Inspection on 04/08/05 for Bilton House

This inspection was carried out on 4th August 2005.

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

Bilton House 10/02/09

Bilton House 12/12/08

Bilton House 10/12/07

Bilton House 14/06/07

Bilton House 03/11/06

Bilton House 01/03/06

Bilton House 22/03/05

Bilton House 08/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bilton House 5 Bawnmore Road Bilton Rugby, Warwickshire CV22 7QH Lead Inspector Sandra Wade Unannounced 4 August 2005 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. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bilton House Address 5 Bawnmore Road Bilton Rugby Warwickshire CV22 7QH 01788 813147 01788 811184 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) Rugby Free Church Homes for the Aged Mrs Veronica Jakeman Care Home 33 Category(ies) of Dementia - over 65 (17) registration, with number Old age (16) of places Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22 March 2005 Brief Description of the Service: Bilton House is a large building which has been extended over a number of years and has bedrooms on two floors which can be accessed by a lift. The property fronts directly onto Bawnmore Road and there is a large visitors car park at the rear of the home which can be accessed via a side entrance. The home is registered to accept 33 older people 17 of which are for people with a diagnosis of dementia. There is level access to the home for wheelchair users to the front and back of the home. The Clarence Cooper Unit accommodates 8 residents with a diagnosis of dementia, this is referred to as the specialist dementia care unit and the main building accommodates the additional 9 people with a diagnosis of dementia. Most of these residents occupy bedrooms on the ground floor. Both the frail elderly category residents and those with a dementia diagnosis freely intermingle with one another within the home. The Clarence Cooper Unit has its own secure gardens but there is also a large well maintained garden with a footpath which residents can utilise from the main building. All rooms in the main building have ensuite showers and toilets. The rooms in the Clarence Cooper unit have ensuite toilets. There are 32 rooms in all but the home have used one of the larger bedrooms as a double hence the registration for 33. There are 5 communal lounges plus large corridor areas which have seating and two dining areas one of which is in Clarence Cooper. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced and took place between the hours of 7.30am and 5.40pm. This was the first visit for this inspection year. The inspection process included a tour of the home, talking with the Manager, examining care plan records, discussions with staff and residents and a review of policies and procedures of the home. On arrival at the home, staff were busy attending to the residents, some of the residents were seated in the main corridor area. What the service does well: What has improved since the last inspection? The manager has taken action to ensure that all appropriate recruitment information has been collected and checked prior to employing new staff to ensure staff have been deemed safe to work with vulnerable people. New arrangements are in place for handling the laundry to ensure this is being managed hygienically to prevent any spread of infection. New dining room chairs were delivered to the home on the day of inspection to provide more comfort and safety for the residents. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 6 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. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 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 Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 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 Information provided to prospective residents is not sufficiently detailed to enable residents to make well informed choices about whether to accept a placement within the home. Assessments of service users are carried out but letters are not written to residents to confirm the home can meet their assessed needs as is required by the Care Home Regulations. EVIDENCE: A combined Statement of Purpose and Service User Guide which gives information about the home has been produced. The home are required to have a comprehensive Statement of Purpose document within the home containing policies and procedures as appropriate. A separate Service User Guide should also be available to residents and visitors to the home which should contain a summary of this document as well as a summary inspection report. These documents do not contain all of the necessary information as required and some of the information is in need of updating. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 9 Some of the service users within the home have been resident for a long time and therefore assessment records were not as detailed as now required. A file for a resident recently admitted did not contain assessment records to demonstrate an assessment of their needs had been carried out. The manager stated that assessments of residents are always carried out and care plans are devised from these which show service user needs and how these are to be met. Letters had not been sent to residents following their assessment to confirm the home could meet their needs as is required by the Care Home Regulations. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 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 Structured care plans are in place but health, personal and social care needs are not always clearly defined so that staff can ensure these care needs are met. EVIDENCE: Residents and visitors to the home stated they were happy with the care being provided and with the staff support being given. It was observed throughout the inspection process that residents looked well kempt and well cared for and staff regularly offered support to those residents who were more dependent and required their assistance. Risk assessments were on files identifying areas of risk applicable to each resident and actions were detailed on how to manage these risks so that the safety of the resident was not compromised. Fall risks were not always confirmed in the mobility care plan to ensure staff gave full consideration to this risk when assisting the resident. