

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

Bilton Court 11/03/09

Bilton Court 28/02/07

Bilton Court 20/09/06

Bilton Court 17/10/05

Bilton Court 04/11/04

Bilton Court 19/05/04

Bilton Court 23/01/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Bilton Court Windermere Drive Queensway Wellingborough Northants NN8 3FR Lead Inspector Linda Clarke Unannounced Inspection 25th February 2008 09:30 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 Bilton Court DS0000012708.V358913.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. Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bilton Court Address Windermere Drive Queensway Wellingborough Northants NN8 3FR 01933 401613 01933 401615 kerry.morgan@anchor.org.uk www.anchor.org.uk Anchor Trust 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) Position Vacant Care Home 48 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (48), of places Physical disability over 65 years of age (24) Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The total number of service users must not exceed 48 in Bilton Court No service users with a physical disability over the age of 65 PD(E) may be admitted to Bilton Court when there are already 24 service users accommodated within the home No one falling within category DE(E) may be admitted into Bilton Court where there ae 10 persons of category DE(E) already accommodated within this home. 8th January 2008 Date of last inspection Brief Description of the Service: Bilton Court is a care home providing personal care and accommodation to forty-eight older people twenty-four who may have a physical disability and ten who may have a dementia related illness. On the day of the inspection there were 47 people living in the home. The home is operated by Anchor Homes, which is part of Anchor Trust. It is situated on a residential estate on the outskirts of Wellingborough with public transport to and from the town centre. The home is purpose built. The home has single bedroom accommodation with en-suite facilities consisting of shower, toilet and washbasin for all residents on two floors. A passenger lift provides access to the first floor. There are four separate units within the home each unit having a communal lounge/dining room. There are pleasant grounds surrounding the home, which are accessible to all the people living in the home. Information about the home can be obtained from Anchor Homes in the form of a Service Users Guide and a Statement of Purpose. Information regarding fees is available from the Manager of Bilton Court; additional costs are applicable for some services, including hairdressing, chiropody and delivery of magazines and newspapers. Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection process consisted of pre-planning the inspection, which included reviewing the Annual Quality Assurance Assessment (AQAA), which is selfassessment tool completed by a representative of the service and previous Inspection Reports. We (Commission for Social Care Inspection) sent surveys to twenty people who use the service of which twelve were completed and returned, twenty surveys were sent to families and friends of people using the service, of which four were completed and returned, eleven staff surveys were sent out of which four were returned, and four health care professional surveys were sent out of which none were returned. The unannounced site visit commenced on the 25th February 2008, and took place between 09:30 and 18:00. The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was ‘case tracking’. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff at Bilton Court. Four people accessing services were selected, with a range of individual needs, including those with Dementia. Discussions were held with seven people who reside at the home and two visitors. What the service does well: People who are considering moving into the home are provided with information about the home and have their needs assessed before they move in. People living at the home have good access to health care, and are supported by care plans, which detail the help and support they require. Staff working in the home have access to a wide variety of training, which enables them to support the people in their care. People living at the home are encouraged and are provided with opportunities to share their views and concerns about the day to day running of the home, and the service they receive, and any ideas and suggestions are acted upon. People we spoke with made various comments: “The care is good, can’t fault anybody, they’re all good.” Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 6 “I enjoy going to bingo and doing the chair exercises, the meals are good and there is always an alternative.” “Care is alright, my relative visits regularly. The staff are kind, polite and courteous, and the food is alright.” “Night staffing levels have improved, staff are polite, courteous and friendly. I am happy to raise concerns. I attend the meetings, and say how I feel, I also enjoying playing scrabble.” “The care and support is okay, staff are polite and courteous. I enjoy playing scrabble, dominoes and bowls. I attend the resident meetings regularly, and adjustments to care are made following discussions at meetings.” What has improved since the last inspection? What they could do better: People living at the home need to be confident that their privacy, dignity and confidentiality are respected, and that other people living at the home do not have access to information about them. The individual care people receive could be improved by care plans being written from the perspective of the person, and include information as to their preferred daily routines, enabling staff to deliver individual and personal care in a manner which reflects individual choices. Staffing levels need to be increased, and greater flexibility to enable individual and personal care to be received by people living at the home at a time and in a manner they wish, whilst ensuring that privacy, dignity and confidentiality is maintained. People we spoke with made various comments: “There is a staff shortage, especially during busy times, we try to be considerate and not ring the bell when staff are busy.” “I don’t like the meals, they’re not tempting, and there is no variety.” “The food is okay, but it is bland, the vegetables are over cooked.” Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bilton Court DS0000012708.V358913.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 Bilton Court DS0000012708.V358913.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 and 5. Standard 6 is not applicable, as the service does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving into the home have access to information about the services provided, and are encouraged to visit and view the home. Potential users of the service can be confident that their needs can be met as identified by their assessment. EVIDENCE: Information available to people who are considering moving into Bilton Court has been updated, detailing the services offered by the home, enabling individuals to consider whether the home will fit their lifestyle. People spoken with, and comments received in surveys we sent out, confirms that people living at the home have received and retain a copy of the homes information guide, which is called the Statement of Purpose and Service User Guide. Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 10 The Statement of Purpose and Service User Guide contains a significant amount of written information, the inclusion of photographs and pictorial information may aid the understanding for some potential users of the service. Discussions with people using the service, and information contained within surveys we sent out, identifies that some uses of the service do not have a contract that outlines the terms and conditions of their occupancy. The Manager was able to show that contracts for all service users are held within the office, it is recommended that all people who use the service are given a copy of their contract. People who are considering moving into Bilton Court where funded by Social Services receive a comprehensive assessment of their needs undertaken by a representative of Care Management, whilst those who fund their own care and those funded by Social Services will have an assessment of their needs undertaken by a representative of Bilton Court. Assessments of prospective users of the service are comprehensive, and cover all aspects of care including why the individual is considering residential care. Assessments include a wide range of additional information about the person’s life such as employment, family history and relationships, hobbies and interests, significant events and medical history. Assessments are then used to develop care plans which detail the care individuals require. People spoken with said that in some instances they had visited Bilton Court before moving in, whilst others had left their relatives to visit on their behalf. Bilton Court DS0000012708.V358913.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service have access to health care services, and are encouraged to comment on the care they receive and are supported by care plans. Peoples right to privacy and respect is not always upheld. EVIDENCE: The care plans and records of four people using the service were viewed, which included one person who had recently moved in, and people with differing needs. Care plans had been developed from individual’s initial assessments, and focused on specific areas of care required by the individual. Care plans made reference to the abilities of individuals and the maintenance of their independence. Where support was required, information detailed how the support was to be given, and when, including the use of specialist equipment where necessary. Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 12 Care plans in some instances were signed by the person using the service, and were generally reviewed on a regular basis, their was evidence that the reviewing of care plans needs to be more robust to ensure that an up to date and accurate record of individuals needs is maintained. Care plans could be further developed by being person centred, and written from the perspective of the individual to include their wishes, preferences and expectations of all aspects of care and preferred daily routines, this would be particularly beneficial those individuals who are unable to express their views or have Dementia. People who use the service are provided with opportunities to contribute to the care they receive, in some instances people who use the service retain responsibility for the ordering and administration of their medication. Individuals are also asked as to the frequency, if any, checks they wish to have during the night, signed agreements are in place where decisions have been made by the individual. Records evidence good and prompt access to health care professionals, and discussions with people using the service and information detailed within surveys we sent out supports this. The Manager advised that a ‘clinic’ would soon be in operation two days a week, and would involve a General Practitioner from a local health centre, to which a majority of people using the service are registered with, visiting the