Inspection on 30/01/07 for Bishops Waltham House

This inspection was carried out on 30th January 2007.

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 16/02/06

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 Tim Inkson Unannounced Inspection 30th January 2007 09:30 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.V323752.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. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 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.V323752.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 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. It has extensive and well-maintained grounds. Potential residents are invited to visit the home for a day and they are given written information about the service provided at the establishment. During these visits potential residents are made aware of the availability of a copy of a report of the most recent inspection of the home carried out by the Commission of Social Care Inspection (CSCI). At the time of the inspection of the home on 30th January 2007 its fees were dependent on an individual’s financial circumstances. Consequently they ranged from the state pension less an individual’s permitted weekly personal allowance (that at the time was £19.60) to a maximum of £392 per week. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit as part of the key inspection of this service was unannounced and took place on 30th January 2007, starting at 09:40 and finishing at 17:10 hours. During the visit accommodation was viewed including bedrooms, communal/shared areas and the home’s kitchen and laundry. Documents and records were examined and staff working practice was observed where this was possible without being intrusive. Residents, visitors and staff were spoken to in order to obtain their perceptions of the service that the home provided. At the time of the inspection the home was accommodating 26 residents and of these 10 were male and 16 were female and their ages ranged from 64 to 103 years. The home was accommodating a resident from a minority ethnic group. The home’s registered manager was present throughout most of the visit and other members of the home’s management team were available to provide assistance and information when required. Other information that influenced the report were notices that the Commission for Social Care inspection had received since the last fieldwork visit made to the home on 16th February 2006, such as incidents/accidents that had occurred. What the service does well: What has improved since the last inspection? Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 6 Accurate records were being kept of the medication administered to residents indicating that it was managed safely and effectively. Details of the Commission for Social care Inspection had been included in the home’s complaints procedure. This should ensure that any individual wishing to contact the organisation that regulates care homes has the information enabling them to do so. The proportion of care staff with a formal qualification indicating that they had the competence to meet the complex needs of residents had increased from 33 to 67 . 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. The summary of this inspection report can be made available in other formats on request. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 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.V323752.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were procedures in place to ensure that the home identified the assistance and support that potential residents needed before they moved into the home. EVIDENCE: The home had a range of written corporate policies and procedures that influenced the way the home operated and among these was one concerned with “Assessment of Need of a Prospective Service User”. A sample of the records of 4 residents was examined and all included a copy of a “care management assessment” of that person’s needs carried out by the adult and older persons department of the local authority before the person concerned moved into the home. The home’s admission procedure included a visit to the home by potential residents during which time their needs were discussed with and identified by staff with the appropriate training and skills. The home provided a “respite care” service i.e. short- term accommodation for individuals in order to provide relief to their carers/relatives in the community. One resident spoken to said, “I came here for a fortnight to see if I would like it and I loved it”. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 9 The home’s pre-admission assessments i.e. “care management assessments” were complemented by more thorough and comprehensive assessments of a resident’s needs when they actually moved into the home. There was documentary evidence that assessments of residents needs were reviewed regularly and revised as necessary when an individual’s circumstances had changed. The home does not provide intermediate care. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had systems in place to ensure; the personal and healthcare needs of residents were met and medication was managed safely and effectively. Among other things staff working practice helped to ensure that residents’ privacy and dignity was promoted. EVIDENCE: The care plans were examined of the same sample of 4 residents as in the section above at page 9. The documents examined were comprehensive and the plans were based on the assessments the home carried out in order to identify what help individuals needed (see pages 9 and 10). Assessments included potential risks to residents e.g. moving and handling; falls; and malnutrition. The plans examined also set out what individuals could do for themselves to maintain their independence and the actions staff had to take and what specialist equipment was needed to provide the support and assistance each person required. There was evidence from documentation and discussion with residents that wherever possible individuals and/or their representatives had been involved in developing the plans and agreed with the contents. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 11 Where care plans referred to the use of equipment or how a specific need was to be met this was observed to be available, provided or in place e.g. Zimmer frame; or profile bed. Records indicated that care plans were reviewed at least monthly and daily notes referred to the actions taken by staff to provide the needs set out in those plans. Staff spoken to knew the needs of the individuals whose records were sampled and they were able to describe the contents of the care plans. Comments from residents about the abilities of staff the care and support that they provided included: • “I get all the help that I need. They are great, the staff. They are lovely. They are a great bunch. I have seen my care plan and I did agree with it … The staff are a great support to me, if I am anxious they tell me to calm down ”. • “I can’t fault it. They are very helpful”. • “I can’t walk so I need a frame. They help me with anything that I need. I feel safe when they help me”. • “I find it very satisfactory. The carers look after you very well and they listen to you … when I have a bath I like someone there all the time. I feel unsafe and ask them not to leave me”. • “They have been very good to me … I think that the staff are competent and properly trained”. One visiting relative described the staff as “very professional”. The records examined indicated that a range of healthcare professionals visited the home and that arrangements were made for treatment for service users when it was necessary. A local general practitioner (GP) held a weekly surgery at the home. Residents said that they saw and received treatment from among others, doctors, podiatrists and opticians and when required arrangements to attend outpatient clinics were made by the home. The home had recently started using a nationally recognised method of identifying the nutritional needs of individuals recommended by the National Institute of Clinical Excellence (NICE) i.e. Malnutrition Universal Screening Tool (MUST) and the weight of every resident was monitored regularly. A visiting healthcare professional spoke positively about relationships with the home and the abilities of the care staff and the home’s registered manager. The home had written policies and procedures concerned with the management and administration of medication. It operated a monitored dosage system and a local pharmacist provided most prescribed medication every 7 days in cassettes/dosette boxes for each person concerned. Other medicines that could not be put into this system because they could spoil, such as liquids or those that were to be taken only when required were dispensed from their original containers. The only staff in the home that dispensed and were responsible for the management and administration of medication on a day-to-day basis were Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 12 members of the home’s management team and all had received training in medicine administration. The home’s care staff (care assistants) had also received training in “medication non administering”. Medication was kept in a locked metal trolley and locked rooms and cupboards and where required in a medical refrigerator. Controlled drugs were stored securely and appropriately. A sample audit of controlled drugs indicated that the relevant records were accurate and up to date. Good practice noted during the fieldwork visit included: • Recording the temperature of the refrigerator used for storing some medication • Sample copies of the signatures of the those staff that dispensed medication • The dating of all medicine containers when they were opened. The home strongly promoted the independence of residents and those residents assessed as being able and who wished to, were encouraged to keep, and take their own medication. At the time of the fieldwork visit 4 residents were managing some or all of their own medication. Records were kept of the ordering, receipt, administration and the disposal of medicines and these were accurate and up to date. At the last inspection of the home it had been noted that there were gaps/omissions in some medication administration records and consequently a requirement to address this was made. On this occasion in the records sampled no omissions were noted. The privacy or residents was promoted by the provision of single bedrooms for all the residents accommodated in the home. Residents spoken to said that staff were friendly and always knocked before entering their rooms. This latter practice was observed during the fieldwork visit. Residents and relatives spoken to described the staff as respectful and polite. Comments from residents about these matters included the following: • “They keep the door closed when they help me”. • “They are all very polite”. • “They are very particular about my modesty”. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 13 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): 12,13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home organised a range of activities and it also promoted residents selfdetermination, enabling residents to exercise choice about all aspects of their daily life. Residents were able to maintain links with relatives and representatives. The dietary needs of residents were well catered for with a balanced and varied selection of food available that met their tastes and choices. EVIDENCE: Written information provided to potential residents about Bishops Waltham house included the following statements about social activities: “We plan social activities with our residents and they can include trips out, entertainment of all kinds, classes and other activities – including quizzes, music and movement, and reminiscence groups. What we do arrange depends on what residents want – sometimes things are arranged for a group of residents, sometimes on an individual basis, and we have a daily schedule of activities for people to take part in. However, if a particular activity doesn’t interest you, you don’t have to join in if you don’t want to”. The information also referred to; a trolley shop run by the home’s league of friends; a visiting hairdressing service; mobile clothing shops; services Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 14 provided at the home by 4 different denominations; and visits from a mobile library. One resident spoken to found the latter extremely valuable particularly as it provided a wide range of large print books. There was timetable on display in the entrance hall of the home about events and activities in which residents could participate. Some care staff that were spoken to during the site visit described relevant training that they had or were pursuing that would enable them to organise or lead stimulating activities for the benefit of residents. This training included a National Vocational Qualification (NVQ) in “The Provision of Activities in Care Settings”. All residents spoken to indicated that their life style preferences were respected and that routines in the home were flexible and relationships were informal, relaxed and friendly. The relatives of one resident provided a specific ingredient that was important for her cultural dietary requirements. Comments from residents about the activities that were organised, their ability to exercise choice and day-to-day routines in the home included: • “You can’t beat it, it is really good, if it wasn’t I would not have stayed here. • There are no routines for God’s sake, it is better here than in my own home”. • “The best thing about it is being looked after and the different things to do. We have singers that come in. We do exercises and have quizzes”. • “There are activities but I don’t take part because I don’t like crowds”. • “You don’t have to do anything, there are no strict routines, only the time of the meals and breakfast is between 8:00 and 9:30 so there is plenty of time … We used to have services every Sunday but not many attended but clergy visit individuals and come and talk to us if we want it, there is still a communion service”. • “They have activities, doing pastry and making little things. I am not really interested but will do it to join in”. Residents and relatives spoken to confirmed that there were no restrictions concerned with visiting the home and relatives said that they were always made welcome. There was information in the entrance of the home with details about an organisation that could provide impartial advice, information and guidance to residents and/or their families. At the time of the fieldwork/site visit several residents was managing their own financial affairs. The majority had delegated the responsibility to either relatives or representatives. It was apparent from discussion with some residents that this had been their choice. Residents were able to bring small personal items into the home and it was apparent from observation during a tour of the building that a number of Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 15 individuals had taken some trouble to personalise their bedroom accommodation. Sensitive information that the home held about residents was kept secure and the home had written policies and procedures about maintaining confidentiality and residents rights to access their personal files and case notes. All residents spoken to were complimentary about the food provided and confirmed that they had 3 meals a day and could have snacks and drinks at other times. The menus/records of food provided indicated that the food was nutritious and there was a wide range of meals provided with a selection of choices every day. In addition special diets and individual preferences and needs were catered for e.g. soft/ pureed meals and diabetics. Fresh ingredients were used in the preparation of meals and the ready availability of fluids and fresh fruit was noted. The ingredients for pureed meals were prepared separately. The menu for the day was displayed in the dining room and residents were asked what choices they wanted at lunchtime during the morning of the meal in question. Individuals’ food preferences, dislikes, food related allergies and their nutritional and dietary requirements were recorded in their care plans and the staff spoken to in the kitchen were also aware of them. The main meal of the day was observed and it was unhurried and staff were sensitive when providing assistance. Comments from residents about the food provided included the following: • “The food is excellent and the cook is very good. The puddings are especially nice. We have nice lunches and you always get a choice from 2 things and if you don’t like them you can have a salad and they are always nice .. The tables are always nicely laid with all the condiments and they use cups and saucers and not mugs, which is nice as I don’t like a mug”. • “The food is excellent. I have no complaints about that. There is always a choice that is put up on the board in the dining room”. • “The food is very good, I can’t grumble. We have breakfast dinner and tea, and coffee and biscuits morning and afternoon”. • “The food is very good. They have a good cook”. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a satisfactory complaints procedure to address the concerns of residents and relatives/representatives but detailed records of complaints should be kept. The home’s procedures in place to protect service users from the risk of abuse should be fully implemented. EVIDENCE: The home had a written policy and procedures about how complaints could be made about the service that it provided. In the written information given to potential residents and retained by them if they moved into the home there was a section entitled “If things go wrong”. It set out the home’s complaints procedure and it included details of the Commission for Social Care Inspection (CSCI) and the address of its local office. A requirement was made following the last inspection of the home by CSCI on 16th February 2006 that the home’s complaints procedure included these details. All residents and relatives spoken to were confident about raising any concerns with the home’s manager or any of the senior staff working in the home. There had been one complaint made to the home since the last inspection on 16th February 2006.The home kept records of complaints and it was noted that this complaint was reported on 28th March 2006 but details about it could not be made available. There had been no complaint about the home made to CSCI during this period. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 17 The expectation set out at 16.3 of the “National Minimum Standards for care Homes for older People” is that the registered person keeps a record of all complaints made and includes “details of investigation and any action taken”. The home had a number of written procedures available concerned with and/or related to the protection of vulnerable adults. These were intended to provide guidance and ensure as far as reasonably possible that the risk of residents suffering harm was prevented. These policies and procedures included the following: • Practice No 103 – Managing the suspected third party abuse of a service user • Practice No 104 – General policy for the restraint of a service user • Practice No 432 – Whistle blowing • Practice No 106 – Use of Bed Rails on a Service Users Bed At Paragraph 5of practice No 106 above it stated: “Written confirmation agreeing to the use of bed rails must be obtained following a multi-disciplinary assessment e.g. the service users GP, care manager, the service users family. This will be retained in the service users notes”. There was no evidence of any such agreement where it had been decided based on a risk assessment that bed rails were required to prevent injury to an individual. As the use of bed rails constitute a form of restraint and their use could be abused e.g. to manage behaviour, certain safeguards concerning their use are essential including written/recorded evidence of a multidisciplinary assessment. Staff spoken to said that they received training about protecting vulnerable adults and they demonstrated an awareness of different types of abuse and the action they would take if they suspected or knew that it had occurred. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 18 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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s environment was safe and generally well maintained. There was an infection control policy and procedures in place and staff practice ensured that as far was reasonably possible residents were protected from the risk of infection. EVIDENCE: At the time of this fieldwork visit the premises was undergoing a programme of refurbishment. In parts its décor, furnishings, fittings and equipment were in good repair and in other parts it was in a poor state due to the extensive building work that had also revealed some problems. These included damp that was causing the growth of mould, stained floor covering on the first floor and colour scheme/decoration on the ground and first floors. These matters were all due to be addressed. There was no unpleasant odour anywhere in the building. The refurbishment programme had resulted in among other things; improved bathing and toilet facilities on the first floor; an upgraded fire alarm system; new windows; redecoration of bedrooms; 2 new passenger lifts; the removal of asbestos; improved lighting in some areas. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 19 Further improvements were planned to include relocating a hairdressing room; provision of better staff facilities; a wet room; a visitors’ room; and a specialist dementia care unit. The County Council as the registered provider/owner arranged for contractors to undertake minor repairs and maintain the grounds surrounding the building. It was noted that several light bulbs in light fittings in the dining room were not working. One of the home’s management team said that they were constantly being replaced and did not last long. The home had comprehensive procedures in place concerned with infection control. It was noted that in accordance with best practice all communal WCs that were seen were provided with liquid soap dispensers (that were full and working) and paper towels. Protective clothing was readily available and staff were observed using gloves and aprons appropriately. The home’s laundry was suitably sited and equipped and effective procedures were in place for the management of soiled laundry items i.e. red dissolvable bags. Residents spoken to commented on the cleanliness of the building. One said, “Oh! they keep it clean, they come with the vacuum often enough”. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The skill mix of the homes care staff team was such that it should ensure that the needs of residents are met. The level of staff deployed in the home at all times should be reviewed. There were procedures in place for the training of new and existing staff to ensure that they had the skills to meet residents’ needs. The staff home’s recruitment procedures were robust and should ensure that as far as is reasonably possible vulnerable residents are protected. EVIDENCE: The care team working in the home at the time of the site visit comprised 16 day care assistants and 5 night care assistants. Out of these 13 (i.e. 67 ) had obtained a qualification equivalent to at least National Vocational Qualification (NVQ) at level 2. The home also had a management team excluding the registered manager that comprised a deputy manager; 4 assistant managers; and 3 night care coordinators. Between them they had the following qualifications: 2 x NVQ level 4 in management 2 x NVQ level 3 in care 2 x NVQ level 2 in care There was a requirement arising from the last inspection of the home on 16th February 2006 that staff must receive the training they required in order to do their jobs. At that time 33 of care staff had obtained at least an NVQ level 2 in care. Since then there had been 100 increase in the percentage of care staff with a formal qualification. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 21 At the time of the site visit to the home the basic care staff rota was as follows: 07:00 to 22:00 22:00 to 07:00 4/5 3 Apart from the care staff the home employed: Administrator Chefs Kitchen assistants Cleaners Laundry assistants As a home owned by the local authority there was also support available from the local authority’s corporate services such as human resources and finance departments. A number of residents and some staff spoken to about their perceptions of the adequacy of staffing levels indicated that at times the number of staff deployed in the home was insufficient and comments included the following: • “Sometimes they are short staffed because they have a lot to do”. • “I don’t think that there are enough staff because I can’t go to the toilet on my own and sometimes when I ring the bell for help they take a long time coming”. • “There are not enough staff sometimes, as there may only be three for the whole building”. • “They could do with more staff as they do seem pushed”. • “Sometimes there are not enough staff but they do come quickly if I use the alarm. Sometimes there are 4 on duty and sometimes there are 3. I feel sorry for them they are running here and there” • “It is OK but it is stressful. I think we need more staff in the evening because we have bathing and drinks to do, although the officers (management team) will help. The trouble is you find that 2 or 3 residents want to go up to bed at the same time”. The home’s registered manager said that staffing levels were based on the number of residents accommodated and their levels of dependency. It was suggested that the building was extensive and it operated over 3 floors and its configuration should be a factor taken into consideration when deploying staff. Due to the number of comments made about staffing levels it is strongly recommended that the adequacy of staffing levels be reviewed. The home had a detailed written policy and procedure concerned with “selection and recruitment of staff” (Practice No 425). It referred to obtaining references and completing checks through Criminal Record Bureau (CRB) and with the Protection of Vulnerable Adults list prior to a person starting work. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 22 The records of 2 staff that had started work in the home since the last inspection on 16th February 2006 were examined and it was apparent that all statutorily required pre-employment checks had been completed before they started work in the home. The home had a written policy and procedure about “staff training” (Practice No 426) and the written information given to potential residents included the following statement: “Care staff at Bishops Waltham House are trained in the care of older people and either have a formal qualification (usually and NVQ) or are working towards one …. The number of staff in all County Council Homes is base on the hours of care that resident need and there are staff on duty day and night”. It was apparent from talking to staff and from the number of individuals in the care and management staff teams that had obtained a formal qualification that there was a commitment to staff training and development and ensuring that their knowledge and skills were updated. Comments made by staff about this matter included: • “I have been here about 11 years. I have NVQ level 2 … We have to do manual handling, health and hygiene and fire safety every year .. I have also done a 4-day course in dementia care”. • “I have been here 7 years. I got NVQ level 2 last March. Every year we do manual handling and infection control. I have done an exercise course with Vitalise and do them with residents. We do fire safety at least once a month”. • “I have been here 8 years. I got NVQ level 2 in 2005.We do infection control and in-house training with hoists and slide sheets. I have done Dementia care. We do fire safety in supervision and sometimes during the week”. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 23 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): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s manager provided effective leadership in some areas of her responsibilities. The home enabled residents to exercise some control over day-to- day life and there were systems for monitoring the quality of the service provided. Systems for promoting the safety and welfare of everyone living and working in the home need to be more robust. EVIDENCE: The registered manager had been responsible for the operation of the home since 1997. She was suitably qualified for the role as she had NVQ level 4 in Management, a Diploma in Social Work and a degree in Applied Social Studies. From discussion with the registered manager, and from observation and discussion with staff, residents it was apparent that the registered manager was knowledgeable and experienced. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 24 There was however some evidence of weakness in her management of some of the home’s systems and her approach to her work. • Records not being kept/or available (see section above about complaints and protection). • Procedures not being fully implemented e.g. use of bed rails (see section above about complaints and protection). • All staff not receiving essential fire safety training (see this section below). • Failed to return a pre-inspection questionnaire sent to her some weeks before the site visit. This was despite the home being contacted by telephone on two occasions and requested to return it without delay. The information would have assisted with the process of inspection. The home had a system in place for monitoring the quality of the service that it provided that included the use of a questionnaire to obtain the views of residents that had respite care. It was stated that the use of questionnaires was to be extended to canvas the views of relatives of all residents accommodated in the home. Audits were undertaken of some of the home’s systems and functions including documents e.g. care plans, to ensure they were complete. Other audits included health and safety and finance. These were conducted by corporate staff e.g. internal auditor. In the information that the home provided to potential residents it stated: “We have regular residents’ meetings to discuss all aspects of life at Bishops Waltham House. This gives everyone a chance to talk about any changes, improvements and activities they would like” These meetings were usually held each month and there was a set agenda that comprised the following topics: • Quality of meals • Choice of menus • Service in dining room • Standards of hygiene in bedrooms, communal rooms • Response times to nurse call system • Attitudes of care staff in terms of assistance given • Attitudes of domestic staff in terms of assistance given • Attitudes of senior staff in terms of assistance given • Opportunities to engage in social activities • Opportunities to attend outside activities, clubs, outings, etc • Comments on general facilities, furnishings, environment The home looked after small sums of money for some residents that was left by or handed over by relatives or representatives. A sample of records of monies held on behalf of residents was checked and they were accurate and up to date. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 25 A number of records/documents that the home is required to keep in accordance with relevant regulations were examined during the site visit and these included: • Plans of Care • Complaints • Medication administration records • Fire and health and safety records • Financial records i.e. money kept on behalf of residents • Reports of monthly visits made to the home on behalf of the owner in accordance with Regulation 26 of the Care Homes Regulations 2001 records No record of a complaint made by a resident in March 2006v could be made available (see also above in the section “complaints and protection”). The home had a written health and safety policy and a range of related procedures. Records examined indicated that the home’s equipment, plant and systems were checked and serviced or implemented at appropriate intervals i.e. hoists; fire safety equipment; portable electrical equipment; hot water system; etc. Records were kept of accidents. Cleaning chemicals were stored safely and the home had product data information about them. An environmental health officer was visiting the home during this site visit and indicated that food hygiene was and had always been managed efficiently by the home. Staff said that they attended regular and compulsory fire and other health and safety training. There was a fire risk assessment for the premises and guards covered all radiators in the home and all windows above the ground floor were fitted with restrictors. There were some matters of concern noted about health and safety mattes in the home: • Records of fire safety training examined indicated that a member of staff received no fire safety training or failed to participate in a fire drill during 2006. • One of the home’s new passenger lifts was in use but there was no documentary evidence that it had been commissioned to be used safely. Information provided by the home’s registered manager on the day of this visit indicated that the existing/old passenger lift had last been serviced on 28th June 2006. There was a requirement arising from the last inspection of the home on 16th February 2006 that all staff must attend fire drills. Consequently this requirement has been repeated. Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 26 Relevant health and safety regulations concerning hoists and lifts indicate that such equipment should be serviced every 6 months. Consequently a requirement has been made with this report that the home makes evidence available at all times that equipment provided at the home for use by residents and persons working in the home is maintained in good working order. Bishops Waltham House DS0000038911.V323752.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? 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 OP18 Regulation 13 (7) & (8) Requirement The registered persons must ensure that before any form of restraint is imposed on a resident that it’s use is agreed following a multi-disciplinary assessment and that a record of that is kept. The registered persons must ensure that all statutorily required records are kept up to date and at all times are available for inspection in the care home. The registered persons must ensure that all staff working in the home receive/attend essential fire safety training that includes fire drills. (Previous timescale of 30/04/06 not met) The registered persons must make available at all times evidence that equipment provided at the home for use by residents and persons working in the home is maintained in good working order. Timescale for action 30/04/07 2 OP37 17 30/04/07 3 OP38 23(4)(e) 30/04/07 4 OP38 24(2)[c] 30/04/07 Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 29 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.V323752.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 © 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 Bishops Waltham House DS0000038911.V323752.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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