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 11 All care plans contain information on how to communicate with the resident and also contain information on their past history. Clear and detailed care plans are in place but some of these had not been updated since March 05 and it was therefore not clear what the current needs were for the residents or what actions staff needed to take to address them. Two residents discussed problems with their hearing, one resident said that their hearing aid was not working properly. On viewing the records for these residents it was evident that they both had hearing aids but there was no care plan in place to address their poor hearing. Care plans should identify staff actions required to address this including the maintenance of the hearing aids. During the handover staff advised that one resident had developed a pressure area which had broken the skin. On viewing the records for this service user it was not evident that staff had developed a care plan for the management of this and the daily records did not acknowledge that there was a pressure area only that cream had been applied to the skin. It was not clear that the district nurse had been contacted to make a visit for treatment and advice. It was noted that pressure relieving cushions were in use around the home to help prevent residents from developing pressure sores. One resident stated their eyesight was poor and in the activity section of the care plan it stated they would like talking books. The resident said that they liked books but had not been able to read since losing much of their sight. There was no care plan in place to confirm this need. The manager said that this resident had not been registered blind but she would follow up this matter. Details of food and fluids taken by one resident at risk of poor nutrition were not specific so that precise amounts of food and drink taken could be established. The introduction of food and fluid intake charts was discussed. Some of the care staff within this home have received training on giving insulin injections for those residents who have diabetes. Staff confirmed that the district nurses monitor the use of the insulin and also routinely check that staff are giving this appropriately. It should be noted that the manager has acknowledged that the care plans need to be updated and also that they require further work to demonstrate that the care prescribed is actually being given. The manager had already taken actions to begin looking at care plans so that she could identify the problem areas and address these with staff. Visitors to the home said that they were kept informed of what was going on in the home as well as any matters relating to the care of their relative. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 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) 12,14,15 Service users found that the lifestyle within the home was what they expected and were satisfied with the social, religious and recreational care being provided. Service users are helped to exercise their choice over their lives. Service users receive an appealing diet but choices offered are not consistently recorded to confirm a balanced, varied and wholesome diet is being provided. EVIDENCE: During conversations with residents they confirmed they liked the home and the company of others. Each service user has a daily activity sheet in their file to confirm what activities they have participated in. Service users said that they felt there was enough activity taking place within the home each day to keep them occupied. On the day of inspection a group of residents went out for coffee which they said they enjoyed. The manager said this was a regular occurrence. One resident said that a garden party had recently been held and the manager said this had been a success in raising funds for the home. Through observation and discussions with residents it was clear that they did not mind having the two client groups mixing together ie “older people” and “dementia”. One resident said that they did not mind at all and that everyone, once you got them talking, had interesting things to say about their life. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 13 Activities being provided include arts and crafts, pottery, gardening, outside visits, croquet, keep fit, painting, brass cleaning etc. These were confirmed in care plans seen. Visitors to the home said that there was always something going on in the home and their relative was able to independently go out of the home for short walks. One resident was seen doing some colouring in the corridor “coffee lounge” area. The main lounge area had been arranged so that there were two separate seating areas giving residents the option to sit in a quieter area or near to the television. Observations confirmed that visitors are welcomed to the home and there are tea/coffee making facilities if they wish to use these near to the main kitchen area. The manager stated that she aims to allow residents as much freedom and choice as is appropriate without compromising their safety. It was clear throughout the inspection that residents feel at ease to utilise all areas of the home including the managers office. The manager stated that some residents must be allowed to do things in their own time so that they do not become stressed. She gave examples of getting dressed in their own time and going to bed in their own time even though this may sometimes be in the early hours of the morning. The manager advised that staff respect the residents choices in regard to these matters. Menus viewed in the home did not show that choices are being offered in regard to the main meal consistently. Service users said that a wide choice was available at breakfast but menus did not always reflect this. Menus also did not show that a choice of a substantial supper is being offered or that a range of drinks are available. It was noted that some of the main meal choices were very similar which would limit the choices available to the resident. The meal provided on the day of inspection looked appetising and residents said that they liked the food. One person said that “staff go to a lot of trouble to give you what you like” and they confirmed that a variety of drinks are offered throughout the day. Residents observed in the dining areas who needed assistance were being supported by staff. In addition the home used plate guards and dishes to assist the residents in eating independently. Menus have not been checked by a dietician to ensure that they are nutritionally balanced. On viewing menus, some of the choices are similar or the same food is being given several times during one week. The manager acknowledged that the menus needed to be reviewed. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 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) 16 Details of how to complain are not sufficiently clear so that service users and visitors know what process to follow. EVIDENCE: There is a complaints procedure available in the home but this has not been updated since the last inspection. The complaints procedure does not detail the name, telephone number and address of the manager and does not state that complainants can write to the Commission for Social Care Inspection. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 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, 21, 26 Service users live in a spacious and well maintained environment with sufficient numbers of toilets and washing facilities and bedrooms are suited to their needs. The home is clean, and pleasant but not all cleaning practices are considered hygienic. EVIDENCE: There are 32 bedrooms within the home, 24 of these have an ensuite shower and a toilet and the remaining eight bedrooms have an ensuite toilet and are based in the Clarence Cooper Unit. This unit accommodates the more dependent residents with dementia. The Clarence Cooper Unit has its own secure gardens but there is also a large well maintained garden with a footpath which residents can utilise from the main building. The main garden has raised flower beds to make it easier for those residents who may have mobility difficulties to reach. There are also several benches available so that residents can sit in the garden if they wish. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 16 There are 5 communal lounges plus a large corridor seating area known as “the coffee lounge”. There are two dining areas, one of which, is in the Clarence Cooper unit. On the day of inspection new dining chairs were delivered with arms to provide more comfort and safety for the residents. Residents within Bilton House are fortunate to have the choice of several seating areas and the home itself is very spacious. The manager confirmed that all room sizes complied with standards but it was noted there was no room schedule in the Statement of Purpose for the home to confirm this. On the day of inspection the home was found to be clean and tidy and there were no unpleasant odours. The carpets within the home are highly patterned. Staff confirmed that residents (in particular those with dementia) try to “step over” the patterns in the carpet. The manager acknowledged this problem and confirmed that it had already been agreed to replace one section of the carpet. Residents said that they were happy with their rooms and confirmed their rooms are cleaned regularly. There are four communal bathrooms (two on each floor) and 4 communal toilets plus all bedrooms have their own toilets. The large bathroom on the ground floor is very spacious and contains a bath and a shower but the décor in this room is not ideal in that one wall has flowered wallpaper which is not considered appropriate for those residents with a diagnosis of dementia. Staff confirmed that some residents had tried to pick the flowers off the wall. It was noted that both bathrooms on the ground floor contained toiletries with no names. In the large bathroom there was also two pairs of nail scissors and a tub of ‘Sudocream’ with no label. In the other bathroom there was a “laundry bag” containing a resident’s Sudocream as well as gloves and nappies. Personal items belonging to residents must be kept in their rooms and any toiletries/creams named so that they are not used communally and there is no risk of cross infection. There is a large laundry room with two washing machines and two driers to complete the laundry for all residents. The manager stated that the washing machines were due to be replaced so that an appropriate sluice cycle was available. The laundry was well organised with labelled baskets to ensure dirty and clean washing is kept separate to prevent any risks of infection. There are hand washing facilities for staff and both gloves and aprons are made available. Since the last inspection the manager has devised a new laundry policy so that staff are clear on the procedures that must be followed to maintain good infection control practices. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 17 There is a sluice sink within the laundry but it was established that commode pots are emptied in toilets in service user bedrooms and are then washed with bacteria cleaner in rooms. This practice is not considered to be in line with good infection control procedures and advice was given regarding this matter. The home have stated that they wish to seek further advice in regard to this matter before adopting any new procedures. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The number of staff on duty could not be established consistently to demonstrate there are sufficient numbers of staff available at all times to meet the needs of the residents. Staff are suitably trained to provide the care required by the two categories of residents within the home. The homes recruitment policies and procedures are appropriate to support and protect the residents from harm but these are not always being followed. EVIDENCE: In addition to the manager there are three assistant managers who form the management team for the home. They support a team of senior carers/carers in meeting the needs of the residents. In addition there are specific staff who are employed for cleaning and catering duties and there is an activity organiser who is employed for 5 days a week. Duty rotas detail designations of staff so it is clear what their role is within the home but due to ongoing changes on the duty rotas it was difficult to establish the number of staff on morning, afternoon and night shifts. The shift pattern for the night staff was not documented so that the hours being provided could be confirmed as sufficient. The home advised that they aim to provide five carers on duty each day plus an assistant manager and 3 night staff which complies with recommended staffing guidelines. Staff spoken to confirmed that if they worked hard then it was possible to get all of their duties done but depending on the needs of the residents there were days which were busier than others. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 19 The manager confirmed that the home had been utilising agency staff to cover shifts and their first names were written on the bottom of the rotas. It was not always clear what shift patterns these staff were working. To ensure there is an effective audit trail, full details of agency staff and the shift times worked should be indicated on the rotas. Staff confirmed that specific staff are allocated to the Clarence Cooper Unit as this unit cares for residents who have more specialist dementia care needs. Duty rotas do not show which staff have been specifically allocated to this area to confirm the staff hours being provided are suitable. The manager has taken action to address staff training on an ongoing basis which has resulted in 13 care staff achieving a National Vocational Qualification in Care (Grade II). A further 8 staff are enrolled to complete this during 2005 to aid them in providing more effective care to the residents. Once this training has been completed, most staff will have a care qualification. Staff files viewed confirmed that, in the main, appropriate recruitment checks are being carried out. Both criminal record checks and checks to see if staff names are on the Protection of Vulnerable Adults (POVA) Register had been carried out. Staff are required to complete application forms and provide evidence that they are who they say they are. Copies of passports or other photo identification was not always available. On one file there was only one character reference available as opposed to two as required. Interview notes are not currently placed on files to demonstrate that equal opportunities are being considered. One file did not contain information to confirm the person was medically and physically fit to carry out their role. One file contained a reference for a job which was not listed on their employment history suggesting this section of their application form had not been completed accurately. New staff were in the process of completing induction training in line with the National Training Organisation standards and the manager was monitoring their progress as appropriate. Statutory training such as moving and handling, basic food hygiene, first aid is being addressed on an ongoing basis and the manager has also made provision for staff to attend other training linked to the care needs of the residents. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 20 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) 31,33,37,38 The manager is both experienced and competent to manage the care home. Quality monitoring systems are not fully developed to demonstrate the home is being run in the best interests of the service users. Some of the record keeping, policies and procedures are in need of further review to demonstrate the home do what they say they do. EVIDENCE: The manager has many years experience of working with older people and holds a Higher National Diploma in Gerontology and has completed the City and Guilds Advanced Management in Care training. The manager is currently completing a National Certificate in Dementia Care which she is due to complete in October 2005. Service users were observed to be at ease when interacting with the manager and during the inspection entered the managers office freely suggesting they did not feel restricted in any way. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 21 Staff felt well supported by the manager and welcomed the extensive training provided. Discussions with residents and visitors suggested that a quality service is being provided by the home. The manager holds regular meetings with staff to discuss any matters which require attention to ensure the quality of the service and care is not compromised. The manager advised that anonymous quality surveys are in the process of being formulated and will be sent to service users and families etc once these have been completed. The manager is aware that the results will need to be published in the home along with any actions to be implemented as appropriate. The home produce a newsletter which is made available to residents and visitors and which details information about events held at the home and what activities and outings the residents have been involved in and changes to management and staff etc. The manager confirmed that only informal meetings are held with residents and therefore notes of these meetings are not kept. It was advised that notes of any future meetings are kept so that the manager can demonstrate that residents have been consulted and involved in making decisions about the home. Various records were viewed during this inspection and details of those requiring attention are detailed in each section of this report. Some of the hot water taps in the home were found to be running above the recommended guideline temperature of close to 43°C which could present a scald risk to the residents. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 22 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 2 x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 2 COMPLAINTS AND PROTECTION 3 x 2 x x x x 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 3 x 2 x x x 2 2 Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 23 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 OP1 OP23 OP37 Regulation 5 4 (1) (c) Schedule 1 Requirement The Statement of Purpose must be reviewed in line with Schedule 1 of the Care Home Regulations to ensure this on its own contains all of the required information. This is to include: * The removal of the reference to the National Care Standard Commission on the first page. *Making it clear that the home has a split registration for two catergories of care and detailing the arrangements in place for meeting the needs of these two categories of residents. This is to include details of where these residents are accommodated in the home and how integration of the two catergories is managed. *The Service User Guide must be a summary document of the Statement of Purpose and be treated as a separate document. This must contain the summary inspection report and make it clear where the full copy can be Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 24 Timescale for action 30.9.05 read within the home (this should be on display). 2. OP3 OP4 OP37 14 (1) Assessment records must be available on residents files to confirm an assessment has been carried out. Letters must be written to new service users to confirm that following their assessment the home can meet their assessed needs. 3. OP7 OP37 12 (1) (a) 15 (2) (b) The manager is to provide an action plan detailing specific dates to review each resident care plan within the home so that:Care plans fully detail the needs of the resident. Care plans are being reviewed on at least a monthly basis so that care needs are up to date. Actions required by staff to meet care needs are fully detailed. Daily records report staff actions taken to meet care needs as specified in care plans. 