Inspection on 26/04/05 for Botham Hall

This inspection was carried out on 26th April 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

Botham Hall 11/12/07

Botham Hall 18/07/06

Botham Hall 03/10/05

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 HD3 5RJ Lead Inspector Karen Summers Unannounced 26 April 2005 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. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Botham Hall Address Botham Hall Road Milnsbridge Huddersfield HD3 4RJ 01484 646327 01484 462286 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) Highfield Operations Limited Ms Christina Halonka Care home only 40 Category(ies) of 40 Old age registration, with number of places Botham Hall J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 4 October 2004 Brief Description of the Service: Botham Hall provides care and accommodation for up to 40 elderly people of either gender who have been assessed as not longer able to live independently. Staff provide 24 hour care that includes meals, laundry and personal care when required. The home is situated in Milnsbridge, Huddersfield. It is purpose built and stands in the grounds of a former residential home. Internally the home has two floors, ground and first, of almost identical design used for service users rooms and communal areas, and a second floor which houses the staff room, office and laundry. The floors are connected by stairs and a passenger lift. Each resident has a single room. Sixteen rooms offer en-suite facilities and all other rooms are close to bathroom facilities. There are also communal areas, including a designated smoking area and outside paved garden areas for service users to use. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an unannounced inspection at Botham Hall on Tuesday 26th April 2005, commencing at 8.40am, and the duration of the inspection was 6.40 hours. The deputy manager, Ms P Halonka, was present at the inspection. The reason for the visit was to carry out an unannounced inspection. The following inspection methods have been used in the production of this report: sampling of records, care plans, individual discussion with 5 service users and 1 relative, discussion with management, tour of the premises and document reading. What the service does well: What has improved since the last inspection? What they could do better: The home should continue to advertise for an Activities’ Co-ordinator and, in the interim period, is advised to have a named carer on duty to carry out activities on a daily basis. The Statement of Purpose needs updating. There should be a procedure and risk assessment for service users taking responsibility for self-administration of their medication. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 Page 6 Service users and their relatives and friends should be informed of how to contact advocates who could act on their behalf. Some of the staff need to complete their NVQ level 2, and have movement and handling training. 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. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.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 Botham Hall J51J01_S26266_Botham Hall_V220645_260405.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 and 3 Progress has been made since the last inspection as the company has reviewed and amended the Statement of Purpose and Service User Guide. EVIDENCE: The Statement of Purpose and the Service User Guide have been reviewed and amended following the last inspection, and both documents are available in audio cassette. They are also located in the entrance of the home for all visitors to read and are given to prospective residents. The information in the Statement of Purpose does not include the number, qualifications and experience of the staff working at the home, nor the age range and sex of the service users. A requirement has been made to include this information. Prior to admission, the manager or her deputy visits the resident in their place of residence and carries out an assessment of their needs. When carrying out the assessment the service user and, where appropriate, his/her representative (if any) and relevant health professionals have input into the assessment. Those service users who are self funding do not have a Care Botham Hall J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 Page 9 Management assessment, however an assessment is done by staff at the home prior to admission. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.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 - 9 Residents receive the level of support they require to ensure that all aspects of their health and social care needs are maintained. As there are no formal arrangements for residents to self-administer their medication, service users are either not offered a choice, or would be potentially placed at risk if allowed to do so. EVIDENCE: Care plans were comprehensive and set out in detail the action which needs to be taken by care staff to ensure that all aspects of the health and social care needs of the resident are met. The plans included risk assessments, with particular attention to falls, and were reviewed once a month or as the needs of the resident changed. The plans were also drawn up with the involvement of the service user, and agreed and signed by the service user or their next of kin/representative. Every six months the manager/deputy meets with the service user and/or their representative, where appropriate, and fully reviews the residents’ needs. This is in addition to the Social Services placement reviews. A relative who visited on a daily basis commented that his wife was well cared for, and that the staff could not do enough for her. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 Page 11 There was not a policy/procedure or a risk assessment relating to residents taking responsibility for their own medication. Ms P Halonka said that none of the service users self-administer their medication. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.