Inspection on 21/07/08 for Bollingbroke House

This inspection was carried out on 21st July 2008.

CSCI found this care home to be providing an Good service.

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

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Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Bollingbroke House Common Road Brierley Barnsley South Yorkshire S72 9EA Lead Inspector Michael O`Neil Unannounced Inspection 21st July 2008 09:40 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 Bollingbroke House DS0000071374.V367144.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. Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bollingbroke House Address Common Road Brierley Barnsley South Yorkshire S72 9EA 01226 712409 F/P 01226 712409 jcbollingbroke@googlemail.com 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) Flagswan Two Ltd Miss Julie Cross Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: Old Age, not falling within any other category, Code OP - maximum number of places 33 The maximum number of service users who can be accommodated is:33 First Inspection since registration of new owners. 2. Date of last inspection Brief Description of the Service: Bollingbrooke House is located on the edge of Brierley village close to the border with West Yorkshire. The home is a large detached property, which was formerly a private family residence. The home stands within its own grounds with ample private car parking to the front and landscaped gardens to the rear. The gardens incorporate a duck pond with resident ducks. People in wheelchairs could find it difficult to negotiate the sloping garden but can easily access the terrace overlooking the garden. The accommodation is on two floors with a passenger lift. The main lounge and the smoke lounge have French windows onto the terrace and overlooking the rear gardens. There are dining rooms, which are both domestic in character. Flagswan Two Ltd were registered with the CSCI as the new owners of Bollingbrooke House in February 2008. Weekly fees vary from £351.50-£388.00 per week. Hairdressing, chiropody, newspapers and toiletries are not included in the weekly fee and were charged separately. The manager supplied this information during our visit on 21st July 2008. Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. This is what was used to write this report. • • • • Information about the home kept by the Commission for Social Care Inspection. Information asked for before the inspection, this is called an Annual Quality Assurance Assessment. Information from surveys that were returned to us by 10 people who live at the home, 7 relatives, 4 health professionals and 8 staff. An unannounced visit to the home. This was carried out by Michael O’Neil, regulation inspector on 21ST July 2008 and included talking to 5 staff and Julie Cross, registered manager about their work and the training they have completed. And checking some of the records, policies and procedures the home has to keep. Some time was spent observing staff supporting people and talking with 7 people and 4 visiting relatives. • We wish to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the service does well: People said “The staff are very helpful” “Staff take time to listen to me” “I receive all the care I need, and more.” Relatives said “The care is excellent ” Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 6 “First class care here ” Health professionals said that staff liaise well with them to ensure people receive a good level of support and made other comments such as; “The people at Bollingbrooke House are supported by kind and caring staff” Relatives said they were able to visit at any time and were made to feel very welcome. We saw that everyone coming to the home was offered hospitality and staff took time to make sure friends and family were made to feel comfortable whilst visiting. There was a relaxed and friendly atmosphere in the home and staff spent time talking to people and their families. People said “We always get a good meal” “The food is very good, its real home cooked food”. The home was clean and tidy and no unpleasant odours were noticeable. People, and relatives said the home was always kept very clean. Staff said that they really enjoyed working at the home and got a lot of job satisfaction. We found that the staff were very enthusiastic to improve the service further. Staff, people, relatives and visiting professionals spoke highly of the manager and said she was very approachable. The home had a good quality assurance system. People who use the service and their families met with the manager of the home on a regular basis. These quality assurance systems will help to ensure that the service is operating in the best interest of the people who live there. What has improved since the last inspection? What they could do better: Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 7 Peoples care plans need further attention and more detail so that the staff know what to do for each person. Areas the home are in need of refurbishment. Repairs need to be carried out so the environment in which staff work is kept safe. 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. Bollingbroke House DS0000071374.V367144.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 Bollingbroke House DS0000071374.V367144.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): Standard 3. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were individually assessed prior to admission to ensure their needs could and would be met. EVIDENCE: Care plans showed that people within the service had been assessed before moving into the home. Risk assessments and a plan of care reflected any specialist interventions. The manager and staff liaised with professionals, the person and their families to find out about peoples needs. The manager visited people and undertook assessments, prior to admission. Bollingbroke House DS0000071374.V367144.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): Standards 7, 8, 9 and 10. