Inspection on 26/05/05 for Bolters Corner

This inspection was carried out on 26th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bolters Corner 29/06/07

Bolters Corner 11/10/05

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 26 May 2005 10:00 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. Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bolters Corner Address Bolters Lane, Banstead, Surrey, SM7 2AB 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) 01737 361409 01737 370856 Mrs Eleni Panayi 13 Shadbolt Close, Worcester Park, Surrey, KT4 7BT Mr Pangratios Panayi Care Home (CRH) 28 Category(ies) of Dementia - over 65 years of age (DE(E)), 28 registration, with number of places Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 2 beds may be used for Respite Care 2. Up to 15 Patients may be treated on a Day Care basis from 0800 to 2000 hours 3. Total Number of beds not to exceed 28 Date of last inspection 06 January 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 H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first 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 unannounced, which meant that visitors, staff and residents were not 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-seven 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 four relatives. 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. What the service does well: The home has a statement of purpose and service users guide which sets out the aims an objectives and facilities of the home. Residents are admitted to the home following a full assessment, which is undertaken by a qualified member of staff. The home has a stable and committed staff team. Staff commented they are supervised and supported and are able to speak with management at any time. The inspector spoke with ten residents who gave positive feedback with regards to the care they receive and stated that the staff are kind and helpful. Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .doc Version 1.30 Page 6 Some residents were unable to communicate and the inspector observed the interaction between staff and residents to be good. 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 H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .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 Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .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) 1,2,3 and 6. The management of the home and staff are committed to ensure each resident has a written contract and is admitted to the home following a needs assessment to ensure that the home can meet the residents identified needs. EVIDENCE: The home had a comprehensive statement of purpose, which accurately reflected the services provided by the home. There is a need to review and update the statement of purpose and the service users guide when necessary. The residents were unable to confirm if the care received meets all their needs. However, relatives were very complimentary about the care provided and stated the home meets all their relatives needs. A full assessment is undertaken of all potentially new residents to the home, and risk assessments for individual residents were seen. A written contract and terms and conditions were observed on resident’s files, details of any extra payments need to be included. Intermediate care is not provided in the home as the home has a long waiting list of 40 persons waiting to be admitted to the home. Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .doc Version 1.30 Page 9 Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .doc Version 1.30 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 standard(s) 7,8 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. EVIDENCE: Care plans were found to be well documented and indicated that resident’s health care needs are being met. The inspector advised reviews of the care plan need to be undertaken on a monthly basis. Each resident has an individual care plan and records seen suggested that residents and family are involved. All residents are registered with one G.P who visits weekly and more often when necessary. Staff was observed to interact in a respectful manner with residents, particularly those with dementia. 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. However, the inspector suggested another area be used for the Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .doc Version 1.30 Page 11 purpose of hairdressing to ensure residents privacy and dignity is respected at all times. Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .doc Version 1.30 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 standard(s) 13 and 15. There are systems in place to involve relatives in the resident’s daily routine. Regular staff meetings take place and relative’s views are both sought and acted upon on behalf of the residents. EVIDENCE: The majority of resident’s have contact with family and friends and some have a care manager, including the privately funded resident’s. Reviews are undertaken on a six monthly basis. Every month a church service takes place in the home and all denominations are taken into consideration. The mealtime arrangements were adequate: there is a choice of two main meals, as well as a choice of desserts. There are meals available for special diets; diabetic, low fat and multi cultural meals are also provided for when requested. The meals being served on the day of inspection were observed to be wholesome and nutritious. The menu is four weekly and was designed by a Dietitian from Epsom & St Hellier NHS Trust as part of a project the home was involved in, Epsom General Hospital, Nutritional Screening Dept was also involved. Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .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 well-documented complaints system, which was working well, and made available to all relatives and staff EVIDENCE: Relatives confirmed they know how to make a complaint and would feel happy to tell the registered manager or a member of staff if necessary of any concerns. The home has received one complaint since the last inspection. The complaint has been dealt with appropriately and records were observed, to be well documented. The majority of staff has received protection of vulnerable adults (POVA) training. Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .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) 19,22, 24 and 26. The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and well maintained. The home was found to meet service users’ individual and collective needs in a comfortable and homely way. EVIDENCE: Since the last inspection a number of areas have been decorated and new furniture and carpets have been replaced. A number of bedrooms are looking very tired and in need of redecorating. However, the home has a substantial waiting list for people wanting to enter the home. The registered manager stated that he has plans to make changes and keep one bedroom free to be able to undertake some of the much-needed decoration. All beds have a pressure-reliving mattress and the home has five special mattresses. One relative commented the “home is run like a big family home. There are plans to change a double bedroom and move a wall in another bedroom to change the layout of the home to two single bedrooms. Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .doc Version 1.30 Page 15 There were a few areas around the home that require attention. The radiators require safety covers and this has been a requirement since the previous inspection. Management of the home stated the radiators would all have covers fitted by the end of October 2005. The inspector advised the registered manager to undertake a weekly inspection on the premises to ensure all areas in the home are well maintained. There is a daily cleaning programme in place. The grounds and garden areas are well maintained. Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .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. The home has a comprehensive staff training programme which incorporates all areas needed to ensure, as far as reasonably possible, that service users are in safe hands at all times. EVIDENCE: Training has been ongoing and the majority of staff has attended a number of training courses. However, there is a need for staff to attend updates to training particularly first aid training, which is required every three years. A training programme to be implemented, to ensure training records are kept up to date. All new staff receive induction training, which covers dementia care and the registered manager to undertake protection of vulnerable adults training (POVA) for all staff. The staffing ratio observed was for two qualified nurses and four care assistants. The manager and proprietor are working in the home on a daily basis. There is also a laundry person/domestic, and a chef on duty. Full recruitment procedures are being followed. All staff has 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. Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .doc Version 1.30 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 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) 31,36,37 and 38. The home has an effective quality assurance and monitoring system in place that is based on seeking the views of the service users. All policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of service users and staff. EVIDENCE: The registered manager is experienced and capable of managing the home, and is in the process of commencing the Registered Managers Award September 2005. 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 every two months by the registered manager. The matron supervises the nursing staff. Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .doc Version 1.30 Page 18 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. There is a new entry system to the home with CCTV, which covers the front door and car park, this also indicates if any resident goes wandering, relatives and visitors are able to access the door entering the building and leaving. Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x 3 x 3 2 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 3 3 x x x x 3 3 3 Bolters Corner H09 H58 S13302 Bolters Corner V222050 260505 Stage 4 .doc Version 1.30 Page 20 Yes 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. 2. Standard 25 10 Regulation 13 16 Requirement All radiators which are accessible to residents, must be covered. (Timescale of 08/04/05 not met) Hairdressing currently undertaken in a double bedroom must be moved to another area. Timescale for action 31/10/05 24/06/05 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. Refer to Standard 30 2 Good Practice Recommendations A training programme to be implemented. Details of any extra costs needs to be included in the contract. 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