Inspection on 26/04/05 for Bodmeyrick Residential Home

This inspection was carried out on 26th April 2005.

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

Bodmeyrick Residential Home 25/05/07

Bodmeyrick Residential Home 11/12/06

Bodmeyrick Residential Home 06/10/05

Bodmeyrick Residential Home 29/12/04

Bodmeyrick Residential Home 11/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Bodmeyrick North Road Holsworthy Devon EX22 6HB Lead Inspector Sue Dewis Announced 26 April 2005 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 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. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bodmeyrick Address North Road Holsworthy Devon EX22 6HB 01409 253970 01409 254448 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Andrew Gordon Orchard Betty M Boundy Care Home 28 Category(ies) of DE(E) Dementia - over 65 (28) registration, with number MD(E) Mental Disorder - over 65 (28), of places PD(E) Physical Disability - over 65 (28) OP Old age (28) Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Registered Manager completes NVQ4 in Care by 2005 Date of last inspection 29 December 2004 Brief Description of the Service: Bodmeyrick provides personal care for 28 older people, some of whom may have dementia, mental health problems or a physical disability.The home is a detached property situated within easy reach of the facilities of Holsworthy. Originally an older type property it has been converted and extended to provide accommodation in 28 single occupancy bedrooms. A passenger lift enables residents to reach all areas of the home. There are two lounges and two quiet rooms. A day care service is provided on two mornings a week. The rear of the property comprises a car parking area. To the front is a lawn area that is pleasant and easily accessed. The home has a specially converted vehicle for taking small groups or individual service users out. Larger group outings use Deer Park’s minibus (owned by the same Registered Persons). Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over eight hours on a weekday in late April 2005. The inspector was shown around the home soon after she arrived there. The inspector spoke with three staff and two service users individually. The inspector also spoke with two service users together. Comment cards were received from five relatives/visitors and four residents. One relative was spoken with over the telephone. What the service does well: What has improved since the last inspection? The pre-admission assessment procedure and care plan recordings have improved to a satisfactory level. Fire doors are now closing correctly and the rear fire escape has been replaced. Several minor repairs have been made to improve the environment. The duty rota now shows the hours worked by the manager during the day. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 6 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. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 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 standard(s) 3 and 5 Prospective residents are assured that the home can meet their assessed needs. EVIDENCE: Following a recommendation from the previous report the manager now ensures that a full pre-admission assessment is completed. The files of the two most recent admissions contained completed forms. Residents are assured verbally that the home can meet their needs prior to admission, but does not confirm in writing that it can meet the needs of prospective residents. The inspector was told that service users are able to visit the home or stay overnight prior to making a decision about staying. Two service users confirmed that they had the opportunity to visit the home prior to their admission, but had chosen not to. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 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 standard(s) 7, 8 and 10 There is a clear and consistent care planning system in place that provides staff with the information they need to be able to meet the needs of the residents. The health care needs of residents are well met, and their privacy and dignity is respected. EVIDENCE: Four residents’ care plans were inspected. All plans contained the necessary information and told staff how they should meet the needs of the resident on a daily basis. Care plans are reviewed and audited each month by the manager. Evaluation sheets are kept in residents’ rooms and all staff are encouraged to write any changes to residents’ needs on them. There is a key-worker system at the home and each key-worker is responsible for ensuring care plans are up to date and regularly reviewed by staff with the service users where possible. Care plans clearly identified health care needs, including diabetes and continence issues. There was evidence of multidisciplinary working towards meeting these needs, including input from District Nurses. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 10 The inspector was told that during the induction process, staff are made aware of the need to respect the privacy and dignity of residents. Staff were seen to knock on doors and offer personal care in a discreet way. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15 Links with visitors and the community are good and support and enrich residents’ social opportunities. Meals were well presented and provide daily choice and variety for residents. The style of cooking does not always please all the residents. Residents’ views are sought from time to time, but they do not all feel that their wishes are acted upon. EVIDENCE: One resident visits the local day centre and the home has access to a local resource centre, giving residents access to craft courses there. One resident told the inspector that she went to church every two weeks. Other residents told the inspector that they walk into town, visit the market and go to coffee mornings. The home tries to arrange weekly outings and residents told the inspector of some of the places they had visited. There was a notice displayed showing weekly activities, which included bingo and scrabble. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 12 Some staff told the inspector that they have some time to spend with residents on a one-to-one basis, but some residents and some staff felt that this time was limited. Two volunteers visit the home through the local volunteer bureau, and spend time chatting with residents. One visitor and several residents said that visitors are made welcome at any time. Residents are encouraged to get up and go to bed as they choose and can spend as much time in their room as they wish. Two residents told the inspector that the best thing about the home was that they were able to do as they pleased. Residents’ meetings are held every six months and residents are asked to complete questionnaires about the service provided. Two residents felt that when they raised matters such as a concrete ramp to the rear door, they were not listened to. However, the manager and other residents said that there was a suitable ramp available for use at the back door. There is a very pleasant dining room and residents can eat there or in their rooms. Lunch was taken with residents and the food was well presented and nutritious and residents are offered a choice for each meal. Two residents commented that though the food was of a good quality and quantity it was not always cooked to their liking. The atmosphere at lunch-time was relaxed and unhurried, and residents who needed assistance were helped discreetly. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a satisfactory complaints procedure, which residents fully understand and are confident in. Staffs’ good knowledge and understanding of Adult Protection issues provides a safe environment to protect residents from abuse. EVIDENCE: There is a clear and concise complaints procedure available in the service users’ guide and displayed in the entrance hall. Residents said that they knew who to talk to if they were unhappy about anything. A complaints log is maintained, showing outcomes of the investigation. The registered manager has completed training on training carers about adult protection issues. She will ensure that all staff receive this training. Staff confirmed that they had had some training on recognising and dealing with abuse. Three staff that were spoken with could identify different types of abuse and would follow an appropriate procedure. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 23, 24 and 26 The standard of the environment within the home is good, providing residents with a clean, attractive and homely place to live. The home is not entirely safe for residents. EVIDENCE: The home was clean, well maintained and free from any unpleasant smells. However, the carpet on the top corridor was beginning to fray along the join, and could become a trip hazard. Soap and towels are provided in all toilets. Staff confirmed that disposable gloves and aprons are available for them to use. Some residents’ rooms have had ‘star-locks’ fitted to the doors. These locks are unsuitable for residents’ rooms as they all have the same key and could result in the resident being locked in their room. The home should consult with Devon Fire and Rescue Service about suitable locks. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 15 Risk assessments were seen for individual residents, which identified specific risks and showed measures in place to minimise them. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 There is a high commitment to training within the home, resulting in staff who are able to recognise and meet the needs of residents. The deployment and numbers of staff available is generally sufficient to meet the needs of the residents. EVIDENCE: The staff rota shows that there are 5 care assistants, a cook and kitchen assistant, a cleaner and a driver on duty each morning. There are three care assistants on duty each afternoon/evening till 9pm and two staff awake each night. The staffing levels are within recommended levels and residents generally felt that this was adequate to ensure a timely response if they needed help. Though there were two comments (one from a resident and one from a visitor) that sometimes they had to wait a long time for call-bells to be answered. Four staff files were inspected. One did not contain references and one had a copy of a CRB (Criminal Records Bureau) check from a previous employer. Both of these staff had been employed for some time, and the inspector saw evidence that recently employed staff files had the required information. Staff training records show that 25 of staff have achieved NVQ level 2 or above. Other training includes First Aid, Moving and Handling and Fire Precautions. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 17 As the dementia care needs of the residents increase the home is looking to provide more training for staff in this area. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36 and 38 The manager gives clear leadership, guidance and direction to staff, ensuring residents receive consistent quality care. This results in practices that promote and safeguard the health, safety and welfare of the residents. EVIDENCE: The manager has worked at the home for several years, is a registered nurse and is working for her Registered Managers Award. Staff and residents said that they felt able to talk to the manager. Staff confirmed that they received regular supervision and notes were seen, though they did not show the outcomes for items that have been raised. The home asks residents, visitors and other professionals to complete quality assurance questionnaires. These must be collated into a report that must be sent to CSCI with a copy made available to residents. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 19 The home does not act as appointee for any resident. Three residents’ finances were inspected. The recording was good and there were two signatures for all the transactions, though no receipts were numbered. Water temperature checks and Legionella checks are regularly carried out. Staff have received training in Health and Safety. Risk assessments were seen for some areas of the building and fire precautions. The risk assessments for the home do not cover all areas, such as stairs. Window restrictors and radiator guards are fitted where needed. The fire log book was correctly maintained. Fire doors are now closing correctly and the rear fire escape has been replaced. Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x 2 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 2 x 2 2 x 2 Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 21 NO 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 3 Regulation 14 (1)(d) Requirement You are required to confirm in writing that the home can meet the assessed needs of the prospective resident You are required to send a copy of the quality assurance report for the home to the Commission and to make it available to residents and their representatives Timescale for action 10 June 2005 5 August 2005 2. 33 24 (2) 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. 2. 3. 4. 5. Refer to Standard 19 23 35 36 38 Good Practice Recommendations You are recommended to attend to the carpet on the top floor corridor to prevent it becoming a trip hazard You are recommended to fit suitable locks to residents doors You are recommended to number receipts You are recommended to record the outcomes of matters raised at supervision You are recommended to expand the risk assessments for the home to cover more areas such as stairs Bodmeyrick D54 D06 S22136 Bodmeyrick V212692 260405 Stage4.doc Version 1.30 Page 22 Commission for Social Care Inspection Suite 1, Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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