Inspection on 11/10/05 for Bolters Corner

This inspection was carried out on 11th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bolters Corner 29/06/07

Bolters Corner 26/05/05

Bolters Corner 06/01/05

Bolters Corner 23/06/04

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

CARE HOMES FOR OLDER PEOPLE Bolters Corner Bolters Lane Banstead Surrey SM7 2AB Lead Inspector Vera Bulbeck Unannounced Inspection 11/10/05 12:00 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 Bolters Corner DS0000013302.V254282.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. Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bolters Corner Address Bolters Lane Banstead Surrey SM7 2AB 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) 01737 361409 01737 370856 Mrs Eleni Panayi Mr Pangratios Panayi Care Home 28 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (28) of places Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Up to 2 beds may be used for Respite Care Up to 15 Patients may be treated on a Day Care basis from 0800 to 2000 hours Total Number of beds not to exceed 28 To include one named Service User under 65 years with Dementia. Date of last inspection 26th May 2005 Brief Description of the Service: Bolters Corner is a large detached property situated close to Banstead local shops. The accommodation in the home is situated on three floors the ground and first floor is accessible by a passenger lift. The third floor accommodates the staff that lives in the home. The home is registered for 28 service users and 15-Day Care Placements. The Day Care facilities are situated in the conservatory at the back of the home, with a separate access as well as the garden. The service users also use these facilities for activities.The grounds of the home are nicely laid out and user friendly for the service users. The service users can access the garden freely and the grounds and gardens are spacious and well maintained. The home was found to be homely and well presented. There is an on going, upgrading of bedrooms and refurbishment programme in operation with substantial improvements to the home. Ample car parking is available at the side of the premises. Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection to be undertaken by the Commission for Social Care Inspection for the year April 2005 to March 2006. For details of how each standard was met please refer to the main body of the report. It will be necessary to review both inspection reports for 2005-06 to obtain a full understanding of the extent to which the home meets The National Minimum Standards for Older People. The inspection was announced, which meant that visitors, staff and residents were aware of the inspection prior to it commencing. The inspector had the opportunity to speak with a number of residents who live at the home. They were all very complimentary about the home and spoke affectionately of the registered manager and staff. Vera Bulbeck, Lead Inspector for the service, carried out the inspection. Mr P Panayi, Registered Manager was present. The home is registered for twentyeight places. There are currently twenty-eight residents living in the home. A full tour of the premises was undertaken. Three care plans were observed and three staff files were inspected. Four members of staff were spoken with during the inspection as well as ten residents and five relatives. The inspector received four relatives comment cards and a letter, which were all very positive and spoke highly of the care provided in the home. A comment card was also received from the G.P who visits the home on a regular basis; the comments were of satisfaction by the doctor. The staff were observed to be courteous and the atmosphere within the home was relaxed and friendly. The inspector wishes to thank the residents and staff for their co-operation and hospitality during the inspection. The residents living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report What the service does well: Bolters Corner offers a homely environment for its residents who spoke well of the home, its staff, and the facilities. When asked about the home, comments such as “Very nice indeed.” and “Haven’t found any fault.” were typical. Residents also commented positively on the staff, one saying “All staff are very good.” and another telling the inspector “Staff are very nice here.” Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 6 The home also has a visiting hairdresser. The handyman/gardener working within the home is an asset; the garden is well kept and pleasant for residents to enjoy. Considering the majority of residents require a considerable amount of attention the staff team appear to manage to residents on an individual basis. Relatives were highly complimentary regarding the care provided. What has improved since the last inspection? 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. Bolters Corner DS0000013302.V254282.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 Bolters Corner DS0000013302.V254282.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): 2, 3, 5 and 6. Each resident is admitted to the home following a needs assessment to ensure that the home can meet the residents identified needs. The home is able to demonstrate their capacity to meet the assessed needs of the resident’s accommodated at the home. The home does not offer intermediate care. EVIDENCE: Three residents files were examined during the course of the inspection. These files contained detailed information on each resident including assessment regarding their health and care needs, risk assessments and details of reviews. It was noted that relatives had been involved with the care plans and had signed to indicate they were satisfied with the care plan. Night care plans were particularly informative and would ensure staff could support residents in the most appropriate way. Contracts were in place for all residents and well documented. Residents spoken to confirmed that their needs were being met. Intermediate care is not provided in the home as the home has a long waiting list of 50 persons waiting to be admitted to the home. Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 9 Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. Policies, procedures and practices are in place to ensure the safe administration of medication. EVIDENCE: Detailed care plans identify resident’s health and personal care needs and arrangements for specialist interventions are made. The home keeps records of opticians, dentist and chiropody visits for residents. Nutritional needs have been identified and individual residents who need close monitoring in this respect are identified. Medication was stored securely for the protection of the residents. Records were well documented and qualified staff administers medication at all times. The residents living in the home are unable to self medicate. Residents spoken to were generally happy with their experiences at the home and they highlighted no issues regarding their privacy and dignity. The inspector noted a number of examples where staff interacted in a positive and respectful way with residents. In was noted the Registered Manager dealt very sensitively with a resident who was concerned about a relative. Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 11 One double bedroom is currently used for hairdressing purposes. Management stated that relatives have been consulted and have agreed for the bedroom to be used. This was identified and discussed at the previous inspection. However, management informed the inspector this area is being addressed and in the plans currently with the planning dept a room has been highlighted for the purpose of hairdressing to ensure residents privacy and dignity is respected at all times. Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 12 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 14. The routines of daily living and activities are flexible and varied to suit individual residents wishes. Residents who are able are encouraged to exercise personal autonomy and choice. EVIDENCE: The majority of residents have contact with family and friends. It was pleasing to note that a number of relatives are constantly visiting the home and some on a daily basis. The inspector was informed they are always made very welcome and kept up to date with any issues or information particularly regarding their relative. Visiting times in the home are variable and there is no time restriction for relatives. One resident commented that though the food was good, they never knew what it was until it arrived. A member of staff confirmed that the menu was in the main kitchen and residents were generally happy with the food It was noted that the majority of residents had a good appetite. The menu is nutritious and appetising and is changed according to the seasons. The last Environmental health report was good apart from the recommendation of a fly screen, which has been attended to. It is recommended that a weekly menu, in a format accessible to most residents, be displayed prominently. Staff will need to continue to explain the Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 13 menu to those residents who would not be able to benefit from a printed version. Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 14 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): 16 and 18. The home has a simple, clear and accessible complaints procedure, which includes timescales for the process. All required policies and procedures are in place to ensure that residents are safeguarded from harm or abuse. EVIDENCE: The home has developed its complaints procedure and has incorporated details of the Commission for Social Care Inspection. The inspector advised the home to provide all residents or relatives with a copy of the complaints procedure. A relative commented that if he had any problems or complaints he would speak with the manager to discuss what action would be taken. The homes policies and procedures for the protection of vulnerable adults and a whistle blowing policy were in place and all staff has received POVA training. Staff confirmed they had undertaken this training and were aware of the procedures. Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 15 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 and 24. The home was found to be homely and comfortable. A number of areas in the home have been refurbished, and some furniture has been replaced. The location and layout of the home is suitable for it’s stated purpose. EVIDENCE: The home was found to be clean and comfortable for the resident’s. There is a daily cleaning programme in place. Bedrooms were personalised and each bedroom door had the residents name on. A number of bedrooms had been partly furnished with residents own belongings. A considerable number of bedrooms have been recently redecorated with new carpets and furniture, including new curtains, chairs and bed covers to match. The home has a rolling maintenance programme. All televisions are to be fixed on the wall to safe guard residents from any possible injury. Management of the home have made a lot of progress to meet the standards and have committed to continuing upgrading the home. Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 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 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): 27, 29 and 30. There were competent and trained staff employed to support residents and who were aware of the changing needs of each individual person EVIDENCE: There are sufficient staff on duty during each shift, these include three care staff, as well as trained staff who have the overall responsibility for care. The manager is on duty on a daily basis, there are two domestic staff and the chef. A maintenance person visits the home on a regular basis and carries out all the jobs required. Full recruitment procedures are being followed. All staff have been checked against the Criminal Records Bureau (CRB) before working in the home. Staff records were observed and found to be well documented, including contracts and terms and conditions. However, photographs of staff should be included on staff file. Training has been ongoing and the majority of staff has attended a number of training courses. However, the training plan needs to be kept up to date. All new staff receives a three to four day induction training programme. And all staff has received (POVA) protection of vulnerable adults training. A number of staff would like to undertake NVQ Level 2. However, there is a problem with the college and their resources to process the training. Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 17 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, 35, 36 and 38. The management approach at the home provides an open, positive and inclusive atmosphere for residents. The home has a quality assurance and monitoring system in place that is based on seeking the views of the residents. All policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of residents and staff. EVIDENCE: The registered manager is experienced and capable of managing the home, and has completed the Registered Managers Award. Staff are supervised on a regular basis and goals are set for training needs and identifying how the home can improve the care provided. All staff receive supervision on a regular basis. A number of records were observed and found to be well documented these include the accident book, fire records, training, residents and staff meetings; as well as health and safety records. Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 18 Records demonstrated that some aspects of health and safety such as infection control were well managed by the home. The inspector advised the management of the home to ensure the water temperature is monitored and recorded on a daily basis and kept to the requirement of 43 . The visitor book must be signed by everyone entering the home as a record to be maintained in the event of a fire to enable everyone in the home to be accounted for. The management of the home is not responsible for resident’s finances, relatives are involved and a number of residents have Power of Attorney who controls their finances. Some residents have their own solicitor. Families of some of the residents provide the home with a sum of money for hairdressing and toiletries. Records were seen and found to be well documented. Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 19 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 3 3 x 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 x 3 x x STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x 3 3 x 3 Bolters Corner DS0000013302.V254282.R01.S.doc Version 5.0 Page 20 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 29 Regulation 19 Requirement Up to date photographs of staff to be held on staff files. Timescale for action 22/11/05 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 2 3 Refer to Standard 30 38 38 Good Practice Recommendations Staff training programme to be updated. Water temperatures to be recorded daily. All visitors to the home must sign the visitor’s book. 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