4. OP8 OP37 12 (1) (a) 13 (1) (b) 17 (1) (a) Schedule 3 (p) Care plans must state specific actions on how to address hearing impairments including how to manage hearing aids so that service users can have effective hearing . Prompt action must be taken to devise care plans for service users who develop pressure areas/sores. Daily records must contain sufficient information regarding the care of pressure sores and any progress or Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 25 31.8.05 30.9.05 30.9.05 deterioration as appropriate. For those residents who have poor nutrition, an appropriate nutritional assessment tool is to be devised and implemented. Details within care plans must be more specific in terms of actual food and fluid taken for those residents who require their nutrition to be monitored. The manager is to confirm if a staff competency tool is in place in regard to care staff who administer insulin and whether records are held on files to confirm this. 5. OP15 16 The registered person shall having regard to the size of the care home and the number and needs of service users provide suitable, wholesome and nutritious food which is varied and properly prepared and available at such time as may reasonably be required by service users. In this regulation “food” includes drink. To demonstrate the above, the manager must be able to show through records all meal and drink choices offered to service users. Details of supper and snacks provided also need to be demonstrated. Advice should be sought from a dietician accordingly in regard to menus being nutritionally balanced. 6. OP16 OP37 22 The Registered Person must ensure the complaints policy and procedure is reviewed in line with this regulation to include: E53 S4210 Bilton House V242676 040805 Stage 4.doc 30.9.05 30.9.05 Bilton House Version 1.40 Page 26 Who service users/visitors should approach in the first instance to make a complaint. What will happen in terms of investigating the complaint. Names, contact numbers and addresses of anyone whom the complainant is referred to. Details that any complaints received by Bilton House will be addressed by the manager within 28 days or sooner as appropriate. Include full name, address and contact number of the CSCI is detailed on the complaints procedure should the complainant wish to refer their complaint on to the Commission. (Above issue outstanding from previous inspection) 7. OP21 23 Toiletries, nail scissors, incontinence pads and underwear must not be stored in bathrooms. These are to be labelled as appropriate and stored in residents bedrooms. The arrangements for undertaking sluicing within the home need to be reviewed. The cleaning of commode pots must be undertaken in a dedicated area and not within residents bedrooms. Advice from the Infection Control Nurse should be sought accordingly in regard to washing and drying of commode pots. Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 27 31.8.05 8. OP26 13 (3) 16 (2) 31.10.05 The manager is to confirm a date for the washing machines to be exchanged for ones with an appropriate sluice cycle. 9. OP27 OP37 18 (1) (a) 17 (2) Schedule 4 (7) The manager must be able to demonstrate that sufficient staff are on duty at all times. The following matters are to be addressed. A review of duty rotas to contain:Full details of agency staff including full names and the shifts worked. Shift patterns of night staff. Details of which day staff are working on the Clarence Cooper Unit. Details of any hours allocated to non caring duties such as laundry so that specific care hours being provided can be calculated and deemed as sufficient. In addition changes made to the original duty rota must be legible. The manager is also to confirm when care staff vacancies have been filled. 10. OP29 OP37 7,9,19 Schedule 2 Staff files must contain all of the required recruitment information consistently. Records must be closely scruitised to ensure any discrepancies are identified and resolved as appropriate. This includes: 31.10.05 31.8.05 Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 28 Clear photo identification. Two written references (one from last employer). Checks to ensure employment histories are fully documented. The manager must be able to demonstrate that equal opportunities is being practiced during recruitment of staff (it is advised that interview notes are kept). 11. OP33 24 The registered person shall establish and maintain a system for reviewing at appropriate intervals, and improving, the quality of care provided at the care home. The registered person shall supply to the Commission a report in respect of any review conducted and make a copy of the report available to service users. The manager must ensure that any system implemented allows for consultation with service users and their representatives. The manager is to confirm a date for implementation of the anonymous quality questionnaires. 12. OP37 37 The manager must ensure that all accidents are reported to the CSCI as detailed in this regulation. 30.9.05 31.10.05 13. OP38 13 (4) The manager is to take action for 31.8.05 hot water outlets to be retested to ensure these to do not present a scald risk to residents. (The recommended guideline is Version 1.40 Page 29 Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc close to 43°C). 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 OP8 Good Practice Recommendations It is recommended that the home implement the use of body charts which can be used to identify any wounds to residents including pressure sores. These should also include the dates of injuries and provide a description of them. It is recommended that the cook devise menus over a block period so that meals can be planned ahead and to enable them to be viewed by a dietician to confirm they are both wholesome and nutritious as appropriate. The physical design and layout of the premises to be used as the care home must meet the needs of the service users. The manager is therefore advised to review the patterned wallpaper in the bathroom to help prevent the service users with dementia display symptoms of confusion. It is advised that the replacement of highly patterned carpets to plain carpets within the corridors is built into any long term plans for refurbishment of the home. 2. OP15 3. OP19 Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 30 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Bilton House E53 S4210 Bilton House V242676 040805 Stage 4.doc Version 1.40 Page 31 - 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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