Inspection on 08/06/07 for Bishops Waltham House

This inspection was carried out on 8th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 30/01/07

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 Marilyn Lewis Unannounced Inspection 8th June 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.V338785.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.V338785.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.V338785.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2007 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 two lifts 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 the 8th June 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 to a maximum of £403 per week. Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to the home took place on the 8th June 2007. The inspector toured the home and met with residents, a care manager, two carers and two assistant unit managers. Records sampled included pre admission assessments and care plans and those for medication, complaints, staff recruitment and training and fire records. The registered manager and deputy manager were not on duty and an assistant unit manager assisted the inspector. Major refurbishment was taking place at the home and accommodation available was limited to twenty-three rooms. People were not being admitted to the home on a permanent basis but those requiring respite were offered a place. At the time of the visit twenty-one permanent residents were accommodated and two people were receiving respite care. The registered manager has been absent from the home for a number of months this year and during the visit the inspector found that the assistant unit managers were working hard to provide good quality care for the residents. The assistant unit managers on duty said that they were unable to keep up to date with ‘paperwork’ such as the care plans due to the additional pressure of ‘running the home’. The service manager with responsibility for line managing the home contacted the inspector following the visit to the home to say that a manager from another care home was going to spend time at the home as the temporary manager to provide support and leadership to staff. The registered manager had not returned a completed Annual Quality Assurance Assessment to the commission as required, to provide information on the quality of care provided at the home. Information received by the commission since the last inspection and contained in the last inspection report was taken into account when writing this report. What the service does well: Residents said that they liked living at the home. During the visit very good interaction was observed between staff and the residents. Residents Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 6 commented that the staff were ‘lovely’ and ‘great’ and said that they were treated with respect at all times. Potential residents spent a day at the home prior to admission to meet residents and staff. Residents felt that any complaints would be taken seriously and acted upon quickly. The home had procedures in place for the protection of vulnerable adults and staff were aware of the procedures to follow should abuse be suspected. The home looked clean and homely. Residents said that they liked their rooms and those seen had been personalised with items such as televisions, photographs and ornaments. Residents said that they were able to exercise control over their lives and could chose to join in social activities that included music and exercises, quizzes and bingo. Residents said that they had really enjoyed the music of an entertainer who had visited the home the day before the inspectors visit. Meals served during the visit were well presented and residents said that they enjoyed the choice of food provided. Comments included ‘ the food is always good’, ‘there is always plenty to eat’ and ‘if you don’t like the meals on the menu the cook will always get you something else’. Carers said that they received good support from the assistant unit managers and were encouraged to attend training sessions and obtain qualifications. Thirteen of the twenty carers hold National Vocational Qualification (NVQ) level 2 or above, providing them with the skills required to fully support the residents. What has improved since the last inspection? A multi disciplinary assessment that includes input from the GP, care manager and if appropriate relative of the resident, is now undertaken for residents where the use of bed rails is thought to be of benefit. Records seen indicated that maintenance checks on the lifts and specialist equipment such as hoists were undertaken regularly to ensure the equipment was in good working order. Staff had received training in fire safety and had attended fire drills. Records for night staff attendance at fire drills was not available at the time of the visit but the inspector was contacted following the inspection by the assistant unit Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 7 manager who had assisted with the visit, to confirm that records for night staff attendance were in place. 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.V338785.R01.S.doc Version 5.2 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 Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care needs assessments for some people being admitted for respite care are not always completed prior to their admission to ensure the home can meet their care needs. The home does not provide intermediate care. EVIDENCE: The assistant unit manager said that potential residents are asked to spend a day at the home to meet the permanent residents and staff. During the visit staff take the opportunity to complete a pre admission assessment of the persons’ care needs. The home was currently not admitting people for permanent stays due to the major refurbishment taking place, but people requiring respite care were being admitted. Assessments were seen for two residents who had recently been admitted for respite care. Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 10 One person had been resident since the 28th May 2007. Night care plans were in place but assessments including a respite plan of care and moving and handling assessment had not been fully completed. The person had been admitted to the home previously for respite care and staff said that they were aware of the care needs and support needed for the person. However details of a leg abscess, that had been noted in the care report provided by the care manager, had not been followed through on the assessment. The person was very independent and staff said that he was able to attend to his own personal care. During the visit to the home staff completed the care assessments. Assessments were in place for the second person who had recently been admitted for respite care. This person had also been admitted to the home on previous occasions. The assessments in place had been reviewed and up dated as necessary. Three residents spoken with during the visit said that they had visited the home for assessment and as one of them said ‘to see what life was like at the home’ before deciding to take a place there. The home does not provide intermediate care. Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff are aware of the needs of the residents but some written care plans do not provide up to date information regarding the residents needs and wishes. Residents feel they are treated with respect at all times. Staff would benefit from a larger medicine trolley that has a lock, so that medicines could be easily and safely stored in the trolley during medicine rounds. EVIDENCE: Information recorded in the pre admission assessments was used to complete the care plans for residents. Care plans seen for one of the two residents who had been admitted for respite care had not been fully completed, including moving and handling assessments, nutrition assessment and wound care. The plans stated that the person was independent and did not require assistance Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 12 with personal care. However the pre admission information stated that the person had difficulty bending down and needed help with shoes and socks. Staff spoken with said that the person had been admitted to the home for respite care previously and they knew the support required to meet the care needs. Daily records seen indicated that staff were assisting the resident with putting on and taking off shoes and socks. A night care plans was in place. Care plans seen for the second person admitted for respite care had been fully completed. Care plans seen for two residents who had lived at the home for a number of years showed evidence of infrequent review. One care plan for night care had been reviewed in November 2005 and then May 2007, and a moving and handling assessment for another resident had been reviewed last in December 2005. Some care plans had been signed by the resident but some seen did not show any evidence of the residents’ involvement in the reviewing of the plans. One resident spoken with said that she knew what was written in her plans as she discussed them with staff and read them to make sure she agreed with the content. Another resident did not know what information was in her current plans. The assistant unit manager said that an audit of the care plans had just begun and reviews were due to take place. A GP visits the home weekly and staff arranged appointments for residents who wish to see the doctor. A resident said that she had asked staff if they could arrange for her to see her GP and they had organised an appointment for her. Another resident spoke with the assistant unit manager during the visit regarding her wishes to see her GP and as the concern was not urgent, this was arranged for the next visit by the GP which was due to take place in a couple of days. District nurses visit the home as needed and were currently visiting on a daily basis to advice and support staff with one resident with high care needs. Records seen indicated that opticians and a dentist also visited as needed. A chiropodist visits the home on a six weekly basis. The assistant unit manager went through the home’s procedures for handling medicines. Systems were in place for recording medicines brought into the home and for medicines that were not required and were returned to the pharmacy. The majority of the medicines are supplied in cassette style containers. The assistant unit manager said that this was shortly to be changed to blister packs making it easier to store the containers. There was limited space in the trolley and it was not possible to store all the separate containers of medicines in the trolley when the trolley was taken around the home for medicines to be Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 13 administered. Some containers were left on the top of the trolley. Staff did not leave the trolley when administering the medicines but they said that issues arose when there was an emergency or assistance was required quickly as the trolley had to be wheeled to a room that it was possible to lock before attending to the needs of the resident. A larger trolley would allow staff to lock medication in the trolley in order to assist in an emergency. There was no key to the current trolley. Only staff who had received training in the administration of medicines were able to do the medicine round. Medication records seen had been completed appropriately. Tempazepam was stored as a controlled medicine and records seen matched the amount held. Three residents were currently administering their own medication. The GP, home manager and the resident had signed consent forms for this. The assistant unit manager said that another resident who had been self administering their medication had been assessed as now not able to do so and staff had taken responsibility for her medicines. The consent forms were contained in the residents’ files. During the visit staff were observed knocking on doors and waiting before entering rooms and doors were closed when residents were being assisted with personal care. Staff spoke with the residents in a caring and friendly manner. A resident said that staff always treated them with respect and ‘were lovely’. Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 14 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. Residents are able to exercise choice over their daily lives, join in with social activities as they wish and enjoy the meals provided. EVIDENCE: The assistant unit manager said that residents had chosen not to have regular church services at the home but liked them at special times of the year such as Easter. Local ministers still visited the home frequently and chatted to the residents. One of the residents did not speak English as a first language. A list of words in both languages were kept in the residents’ records but staff said that the resident had lived at the home for many years and was now able to speak quite a lot of English and staff were able to chat with the resident. One carer has completed an NVQ in providing activities in a care setting and two carers have received training to provide residents with gentle exercise programmes. Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 15 The homes’ activity programme was displayed in the reception area. A resident said that activities included music and exercise, different exercises, quizzes and bingo. Five residents said that they had really enjoyed the music of an entertainer who had visited the home the day before the inspectors visit. One resident said that he enjoyed wiping down and laying the tables in the dining room and another said that they liked sitting in the reception area and watching people coming and going. Another resident said that they went out with friends or relatives each week and occasionally stayed with relatives over night. Residents said that their relatives were able to visit at any time. It was evident during the visit that the residents were able to choose for themselves what they wanted to do in the day. Residents said that staff told them what was due to take place for activities in the day but they were able to choose to join in or not. One resident said that she liked to spend time in her own room and staff respected her wishes. All residents spoken with said that the food provided at the home was good. A cooked breakfast was available each morning for those who wished it. The daily menu was displayed in the dining room and lunch on the day of the visit was a choice of lamb steak or pork casserole with potatoes, mixed vegetables and beans followed by peaches and cream. The cook said that she had a list of the residents’ likes and dislikes and any dietary needs and this was taken into account when developing the menus. Other alternatives were available and if a resident did not wish the main choices they would chat with them to see what they would like. Residents confirmed that they were able to have alternative meals. Meals served at lunch were well presented and residents said that they enjoyed their meals. Bishops Waltham House DS0000038911.V338785.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 good. This judgement has been made using available evidence including a visit to this service. Residents feel that any complaints will be taken seriously and they are protected by staff awareness of the prevention of abuse. EVIDENCE: No complaints or adult protection issues have been reported to the commission since the last inspection. The home has a complaints policy in place that indicates who will investigate the complaint and timescales for the process. Residents said that they would speak with the registered manager or one of the assistant unit managers if they had any complaints. The residents said that they had never had cause to make a complaint but thought that staff would listen and act if needed to resolve any issue. The homes’ complaints log indicated that one complaint had been received since the last inspection. A record of the complaint had been logged and a meeting was due to be held with the complainant, the registered manager of the home and the service manager to discuss the issue raised. At the time of the last inspection visit the homes’ written procedures related to the protection of vulnerable adults stated that ‘written confirmation agreeing to Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 17 the use of bed rails must be obtained following a multi-disciplinary assessment’. Multi disciplinary assessments had not been undertaken. Since the last inspection multi disciplinary assessments have been completed for all residents where bed rails were in use. The assessments had involved the GP, care manager and where appropriate the relatives of the resident. An occupational therapist had been contacted for advice regarding the use of bed rails for one resident. Two carers spoken with said that they would report any concerns regarding suspected abuse, immediately to the manager or person in charge. Records seen indicated that staff had received training in the prevention of abuse but for many staff members this had taken place in 2003/2004 and it was necessary for a refresher course to be arranged to ensure staff were aware of the up to date procedures for adult protection. Bishops Waltham House DS0000038911.V338785.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, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Bishops Waltham House provides a safe, clean and homely environment for those who live, visit and work there. EVIDENCE: Major refurbishment work has been taking place at the home over the last three years. The home has accommodation over three floors with two new lifts and stairs providing access to each floor. Some areas of the home are not in use due to the refurbishment work. At the time of the visit 23 rooms were in use by residents. The reception area of the home looked welcoming and there is a small seating area provided where residents are able to sit and chat. Residents have access Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 19 to a large lounge and dining room on the ground floor and there is also a lounge and small sitting room on the first floor. Residents said that they liked their rooms and those seen looked clean and homely and contained many personal items such as television, photographs and ornaments. The residents said that they had a key to their room and were able to lock the door if they wished when