CARE HOMES FOR OLDER PEOPLE
Bishops Court Care Home Tuxford Road Boughton Newark Nottinghamshire NG22 9HY Lead Inspector
Richard Ramsden Unannounced Inspection 27th October 2005 10:15 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 Bishops Court Care Home DS0000035672.V260345.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. Bishops Court Care Home DS0000035672.V260345.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bishops Court Care Home Address Tuxford Road Boughton Newark Nottinghamshire NG22 9HY 01623 862043 01623 836070 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) Nottinghamshire County Council Vacant Care Home 45 Category(ies) of Dementia (19), Dementia - over 65 years of age registration, with number (19), Old age, not falling within any other of places category (45), Physical disability (5) Bishops Court Care Home DS0000035672.V260345.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Out of the total number of beds (45), there will be 19 beds for DE 55 and over and/or DE(E) Out of the total number of beds (45), 5 may be used for PD 55 and over Service users shall be within category OP(45) Date of last inspection 11th June 2005 Brief Description of the Service: Bishops Court is a Care Home providing personal care for 45 older people of both sexes, in single rooms with hand washing facilities. It is owned and managed by Nottinghamshire County Council Social Services and is a single storey building, which was purpose, built in the 1980s. It comprises of five units, each having its own lounge, dining room, bathing and toilet facilities as well as a small kitchen for the preparation of snacks. Communal space and lounges are also available throughout the home. There are and Paul ground surrounding the home and a safe enclosed patio garden, which is accessible to all of the residents. Bishops Court is situated with half a mile of the centre of Ollerton, with shops, pubs, library, a doctor’s surgery and leisure facilities. Bishops Court Care Home DS0000035672.V260345.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One Inspector completed this unannounced inspection over one day; it took approximately 5 1/2 hours. It included the inspection of care and other records, a discussion with four residents’ two members of staff and the homes acting manager. A partial tour of the building was also completed. What the service does well:
Even though the manager is not yet registered with the Commission for Social Care Inspection the home is well managed and is run in the best interests of the residents who live there. The residents spoken with during the inspection stated that the staff couldn’t be faulted. They said that they are always friendly and respectful and that they ensure that their privacy and dignity is maintained at all times. The interaction between residents and staff was of a very good standard. People said that they like their bedrooms and confirmed that they had been encouraged to bring small items of furniture, photographs etc to personalise their rooms. The residents believe that their health care needs are appropriately met. One person said that their health has improved significantly since they moved into the home. The home has a clear commitment to staff training, 73 of staff have either completed or are currently completing their NVQ training. The residents said that they find the home well decorated and comfortably furnished. There were many aspects of good practice highlighted in the main body of this report. Bishops Court Care Home DS0000035672.V260345.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by
Bishops Court Care Home DS0000035672.V260345.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Bishops Court Care Home DS0000035672.V260345.R01.S.doc Version 5.0 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 Bishops Court Care Home DS0000035672.V260345.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The literature supplied to prospective residents does not contain sufficient information to enable them to make an informed choice as to whether the home will meet their individual needs. EVIDENCE: The literature supplied the prospective residents has been produced in a userfriendly format. (This is good practice). However the information in this literature needs to be updated to show that the Commission for Social Care Inspection now has the responsibility for registering and monitoring the standards in this home. The complaints records also need to state that people can contact NCSC if they have any complaints that they do not believe the homes management have appropriately resolved/investigated. The literature must also include the qualifications of the staff, the service users views of the home and a copy of the most recent inspection report summary. Bishops Court Care Home DS0000035672.V260345.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8. Each resident has an individual care plan, which appropriately identifies their personal and social care needs. The care plans are being regularly reviewed but there is no evidence that resident and where appropriate their representatives are involved in the review process. Resident’s health care needs are being fully met. EVIDENCE: The residents care plans viewed during this inspection contained appropriate information to inform staff what assistance/support each resident requires on a daily basis. The records showed that the care plans are being reviewed on a monthly basis, however there was no evidence that residents and where appropriate their representatives have been involved in the review process. It is essential that this evidence be provided as the resident spoken with during the inspection could not remember being informed about any changes to their care plans.