home, and seeing anyone who had a concern regarding their health. The medication records and medication were viewed of four people and was found to be in good order. Medication is kept within a lockable facility on each floor, and is only accessible by staff that have the responsibility for administering medication. Individuals spoken with and information contained within surveys we sent out, confirms that people using the service feel that they receive the care and support they receive, and that staff are polite and courteous and respect their privacy and dignity, however some concerns were expressed with regards to staffing levels. Staff were observed knocking on the doors of bedrooms and waiting for a response until entering, people living at the service in some instances have a telephone installed in their room, and mail is distributed to people living at the home. Observations and conversations with people using the service identified that people who use the service do not in all instances have their privacy, dignity and confidentiality ensured. Staff were over heard during lunchtime discussing whether an individual was being fed, whilst some people using the service had a clear understanding of the needs of other individuals living at the home, as Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 13 staff gave these as reasons as to why they could not immediately respond to their request for assistance. (Additional information contained within the Staffing section of the Inspection Report). Care plans included information, where expressed, by an individual with regards to illness, death and dying, and any specific arrangements or contact details. Bilton Court DS0000012708.V358913.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service have access to a range of activities within the home; their choices, preferences and cultural needs are not in some instances met with regards to the provision of meals. EVIDENCE: People who use the service have access to a range of activities provided and organised by the Activity Organiser and Volunteers. Activities in some instances are provided by entertainers who visit the home and provide talks, one recent talk provided by a representative the Royal Society for the Protection of Birds (RSPB), talks on significant historical events, a classical concert and a visiting organ player. People who use the service said the activities they attend include chair exercises, bingo, scrabble, dominoes and crosswords. In some instances people living at the home have newspapers and magazines delivered. Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 15 Church Services are held within the home, one person living at the home said that they accompanied by other users of the service went to the local Church which they accessed independently. People spoke of the recent Valentines Day celebrations, saying that the dining room was decorated with balloons, thank you letters from relatives about the success of the day had been received by the Manager. Celebrations also take place at Christmas, Easter, Halloween and the Birthdays and Wedding Anniversaries of people living at the home. People we spoke with and information provided within surveys we sent out, states the relatives are encouraged to visit at any time, without appointment. People who live at the home and their relatives have the opportunity to attend monthly meetings, the most recent meeting identified that a number of people at the home were unsatisfied with the quality and variety of food. In response to these concerns the Manager had spoken with a number of people over several days, asking and recording their views as to the meal they had just eaten. Surveys were also sent asking for suggestions on meals to be added onto the menu. People we spoke with expressed mixed views as to the quality and variety of food, in some instances people said that the food was bland, and did not reflect their cultural diet and preferences. Observations on the day of the site visit noted that whilst some ate heartily of their meal, others did not. Meals are cooked on sight in the kitchen, and are then sent to the individual wings in heated trolleys. Serving dishes are placed on dining tables, enabling people to serve themselves; improvements to the dining experience could be achieved, by consideration being given to the environment and it how it impacts on the experience people have whilst eating their meals. Dining chairs and tables are easily accessible by those with mobility difficulties including those who use a wheelchair. Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supported by processes, which promote their safety and well-being, and by practices, which enable them to raise concerns. EVIDENCE: Bilton Court has a complaints procedure which outlines the process for people who wish to raise a concern, information supplied by the Manager prior to the site visit identified that the home has received six concerns since the last inspection, which were all resolved within 28 days. Records we viewed detailed the nature of the concerns raised, how these were investigated and the response given to the complainant. People we spoke with were aware of how to raise concerns and complaints, and surveys we sent out to people who use the service and their relatives and friends confirmed that all are aware of how to make a complaint, and expressed general satisfaction with the response they had received. We have received one complaint in the last twelve months, which was with regards to staffing levels, and one complaint received by the home earlier in 2008 was with regards to staffing levels. (Additional information contained within the Staffing section of the Inspection Report). Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 17 Staff recruitment practices are robust, staff upon completing an application form, if considered to have the appropriate skills are sent a pre interview questionnaire, which they complete prior to attending for an interview. If successful two written references and appropriate checks are carried out by the Criminal Record Bureau to establish as to whether an individual has any convictions which may make them unsuitable to work with vulnerable adults. Staff receive training in the safeguarding vulnerable adults, which provides them with information as to the forms which abuse may take, and signs for spotting potential abuse may be taking place, and their role and responsibility in reporting their concerns. Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service live in clean, well-maintained and comfortable accommodation. EVIDENCE: Bilton Court comprises of four wings, two located on the ground and two on the first floor. The two on the ground floor are named Lavender and Waverley, whilst those on the first floor are called Mentmore and The Haven. Access to the first floor is via a stairwell or passenger lift. Each villa is self-contained with open plan communal living space comprising of a lounge and dining area, with a kitchenette attached. Each villa has single bedrooms and one shared room, all benefiting from an en-suite, which includes a wash hand basin, toilet and shower. People living at the home are Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 19 encouraged to personalise their rooms, to make them a comfortable and relaxing environment for them to live in. The Manager advised that communal areas of the home were to be decorated and have new curtains in the next few months, to create a more homely and individual feel to the villas. Bilton Court is light and airy with large windows letting in natural light. Equipment is available in the home to assist people in undertaking daily activities such as hoists, walking aids, grab rails and passenger lifts. People using the service, and comments included with surveys we sent out expressed satisfaction with the environment and its cleanliness. Information supplied by the Manager within the self-audit took evidenced that regular checks are carried out on appliances within the home, including gas, electrical and fire systems. Day to day practicalities of the home do impact on people using the service, and are intrusive, call bells sound throughout the home, and senior staff carry telephones, both impact on the day to day lives of people living at the home. Consideration needs to be given as to how the day to day running of the home impacts on the daily lives of people, and how these can be reduced to create a more homely and relaxing environment. Bilton Court has a central laundry, clothing of people using the service are washed separately, which is a good infection control measure, and reduces the likelihood of clothing being given to the wrong owner. Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Enthusiastic and trained staff support people using the service, but they do not have their needs timely met due to insufficient staffing levels. EVIDENCE: Staffing levels have continued to be a problem with a complaint being made to the Manager earlier in 2008, when a person who resides at Bilton Court, had contacted their relative at home to tell them that they had been ringing their call bell for along time and no one had answered. The complaint was investigated, and a contributory factor had been staffing levels and staff having to respond to an emergency. We also received a complaint in September 2007, with regards to staffing levels, which was investigated and addressed by the Manager, and involved the use of Agency Staff. Staffing levels have not significantly improved since the last Key Inspection, the Manager advised that a number of staff had recently been recruited, but they were awaiting all the necessary pre-employment checks before commencing work. Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 21 The Manager advised that once the new staff commence work, their will be 2 members of staff supporting each wing, supported by a Team Leader on duty for the home in the morning, this will represent an increase of 1 carer when compared to the last Inspection. In the afternoon there will be 6 care staff and a Team Leader, which will be an increase of 1 to 2 carers when compared with the last Inspection. Staffing levels during the night have already improved with 1 Team Leader and 4 carers now being on duty. The Manager and Deputy Manager will be available during office hours. A significant number of people who use the service require the support of two staff, when this occurs other people who use the service do not have anyone to respond to their call bells, without one carer leaving one person to attend to another, flexibility needs to be built into the deployment of staff, and the number of staff needs to be continually reviewed, to ensure that the individual and collective needs of people using the service are met. All people who we spoke with expressed concerns with regards to staffing levels, and were aware that new staff have been employed and are awaiting for additional information before they can start. One person said that sometimes there is only one carer on their wing, whilst others said that staffing levels were of concern during busy times of the day, mostly early morning when people wanted to get up, have a wash and shower and have breakfast. Another person spoken with said that they try to be considerate when using their