CARE HOMES FOR OLDER PEOPLE
Bishop`s Court Sefton Park Care Village Sefton Park Road Liverpool Merseyside L8 3SL Lead Inspector
Trish Thomas Unannounced Inspection 8th June 2007 10:00 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.V342450.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bishop`s Court DS0000059340.V342450.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 vacant post Care Home 41 Category(ies) of Dementia - over 65 years of age (41) registration, with number of places Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Three named people 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 One additional named resident requiring palliative care under the age of 65 years 14/02/07 Date of last inspection Brief Description of the Service: Bishops Court is situated in a busy suburb of Liverpool and is registered for forty-one residents’ who have been assessed with dementia. The building is modern, purpose built and provides ground floor accommodation. Bishops Court is surrounded by pleasant grounds and has a secure courtyard garden. Residents have single bedrooms, twenty-two having en-suite facilities. Bishops Court is close to the city centre and all local shopping and public amenities. Fees for placements are agreed with the placing authority and in general are dependant upon the assessed needs of people who are placed. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over a six hour period and the methods used were, discussion with residents, the manager, Mrs. Jill Sinclair and staff, and touring the premises. A sample of records maintained in Bishops Court regarding care practice, health & safety and staffing were read. What the service does well:
Bishops Court is a purpose built care home with surrounding gardens, a car park and central courtyard garden. There is level access to the building at the front and to the courtyard, from the corridor. There is a pleasant reception area with adjoining office. The home is registered for people who are assessed with dementia and exits are protected with keypads to ensure their security. Residents’ diversity is respected as their religious beliefs are recorded on their care plans and action taken to address their wishes and preferences. It is stated in the service user guide, that local clergy visit the home regularly to provide religious services and communion. Bishops Court service user guide states that residents’ family and friends are encouraged to visit regularly and maintain contact by letter or telephone when visiting is not possible. This document also gives details of arrangements for getting in touch with advocacy services and this would be arranged for residents who have no family contacts. Bishops Court has a procedure for managing residents’ medication. The storage area was visited and medication administration sheets were read. Drugs are stored in a locked room and the storage arrangements were satisfactory. There are systems in place for the auditing of drugs, management of controlled drugs, and for the return of unwanted medication to the pharmacy. There is a range of leisure facilities and equipment on offer. The home’s brochure states, “Regular and varied activities are arranged including games, musical afternoons and visitors from entertainers. The company’s own fleet of mini buses are used for regular outings.” Residents of Bishops Court have use of the facilities of the Wellcare village, including the hydrotherapy pool, snoezelen and cinema, though none of the residents were using these facilities at the time of this visit. Residents’ complaints are listened to and they are protected by the home’s policies and training. Bishops Court has a complaints procedure, which is
Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 6 made available to residents and their representatives. A record of complaints is maintained in the home and the report for the most recently investigated complaint was read. This complaint had been investigated in-house, and remedial action taken where shortfalls in service were identified. Bishops Court provides a series of aids and adaptations to support people who have poor mobility including hoists, assisted baths, grab rails and slide sheets. Residents individually have mobility and sensory aids supplied, subject to assessment. Bishops Court has policies on the control of infection. These include procedures for MRSA and the cleansing of equipment. Domestic staff are employed and protective gloves and aprons are provided to staff, as are the procedures to be followed in controlling the spread of infection. Training and instruction is provided to domestic staff in infection control and the control of substances hazardous to health. The numbers and skill mix of staff are in place to meet residents’ needs and there is a thorough recruitment procedure followed. A schedule of the PIN numbers of nursing staff was seen and was in order. Over 75 of care staff have NVQ 2 and ongoing mandatory training and service specific training is provided for staff. Training schedules show that staff have received the training relating to safe working practices such as moving and handling, fire safety, food hygiene and infection control. There are systems in place for safe storage of cleaning substances and removal of waste. Mrs. Sinclair has established a newsletter, which is distributed to residents and their families. The newspaper has been set up as a way of engaging with the families of residents, who live outside of Liverpool or who are unable to visit. A group of relatives has met recently with the intention of raising funds and a self-help group has also resulted from their enthusiasm. What has improved since the last inspection?
