CARE HOMES FOR OLDER PEOPLE
Bolton Hall Care Home Carrhead Lane Bolton On Dearne Rotherham South Yorkshire S63 8DA Lead Inspector
Christine Rolt Unannounced Inspection 25th January 2006 9:20 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 Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 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. Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Bolton Hall Care Home Address Carrhead Lane Bolton On Dearne Rotherham South Yorkshire S63 8DA 01709 881456 01709 891731 bolton.hall@craegmoor.co.uk 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) Yorkshire Parkcare Company Limited Mrs Pat Davies Care Home 80 Category(ies) of Old age, not falling within any other category registration, with number (80) of places Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. All 80 OP beds may instead be used in the category PD, Physical Disability for people aged 60 years and above, whose disability is as a result of the ageing process. 14th September 2005 Date of last inspection Brief Description of the Service: Bolton Hall is a purpose built two-storey care home with landscaped gardens and ample car parking space. The home is registered for 80 residents and provides both personal care and nursing care. There are local amenities within the immediate vicinity. The railway station, which serves Leeds and Sheffield, is a few minutes walk from the home, and the A1 motorway is approximately 10 minutes drive from the home. Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took approximately three hours. The majority of the key standards were checked at the previous inspection on 14th September 2005. With the exception of two requirements all standards had been met. The main aim of this inspection was to inspect the key standards that had not been covered at the last inspection and also check whether the two requirements had been met. The inspection included a partial check of the premises, sampling records and policies, discussions with staff and residents and observations of the daily routine. The majority of residents and staff were seen during the inspection, and of these seven residents, four staff and the registered manager were spoken to in detail. The inspector thanks the manager, staff and residents for their co-operation during this inspection. What the service does well:
Residents were well cared for. They were clean and dressed appropriately. Staff had paid attention to detail ie jewellery, watches, to ensure that residents were treated as individuals. Staff treated residents with respect. Residents made choices about how they spent their day and said that they enjoyed living at the home, they had nice rooms, the food was good and they liked the staff. One resident said “I’m highly satisfied”. Staff were well trained and encouraged to attend training courses for their personal development. There was a very low turnover of staff. The manager said that she did not need to use agency staff to cover shifts because she had a good staff team and was obviously proud of her staff. The company valued its staff and provided financial incentives for qualifications and length of service. Thirty-seven of the staff had worked at the home for ten years or more and those interviewed on the day had worked at the home for three years or more and said that they enjoyed their jobs. This provided a stable atmosphere for residents and ensured that staff had a good knowledge of residents’ needs. The manager and her deputy have both attained the Managers Award. The manager kept up to date with current practice for her own personal development. Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 6 Bedrooms were personalised by their occupants. The home was clean and bright and hygienic. No hazards were noted. The home has a quality assurance system in place. 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. Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 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 Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 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): Standard 3 was checked at the previous inspection and the standard was met. The home does not provide intermediate care therefore Standard 6 is not applicable. EVIDENCE: Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 Residents’ health care needs were fully met. EVIDENCE: At the last inspection, a requirement was made under Standard 8 for the health care assessment to include a nutritional assessment. Two care plans were checked and both contained these assessments, and there was written evidence that they had been reviewed. The manager explained that in the past nutritional assessments had been carried out, but only for residents who were deemed to be at risk. Since the last inspection, nutritional assessments had been implemented for all residents to ensure that any deterioration was monitored. Standards 7, 9 and 10 were met at the last inspection. Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 10 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, 14 and 15 Residents’ lifestyle matched their expectations and preferences and they were able to exercise choice and control over their lives. EVIDENCE: Residents interviewed said that they liked living at the home and could choose how and where they spent their day, and from comments made, it was evident that they could choose what time they went to bed. A lounge on the first floor was used for activities and an activities co-ordinator was employed. Residents said that they could choose to participate or not. Some residents were having late breakfasts. The manager said that mealtimes were staggered to fit in with residents’ lifestyles. Residents said that the meals were “nice” and “good”. Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Service users were protected from abuse. EVIDENCE: The home had the company’s adult protection policy and procedure and also a copy of the Barnsley Multi-Agency Adult Protection Policy and Procedures. There was also a list of telephone numbers of people within the company who should be contacted if there was an allegation of abuse. The manager was advised to produce a simple step-by-step local procedure to ensure that staff left in charge were aware of how deal with an allegation of abuse and who to contact both inside and outside the company. Staff who were interviewed knew about ‘whistle blowing’ and said that they would inform the manager or the person in charge if they suspected that a resident was being abused. The manager said that some staff had attended adult protection training and others were due to attend the next session. The staff verified this. Residents said that they liked the staff. There were no allegations of abuse. Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 12 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, 24 and 26 The how was clean, pleasant, hygienic and safe. EVIDENCE: The home was clean and bright and there were no offensive odours. Residents said that they liked living at the home and had nice bedrooms. Two bedrooms were checked and these had been personalised by their occupants. Bathrooms were clean and tidy. The laundry was sited away from food preparation areas. The laundress demonstrated her knowledge of temperatures for washing different types of laundry. Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 13 No hazardous substances had been left out. All electrical equipment and appliances seen during the inspection were in working order. Ancillary staff said that they had the equipment and supplies to be able to do their jobs. Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 Trained and skilled staff met residents’ needs. Staff turnover was low. EVIDENCE: There were ample staff on duty during the inspection. The manager said that staff support was so good that they did not need to use agency staff. She commented that the company valued and supported its employees by promoting training and providing financial incentives for carers who had attained National Vocation Qualifications. There was also recognition through financial incentives for staff who had worked at the home for three years or more. The manager said that thirty-seven of the staff had worked at the home for ten years or more. Staff interviewed during the inspection had worked at the home for between 3 and 11 years. Approximately 40 of care staff had attained NVQ Level 3 in care and a further 25 were in the process of completing this. Ancillary staff also undertook NVQ training relevant to their roles. Some staff were studying for Access to Nursing. Health and safety training including moving and handling, first aid, basic food hygiene, fire awareness and infection control was ongoing. Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 15 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37 and 38 Residents benefited from a well run home. The manager was known to residents and respected by the staff. Staff supervision was in place and record keeping was up to date. EVIDENCE: The manager had been in post for over ten years and had worked at the home for thirteen years. She demonstrated that she had a good awareness of residents and staff, and promoted staff training. She undertook training relevant to her role and had recently attended a course on recruitment and disciplinary procedures. Both she and the deputy manager had attained the Registered Managers Award. Staff said that they respected the manager and were happy working in the home. Residents said that they were well looked after and that they liked the home and the staff.
Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 16 The quality assurance system included the views of residents and their relatives. Examples of these were seen and where comments had been made, these were duly noted for attention and improvement. Records seen during the inspection were up to date. Staff said that they had one-to-one supervision with the deputy manager every one to two months and also had a yearly appraisal with the manager. Records of supervision sessions were kept. Health and safety was promoted through training and programmes/systems implemented within the home. Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 18 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. Standard Regulation Requirement Timescale for action 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 OP18 Good Practice Recommendations A simple step by step local procedure of how to deal with an allegation of abuse and who to contact both inside and outside the company would assist staff left in charge of the home. The home should continue with its training programme to ensure that 50 of staff are qualified to NVQ level 2 or equivalent. 2. OP28 Bolton Hall Care Home DS0000006473.V274485.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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