Inspection on 11/12/07 for Botham Hall

This inspection was carried out on 11th December 2007.

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

Botham Hall 18/07/06

Botham Hall 03/10/05

Botham Hall 26/04/05

Botham Hall 04/10/04

Botham Hall 27/05/04

Botham Hall 04/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Botham Hall Botham Hall Road Milnsbridge Huddersfield West Yorkshire HD3 4RJ Lead Inspector Karen Summers Key Unannounced Inspection 11th December 2007 08:30 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 Botham Hall DS0000026266.V357363.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. Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Botham Hall Address Botham Hall Road Milnsbridge Huddersfield West Yorkshire HD3 4RJ 01484 646327 01484 462286 bothamhall@schealthcare.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) Southern Cross Care Homes Limited Ms Christina Halonka Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person aged under 65 years of age - category PD Date of last inspection 18th July 2006 Brief Description of the Service: Botham Hall provides personal care and accommodation for up to 40 older people of either gender, and over the age of 65 years. The home is purpose built and stands in the grounds of a former residential property. The accommodation if over three floors, with lounges, a smoking room, and a dining room on the ground and first floors, and staff accommodation on the second floor. There are forty single bedrooms, sixteen of which have en-suite facilities and all other rooms are close to bathroom facilities. Outside there is a large paved patio area, with well-kept tubs and hanging baskets. Botham Hall is close to local amenities such as shops, and churches. Fees at the home start at £ 332.98 - £425.50 per week. Items not included in the fee include: Hairdressing, toiletries, and newspapers/ magazines. Information about the home in the form of a Statement of Purpose, Service User’s Guide and the latest CSCI inspection report are available from the home. Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an inspection, which included an unannounced visit to the home by an inspector on Tuesday 11th December 2007, commencing at 8.45am, and the length of the inspection was 7.00 hours. There were 37 people living at the home on the day of this visit. Prior to the visit, the manager was asked to complete an annual quality assessment document. This she did, and the document provided the Commission for Social Care Inspection (CSCI) with a lot of information about the way the home is run, and what they hope to achieve in the future. During the visit the inspector spoke with members of staff, people who receive care and two relatives, to obtain their views. The inspector also looked at a sample of care records, staff recruitment records, staff training records, quality assurance audits and looked around the home. To enable people who use the service to comment on the care it provides, ten surveys were sent out to people living at the home. Five of these were returned. Ten were sent to their next of kin and five of these were returned. Surveys were also sent to people’s doctors and health care workers (social workers, community nurses). None of these were returned at the time of writing the report. The feedback from those who returned surveys to the Commission was positive. The Commission would like to thank all the people who gave feedback about this home, and would like to thank the manager and staff for their cooperation throughout the inspection process. What the service does well: The standard of care and the service provided continues to be maintained to a high standard. Relatives’ surveys asked, “What do you feel the care home does well?” Responses include: • “Looks after my mother and her often changing needs as well as they can. Asks me about any problems concerning her care. Update care plans regularly.” “Being a care home.” • Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 6 • • “I have only ever known the staff be pleasant and helpful with both residents and visitors.” “First class care for my mother.” As a tribute to the standard of food provided the home has received a four stars, “Very Good” award in association with Kirklees Council’s Health Choice Award. “Scores on the doors” People’s individuality is taken account of; their cultural needs are assessed, and they are encouraged to follow their religious beliefs. Equipment is also provided to assist people with mobility needs, and large print books are made available. 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. The summary of this inspection report can be made available in other formats on request. Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 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 Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&5 Standard 6 - the home does not take people who require intermediate care. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are assessed prior to them moving into the home and are able to visit the home to establish whether or not it is the right place for them. EVIDENCE: The care records of three people who use the service were examined, and the records contained a pre-admission assessment carried out by the funding local authority. In addition to this there was evidence that the home had also carried out an assessment to ensure that they can meet any identified need and the placement will be appropriate. The manager also said that people were given information about the home and were encouraged to visit and spend some time there before making a decision to move in. With the exception of Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 9 one person, people stated that they receive enough information about the home before making a decision to move in. Botham Hall DS0000026266.V357363.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): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The level of care people need, which includes their health, personal and social care needs are clearly highlighted within their care plan. People are treated with respect. EVIDENCE: Three people’s care records were looked at in detail and the documentation clearly identified the care needs, and the level of support the person requires. Risk assessments had also been completed and included the risk of falls. There were also movement and handling assessments, nutritional assessment, skin integrity, social interests, religious and cultural needs, and people’s likes and dislikes recorded. There was evidence that care reviews had taken place, and that the care plans are updated monthly or as the needs of the person change. Discussion was held with the manager that staff should ensure that the daily record reflects the care that has been planned for the person that day. Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 11 Information provided by the home confirmed that people are consulted on their care plans and that their care plans are reviewed and kept up to date. Staff respect the residents privacy and dignity by knocking on doors and wait to enter and call residents by their preferred name of address, which is documented. Relatives said that the home help their relative to keep in touch and one said sometimes. Relatives who were spoken with on the day of inspection said that the home always kept them informed and kept in touch. People also said that they receive the care and support that they need and one person said, “The staff are all very good.” Everyone said that the staff listen and act on what they say, and one person said, “Yes, I am happy with the staff.” Staff were seen to talk to people by name and respect their wishes. There was also evidence in people’s care records that they are able to access health care services, such as the dentist, chiropodist, optician and everyone living at the home is registered with a doctor. People confirmed that they receive the medical support they need. The manager confirmed that all staff that gives medication to people have had training and there was evidence to suggest that the training had taken place. A sample of medication and records were checked and the storage, administration and recording of the medication were done correctly. Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to maintain contact with their family and friends, and staff assist people in having a choice in most things they do. Meals provided are good, varied and served in a pleasant environment. EVIDENCE: At the time of the visit people were seen to be either spending time in their bedroom or sat chatting in the lounge and generally passing the time of day. The routines of daily living were seen to be flexible and people said that they chose how they spent their day. A new activities coordinator has recently been employed and she works sixteen hours a week, Monday to Friday. The information provided by the home states that activities are varied to try to suit all tastes, and that regular meetings are held with people who live there, to determine which activities are successful and which are not. There is a weekly activity plan letting people and their families know what activity is available each day, and this is displayed in the entrance of the home and on the corridor wall on each floor. Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 13 The existing records of activities that individuals are involved in on a daily basis were listed and a key used to show what activity take place. The information relating to people who were not involved in activities due to their choice or being ill had not been recorded which could be misleading and show that those people’s needs are not being met. This information, and the information relating to peoples general involvement in activities, needs to be recorded in greater detail to show the persons involvement and their enjoyment of the activity. Relatives who were visiting confirmed that the home has an open visiting policy where visitors are welcome at any time, and they said that they are always made welcome. One person said that it was their mums home and that staff made them welcome no matter when they visited. Photographs of recent events where individual people had taken part in are displayed on the corridors walls and entrance to the home, and include a restaurant evening where relatives and visitors were also invited. Activities include; Keep fit ball, doughnut making, and a day out to the garden centre, quizzes, etc. In addition to this entertainers visits the home approximately monthly, and choirs from the local schools are booked to visit regularly over the Christmas period. One person said that there are sometimes activities arranged by the home that they could take part in, another person said sometimes, and the majority of people said that there are always activities that they can take part in. A visitor to the home said that relatives are encouraged to join in with the fund raising events and that they enjoy the involvement. The hairdresser visits weekly, and a priest visits every Friday for those who wish to take Communion. The library also visits approximately every six weeks, and provides large print books and audiotapes of books and newspapers for people who have sight impairment. Newspapers are also provided by the home, and people can purchase their own if they so wish. A varied menu is available in the home that offers choice and special diets were been catered for. When asked if people like the meals at the home everyone said that they did. One person commented, “I really enjoy all the meals I receive at the home.” Another person said, “My breakfast is my best meal.” A visitor also said that if it is a mealtime when they visit, then they are usually offered a meal and that the meals are always very nice. As a tribute to the standard of food provided the home has received a four stars, “Very Good” award in association with Kirklees Council’s Health Choice Award. “Scores on the doors” . Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are protected from abuse and they can be confident that their complaints will be listened to and acted upon. EVIDENCE: The home’s complaints procedure was displayed in the entrance to the home, and the manager said that it is made available to all people living at the home and their visitors. According to information provided by the home, there have not been any complaints within the last twelve months. Most relatives said they know how to make a complaint and knew who they would go to if they were concerned about something. Also people who live at the home know how to complain and who they would speak with. One person said, “I would speak to one of the girls if I wasn’t happy.” Staff who were spoken with said that they were aware of the procedure to follow if they suspected abuse of a person, and that they also were aware of the home’s Whistle blowing policy. Training records were seen and showed that staff have attended safeguarding (adult protection) training. Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 15 Information provided by the home also confirmed that safeguarding training is provided for staff, and policies and procedures relating to the protection of vulnerable adults are readily available within the home. Botham Hall DS0000026266.V357363.