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Each person had a plan of care, however these did not include sufficient detail to ensure that all peoples changing needs were being met all the time. People were treated with respect and said they were very happy with the care they received. Medication policies and procedures were well managed ensuring the safe administration of medication. EVIDENCE: Three peoples care plans were checked. The peoples care plans checked were good in that they contained details about the person’s personality and their preferences and choices. Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 11 Risk assessments were included within the documentation and included moving and handling, nutritional, skin integrity, and other risk factors. The care plans however were inadequate because: Staff failed to developed a full and detailed care plan when the risk assessment, mentioned above, identified that the person was at risk of developing pressure sores. Staff had failed to date and record the time when writing peoples notes. Staff had also failed to sign a care plan they had written. Staff need to remember that peoples care plans and daily notes are a legal document. Some care plans did not contain enough detail of the staff interventions required to meet that persons needs. For example staff had only recorded “give softened food” for a person with swallowing difficulties. Much more detail is required for example” ensuring the person is sat upright when eating” and “taking time to assist people with their food” etc. The care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. The manager and inspector spent time discussing the shortfalls in the care plan documentation. The manager gave assurances that the inadequacies raised would be addressed immediately. People looked clean, well dressed and had received a good level of personal care. People said “The staff are very helpful” “Staff take time to listen to me” “I receive all the care I need, and more.” Relatives said “The care is excellent ” “First class care here ” “Staff do a wonderful job” Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 12 “I’m kept informed about what is going on and whenever I visit the staff are always helpful, nothing is too much trouble.” Health professionals said that staff liaise well with them to ensure people receive a good level of support and made other comments such as; “The people at Bollingbrooke House are supported by kind and caring staff” “The privacy and confidentiality of people are always respected by the staff.” Staff were aware of the need to treat people with dignity and respect and were observed interacting in a friendly and pleasant way. Medicines were securely stored in locked trolleys within locked cupboards. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. Staff said they had received recent in-depth medication training. They said the certificates for this training had not been issued yet. Despite the inadequacies in the care plan documentation evidence shows that people at Bollingbrooke House experience good outcomes relating to health and personal care. This judgement is based on the evidence that the service has far more strengths than areas for improvement. The manager has also given assurances that the areas in need of improvement will be addressed and managed promptly. Bollingbroke House DS0000071374.V367144.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): Standards 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had a choice of lifestyle within the home and were able to maintain contact with family and friends ensuring that they continued to be involved in community life. People were able to make choices about daily living and be involved in some social activities. Meals served at the home were of a good quality and offered choice to ensure people receive a balanced diet. EVIDENCE: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home and in the homes gardens. Relatives said they were able to visit at any time and were made to feel very welcome. We saw that everyone coming to the home was offered hospitality and staff took time to make sure friends and family were made to feel comfortable whilst visiting. Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 14 People and relatives said that there were some activities planned such as trips and entertainers visiting the home. We saw that some people welcomed the opportunity to undertake simple activities and talk to staff or other people in the home. There was a relaxed and friendly atmosphere in the home and staff spent time talking to people and their families. The mealtime experience for people in the home was very positive. Tables were set nicely. Staff were supporting people with their meal in a polite and discreet way. People said “We always get a good meal” “The food is very good, its real home cooked food”. The cook was aware of peoples special dietary needs. Choices of meals were advertised on a board outside the dining rooms. Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and people and their relatives felt confident that any concerns they voiced would be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected from abuse. EVIDENCE: People and their representatives had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. People said that they felt very comfortable in going to the manager knowing that any concerns they may have would be addressed without delay. Regarding safeguarding adults, the safeguarding policies and procedures were available to the staff. Staff had undertaken Safeguarding Adults training, and the manager was able to evidence this by producing the training records. Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 16 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): Standards 19 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The home was clean, pleasant and hygienic although some areas of the home are in need of redecorating and refurbishing. EVIDENCE: The home was clean and tidy and no unpleasant odours were noticeable. People, and relatives said the home was always kept very clean. Lounge and dining areas were domestically furnished to a good standard. In the last few months’ new dining room furniture has been purchased and the dining rooms have been redecorated. People and relatives commented how pleasant these rooms now were. Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 17 People said they were very comfortable at the home. They had a variety of furniture and touches such as ornaments and pictures that gave their rooms a homely feel. Some areas of the home are in need of refurbishment and redecoration. In particular the paintwork on some corridors is damaged and needs redecoration. Also the furniture in some bedrooms is damaged and worn and needs replacing. Some bedrooms and corridors are also in need of redecoration. The laundry floor was found to be wet and slippery. This is a clear hazard for staff. Staff said a pipe was leaking water and had been for a few weeks. This water pipe must be repaired so that the workplace for staff is made safe. The gardens were well maintained and accessible. People were sat in the gardens enjoying the sunshine with their relatives and staff. Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Staff were employed in sufficient numbers and the services recruitment procedures promoted the protection of people. People receive care from a well-trained staff team. EVIDENCE: People spoke highly of the staff team and said staff always listened and acted on what they said. People said that staff were “always” available when needed. Staff and the manager confirmed that staffing levels were adequate. Four staff files were checked. The files contained a range of information including two references and a declaration of health and identification. The staff had undertaken a criminal record bureau check (CRB), at the enhanced level. This confirmed thorough recruitment practices were in place, which was sufficient to safeguard people. Staff said that they really enjoyed working at the home and got a lot of job satisfaction. We found that the staff were very enthusiastic to improve the service further. Staff were able to talk about the various training courses that Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 19 they had attended. Development and training records were checked these records showed when staff had completed mandatory training and refresher training. Over 50 of the staff team had achieved their NVQ Level 2 or above and others were due to commence this training shortly. Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 20 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): Standards 31,32,33,35,and 38. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The procedures and ethos of the home ensure that the home is run in the best interests of people who use the service. The homes procedures promote the health, safety and welfare of people who use the service and the staff. EVIDENCE: The manager, Julie, has many years experience within the nursing and caring profession and is working towards achieving the Registered Managers Award. Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 21 She is committed to ensuring that people staying in Bollingbroke House were consistently well cared for, safe and happy. Staff, people, relatives and visiting professionals spoke highly of the manager and said she was very approachable. The home had a good quality assurance system. There was evidence of internal auditing of the homes environment, services and records. Staff meetings were held and minutes of these meetings were seen. The responsible individual visited the home on a regular basis, a report was written following the visits. People who use the service and their families met with the manager of the home on a regular basis. These quality assurance systems will help to ensure that the service is operating in the best interest of the people who live there. Staff said they really enjoyed working at Bollingbrooke House and got a lot of job satisfaction. Several staff members said they met the Operations manager frequently, however they said they were disappointed that they had not met the new owners of the service. Staff said they were given assurances that a meeting would happen several moths ago. Meetings with management and staff need to happen frequently so that the communication channels are clear and a positive and inclusive atmosphere between staff and management is developed. A sample of people’s personal money accounts were checked. Receipts and records tallied. The fire risk assessment had been reviewed in February 2007. No issues requiring attention were highlighted in the review. Staff said they had received recent fire safety and other health and safety training .A sample of records showed that staff were receiving this statutory training. At the time of the visit fire exits were clear and hazardous products were safely stored in the home. This will promote the safety and welfare of the people. Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 22 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 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The care plan must set out in sufficient detail the action, which staff need to take to meet all aspects of the health and personal needs of the person. Staff must sign and clearly record the date and time when entries are made in peoples daily notes. A programme of renewal of the fabric and decoration must be produced, and work started to implement the plan. All areas of the home must be kept in a good state of repair so that staff and peoples are safe. (Laundry floor) Timescale for action 01/10/08 2. OP7 15 01/10/08 3. OP19 23 01/12/08 4. OP19 23 01/08/08 Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 24 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 OP32 Good Practice Recommendations Regular meetings with the management and staff should be held to ensure that the processes for managing and running the home are open and transparent. Bollingbroke House DS0000071374.V367144.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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