Inspection on 13/07/09 for Bishop`s Court

This inspection was carried out on 13th July 2009.

CQC 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 CQC 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 13/01/09

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 12/01/06

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 25/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Bishop`s Court Sefton Park Care Village Sefton Park Road Liverpool Merseyside L8 3SL Lead Inspector Trish Thomas Key Unannounced Inspection 13 July 2009 8:00 DS0000059340.V376230.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bishop`s Court Address Sefton Park Care Village Sefton Park Road Liverpool Merseyside L8 3SL 0151 291 7800 0151 291 7801 bishopscourt@europeanwellcare.com 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 Manager post vacant Care Home 41 Category(ies) of Dementia (41) registration, with number of places Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of service users who can be accommodated is: 41 Date of last inspection 13 January 2009 Brief Description of the Service: Bishop’s Court is a care home in a busy suburb of Liverpool and is registered as a home for forty-one people who have dementia. The building is modern, purpose built and provides ground floor accommodation. Bishop’s Court has pleasant grounds, parking facilities and a courtyard garden. Residents have single bedrooms, twenty-two having en-suite facilities. The home is close to Liverpool city centre, to local shops and public amenities. It is owned by European Wellcare Homes Limited. The fees per week in Bishop’s Court range from £500.00 to £614.71. Bishop`s Court DS0000059340.V376230.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 two stars. This means that people who use this service experience good quality outcomes. This visit was just one part of the inspection. Before the visit took place we (the commission) asked the manager to complete a questionnaire that we call an Annual Quality Assurance Assessment or AQAA for short. It gives us information about how the home is meeting the needs of the people who use the service and includes future plans for further development. Surveys were also made available to people living in the home and staff to find out their views. During our visit, we walked round the home and we checked various records to see what care people living there receive. We used a system called “case tracking”. This is a way of inspecting that helps us to look at services from the point of view of some of the people who use them. We track people’s care to see whether the service meets their individual needs. We spoke with people who live at the home and they told us what they thought about it. We also spoke with staff who gave us their views about Bishop’s Court. We have included their views throughout the report. References to “we” or “us” in this report represent the Care Quality Commission. What the service does well: Visitors we spoke with were satisfied with the service in Bishop’s Court, describing staff as “marvellous” and “brilliant”. They said that staff are quick to give support as people need it and are calm when helping those who may become agitated. People who live in Bishop’s Court told us their home is comfortable and clean. One person said they like to go outside in good weather and it is easy to get out to the garden and inside again, which is very nice. Observation during the visit and the records we read showed us that people are benefiting from aromatherapy sessions, poetry readings and an improved activities programme. There was good evidence that people who wish to follow their chosen beliefs have visits from religious ministers and are encouraged to stay in touch with local communities of the same faith. Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: A full assessment of people’s needs and choices must be completed before they move into the home. This will help staff to plan how they intend to support the person successfully. The service user guide should be reviewed and consideration given to including pictures and larger print. This will make it easier for people to read and understand as much as possible about the service they can expect to receive. Short term care plans should be put into place whenever a person develops a short term health need, such as an infection. This will help to ensure all staff have clear guidance to follow for as long as this support is needed. Care plans should clearly highlight the dates people need medical intervention, such as with a continence aid. This will help to ensure people get the support they need in a timely manner. The manager should monitor care records to ensure that they are legible at all times. This will help to ensure clear information about the person and the support they need is readily available. Advice should be sought on further adapting the environment at Bishop’s Court to support the people living there to find their way around more easily. Once this advice is obtained a clear plan should be put into place for implementing it within set timescale. Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 7 Staff need to make sure that noise from the laundry does not disturb people in nearby bedrooms. This will help to ensure the atmosphere is relaxed and people’s comfort and wellbeing in their home is being supported. Where a concern is raised regarding staffing matters, records should be clear as to whether these were investigated and any outcome. This will help to ensure that a clear audit trail is available if needed in the future. Staff should make sure that personal allowance accounts are updated as soon as money is transferred or given to the person. This will help to ensure that people’s money is correctly accounted for at all times. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Bishop`s Court DS0000059340.V376230.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 Bishop`s Court DS0000059340.V376230.