Inspection on 16/02/06 for Bishops Waltham House

This inspection was carried out on 16th February 2006.

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

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

Other inspections for this house

Bishops Waltham House 08/06/07

Bishops Waltham House 30/01/07

Bishops Waltham House 06/06/05

Bishops Waltham House 16/02/05

Bishops Waltham House 10/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Bishops Waltham House Bishops Waltham House Free Street Bishops Waltham Southampton Hampshire SO32 1EE Lead Inspector Marilyn Lewis Unannounced Inspection 16th February 2006 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 Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bishops Waltham House Address Bishops Waltham House Free Street Bishops Waltham Southampton Hampshire SO32 1EE 01489 892004 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) Hampshire County Council Mrs. Janice May Dyet Care Home 52 Category(ies) of Dementia - over 65 years of age (52), Old age, registration, with number not falling within any other category (52) of places Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users are not to be admitted under the age of 65 years Date of last inspection 6th June 2005 Brief Description of the Service: Bishops Waltham House is registered to provide accommodation with care for up to fifty-two people in the categories of old age or old age with dementia. The home was built in the 1970s and is located on the outskirts of the village. Accommodation is provided on three floors and has the facility of a lift to access the upper floors. The home is owned by Hampshire County Council and is currently undergoing an extensive upgrade and refurbishment. The home has a large garden area with large fishpond and well-maintained grounds. Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 16th February 2006. The registered manager was not on duty and the assistant unit manager in charge of the home assisted the inspector. The inspector toured the home and met with six residents and two staff members. Care plans were sampled for four residents and records were seen for staff training, supervision, complaints, medication and fire drills. The home is able to accommodate fifty-two residents the number residing at the home has reduced due to the major refurbishment taking place. At the time of the inspection eighteen people were resident at the home. What the service does well: What has improved since the last inspection? The major refurbishment is continuing and residents are now accommodated on the first and second floors and are slowly able to access more areas of the home. Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 6 The home now employs night co-ordinators to support and supervise night staff. This has resulted in the ‘sleep over’ of assistant unit managers ending and the night co-ordinators have become additional wake staff on duty. 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 contacting your local CSCI office. Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 The home is not providing intermediate care while the refurbishment is taking place. EVIDENCE: The home is currently undergoing major refurbishment and intermediate care is not being provided. The other standards were met when assessed during the inspection dated 6th June 2005. Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Care plans provide staff with the information required to support the residents who his health care needs are met and who feel they are treated with respect. However the poor recording of medicines administered could put the health of residents at risk. EVIDENCE: Care plans sampled for three residents contained information on all aspects of care needs including personal and social needs. The care for the residents was tracked through the inspection and the plans were seen to reflect their needs. The plans contained risk assessments for mobility, risk of falls and pressure areas. The residents’ preferences for the way they received care were documented, for example, one person liked to wash their own face and hands. One plan for night care needed more detail as it indicated that the resident was unsettled at night but did not give any advice as to how this could be resolved such as being offered a warm drink. The records seen indicated that residents’ health care needs were being met. GPs visited weekly and on request and district nurses were involved in caring Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 10 for residents as required. A member of the community physical disability team advised on mobility issues. An optician from the local village visited residents on request and a chiropodist attended six weekly. The assistant unit manager said that they were contacting dentists in the area who would provide treatment on the NHS but that it was proving difficult. The assistant unit manager said that only staff who had received training in handling medicines were allowed to administer the medication. The home has a system for administering medicines that allowed staff to mark the medication charts by ticking them when medicines had been administered. A separate sheet for staff to sign to record that they had administered medicines was kept in another office. There were gaps in recording in both the individual medication charts for residents and the separate sheet for signatures. The medicines are supplied by the pharmacy in cassette boxes with the medication chart slotted into the back of the container. The medication charts are returned to the pharmacy on a weekly basis and therefore it was only possible to check these for the current week. Staff must follow appropriate procedures for administering medication and must sign the medication chart on each occasion. It would be advisable to retain the medication charts when the cassette boxes are returned to the pharmacy so that checks can be made on their completion. During the inspection staff were observed talking to residents in a friendly, caring manner and were seen to knock on doors before entering rooms. Three residents spoken with said that they were treated with respect and that staff were caring and very good. Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 Residents are able to receive visitors as they wish. EVIDENCE: The assistant unit manager said that visitors are welcome at the home at any time although it is suggested that they try not to arrive during a meal time as residents will sometimes not finish their meal in their wish not to keep their visitor waiting. Two residents said that they received visits from relatives frequently and that they were always made to feel welcome. The other standards were met when assessed during the last inspection and information can be found in the inspection report dated the 6th June 2005. Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 12 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 and 18 Residents feel that any complaint will be taken seriously and acted upon and they are protected by staff awareness of abuse. EVIDENCE: The home has a complaints procedure in place that states who will investigate the complaint and timescales for the process. The procedures need to include information on making a complaint to the commission. Copies of the complaints procedure were available for residents and visitors to the home and two residents spoken with knew how to make a complaint and both felt that any complaint would be investigated and acted upon. No complaints had been recorded since the last inspection. Staff receive training in abuse awareness and the home has clear procedures to be followed should abuse be suspected. Two staff members spoken with knew the procedures and said that they would not hesitate in reporting any concerns. Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 13 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 and 26 The major refurbishment of the home has taken a considerable time and residents would like the work to be completed quickly. EVIDENCE: The home is owned and operated by Hampshire County Council. Major refurbishment work has been taking place at the home for the last eighteen months. Much of the work is to remove asbestos that was used in the construction of the property in the 1970s. The work has resulted in the number of residents living at the home being reduced, with only eighteen resident at the time of the inspection. The home normally is able to accommodate up to fifty-two people. Two residents spoken with during the inspection said that they would be very pleased when the work was completed and hoped that would be soon. Staff spoken with said that they did not know when the work was due to be finished. Areas of the home accessed by residents looked clean and in reasonable condition. Residents’ individual rooms looked homely and contained many personal items such as photographs and ornaments. Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 14 Specialist equipment such as hoists were available for residents assessed as requiring it and a passenger lift and stairways allow access to each floor. Grab rails and ramps are provided where required. A call alarm system is provided throughout the home and during the inspection call alarms were seen to be available and accessible to residents. Bathrooms and toilet facilities currently available for residents looked clean and in good order. The home has a laundry area that is away from food preparation areas and on the day of the inspection the laundry looked to be in good order. Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 15 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 and 30 Residents’ needs are met by the number and skill mix of staff employed at the home but the lack of clear training records could result in staff not receiving the training they require to do their jobs. EVIDENCE: The home employs a registered manager, deputy manager, four assistant unit managers, three night co-ordinators and twenty-one carers. The number of staff on duty has been organised to meet the needs of the current number of residents. Night co-ordinators have been employed recently to support and supervise the night staff and they replace the ‘sleep over’ assistant unit manager. Residents spoken with said that they felt there were sufficient staff on duty, as they did not have to wait long if they called for assistance. Although one resident did comment that he had waited quite some time for a staff member to assist him walking. One assistant manager holds a National Vocational Qualification (NVQ) level 4, one holds NVQ level 3 and two are due to start level 3 in the near future. Seven of the twenty-one carers have NVQ level 2. It was difficult to ascertain which members of staff had received training, as the training records did not appear to be up to date. Records seen indicated that seven staff members had attended training in dementia care and thirtytwo had attended sessions in abuse awareness. However only twelve staff Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 16 members had completed infection control training and the records indicated that no staff member on night duty had completed the session. The assistant manager said that all staff had received training in moving and handling in 2005 and were due to attend refresher courses in 2006. An audit of staff training is required and training records need to be updated to provide a clear record of staff training attended. Standard 29 was met when assessed during the inspection dated 6th June 2005. Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 The registered manager runs the home in the best interest of the residents, who benefit from the open approach to management operated at the home and their financial interests are safeguarded by the clear procedures in place for handling finances. Staff receive regular supervision however the safety of residents could be put at risk by staff who have not attended fire drills. EVIDENCE: The registered manager holds NVQ level 4 in Management, a Diploma in Social Work and a degree in Applied Social Studies. Mrs Janice Cadden-Biddle has been the manager of the home since 1997. Staff spoken with said that they received support and encouragement from the registered manager and residents said that they found her easy to talk with and that she was friendly and caring. Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 18 Residents meetings are held once a month and minutes of the meetings are available for all residents. Minutes of the last meeting were displayed in the reception area of the home and indicated that residents’ bedrooms, meals, activities and an update of building work had been discussed. Two residents spoken with said that they enjoyed the meetings and felt able to discuss any issues they wished. It was evident during the inspection that residents and visitors felt able to speak to staff about any issue. Staff meetings are usually held six monthly but the frequency is flexible depending on issues arising within the home such as the building work taking place. Records seen indicated that staff receive regular supervision. The registered manager supervises the assistant unit managers and night co-ordinators, who in turn supervise the carers. Supervision takes place once a month and the supervision meeting covers all aspects of personal development including the strengths and weaknesses of the staff member, training and care issues. The home keeps small amounts of money in the home for some residents. The monies are stored individually in a safe place. Receipts are kept for all transactions and records for two residents matched the money held. Some residents keep control of their own finances or they are assisted by their relatives. During the inspection hazardous substances such as cleaning fluids were stored appropriately. Health and safety information posters were displayed around the home. The kitchen looked clean and in good order with food stored appropriately. Fire records seen indicated that the fire alarm was tested weekly and fire safety equipment checked on a regular basis. However the records indicated that not all staff, in particular the night staff, had attended fire drills. Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 3 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 x 2 Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement The registered person must ensure that staff adhere to the procedures for administering medication. The registered person must ensure that the complaints procedures include the name, address and telephone number of the commission. The registered person must ensure staff receive the training required to do their jobs. An action plan that includes an up to date training record for staff is to be forwarded to the commission. The registered person must ensure all staff attend fire drills and records of staff attendance at fire drills must be kept available in the home. Timescale for action 17/02/06 2 OP16 22(7) 31/03/06 3 OP30 18(1)(c) 30/04/06 4 OP38 23(4)(e) 30/04/06 Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bishops Waltham House DS0000038911.V283422.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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