Bishops Court Care Home DS0000035672.V260345.R01.S.doc Version 5.0 Page 11 It was also noted on one of the care plans viewed during the inspection the residents had asked to have two baths each week. When the bathing records were checked there were two months when the resident had not even had one bath a week. The manager was advised that the home must always try to comply with the resident’s request to have two baths each week. As an absolute minimum the resident must be offered one bath each week. If for any reason the resident refuses to have a bath this should be recorded in their care records. The records show the residents health care needs are being adequately met. The resident spoken with said that they are very satisfied with the health care arrangements made by the home, one person said their health had improved significantly since they moved into Bishops Court. The inspector was informed that one person has chosen to arrange his or her own optician’s appointments etc. (This is good practice). Bishops Court Care Home DS0000035672.V260345.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Residents are helped to exercise choice and control over their lives. EVIDENCE: The manager stated that all new residents are asked during the admission process if they wish to manage their own finances. This issue is also discussed as part of the official review process. Age concern leaflets are provided to all residents detailing what advocacy services are provided. These leaflets are also displayed in the main reception hall. (This is good practice). A copy of Nottinghamshire County Councils Access to Records Policy is included in the literature provided in each resident’s bedroom. The staff spoken with during the inspection had a basic understanding of the Access to Records Policy but do need to be reminded of the actual process to follow if people ask to see their individual records. Bishops Court Care Home DS0000035672.V260345.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): 18 Residents are protected from abuse. EVIDENCE: The home has an appropriate Whistle blowing procedure and a copy of the local Vulnerable Adults Procedure. The staff spoken with during the inspection were aware that they must report any incidents or accusations of abuse. One member of staff said that she had received training in adult protection issues. The inspector was informed that there have been no allegations of abuse in the last 12 months and that no staff members have been referred for inclusion on the P.O.V.A. lists. Bishops Court Care Home DS0000035672.V260345.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): 24,25,26. Not all residents have keys to lock their bedroom doors. Residents are no longer at risk of burning themselves on unguarded radiators. The home was appropriately clean and odour free at the time of this inspection. EVIDENCE: At the last inspection a requirement was made that every resident must be provided with the key to his or her bedroom doors and to the lockable facilities in their bedrooms, unless a risk assessment suggested otherwise. The manager stated that he has experienced difficulty in locating the keys for every bedroom door. He said that as an interim measure people who wish to lock their bedroom door have been provided with locks and keys. However there are insufficient keys to enable all residents to lock their bedroom doors. One of the residents spoken with during the inspection said that they would like to lock their bedroom door but that they do not have Key.
Bishops Court Care Home DS0000035672.V260345.R01.S.doc Version 5.0 Page 15 Every bedroom door must have lockable facility so that people can make a genuine choice about whether they wish to lock their bedroom doors. Radiator covers have been provided to all but one area that the residents have access to. One bathroom radiator cover was faulty and has had to be reordered. The inspector was advised that this should be fitted in the very near future. The radiator covers have helped to ensure that residents are not at risk of burning themselves. (This is good practice). The residents spoken with so that they are very satisfied with their bedrooms and that the home is always kept clean and tidy. The bedrooms viewed during the inspection all contained personal items helping to create individual personalised areas. Since last inspection the relevant sections of the homes infection control policy have been displayed in the laundry. This will help to ensure that staff are aware of the steps to take to avoid cross infection. Bishops Court Care Home DS0000035672.V260345.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): 28,29. Adequate staff training is provided to ensure that residents are in safe hands at all times. Residents are supported and protected by the homes recruitment policies and practices. EVIDENCE: The home is able to demonstrate a commitment to staff training. 75 of staff have either completed or are currently completing their NVQ training. (This is good practice). The staff spoken with during the inspection confirmed that they have received a considerable amount of training over the last year. The senior staff are now ensuring that all volunteers have a criminal records bureau check prior to them volunteering at the home. Bishops Court Care Home DS0000035672.V260345.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): 31,33,35. The home is well managed and the manager has submitted an application to registere with the Commission for Social Care Inspection. The home is run in the best interests of the residents. Resident’s financial interests are safeguarded. EVIDENCE: Since the last inspection the acting manager has submitted an application form to be registered with the Commission for Social Care Inspection. The registration process should be completed in the very near future. The home operates the Nottinghamshire County Councils Quality Assurance System. Performance and development plans are produced from the information collated as part of the quality assurance system. It is
Bishops Court Care Home DS0000035672.V260345.R01.S.doc Version 5.0 Page 18 recommended that the home satisfaction questionnaire is the extended to service users families and professionals concerned with the home. Resident’s financial records were checked at random and were well maintained. Bishops Court Care Home DS0000035672.V260345.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 2 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X 2 3 3 STAFFING Standard No Score 27 X 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Bishops Court Care Home DS0000035672.V260345.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 OP1 Regulation 5 Requirement Timescale for action 05/12/05 2 OP7 15 3 OP7 12 4 OP24 16 It is required that the literature supplied to prospective residents includes:1.Information stating that the commission for social care inspection is now responsible for registering and monitoring standards in the home and that complaints can be referred to them. 2.Details of the staff’s qualifications and experience. 3.A copy of the most recent inspection report summary. It is required that documentary 05/12/05 evidence shows that residents and where appropriate their representatives, are involved in the reviewing of care plans. (Previous timescales are of 31/05/05 and 04/07/05 not met) It is required that residents are 27/10/05 offered the opportunity to bath at least once each week. If the resident refuses a bath their decision should be recorded in their records. It is required that all residents 05/12/05 are offered Keys to enable them
DS0000035672.V260345.R01.S.doc Version 5.0 Bishops Court Care Home Page 21 to lock in their bedroom doors, unless there risk assessments suggest otherwise. If people do not wish to have a Key to their bedroom this decision must be recorded in their individual records. (Previous timescale of 04/07/05 not met although the manager has provided Keys and locks to some residents). 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 OP33 Good Practice Recommendations It is recommended that the homes Satisfaction Questionnaires be extended to include the views of other stakeholders i.e. GP’s chiropodists etc. Bishops Court Care Home DS0000035672.V260345.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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