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The correct admissions process is not always being followed by staff who carry out assessments, which could mean that people’s care needs may not always be identified before they move in to Bishop’s Court. EVIDENCE: Before anyone first moves into Bishop’s Court, senior staff meet with them and carry out an assessment of their needs. We looked at assessments for two people who had recently moved into the home. Staff are currently using a pre printed assessment form that covers a number of different areas of the person’s support needs and their lifestyle choices. We found that some of these sections had been completed. This included information on the person’s health history and some of the areas of their health and personal care that Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 10 they needed support with. However other sections such as those on behaviour and how people communicate had not been fully completed and nor had the declaration regarding whether or not the home would be able to meet the person’s needs. The manager advised that they do not find the current forms suitable for assessing the needs and choices of people considering moving into the home and told us that they intend to review these. However, in not fully documenting information about all areas of people’s support needs and choices, staff may not have sufficient information available to support the person in a way that is both safe and meets their needs and choices. As some of the people who are considering moving into Bishop’s Court may not be able to communicate their feelings verbally, it is particularly important that as much information about them as possible is obtained and recorded. This will help staff to plan how they will successfully support the person. Information about the home and the service it provides is made available to anyone considering moving in and their relatives via a service user guide. However, this is written in small print which may make it difficult for people to read and understand. The addition of photographs and pictures and the use of larger print may make it easier for people to read and therefore understand more about the service they can expect. Bishop’s Court doe not provide an intermediate care service and standard 6 was not assessed. Bishop`s Court DS0000059340.V376230.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in Bishop’s Court have their needs met and their care is provided in a manner that protects their privacy and dignity, although some improvements could be made to make sure that staff always have the guidance they need to support people properly. EVIDENCE: Visitors we spoke with told us that they are happy with the care and support staff at Bishop’s Court provide for their relatives. One person described staff as “brilliant”, explaining that they are quick to offer people support with their personal care and that they are always calm when supporting people who may be challenging. Another relative described staff as “marvellous” again telling us that she had observed staff taking their time when offering support. Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 12 We examined care plans and records for six people who live at Bishop’s Court. Care plans contain a series of assessments for the person relating to their health and personal care. This includes assessments of their skin condition, moving and handling needs, and nutrition. Where an assessment finds that the person is at risk then a care plan is in place to guide staff on how to minimise that risk and support the person safely. These assessments and care plans are reviewed regularly which helps to ensure that any changes to the person’s health or their support needs can be quickly identified and dealt with. Nurses at the home are taking part in a pilot scheme with the local Primary Care Trust with regards to wound care. This has involved them attending training and completing new documentation. We looked at records for one person who had developed a wound and noted that staff were following guidance, completing records fully and ensuring equipment was in place, as needed. This again helps to ensure that people are receiving care that is in line with current best practice and that will support them with their health care needs. Good practice was noted in that short term care plans had been put into place to deal with the recent heat wave and support people through this. In addition a senior member of staff was able to explain the action plan they had put into place to deal with a possible flu outbreak. This included ensuring extra protective clothing and cleaning products were available in the home. We looked at records for one person who had recently needed antibiotics. These showed that staff had quickly noted an issue with the person’s health and sought appropriate advice. However no short term care plan had been written for supporting the person through this. A short term plan would help to ensure all staff are aware of the issue and had clear guidance to follow. We also noted that one person had a continence aid that needs to be changed every few weeks. The manager was aware of the date for this but we could find no record in the care plan. This should be clearly recorded so that all staff will be made aware of the support the person needs and can take responsibility for ensuring they get this support within the relevant timescale. We looked at a sample of medication records and storage in the home. We found that medication is stored correctly and that records are well completed. Senior staff carry out an audit of medication management within the home. This all helps to minimise any errors in dealing with medication, which could adversely affect people’s health. The manager confirmed to us that a protocol is in place for the handling and recording of prescribed external preparations (e.g. creams) to help ensure they are safely used as prescribed. The procedure now followed in Bishop’s Court is that only nursing staff will apply and record the application of prescribed creams for each person. This will provide continuity and avoid the risk of applications being overlooked and skin conditions not being treated properly. The manager explained that in instances where medication has been refused, this is recorded on the Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 13 medication administration record and the person’s doctor informed so that any resulting adverse effects can be addressed and the person’s welfare protected. Bishop`s Court DS0000059340.V376230.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Social activities and meals are both well managed so they daily variation and interest for people living in the home. EVIDENCE: An activities coordinator has been employed to work at Bishops Court thirty five hours a week. There are aromatherapy sessions for people twice weekly and a weekly visit from the local librarian who holds poetry and reading groups. Ministers from the local Church of England visit weekly and hold a service in the home with singers and the manager advised they have had Roman Catholic services in the home also. There is evidence that people of other faiths and races have their spiritual support needs met and are encouraged to stay in touch with their local community. One of the people living at Bishop’s Court told us that they enjoy the activities arranged by the home and particularly enjoy the outings they go on with staff. Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 15 A series of photos on the wall showed that people have been out on day trips, had entertainers visit the home and taken part in ‘great tea party’ to which members of the local community came. The different activities offered for people helps to lessen the risk of them becoming bored and losing community contact whilst living at Bishop’s Court. During our visit we met several visitors to the home. In discussions with a couple of them they told us that they are able to visit at any reasonable time and are always made welcome. We observed that people can see their visitors either in communal areas or in the privacy of their room, as they prefer. Meals are prepared and sent to Bishop’s Court from the main adjoining kitchen, which also supplies other homes on the site. The chef was able to explain how he caters for different diets, and confirmed that he is able to obtain advice and produce to meet the needs of people who may have different cultural or religious dietary requirements. A ‘lite bite’ menu is displayed on the notice board. This is in picture format to make it easier for the people living there to understand. This menu advises that snack and light meals are available twenty four hours a day, should people require them. Conditions in the dining room were pleasant and relaxed during our visit and people were choosing from a breakfast menu of cooked breakfast and toast. There was a choice of breakfast cereals available also. The cooked breakfast had been prepared in the main kitchen and was being served from a heated trolley. There were staff in the room to support people who needed help with their food and a designated dining room assistant preparing drinks. People were also being served breakfast in their bedrooms by choice. Bishop`s Court DS0000059340.V376230.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are complaints and safeguarding procedures for Bishop’s Court, which are understood by staff so that people living at the home have their concerns listened to and are protected from harm. EVIDENCE: We found that there are good procedures so people who live in Bishop’s Court and their representatives can express their concerns and be listened to, their rights are protected and they are safeguarded from abuse. The complaints procedure is displayed in the foyer and records of complaints and action taken are kept in the home. We have not received any complaints or safeguarding referrals about Bishop’s Court since our last visit to the home. Staff who we spoke with during our visit understood safeguarding procedures and had received updated training in this recently. This helps to make sure they know what to do to protect the people living in the home from harm and abuse. Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Bishop’s Court is comfortable, hygienic and well maintained, however the environment lacks the orientation aids needed to support and stimulate people who have dementia. EVIDENCE: We walked around the building, spoke with people who live in the home and domestic staff. The home has been decorated throughout in the last two years and furnishings and floor coverings have been replaced. People told us they like their bedrooms and that the dining room and lounges are brighter and more homely. The courtyard is now in good condition and is easy for people to get to, as they were seen going in and out to enjoy the fine weather. There is Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 18 now a sensory garden with canopy and seating, which provides another relaxing outside area for people to use. Some orientation adaptations have been provided in the home to support the people living there. This includes the use of clear picture signs on bathroom and toilet doors. However there is a lot of best practice guidance available regarding how environments can be adapted in an adult way to support people who have dementia to understand and find their away around more easily. In discussions with a senior manager from the organisation she explained that the company have experts in caring for people with dementia who will be able to offer them advice on the environment and adaptations that can be made. There are adaptations available throughout the home to support people with their mobility and personal care. These include bath chairs, hoists and grab rails. In addition people have access to call bells that they can use to summon help from staff. During our visit, we saw that these were answered quickly by staff. The building was clean and odour free during our visit and people told us staff work hard to keep it that way. We saw plenty of cleaning materials being stored safely and domestic staff told us there are systems and training for infection control to ensure the home is safe for people who live and work there. Staff told us that toilets are checked every two hours and cleaned if necessary, to make sure they are hygienic for people to use. Most of the people we spoke with said their home is “ok” and “comfortable” and people were spending time as they chose. We were told by one person who was in their bedroom that the music constantly playing in the nearby laundry was a disturbance. Staff should make sure that people are not disturbed through the noise from utility areas, as Bishop’s Court is primarily a home and people should have a choice of when they will listen to the music they like. Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Bishop’s Court receive care and support from staff who have been vetted and have the skills to make sure that people are supported properly and safely. EVIDENCE: During our visit we noted that staff provide support to people quickly and discreetly when needed. We also observed that staff have built good relationships with the people living at Bishop’s Court and had a good understanding of their support needs. One relative described staff as, “marvellous” and another explained that she observes them taking time to “sit and chat” with people and that they are “good to them all”. We looked at personnel files for a number of staff who work within different roles at Bishops Court. We found that before anyone new starts work in the home a series of checks are carried out on them. These include obtaining written references, checking with the protection of vulnerable adults register and obtaining a Criminal Records Bureau check. A member of staff has spent some time checking that staff files for longer standing members of staff Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 