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): 19 & 26 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 the service. The home offers people a homely, comfortable and clean environment. EVIDENCE: As part of the inspection a tour of the home was conducted which included the communal areas, a number of peoples bedrooms, and the laundry. The decorative condition of the home continues to be a good standard, and there was evidence that there is a programme of routine maintenance and renewal of the fabric and decoration of the premises. New furniture had recently been purchased for the lounges and bedrooms and the dining room floor coverings replaced. Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 17 The premises were clean and systems are in place to control the spread of infection. The home is smoke free. Without exception people commented that the home was always clean, and a relative said that there are never any unpleasant odours. The atmosphere on the day of the visit was warm and friendly and people looked comfortable whilst sitting in various parts of the home. The information provided by the home states that to ensure the environment is kept up to a standard there are audit tools that the manager completes each month, and this includes health & safety meetings. The operations manager also monitors the audits each month to ensure that a high standard is maintained. Botham Hall DS0000026266.V357363.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): 27 – 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 the service. There are sufficient numbers of staff to meet people’s needs. Staff receive training to assist them to carry out their responsibilities and they have had all the necessary checks before working with people so that they are kept safe. EVIDENCE: The duty rota confirmed there to be five/ four care staff on duty during the day and three care staff work during the night. The home also has full time support staff for the maintenance of the home, and this includes Kitchen staff, domestics, laundry and maintenance person. With the exception of one person people said that there are always staff available when you need them. And relatives said that the staff have the right skills and experience to look after people properly. Fifty percent of care staff have an NVQ (National Vocational Qualification) level two or above, and a three staff are working towards the qualification. It was evident from observation and discussion with people and staff that staff have the skills necessary to support people. Staff were observed to approach people in a skilled and respectful manner. Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 19 The recruitment files of three members of staff were looked at in detail and they contained the required information and employment checks. These checksare necessary to help protect people from potentially unsuitable staff. The company carries out equal opportunities monitoring of all new employees, and has recruited a number of overseas care staff. Information provided by the home states that new staff have induction training in accordance with Skills for Care, the National Training Organisation for care staff. Information provided by the home said that strict policies and procedures ensure that only the most appropriate people are recruited, and that many of the staff have been working at the home for a number of years. The information also said that staff have pride in there home and are willing to cover holidays and sickness in preference to using agency staff, therefore ensuring continuity of care for the people in their care. Botham Hall DS0000026266.V357363.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): 31, 33, 35 & 38 People who use the service experience Excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People benefit from the management approach of the home and the manager ensures so far as is practicable that the health, safety and welfare of people and staff are protected. The home is run in the best interest of people who live there. EVIDENCE: Mrs C Halonka is the manager, and she has a number of year’s experience of working with older people and has completed the Registered Managers Award. Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 21 Staff spoke positively about Mrs Halonka saying she was supportive and approachable. For those people who wish, small amounts of personal money are held safely at the home. The financial computer records of three people were examined and satisfactory records were maintained. Receipts are kept of all transactions made. The manager said that meetings involving people who live at the home take place monthly, and records of the meeting are kept. The things that are discussed at the meetings include the activities, quality of care, the quality of food and the menus, choice, areas of concern, activities etc. The manager also said that she has relatives meeting approximately twice a year however, at the last meeting only two relatives came, and a visiting relative also confirmed this. The relatives were very complimentary about the staff and the service that their relative receives. They said that they could not stress what an excellent job the staff do. Opinion surveys have recently been sent out and the manager is waiting for them to be returned. The results of the surveys the manager said would be displayed in the entrance of the home for people to see. Comments received include one from a family who say they are very pleased with the care and support give to their mother and another who say thank you for doing a difficult job. The operations manager visits the home monthly and writes a report on her visit that is used to monitor the quality of the service. The manager also audits the bedrooms, medication, care plans, etc on a monthly basis, and the company monitors the results to ensure that standards are maintained. Staff said that they received regular supervision, and there were records to show what had taken place. Satisfactory records were seen for fire alarms and emergency lighting. There was also evidence to suggest that all staff have had fire drills/ lectures and movement and handling training, and staff also confirmed this. Botham Hall DS0000026266.V357363.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 3 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 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 X 3 X 3 X X 4 Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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. 2. Refer to Standard OP7 OP12 Good Practice Recommendations Staff should ensure that the daily record reflects the care that has been planned for the person that day. To show peoples involvement and enjoyment of activities a better record should be made of activities undertaken. Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Botham Hall DS0000026266.V357363.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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