they left the room. Sufficient bathroom and toilet facilities were provided. One bathroom on the first floor had a hydro bath and overhead hoist to enable staff in moving residents with poor mobility into the bath. Staff said that they had the specialist equipment such as hoists they needed to fully support the residents. A call alarm system was provided throughout the home and staff used an intercom systems to speak with other staff members to request assistance. The registered managers room was on the top floor and also the treatment room where the controlled drugs cupboard was kept. The laundry on the ground floor looked to be in good order with hand washing facilities provided and soiled laundry stored appropriately. Protective clothing such as disposable aprons and gloves were readily available and staff were seen to use it as needed. The home has pleasant gardens with a fishpond and seating areas. Further improvements to the environment should be provided when the refurbishment work has been completed including better staff facilities and a room for visitors. Two residents said that they felt the refurbishment work had been going on a long time and one said that they were ‘looking forward to the day when it was finished’. Bishops Waltham House DS0000038911.V338785.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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels need to be reviewed taking into account the needs of the residents and the layout of the home. The home follows robust procedures when recruiting new staff but records are not always available to confirm this. An audit of staff training was being undertaken and any training requirements were being addressed. EVIDENCE: Three residents said that they thought enough staff on duty but there were comments of ‘ they work very hard to keep up with the wishes of the residents such as when they ask to be assisted to the toilet’ and ‘sometimes I have to wait a long time to get help to the toilet’. At the last inspection comments received also indicated that staffing levels needed reviewing to take into account the layout of the home. This still needs to be done to ensure staffing levels are sufficient to support the residents and meet their care needs. It was evident during the visit that staff are very committed to providing good care for the residents. A staff member said that the layout of the home, with Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 21 some residents on each of the three floors, made it difficult for them to sometimes attend to a resident as quickly as they would wish. Residents said that the staff are ‘lovely’, ‘great’ and ‘can’t do enough for you’. The home employs the registered manager, deputy manager, four assistant unit managers, three night co-ordinators and twenty carers. On the day of the visit an assistant unit manager was on duty with three carers. One of the carers was the domestic who had changed roles for the day due to staff shortages. Records seen indicated that the domestic had not received training in moving and handling but the assistant unit manager and the domestic said that she had received the training but it had not been recorded. As the domestic was needed for care duties there was no domestic on duty for the day. Separate staff were employed for administration and catering duties. The registered manager was currently not in work due to sickness and the deputy manager was on leave. Rotas seen indicated that at night one night co-ordinator and two carers were on duty. Thirteen of the twenty carers hold NVQ level 2 or above in care. One carer spoken with had completed the NVQ course and she said that she had received very good support and encouragement from the assistant unit managers to attend training sessions and obtain the qualification. Another carer said that she had been nominated to do the course and was waiting for a start date. One staff member had commenced work at the home since the last inspection. Records seen contained a completed application form and proof of identity but only one reference. There was also no confirmation that Protection of Vulnerable Adult or Criminal Records Bureau checks had been completed prior to the person starting work. The assistant unit manager contacted the Human Resources department and received confirmation that the second reference had been received and the checks completed prior to the person starting work at the home. These records must be made available for checking at future inspections. The assistant unit manager said that an audit of staff training was taking place and training would be arranged for staff where training requirements were identified. Records seen indicated that staff had received training in adult protection, though this needed updating and food hygiene. All staff had attended training in moving and handling, although the records did not confirm this for the domestic working as a carer on the day of the visit. Training was being arranged for two kitchen assistants who had not received training in infection control. Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 22 All the assistant unit managers and night co-ordinators had received training in the safe handling of medicines and carers had attended training sessions in medication but not the administration of medicines. Five staff members had attended training in the care of people with dementia. Bishops Waltham House DS0000038911.V338785.