With regards to health and safety requirements, a nurse call bell has been fitted in the toilet referred to in two previous inspections (confirmed by the manager, Mrs. Sinclair). Mrs. Sinclair said a risk assessment has been carried out for the courtyard where tripping hazards have been identified. This document was not seen as Mrs. Sinclair said it was at head office. A requirement from the last inspection is repeated in this report along with a further requirement regarding the courtyard, which has been made as an outcome of this visit. Supernumerary management hours have increased and will be raised further at full occupancy of Bishops Court, in addition three nurses have been recruited and a handy-person employed
Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 7 What they could do better:
Arrangements should be in place to ensure a copy of the care management plan is obtained prior to a resident being admitted, to help inform the initial assessment process. Staff should ensure that the initial assessment document is completed in full, with as much detail as possible, to aid the assessment and care planning process. The section stating whether or not the home is able to meet a person’s needs should be routinely completed. To ensure that residents are not placed at risk, care plans are to be followed at all times (this refers to bed rest and pressure care), and staff should be reminded of their responsibility in this during supervision sessions and handovers. For ease of access by staff, it is recommended that the system for filing residents’ individual information be reviewed. There were difficulties experienced by Mrs. Sinclair in locating some records during the visit. To ensure that residents’ dignity is reflected in their appearance, it is recommended that residents’ clothes are checked and arrangements should then be made to replace worn clothing as needed. To ensure residents’ dignity is reflected in the environment it is advised that a quiet area/lounge be established for agreed periods. To ensure that consultation with residents, relatives and representatives is ongoing regarding the service in Bishops Court, a bi-annual quality monitoring system is advised. It is advised that assessments of the social needs and preferences of residents, be carried out and leisure events provided for individuals and small groups in accordance with the assessment outcomes making full use of the full range of facilities on offer. The radiator cover in the smoking room is to be repaired and to ensure that the interior is maintained to the highest standards, it is recommended that a review of the ground floor communal areas is carried out and remedial work scheduled The courtyard garden is to be cleared of weeds and rubbish, and made suitable for residents who wish to go outside. Remedial work is to be carried out following risk assessment, to eliminate tripping hazards identified. To ensure up to date records of transactions are available for all residents, a requirement is made, regarding management of residents’ personal finances. Requirements regarding health and safety have been made. To ensure that fire alarms are activated in case of fire, the fire systems tests are to be carried out weekly. To ensure that residents, staff and visitors are protected, fire doors are not to be wedged open. To ensure that equipment in the home is in
Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 8 working order and residents are not placed at risk, the light in room 5 (toilet) to be repaired. The requirements, which relate to fire equipment (weekly fire alarm tests) and courtyard garden risk assessment are outstanding from two previous inspections and should be addressed within the given time limits. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 9 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.V342450.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Residents/representatives have the information they need before a decision is made to move in to Bishops Court however, pre-admission assessments lacked detail needed to ensure that their needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 1,2,3. All residents of Bishops Court have a contract of residence which sets out the terms and conditions of residence including, fees (and who will pay them), facilities, medical arrangements, staffing, personal monies, arrangements for complaints investigations, and notice periods. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 11 People who live at the home are provided with a service user guide, which describes the service and accommodation to be provided in Bishops Court, and a copy of the complaints procedure. A sample of care plans was read and pre-admission assessments carried out by staff from Bishops Court were checked. These records lacked the level of information needed to ensure that their need can be met by the services and facilities on offer in Bishops Court. To ensure that staff have the information they need to demonstrate that the person’s needs will be met, requirements are made under Regulation 14. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. All residents have a care plan and a new format is to be established, but some care records were not easily accessible and some lacked detail. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 7,8,9 and 10. All people residing at Bishops Court have a care plan and a sample of files was read. The care plans follow a standard format with systems for action planning, assessing risk and reviewing support needs. For one resident there was a care plan set out by district nurses to address pressure sores. This care plan was not being followed with consistency by staff. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 13 There were gaps in the monitoring charts, and on one occasion, this person had been assisted to the dining room. The district nurse’s care plan stated bed rest at all times on airflow mattress, with two- hourly turns and fluid monitoring for this very frail lady. To ensure that residents are protected from risk through lack of consistency of care, a requirement is made that care plans be followed as they are written, by all staff. There are qualified nurses on duty in Bishop’s Court throughout the day and night. All residents are registered with G.P.s in the area, and there was evidence in their care plans that they have access to paramedical and mental health services, district nurses and tissue viability nurses. For one such referral, there was evidence of some weeks having passed before treatment for a pressure sore was referred to the district nurse. The manager, Jill Sinclair, said that nursing staff in Bishops Court were dressing the pressure sore between March and May 2007, when this person was referred to the district nurse. There were no clear records provided during the visit, as to the condition of the pressure area when first observed by nurses in Bishops Court and up to the date when it was referred for treatment, and a recommendation is made regarding record keeping. For some of the records which were requested during the visit, such as accident reports and nurses daily records, there appeared to be difficulties in locating the information, as it was not contained in the file of the individual (regarding the condition of pressure areas) or the central files (with regards to an accident report). To ensure that staff have all the information they need to provide support to residents, a recommendation is made that file management in Bishops Court be reviewed. Mrs. Sinclair said that a revised care plan format is to be set up in Bishops Court. A blank copy of the document was seen, it appears to provide an in depth format to care giving, and Mrs. Sinclair said that staff would receive training in the process. Bishops Court has a procedure for managing residents’ medication. The storage area was visited and Medication administration records were read. Drugs are stored in a locked room and the storage arrangements were satisfactory. There are systems in place for the auditing of drugs, management of controlled drugs, and for the return of unwanted medication to the pharmacy. For the residents whose care was tracked, there were stocks of medication in store and the amounts balanced with the number recorded as being administered. Residents of Bishops Court are assessed as having dementia and nursing needs. Residents’ privacy was being respected during the visit, as bedroom and bathroom doors remained closed and staff were respectful towards residents when prompting and supporting them. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 14 Residents’ diversity was not fully respected regarding limited capacity and lack of awareness of their own appearance and grooming. The condition of the clothing of one resident was discussed with Mrs. Sinclair. This lady had a hole in her cardigan and her clothing in general looked worn. Mrs. Sinclair said that some residents do not have the resources to buy clothing and when needed, the organisation would arrange for some to be provided. To ensure that residents’ clothing reflects their right to dignity, it is recommended that, key workers carry out reviews on residents’ clothing. Arrangements should be made with residents’ representatives for clothes to be replaced as necessary. During a tour of the premises, there were different types of music being played in the lounges and on the main corridor (which in some areas were merging) and this did not provide a relaxing environment. The music heard in the corridor was loud as was the music heard from the radio of a resident’s bedroom as she slept. To ensure that residents are provided with a choice of (peaceful/musical) environment, it is advised that a quiet lounge is established which is aids conversation between residents and staff. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. There are good facilities on offer to residents to provide a more stimulating quality of life, but these were not being used to full effect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 12,13,14,15. Bishops Court has an activities co-ordinator for forty hours a week, who was on duty during the time of this visit. During the afternoon, a number of residents were watching a film. One lady said she was going out with a relative and she requested some spending money from Mrs. Sinclair, manager. Some of the residents were in the lounges listening to music during the morning or sleeping. There appeared to be a lack of stimulating activity during the late morning, one lady was discovered alone in a wheelchair in the dining room calling for the toilet. Staff attended promptly when the nurse call bell was used.
Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 16 A gentleman in one of the lounges appeared to be restless and agitated, and a lady was attempting to go out into the courtyard but the door was bolted and she was becoming agitated. Eventually, a member of staff stood with her and gave some reassurance but she was not assisted outside. There is freedom of movement for residents throughout the corridors and communal areas. There are three lounges for residents, including a smokers’ lounge. Some of the residents were moving freely between the lounges and dining areas and there was a member of staff in each of the two of the lounges supervising residents. There were no staff observed as being present in the smoking lounge other than to light residents’ cigarettes as they do not have possession of lighters or matches. The home’s brochure states, “Regular and varied activities are arranged including games, musical afternoons and visitors from entertainers. The company’s own fleet of mini buses are used for regular outings.” Mrs. Sinclair said that residents of Bishops Court have use of the facilities of the Wellcare village, including the hydrotherapy pool, snoezelen and cinema, though none of the residents were using these facilities at the time of this visit. The relaxation and entertainment facilities on offer to residents are very good but were not being used to best effect. To ensure that residents are provided with the social activities, which meet their preferences and abilities in providing diversion and stimulation, a recommendation is made. It is advised that assessments of the social needs and preferences of residents, be carried out and leisure events provided for individuals and small groups in accordance with the outcomes. Bishops Court service user guide states that residents’ family and friends are encouraged to visit regularly and maintain contact by letter or telephone when visiting is not possible. This document also gives details of arrangements for getting in touch with advocacy services and this would be arranged for residents who have no family contacts. Residents’ cultural diversity is respected as their religious beliefs are recorded on their care plans and action taken to address their wishes and preferences. It is also stated in the service user guide, that local clergy visit the home regularly to provide religious services and communion. There is some diversity of culture and race among residents, and the beliefs of one resident were discussed with the Mrs. Sinclair who was aware of the requirements regarding diet and worship, which she said would be supported if the person a showed a will to follow these beliefs. Nutritional assessments are carried out for residents, their weight is monitored and special diets are catered for. A light meal of soup and sandwiches was being served for lunch and meals are served in the two dining rooms or in residents’ bedrooms if preferred.
Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 17 There is a small kitchen where drinks are made and from where meals are served the both dining rooms. The main meal, served in the evening, provides a variety of cooked dinners with seasonal vegetables and desserts, and for breakfast there is a choice of cereals. Meals are cooked in a central kitchen, shared by three homes, which was visited and was well fitted and equipped. The cook said that all the equipment he uses, was in working order. He confirmed that he has received training in nutrition/diets for people who have dementia. A record of meals served in the home is maintained and the menus had recently been reviewed. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 18 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents’ complaints are listened to and they are protected by the home’s policies and training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 16, 18. Bishops Court has a complaints procedure, which is made available to residents and their representatives. A record of complaints is maintained in the home and that for the most recently investigated complaint was read. This complaint had been investigated in-house, and remedial action taken where shortfalls in service were identified. The home has a procedure for protection of vulnerable adults and “whistle blowing”, and staff have received POVA training. There was a POVA investigation in progress at the time of the visit and the investigating officer from Liverpool Social Services was on the premises for part of this visit. The investigation is ongoing. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Bishops Court provides a good range of accommodation and aids but some areas are in need of refurbishment and repair. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standard 19 and 26. Bishops Court is a purpose built care home with surrounding gardens, a car park and central courtyard garden. There is level access to the building at the front and to the courtyard. There is a pleasant reception area with adjoining office. The home is registered for people who have dementia and exits are protected with keypads to ensure residents’ security.
Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 20 There are three lounges and two dining rooms with a long corridor linking them, which also gives access to the courtyard. The lounges are furnished with enough seating for residents, with music systems and television. The smoking lounge and second dining room are sparsely furnished (with few comforts or items of interest), and are in need of refurbishment. Dining room furniture is marked and looks in poor condition. (A recommendation from the last visit is repeated regarding repair, replacement of dining furniture). The flooring in the smoking room looked worn and stained and was damaged in places. This lounge was dull and lacking in interest and the radiator cover was in need of repair. The communal areas in general have an institutional appearance though pictures and collages have been placed in the corridors. To ensure that the interior is maintained to the highest standards, it is advised that a review of the ground floor communal areas is carried out and remedial work scheduled. Also to avoid risk to residents a requirement is made