call bell, trying to avoid busy times, the person did say that staff did respond to their initial call, and gave an explanation as to why they couldn’t attend to their needs yet, due to the needs of other. People using the service should not be put into a position, where they feel that other peoples needs are of more importance that theirs, and be provided with information which gives them to understand the care needs of others. A training programme for staff is in place, which covers a variety of topics relevant to the care and welfare of people living at the home, including health and safety topics and specialist training such as Dementia Care, Catheter Care and Pressure Area Care. New staff complete a six week BTEC induction programme, one member of staff confirmed their induction included working alongside an experienced member of staff for two weeks, and attending a variety of courses which included moving and handling, Dementia Care and fire safety. Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 22 A member of staff spoken with spoke enthusiastically about a Dementia Care course they had recently attended, stating that the course had provided a valuable insight into Dementia and its affects on people living at the home, and how they as a member of staff could provide the appropriate care and support. Information supplied by the Manager prior to the site visit evidenced that 32 of staff had attained a National Vocational Qualification in Care, with an additional 52 of staff working towards an NVQ. The records of five members of staff were viewed, all were found to contain evidence of a robust recruitment practices. (See Complaints and Protection section). Bilton Court DS0000012708.V358913.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, 33, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Management of the home provides opportunities for people who use the service to comment on the service they receive, and oversees the day-to-day running of the home. EVIDENCE: The Manager of the service has been in their current post since April 2007; prior to this they were the Deputy Manager. The Manager has recently commenced a course to gain the Registered Managers Award, and has already attained a National Vocational Qualification at level 3. The Manager confirmed their intention to submit an application to become the Registered Manager to the Commission for Social Care Inspection. Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 24 People who use the service are encouraged to express their views and comment on the day to day running of the home and how it affects the service they receive. Monthly meetings are held, to which people living at the home and their relatives are invited. People using the service said they attended these meetings, and found that their views were listened to and acted upon. Staff have recently began to benefit from receiving a supervision from a member of the Management Team, supervisions support staff in delivering the appropriate care to people who use the service, by providing opportunities to discuss their work practices and to explore training needs. Staff meetings are held monthly, one meeting is for all staff, other monthly meets are for care staff working within each Villa. Staff spoken with confirmed their attendance at staff meetings, and minutes are kept and are available. Meetings provide an opportunity for staff to share information and review the quality of care they deliver. Bilton Court produces a monthly newsletter to people who use the service, their relatives and provides, and includes information about forthcoming events, including parties and celebrations. A notice board in the foyer is used to provide information, and includes questionnaires for individuals to complete and comment on the services provided by the home. Information supplied by the Manager prior to the site visit detailed that the homes systems, which support people living at the home are regularly and well maintained. Bilton Court DS0000012708.V358913.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 3 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 3 X 3 Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP10 Regulation 12(4) Requirement People using the service to be confident that their privacy, dignity and confidentiality are respected, and that information about them is not shared with others who use the service. People who use the service to receive a varied diet, which reflects their individual requirements and preferences. Sufficient staff to be employed by the service to ensure that the individual and collective needs of people residing at the home are met, and that there is flexibility in staffing levels to deal with emergency situations. This is an outstanding requirement. A new timescale has been set. Timescale for action 25/03/08 2. OP15 16(2) 25/06/08 3 OP27 18(1) 28/06/08 Bilton Court DS0000012708.V358913.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 OP2 Good Practice Recommendations People who use the service to be given a copy of their contract which outlines the terms and conditions of their occupancy including information regarding fees. People who use the service should be supported by care plans, which are person centred, and include information on their preferred daily routines, preferences and wishes in all aspects of their care. 2. OP7 Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. Extracts may not be used or reproduced without the express permission of CSCI Bilton Court DS0000012708.V358913.R01.S.doc Version 5.2 Page 29 - 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. 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