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) 12 - 15 Service users are restricted in the variety of activities that take place as there is no formal/designated activities’ person working during the week. Service users are encouraged to maintain contact with family and friends, and they visit on a regular basis. A variety of meals are offered that take into account the likes and dislikes of the service users. EVIDENCE: An activities person works on a Saturday however, there is no formal activities person working on any other day. Staff are helping with activities until a Coordinator is appointed. The majority of service users were either watching television or talking with staff and three service users had visitors. An activities’ person visits monthly. The activity that was to take place on the day of inspection was displayed in the main corridors and lift. Previously the manager has completed a pre-inspection questionnaire and recorded a variety of activities that take place. A service user commented that she has a regular visitor but she usually likes to sit in her room. Daily records were examined of residents joining in activities, however it had been recorded that a number of residents chose not to join in. Residents are taken out of the home to places Botham Hall J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 Page 13 of interest, and one service user commented on the good time that she had had, when staff took a number of service users to a local restaurant just before Christmas. The atmosphere was relaxed and staff were seen to be responding to visitors and residents in a kind and caring manner. A relative commented on how welcoming and caring all of the staff were. There is no information informing service users and their relatives and friends of how to contact external agents, eg. advocates, who could act in their interest. Menus were inspected and offered variety and choice and a service user who was spoken with commented on how nice the food was, especially the puddings. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 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 standard(s) 16 - 18 Service users and their relatives and friends can be confident that their complaints will be listened to, taken seriously and acted upon in a timely manner. Service users’ legal rights are protected. Until all staff have received Adult Protection Awareness training, service users are not protected from the potential risk of abuse. EVIDENCE: There is a simple and clear complaints procedure that is located in the Service User Guide and displayed in the entrance hall to the home. There have not been any complaints since the last inspection. For those service users who wish to participate in the civic process then they can do so by completing a postal vote or, if they wish, they will be supported to visit the local polling station. Seven staff have had protection of vulnerable adults training, and further staff are waiting to be notified of a date when they can attend the course. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 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 standard(s) 19 - 26 The location and layout of the home is accessible, safe and well maintained and meets residents’ needs in a comfortable and homely environment. EVIDENCE: The decorative condition of the home was of 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. One of the bedrooms inspected had recently been redecorated and the handyman was in the process of redecorating another. Toilets are clearly identified and located close to the lounge and dining areas. Service users have access to all communal and private space and Ms P Halonka said that there are also plans to enclose and provide further planting to develop the patio area to the front of the building. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.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 and 28 The staffing numbers are appropriate to meet the needs of the existing service users, however should the needs of the service users increase then the staffing levels may also need to increase. By the end of December 2005, there will be a minimum ratio of 50 of care staff having an NVQ level 2 or equivalent. EVIDENCE: Duty rotas were inspected and there were 6 care staff, including the manager, working during the daytime, 4 staff in the evenings and 3 staff on night duty. When new staff are inducted they shadow more experienced staff and are not included in the staffing numbers. In addition to this, support staff are employed to work in the laundry and kitchen, and there is also a full time handyman and part time administrator. There remain a number of service users with varying degrees of dementia and dependency; Ms P Halonka confirmed that there is sufficient staff on duty to care for the needs of the present service users. Five staff have NVQ level 2 and a further 9 staff are working towards the qualification. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.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) 33 & 38 The service users benefit from the management approach of the home and the registered manager ensures so far as is practicable that the health, safety and welfare of service users and staff are protected. EVIDENCE: Mrs Halonka should be congratulated as she has attained the company’s “Manager of the Year Award” 2004. The home has attained the quality assurance standard ISO 9001 and the certificate was displayed in the entrance hall. The fire procedure is also displayed in the entrance hall. The recording of fire lectures, drills, alarms and emergency lighting were satisfactory. The domestic hot water and health and safety check are carried out monthly and satisfactory records were maintained. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 Page 18 Ms Halonka, deputy manager and another member of staff are movement and handling assessors, and Ms Halonka confirmed that, with the exception of staff that have recently joined the team, all staff have had up-to-date movement and handling training. Ms Halonka also said that she would ensure that every member of staff has up-to-date movement and handling training. Nineteen members of staff have completed first aid training. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.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 1 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 x STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 3 x x x x 2 Botham Hall J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 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 OP 1 Regulation 4.(1)(c ) Schedule 1 Requirement Schedule 1 - The statement of purpose should include the number, relevant qualifications and experience of the staff working at the care home, and the age range and sex of the service users. Timescale for action 31 May 2005 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 9.1 12.3 Good Practice Recommendations There should be a procedure and risk assessment regarding service users taking responsibility for self administration of their medication. The registered person should continue to advertise for an Activities Co-ordinator. In the interim period you are advised to designate a carer to carry out activities on a daily basis. Residents and their relatives and friends should be informed of how to contact external agents e.g. advocates, who will act in their interest. A minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent)is achieved by December 31 2005. The registered manager should ensure that all staff have J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 Page 21 3. 4. 5. 14.3 28.1 38.2 Botham Hall had up to date movement and handling training. Botham Hall J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 Page 22 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 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 J51J01_S26266_Botham Hall_V220645_260405.doc Version 1.30 Page 23 - 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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