that the radiator cover in the smoking room is repaired. The main grounds were in good condition on approach to the home but the integrated courtyard was in need of planting, tidying and weeding, looking overall, neglected and un-cared for. There were quantities of empty soft drinks bottles and rubbish observed and tall weeds were growing through the paving. There is an attractive fountain, which was turned on part way through the visit. This courtyard is further evidence of a good facility, which could provide secure outside space for residents, which was not being used at the time of visit. A requirement is made that this area is to be cleared and made suitable for residents. One of the residents wanted to go out to the courtyard, but the door was bolted and in its current state the courtyard would not have been suitable. Residents’ bedrooms are for single occupancy with wash hand basins and some have en-suites. There are toilets and bathrooms throughout the premises for residents’ convenience. A bedroom (which was visited) had been recently decorated. There is ongoing damage to decoration in the home due to the needs and behaviour of some of the residents, and remedial work is needed on a regular basis. Mrs. Sinclair said that there are plans to replace some of the furniture and there is a budget for repairs in Bishops Court. Bishops Court provides a series of aids and adaptations to support people who have poor mobility including hoists, assisted baths, grab rails and slide sheets. Residents individually have mobility and sensory aids supplied, subject to assessment. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 21 Bishops Court has policies on the control of infection. Those for MRSA and the cleansing of equipment were discussed with the deputy manager. Protective gloves and aprons are provided to staff, as are the procedures to be followed in controlling the spread of infection. Training and instruction is provided to domestic staff in infection control and the control of substances hazardous to health. Cleaning materials are kept in a locked cupboard when not in use. The laundry is a shared facility and is well organised with good ventilation, and equipment was in working order. There were two members of staff on laundry duty at the time of visit. There are systems for controlling infection (colour coded laundry bags) and there are sluice facilities on the industrial washing machines. There is a system of marking clothing and returning it to residents’ bedrooms to avoid items being mislaid. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The skill mix of staff meets residents’ needs and there is a thorough recruitment procedure followed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 27,28, 29, 30. A schedule of the PIN numbers of nursing staff was seen and was in order. Mrs. Sinclair said that over 75 of care staff have NVQ 2 and ongoing mandatory training and service specific training, such as for dementia and challenging behaviour is provided for staff. The staff rosters were seen. On duty on the morning of this visit when thirtyeight people were in residence were, two Registered General Nurses, (who are manager and deputy manager), six care assistants, two domestics, handy person and (shared) cooking staff. Mrs. Sinclair said that three qualified nurses had been appointed and were due to take up their posts. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 23 I spoke with a member of care staff who said she has NVQ2 qualification and has recently undertaken health & safety, protection of vulnerable adults training, and patient handling. She said she had good support and guidance from the management team. She said that it is a busy home and residents need a lot of support because of their mental health needs. A sample of staff files was read and was in good order and well organised. There was evidence of application forms, two references, CRB clearances, job descriptions and contracts of employment. There were records of formal supervision (one to one) sessions and staff appraisals. Samples of training observed in staff files for care assistants were, NVQ2, dementia, first aid, fire safety, POVA, moving and handling, fire safety, health & safety, COSHH. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 24 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. Fire safety procedures are consistently being neglected, regarding weekly systems tests and this would place residents, staff and visitors at risk if the system failed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 31,33,35, 38. Mrs. Sinclair is the manager of Bishops Court and is a qualified RGN there is also a deputy manager, who is also a qualified RGN. Mrs. Sinclair was not registered with CSCI at the time of this visit.
Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 25 Mrs. Sinclair said that supernumerary management hours have been increased and will rise further on full occupancy in Bishops Court. Mrs. Sinclair has established a newsletter, which is distributed to residents and their families. Mrs. Sinclair said she has previously sent out quality questionnaires to interested parties and there has been a very low return rate. She regards the newsletter as an alternative method of engaging with the families of residents, who live outside of Liverpool or who are unable to visit. A group of relatives has met recently with the intention of raising funds for Bishops Court, and a self-help group has also resulted from their enthusiasm. There were no quality monitoring outcomes available and it is advised that a quality monitoring system be established for Bishops Court to ensure ongoing consultation with interested parties on the quality of service. Discussion took place with Mrs. Sinclair, during the visit, regarding management of resident’s personal allowances. The records available were the petty cash account and a list of residents who smoke having £20.00p recorded as a charge against each name for cigarettes. The number of cigarettes supplied for the charge was not stated. There were no receipts held with this record, nor was there a running account of credits and debits of their personal allowances. Mrs. Sinclair said that residents have access to their