20 contain all the required information. Where gaps are identified he is in the process of writing to people to ensure the information is provided. This is being closely monitored to ensure information is available within a tight timescale. These checks and required information help to ensure staff are suitable to work with people who may be vulnerable. Training records and discussion with some of the staff team showed that staff are receiving training in a variety of areas. This includes areas of basic care practice such as moving and handling people and safeguarding adults, as well as more specialist areas such as supporting people who have dementia and dealing with pressure sores. Good practice was also noted in that staff are receiving training in new legislation that applies to supporting the people who live at Bishop’s Court. For example staff have attended training on the Mental Capacity Act and the Deprivation of Liberty safeguards. This training all helps to ensure that staff are up to date with current best practice and legalisation in supporting people safely and well. We saw a copy of concerns raised by a member of staff about a staffing issue. Although the manager was able to give a clear explanation of the action that was taken regarding this, no formal record was available on file. In order to provide a clear audit trail in the future it is important that any concerns raised are clearly documented along with the action taken to deal with them and any outcome that results. Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Bishop’s Court is being run in the best interests of people who live there so their welfare is promoted and protected. EVIDENCE: The manager told us she is due to submit her application to be registered with the Care Quality Commission. Staff told us they are well supported by management and that there is a good teamwork in the home. The manager was able to discuss the improvements she has made since taking up her post and of her plans for the future development of the home. Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 22 Records and certificates we saw showed that regular checks are carried out on the building and equipment. This includes checking the electrics, bed rails, fire safety equipment and water temperatures. These checks help to ensure that Bishop’s Court is a safe place for people to live, work and visit. To check that people’s financial interests are protected, we looked at how people’s personal allowances held in safe keeping are managed in Bishop’s Court, by checking the records for two people. A running total of debits and credits to each person’s accounts is kept, having two signatures to each transaction as a safety measure. The accounts are audited every week by the manager and regularly by head office to ensure they are properly maintained. One account we looked at did not balance because money had been taken out of safekeeping for a purchase, but had not been recorded or signed for and the total amount had not been changed. On informing the manager, the error was corrected without too much delay. Staff need to ensure they follow procedures and keep these accounts up to date so that all monies can be accounted for in records. There are a number of systems in place at Bishop’s Court to check the quality of the service they provide. This includes audits carried out by the management team on medication and care plans. These internal audits provide a clear way for senior staff to quickly note and deal with any issues that may arise. Surveys had been sent out to relatives of the people living at Bishops Court. Although no overall summary of the results of these had been compiled, as yet, the manager was able to give a good explanation of the action she had taken to deal with any issues that were raised. These surveys provided a formal way for representatives of the people living at Bishop’s Court to comment on the support people receive and help to plan future improvements. Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 23 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement A full assessment of people’s needs and choices must be completed before they move into the home. This will help staff to plan how they intend to support the person successfully. Timescale for action 27/08/09 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 OP1 Good Practice Recommendations The service user guide should be reviewed and consideration given to including pictures and larger print. This will make it easier for people to read and understand as much as possible about the service they can expect to receive. Short term care plans should be put into place whenever a person develops a short term health need, such as an infection. This will help to ensure all staff have clear guidance to follow. 2 OP7 Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 25 3 OP7 Care plans should clearly highlight the dates people need medical intervention, such as with a continence aid. This will help to ensure people get the support they need in a timely manner. The manager should monitor care records to ensure that they are legible at all times. This will help to ensure clear information about the person and the support they need is readily available. Advice should be sought on further adapting the environment at Bishop’s Court to support the people living there to find their way around more easily. Once this advice is obtained a clear plan should be put into place for implementing it within a set timescale. Staff need to make sure that noise from the laundry does not disturb people in nearby bedrooms. This will help to ensure the atmosphere is relaxed and people’s wellbeing in their home is being supported. Where a concern is raised regarding staffing matters, records should be clear as to whether these were investigated and any outcome. This will help to ensure that a clear audits trail is available if needed in the future. The manager of Bishop’s Court should apply for registration with the Commission for Social Care Inspection, as required by the Care Standards Act 2000. Staff should follow procedures by making sure that personal allowance accounts are updated as soon as money is transferred or given to the person. This will help to ensure that people’s personal money is accounted for at all times. 4 OP7 5 OP19 6 OP19 7 OP29 8 OP31 9 OP35 Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 26 Care Quality Commission North West Region Citygate Gallowgate Newcastle upon Tyne NE1 4WH National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Bishop`s Court DS0000059340.V376230.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!