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, 32, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of stable leadership at the home has resulted in some records not being kept up to date and staff not receiving supervision to ensure they receive feedback on their performance. This could result in the home not being run in the best interests of the residents. EVIDENCE: The registered manager has been on sick leave for a time during the last four months and was again on sick leave at the time of the visit. The deputy manager was not on duty on the day of the visit. The assistant unit managers spoken with said that they knew some of the ‘paperwork’ was not up to date as Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 24 they were concentrating all their efforts in providing good quality care for the residents. One of the assistant unit managers said that some support had been received from a service manager but unfortunately this person was now away from work and another service manager was taking his place. This service manager contacted the inspector following the visit to notify the commission that a temporary manager had been placed at the home to support staff during the registered managers absence. A care manager visiting the home said that she had spent quite a bit of time at the home over the last few months and had seen the assistant unit managers and staff working very hard to keep the quality of care provided good. It was evident during the visit that the assistant unit managers spoken with were committed to providing good care for the residents and support for the staff and the moral of staff was good even though they felt, as one person said, ‘a bit forgotten at times’. The lack of stable management of the home has been a factor in records not being kept up to date and the lack of staff supervision. Also the Annual Quality Assurance Assessment documents sent to the registered manager prior for completion prior to the visit had not been completed and returned, even though a reminder letter was sent. Residents said that they felt able to talk with staff about the quality of care provided at the home and were also able to discuss issues relating to life at the home during resident meetings which took place monthly. Records seen for the last meeting indicated that a wide and varied range of topics was discussed. Questionnaires had been provided for residents who had been admitted for respite care. Issues raised in the questionnaires such as poor lighting in the lounge were being addressed. The assistant unit manager said that feedback was given on a one to one basis for the residents who had completed the questionnaires and on a one to one basis or if appropriate, as a group for other residents. During the visit staff spoke with a relative in a very caring, friendly and sensitive manner. Staff meetings were held usually on a two monthly basis. A service manager attended the last meeting to discuss the ongoing refurbishment programme with staff. The home has clear procedures for the handling of residents’ money. Small amounts of money are held for some residents. The monies are kept in individual containers in a safe place. Records are kept of all transactions and records seen for three residents matched the amount of money held. Two staff members spoken with said that they had not received formal supervision for a long time. An assistant unit manager said that she had had to postpone some of the supervision session she had arranged due to the need Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 25 for pre admission day assessments to be completed and the pressure of working without a registered manager. The two assistant unit managers spoken with had not received training in providing staff in a care setting with supervision. The assistant unit managers had not received regular supervision themselves. The home had health and safety policies and procedures in place and notices were displayed in the home. Staff had received training in health and safety and during the visit safe working practices were observed when assisting residents with poor mobility. Hazardous substances such as cleaning fluids were stored securely. The kitchen looked clean and food was stored appropriately. At the time of the last inspection visit records were not available to confirm that one of the new lifts was safe to use. Records seen on this visit indicated that the two new lifts were safe to use and regular maintenance checks had been completed on specialist equipment such as the hoists and the assisted bath. Fire records seen indicated that regular checks were undertaken for the fire alarm system, fire safety equipment and emergency lighting. Records for staff attendance at fire drills indicated that night staff had not attended drills in 2007. It was a requirement of the last two inspections that all staff attend fire safety training and fire drills. Following the visit an assistant unit manager notified the inspector that the night staff had attended fire drills and records were available to confirm this but these had not been available for the inspector during the visit. The assistant unit manager said that the records had been kept in a different folder and the staff assisting the inspector during the visit were unaware of where they were kept. Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 26 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 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 x 3 2 x 3 Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 27 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 OP3 Regulation 14 (1) Requirement Pre admission assessments need to be completed for all residents including those admitted for respite, to ensure the home can meet their care needs. Care plans need to be completed and reviewed, if possible in consultation with the resident to ensure the plans record the residents current needs and wishes. Staffing levels should be reviewed to ensure sufficient staff are on duty at busy times of the day. Staff recruitment records including references, POVA and CRB checks should be available to inspectors for them to confirm all the necessary documentation has been obtained. Staff must receive supervision to ensure they are provided with feedback on their performance. Timescale for action 08/07/07 2. OP7 15 (2) 31/07/07 3 OP27 18 (1) (a) 31/07/07 4 OP29 19 (4)(b) 31/07/07 5 OP36 18 (2) 31/08/07 Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 28 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 OP9 Good Practice Recommendations It is recommended that a larger medicine trolley with a lock is provided to enable staff to safely store medicines during a medicine round. Bishops Waltham House DS0000038911.V338785.R01.S.doc Version 5.2 Page 29 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.V338785.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!