personal allowance at all times and the records of transactions are held at head office, which is close to Bishops Court. To ensure up to date records of transactions are available, a requirement is made, regarding management of residents’ personal finances. Training schedules show that staff have received the training relating to safe working practices such as moving and handling, fire safety, food hygiene and infection control. There are systems in place for safe storage of cleaning substances and removal of waste. A record of accidents is maintained and these are monitored and risk assessed (records were seen attached to the accident records). One accident record proved difficult to find and a recommendation is given elsewhere in this report (under standard 7), regarding file management. A series of maintenance certificates was read and found to be satisfactory. Mrs. Sinclair said Bishops Court now employs a handy- person who will be responsible for health and safety tests and checks. The fire safety records were generally satisfactory, the last fire drill was in March 07, fire safety training in January 07. The weekly fire alarm systems tests had not been carried out since February 07. The need to carry out the system test without delay and on a regular weekly basis was discussed with Mrs. Sinclair and a requirement is made. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 26 There is a smoking lounge and residents request a light for their cigarette from staff. Metal bins and large ashtrays were observed in this lounge. Risk assessments are carried out for residents who smoke. Room 5 (toilet on main corridor) was entered and the light switch was tested and found to be not in working order. This was discussed to the manager, along with the risk to residents who may enter and have an accident in the dark, and requirement is made with regards to repairing the light. Mrs. Sinclair said that the light had been reported for repair and the room had been locked. One of the lounge doors was wedged open (with a plastic wedge), during the morning period. Mrs. Sinclair was reminded that fire doors must not be wedged open as this poses a risk to residents, staff and visitors in case of fire. A requirement is made under Regulation regarding fire doors being kept closed. Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 27 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 2 X 2 X 2 X X 1 Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 Requirement A risk assessment in relation to the rear garden area should be made with appropriate action taken as a result of the risk assessment. This specifically relates to the identified trip hazards in the enclosed garden area. (Repeated from two previous inspections extended time limit given). To avoid risks to residents, the radiator cover in the smoking room to be repaired. To ensure that fire alarms are activated in case of fire, the fire systems tests are to be carried out weekly (outstanding from two previous inspections discussed as a matter of urgency with the manager and extended time limit given). To ensure that residents, staff and visitors are protected, fire doors are not to be wedged open. To ensure that equipment in the
DS0000059340.V342450.R01.S.doc Timescale for action 20/07/07 2. OP19 23 13/07/07 3. OP38 23 13/07/07 4. OP38 23 13/07/07 5. OP38 23 13/07/07
Page 29 Bishop`s Court Version 5.2 6. OP35 13 7. OP3 14 home is in working order and residents are not placed at risk, the light in room 5 (toilet) to be repaired. To ensure that a transparent system for managing residents’ personal allowance is in place, a record of residents’ personal allowance accounts to be available for inspection in the care home. Arrangements to be in place to ensure a copy of the care management plan is obtained prior to a resident being admitted, to help inform the initial assessment process. 20/07/07 20/07/07 8. OP3 14 Staff who carry out assessments, 20/07/07 should ensure that the initial assessment document is completed in full with as much detail to aid the assessment and care planning process. The section stating whether or not the home is able to meet a person’s needs should be routinely completed. To ensure that residents are not placed at risk, care plans are to be followed at all times (this refers to bed rest and pressure care), and staff should be reminded of their responsibility in this during supervision sessions and handovers. The courtyard is to be cleared of weeds and rubbish, and made suitable for residents who wish to go outside. 13/07/07 9. OP7 15 10. OP19 23 13/07/07 Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 30 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 OP19 Good Practice Recommendations The marked dining room chairs and tables should be restained or replaced. It is recommended that the condition of residents’ pressure areas, when receiving treatment by staff, is recorded and held in the individual’s care plan. For ease of access by staff, it is recommended that the system for filing residents’ individual information be reviewed. To ensure that residents’ dignity is reflected in their appearance, it is recommended that the condition of residents’ clothing, is reviewed by key workers, and arrangements made to replace clothing as needed. To ensure residents’ dignity is reflected in the environment it is advised that a quiet area/lounge be established for agreed periods. It is advised that assessments of the social needs and preferences of residents, be carried out and leisure events provided for individuals and small groups in accordance with the assessment outcomes making full use of the facilities on offer. To ensure that the interior is maintained to the highest standards, it is recommended that a review of the ground floor communal areas is carried out and remedial work scheduled. It is advised that Mrs. Sinclair applies for registration with CSCI. To ensure that consultation with residents, relatives and representatives is ongoing, a bi-annual quality monitoring system is advised. 2. 3. 4. OP7 OP7 OP7 5. OP10 6. OP12 7. OP19 8. 9. OP31 OP33 Bishop`s Court DS0000059340.V342450.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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