Inspection on 17/11/05 for Bishop`s Court

This inspection was carried out on 17th November 2005.

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

The inspector 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 12/01/06

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 17th November 2005 09:00 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.V277861.R01.S.doc Version 5.0 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.V277861.R01.S.doc Version 5.0 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.V277861.R01.S.doc Version 5.0 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 27th July 2004 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 seven years old, with secure gardens, which are well maintained and cared for. Residents’ have access to all parts of the building, which is at ground floor level. An activities organiser is employed in the home for 21 hours per week to engage residents’ in activities of their choice and preference. The home is developing Person Centred Care, as a philosophy to care for the residents’ in the home. All residents’ have their own private room, 22 of the rooms have en-suite facilities. Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 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 members, student nurse and the manager. A tour was made of the home, and documentation was examined including resident’s files, staff files, policies and procedures, certificates relating to Health and Safety, and fire safety records. What the service does well: What has improved since the last inspection? What they could do better: The staff must ensure risk assessments are completed for each resident. There is also urgent need for the odorous carpets to be replaced. Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 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.V277861.R01.S.doc Version 5.0 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.V277861.R01.S.doc Version 5.0 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, 4, 5, 6 Residents’ are only admitted following a full assessment of their needs; this protects residents’ safety and interests. EVIDENCE: The home has a detailed Statement of Purpose and Service User Guide available to all. All residents who are admitted to the home have a copy of the terms and conditions, these are concise and clearly written. The manager or suitable designated person carries out a pre-admission assessment to ensure the needs of each individual can be met. Potential residents’ are encouraged to visit the home if appropriate, they can stay for a period of a few hours at no extra cost; including staying for a meal at no extra cost. The home keeps a record of all professional personnel visiting the home in relation to residents’ care. The home has close links with the local hospital; they access support if needed in relation to Dementia care advice. The home does not provide intermediate care. Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 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, 11 Care plans are reviewed monthly to ensure care carried out is appropriate. Risk assessments are not up to date and therefore could put residents’ at risk. EVIDENCE: Individual care plans are in place, all aspects of personal, nursing and social care is included. Evidence was seen that care plans are being reviewed on a monthly basis. Risk assessments are not complete and some residents’ do not have the risk assessments required as per care plan documentation indicates this puts residents’ at risk. The manager stated that wherever possible residents’ and their families are included in the care planning process. Residents’ privacy is respected at all times; residents’ can receive their visitors in private. The Company has just reviewed its policies and procedures, where required policies have been renewed. Medication stocks are well managed. The returns book was found to be up to date and well documented. However, it was evident that not all medication administered had a signature. There were also no dates recorded when Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 Page 10 medication kept in the fridge had been opened therefore putting residents’ at risk. Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 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 The activities within the home are well documented ensuring residents’ lead interesting and diverse lives if they choose to do so. EVIDENCE: Activities are planned in relation to the client group. The home employs an activities organiser for 21 hours per week. The home has made contact with the Alzheimer’s Society; they provide the home with support and training to assist in meeting the needs of the residents’. The home has access to a mini bus, which it shares with its sister home. This enables residents’ to enjoy many outings. On admission to the home relatives receive a questionnaire; this addresses the preferences and social history of the resident. This information is used in planning activities within the home. Activities are well documented in a separate file and reviews maintained. The home has an open visiting policy; they have contacts with the local community including the local church, which visits on a weekly basis. The menu is displayed on the dining room notice board. Individual preferences are catered for if residents’ wishes are different from the menu. The lunchtime meal was observed. The meal was presented well and residents were not hurried. The menu has been adapted to include finger food. Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 Page 12 Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 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, 17, 18 The home has a robust complaints procedure, which helps safeguard, and protect residents’. EVIDENCE: The home has a robust complaints procedure, which is clear and displayed in the reception area on the wall. Minor complaints are recorded in a book and action taken is also documented with the complaint. There have been no complaints to the Commission for Social Care Inspection. All residents’ are registered on the Electoral Roll. Any resident who wishes to vote can do so through either by attending the local polling station or through the postal voting system. Families are encouraged to participate so to ensure residents’ rights are protected. The Adult Protection policy is adequate; staff receive training in adult protection during their induction. Some staff have received additional training in adult protection. The home is in receipt of the Liverpool Adult Protection Guidelines Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 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, 23, 24, 25, 26 There has been improvement to the decoration, however the malodorous carpets need replacing to ensure the home remains comfortable for all living in it. EVIDENCE: The homes’ corridors are currently being redecorated to show colour coding so to help orientate residents’. The communal areas have evidence of reminiscence scenes, they are relating to the area of where they are placed. During the tour of the home it was noted that many of the residents’ rooms had been personalised to provide a homely effect. There are several bedrooms that require carpets to be replaced as they have been cleaned but still remain odorous. The manager has submitted a request to senior management for replacement carpets to 13 rooms. The home has introduced picture format as well as written format to assist residents’ in identifying key areas in the home i.e. dining room, lounges and smoke room. Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 Page 15 Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 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 Staff files did not contain information to prove staff had been POVA (Protection of Vulnerable Adults) checked, this could prevent residents’ safety being protected against abuse. EVIDENCE: The home is well staffed, rotas were examined and it was noted that all shifts were appropriately covered. 50 of care staff has completed their NVQ2 training, and a further course is currently being run. The company cover all aspects of mandatory training, and provide regular training to the staff within the home. The home also has access to training from outside agencies such as Alzheimer’s’ Society, District Nurses and other health care professionals. A selection of staff personnel files were examined, not all information was contained within the files, POVA (Protection of Vulnerable Adults) was not evident, and one file did not contain any references. This information is required to ensure protection of residents’. Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 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, 36, 37, 38 The home is well organised, there is a strong sense of leadership, ensuring that staff are well directed to provide high quality care to residents’. EVIDENCE: The home has just appointed a new manager, the manager has been in post for 4 weeks, and an application to register has been submitted to the Commission for Social Care Inspection. The manager has completed the Registered Managers Award and NVQ4 earlier this year. Staff who spoke to the inspector stated that they felt they found the manager approachable and eager to develop the home further. Staff stated they have all received formal supervision sessions, appraisals are currently being held for all staff. There are regular meetings held to allow both residents’ and relatives and staff the opportunity to express their concerns and points of view. The home has up to date certificates relating to Health and Safety. Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 Page 18 There was evidence of staff receiving regular fire drills along with fire training sessions. Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 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 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 3 3 3 3 3 2 3 3 Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 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 Standard OP7 Regulation 13 (4) Requirement The Registered Person shall ensure that unnecessary risks to the Health and Safety of residents’ are identified and so far as possible eliminated. The Registered Person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. 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. The Registered Person shall ensure that the persons working at the care home are appropriately supervised. Timescale for action 12/12/05 2 OP9 13 (2) 01/12/05 3 4 OP26 OP29 16 (2) (k) 19 (1) (a) 31/12/05 12/12/05 5 OP36 18 (2) 12/12/05 Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 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. 1 Refer to Standard OP18 Good Practice Recommendations It is strongly recommended that all staff receive POVA training additional to induction training. Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 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. Extracts may not be used or reproduced without the express permission of CSCI Bishop`s Court DS0000059340.V277861.R01.S.doc Version 5.0 Page 23 - 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. 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