CARE HOMES FOR OLDER PEOPLE
Bishopsgate Lodge Care Home Hexham Street Bishop Auckland Durham DL14 7PU Lead Inspector
Belinda Parker Unannounced Inspection 12th October 2005 09:00 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 Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bishopsgate Lodge Care Home Address Hexham Street Bishop Auckland Durham DL14 7PU 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) 01388 607580 01388 451140 Southern Cross Healthcare Services Limited Mrs Valerie Davies Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51), Terminally ill (3) of places Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Terminal Illness. Up to 3 persons with a terminal illness (palliative care) over the age of 55 years, may be accommodated, commensurate with the home`s statement of purpose and function and where appropriately qualified and competent staff are provided. 9th May 2005 Date of last inspection Brief Description of the Service: Bishopsgate Lodge Care Home is situated on the outskirts of Bishop Auckland. The home was purpose built and can accommodate up to 51 service users. The home provides 24-hour personal care (including nursing care) for older people with general nursing needs. The home is on three floors and is easily accessible to all service users. There are a number of communal rooms including lounges and dining rooms. Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 12/10/05 over a period of hours. The inspector was accompanied for part of the inspection by two members of Darlington Association for Disability, talking to service users who have hearing and visual impairments to find out if they feel that the home communicates effectively and are given the opportunity to make their views known on any aspect of the service delivery. The inspector toured the home and a number of records were examined. Since the last inspection one of the five requirements made remain outstanding and must be addressed to ensure the protection of service users. What the service does well: What has improved since the last inspection? Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 Page 6 The home is currently implementing new paperwork, so therefore all service users are being reassessed to ensure their changing needs are being met. Improvements to the environment are ongoing including redecoration and window replacement, which will increase the standard of comfort for the people who live in the home. 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. Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 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 Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 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): 1 and 2. Standard 6 is not applicable The home’s Statement of Purpose and Service User Guide are good providing service users and prospective service users with current details of the services the home provides enabling an informed decision about admission to be made. EVIDENCE: The Statement of Purpose and Service User Guide have been updated October 05 and provide clear information on the service offered in a user-friendly format. This information gives prospective service users and their relatives the necessary information to make a decision as to whether they wish to move into the home. The company is currently reviewing the Terms and Conditions of residency. The manager said this revised document will be implemented to all service users as soon as possible. Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 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 11 Since the last inspection a new care planning system is currently being implemented which will improve the range of information available to staff to meet the individual needs of the service users. It is evident that service users and staff have a positive relationship. The home has made limited progress to improve their procedures for recording medication placing service users potentially at risk. EVIDENCE: Following a recent organisation merger the manager provided evidence to show that a new improved care plan is currently being implemented, which provides staff with extra information to adequately meet the individual needs of the service users. This care plan includes risk management strategies to enable service users to lead an independent lifestyle of their choice, and improved nutritional screening to ensure their dietary needs are being met. It remains a concern that staff continue to make errors when recording medication on MAR sheets and the Controlled drugs register even though this was discussed with the manager at the last inspection. Potentially service users could be put at risk due to poor practice being carried out by staff who have responsibility for medication.
Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 Page 10 Service users spoken to during the inspection said staff gave them respect and helped them appropriately when assisting with personal care. A service user who had a visual impairment said the staff tell her the colours of her clothes to enable her to make a choice for the day. Good interaction was observed between staff and service users. The manager and staff demonstrated during discussion the importance of good communication ensuring service users especially those with a sensory disability receive the necessary information they need to make choices and to make their views on the service delivery known. Comments from service users spoken to with a sensory impairment included, “ I always sit next to matron at meetings so as I don’t miss anything”, “ I don’t go to meetings, but a member of staff reads the minutes of the meeting to me”, “ I can’t hear properly but the staff know to speak to me face to face”. The home has in place a policy and procedure in place in the event of death occurring. The manager said in the event of a service user dying, family members if they so wish can stay with the service user and drinks and snacks would be provided. Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 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): 12 and 15 The home provides a range of activities to enhance social opportunities for the people living in the home. The dietary needs of service users are adequately met as well as offering a varied and balanced selection of food being made available. EVIDENCE: Since the last inspection a new activities co-ordinator has been appointed. The activities co-ordinator has developed in consultation with service users and the manager a monthly activity programme that meets the collective interests and choices of the people living in the home. The manager said the routine within the home is flexible. Service users spoken to confirmed this. Service users were observed having lunch in an unhurried and relaxed atmosphere. It was evident that service users had a choice of main meal. Service users who required assistance with feeding where supported appropriately by staff. Care plans contain documentation to enable staff to record that the dietary needs of service users are being met. Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 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): 18 The home has in place robust procedures and processes to ensure the people living in the home are protected from abuse or neglect. EVIDENCE: Since the last inspection the majority of staff have attended POVA training (Protection of Vulnerable Adults). The manager said as new staff commences extra training sessions are arranged throughout the year. There have been no POVA referrals since the last inspection. All staff working in the home has a current Criminal Records Bureau check to ensure the protection of service users from abuse or neglect. Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 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 Recent investment has significantly improved the appearance of this home creating a comfortable and safe environment for those who live there. EVIDENCE: Since the last inspection there has been substantial financial assessment by the provider to enhance and improve the environment and communal facilities for the benefit of service users. Bathing facilities have been improved to provide a choice of showering or assisted bathing, a new sluice has been installed. Window replacement remains ongoing, which will improve the standard of comfort for service users. Service users commented positively on the standard of the communal and their personal accommodation. One service user spoken to said she “ Liked the homely feel of her room”. The home was observed to be clean and free from odour. Policies and procedures are in place to prevent and control the spread of infection.
Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 30 The training and development of care staff has improved ensuring the people living in the home receive a good standard of care from skilled and competent staff. EVIDENCE: The manager said the home is still working towards 50 of staff achieving NVQ2 in care. There has been recent difficulty in enquiring an appropriate training company to facilitate this training for staff but this has now been addressed and staff will shortly be continuing with or commencing the course. This training provides staff with the necessary skills and abilities to meet the needs of service users living in the home. Evidence was available to show that staff attend regular training to develop their skills and knowledge to ensure that the people living in the home benefit from a good standard of care service delivery. It was pleasing to hear training is to be made available on ‘Sensory Deprivation’, which will equip care staff with the appropriate skills when communicating with service users with a sensory impairment. Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 Page 15 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 and 36 The manager is experienced and provides clear leadership throughout the home. Robust procedures are in place for the safekeeping of service users monies and monitoring service performance to ensure the protection of service users. EVIDENCE: As for Standard 30 the manager is to continue with the Registered Managers Award, which will enhance her skills and knowledge in the management of the home and care service delivery to the people who live in and visit the home. The manager described her management style as flexible and adaptable to the needs of the people living in the home and listening to the views of her staff on her approach to leadership. Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 Page 16 The manager is an experienced and qualified nurse with many years experience working with older people. The manager had available evidence to show that she regularly updates her knowledge and skills in the care of older people. The home has a system of continual self-monitoring and audit to ensure the service delivery remains at a good standard at all times for the people who live in and visit the home. A current up to date record of money held on behalf of service users by the home was available. Receipts where available for all financial transactions made. Money held on site is stored in an appropriate locked facility. Evidence was available to show that in June 2005 the home implemented a new system for the formal supervision of staff an up to date record of staff supervision sessions was available for inspection. Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 x 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x 3 3 x x Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement The registered Manager must ensure staff adhere to the procedures for recording medication received into the home. For daily recording on MAR sheets staff must sign and date if a medication has been discontinued. The Controlled drugs register must contain evidence that two staff have signed for the return of Controlled drugs to the pharmacy. (Outstanding since the last inspection). Timescale for action 12/10/05 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 OP31 Good Practice Recommendations The registered manager must commence and work towards achieving the Registered Managers Award to develop her management skills and abilities to ensure a good standard of care service delivery for the people who
DS0000000699.V255813.R01.S.doc Version 5.0 Page 19 Bishopsgate Lodge Care Home 2 OP28 3 OP19 live in and visit the home The registered manager should ensure the home continues to work towards 50 of staff achieving NVQ2 in care to ensure the people living in the care home are cared for by skilled and competent staff. The registered provider should continue with redecoration and refurbishment within the building to improve the comfort standards for the people who live in the home. Bishopsgate Lodge Care Home DS0000000699.V255813.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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