Inspection on 12/01/06 for Bishop`s Court

This inspection was carried out on 12th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bishop`s Court 13/07/09

Bishop`s Court 13/01/09

Bishop`s Court 17/10/08

Bishop`s Court 01/07/08

Bishop`s Court 14/04/08

Bishop`s Court 08/06/07

Bishop`s Court 29/06/06

Bishop`s Court 17/11/05

Bishop`s Court 27/07/04

Bishop`s Court 10/05/04

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

CARE HOMES FOR OLDER PEOPLE Bishop`s Court Sefton Park Care Village Sefton Park Road Liverpool Merseyside L8 3SL Lead Inspector Andrea Morris Unannounced Inspection 12th January 2006 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 Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 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. Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bishop`s Court Address Sefton Park Care Village Sefton Park Road Liverpool Merseyside L8 3SL 01512917800 02077248686 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) European Wellcare Homes Ltd Sandra Watkins Care Home 41 Category(ies) of Dementia - over 65 years of age (41) registration, with number of places Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named person under 65 years old may be accommodated The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 17 November 2005 Date of last inspection Brief Description of the Service: Bishops Court is situated in a busy suburb of Liverpool. The home is registered for 41 residents’ who suffer from Dementia. The building is modern and has secure gardens; which are maintained to a good standard. Residents’ have access to all parts of the building, all of which is at ground level. The home is continuing developing its Person Centred Care approach as its main philosophy of care. All residents’ have their own private room, 22 of the rooms have an en-suite facilities. Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours. The inspector spoke to residents’, staff and the acting manager. A tour was made of the home, various forms of documentation was examined including residents’ files, staff files, certificates relating to Health and Safety and the fire training records. What the service does well: What has improved since the last inspection? What they could do better: There are still carpets needing to be replaced so to ensure all rooms are odorous free. Money held in the home needs to be organised to ensure money held for residents’ is separate from money needed as petty cash for the homes purpose. The home must ensure all facilities are maintained to a good standard, bathroom taps were found not to have running hot water and one tap was constantly running. All bathroom areas must have call bell system so to ensure residents’ safety is maintained. Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 6 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. Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 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 the following standard(s): 1, 2, 3, 5, 6 Residents’ are only admitted to the home following a full assessment of their needs has been made. This ensures the residents’ safety is maintained. EVIDENCE: The statement of Purpose has been up dated identifying the change in management. Every resident who enters the home is issued with a written contract that clearly states the terms and conditions. The manager or suitably qualified person carries out a pre-admission assessment on all residents’ wishing to enter the home. Any prospective resident can visit the home, no appointment is needed and if they wish they can stay for a few hours or a meal at no extra cost. Families are also encouraged to visit the home if they choose to do so. The home does not provide intermediate care. Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Medication is organised well this ensures the safety and well being of all residents’. However, risk assessments are not being reviewed on a regular basis this could lead to residents’ welfare being compromised. EVIDENCE: Individual care plans are created for each resident, they cover all aspects of health, social and personal care. A selection of care files were examined and they were found to have the relevant care plans in place. However, it was evident that not all risk assessments were being reviewed and this must happen to ensure residents’ safety is maintained Medication was checked and it was found that all residents’ medication was correct. Stock levels were appropriate and all medication was dated on opening. This practice safeguards residents’ from harm. The treatment room was found to be well ventilated and all fridge and room temperature recordings were up to date. During the tour it was witnessed that residents’ were treated with respect. Staff ensured that residents’ dignity was maintained at all times. Residents who spoke with the inspector stated they felt they were listened too and their feelings and decisions were respected. Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 10 Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Activities are planned in conjunction with the residents’ likes and preferences. They assist with promoting choice and cultural satisfaction. EVIDENCE: The home employs an activities organiser 21 hours per week. The home has maintained its contact with the Alzheimer’s Society, who provides both training and guidance in Dementia care. The home displays the monthly activity plan on the notice board and a daily notice is displayed in both picture and word form for the residents’. The home has its own mini bus; which is regularly used to take residents’ on outings. The home operates an open visiting policy. The home encourages all residents’ to maintain contacts with the local community. Residents’ meetings are held on a 2 monthly basis. This enables residents’ to express their opinions. Menus were examined; the rota runs over a four weekly cycle. The option for finger food is available upon request. Menus are displayed daily on the notice board. Alternative choices are available if any resident doe not wish to have the recorded option. The manager is currently making displays for picture format of the daily menu so to assist residents’ in making appropriate choices. Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 12 Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home has an adequate complaints procedure, which helps safeguard and protect residents’ from harm. EVIDENCE: The homes complaint procedure is displayed in the entrance area. It is clear and concise. Information on how to contact the Commission for Social Care Inspection is displayed also. There have been no complaints to the Commission for Social Care Inspection since the last inspection. All complaints received into the home are documented along with the outcome. Residents’ stated they felt they were listened to, and staff did respond to requests or concerns raised. The home carries out internal adult protection training by the aid of a training video. The staff complete a questionnaire enabling knowledge to be checked. All staff have received this form of training since the last inspection. The manager identified that staff will receive adult protection training on a rolling training programme. All new staff receives adult protection training during their induction period. Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 26 The home must ensure the environment is safe and the environment is maintained to a good standard so to ensure the safety of the residents’ is maintained. EVIDENCE: Generally the environment is maintained to an adequate standard. However there is still some carpets still requiring renewing due to them being odorous. Re-decoration has been completed in the corridors of the home; rooms are redecorated on an ongoing basis During the tour of the home it was noted that a hot water tap in one bathroom was not warm, a request was made during the inspection for this to be fixed. Another bathroom was found to have a hot water tap that did not turn off. One toilet was also found to not have a call bell cord available. The home has adequate supply of hoists that are regularly serviced and are maintained to a good standard. Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 15 It was noted during the tour that the majority of residents’ rooms had been personalised. The staff encourages residents’ to bring in small personal items so to make their environment as homely as possible. New bedding has been purchased for all the bedrooms, the lounge area was found to be comfortable and relaxing. The dining room furniture was found to be in need of replacing as it is badly marked. The home operates an internal training programme so to ensure all staff receives the compulsory training so to ensure residents’ are cared for appropriately. Records for all staff training are maintained to a good standard. Training is also accessed through outside professionals such as Continence advisory, Alzheimer’s Society. Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The homes’ recruitment procedure is still not adequate this puts residents’ at risk. EVIDENCE: Duty rotas were examined and it was noted that all shifts were covered with no need for agency staff. A selection of staff files was examined; although there has been some improvement from the last inspection there is still information missing, this must be addressed so to ensure residents’ are safe. Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38 The home needs a permanent manager to be appointed so to ensure the running of the home is maintained to a good standard. EVIDENCE: The home is currently being run by an acting manager, an application to register a manager is needed to be made to ensure the running of the home is maintained to a good standard. Staff and residents’ both stated they felt supported by the current acting manager. Staff and residents both said they felt the acting manager was approachable and supportive. Residents’ stated they were able to choose how they spent their day. Evidence was seen of staff assisting residents’ to their preferred place i.e. bedroom or alternative living area. Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 18 The home holds only money in small quantities for residents’ however on checking the finances that were in the home they were found to be mixed up and did not match the documentation. All staff are currently receiving supervision, the acting manager is leading these sessions. Certificates relating to Health and Safety were examined along with fire documentation. All were found to be in date and appropriate. Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 19 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 3 3 N/a 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 N/a DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 N/a 18 3 2 3 2 3 N/a 3 N/a 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 2 3 3 3 Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP19 Regulation 15(2)(b) 23(2)(b) Requirement The registered person shall keep the residents’ care plan under review. The registered person shall ensure the premises are kept in a good state of repair. Bathroom taps to be working appropriately at all times. The registered person shall keep the home free from offensive odours. The registered person shall not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraphs 1 to 7 of schedule 2 of the National Minimum Standards. The registered provider shall appoint an individual to manage the care home. The registered person must ensure residents’ money is deposited appropriately for safekeeping and records are maintained to a high standard. Timescale for action 31/01/06 31/01/06 3 4 OP26 OP29 16(2)(K) 19(1)(a) 31/03/06 15/02/06 5 6 OP31 OP35 8(1) 16(2)(l) 28/02/06 28/02/06 Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bishop`s Court DS0000059340.V277818.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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. 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