Inspection on 03/10/05 for Botham Hall

This inspection was carried out on 3rd October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 Announced Inspection 3rd October 2005 09:15 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.V254404.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Botham Hall DS0000026266.V254404.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Botham Hall Address Botham Hall Road Milnsbridge Huddersfield West Yorkshire HD3 4RJ 01484 646327 01484 462286 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.V254404.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person aged under 65 years of age - category PD Date of last inspection 26th April 2005 Brief Description of the Service: Botham Hall provides care and accommodation for up to 40 older people of either gender that 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. Stairs and a passenger lift connect the floors. 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 DS0000026266.V254404.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an announced inspection at Botham Hall on Monday 3rd October 2005, commencing at 9am, and the duration of the inspection was 8 hours. Mrs M Halonka, the manager, and Mrs J Gardner, regional manager, were present at the inspection. The following inspection methods have been used in the production of this report: sampling of records, care plans, individual discussion with 9 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: Following the pre admission assessment, the manager must confirm in writing that the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. There should be a procedure and risk assessment regarding service users taking responsibility for self-administration of their medication. The complaints procedure should contain the stages and timescales for the process and an assurance that the complaint will be responded to within a maximum of 28 days. Botham Hall DS0000026266.V254404.R01.S.doc Version 5.0 Page 6 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 DS0000026266.V254404.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Botham Hall DS0000026266.V254404.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-3 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. Following a pre admission assessment, the service user cannot be assured that their needs can be met, unless they receive conformation in writing from the registered person. EVIDENCE: There is an up to date statement of purpose and service user guide, and both documents are available in Braille and audiocassette. Service users are provided with a statement of terms and conditions at the point of moving into the home, or contract if purchasing their care privately. Following a satisfactory pre admission assessment, the manager verbally contacts the social worker and agrees to offer a placement. As stated in the Regulations, the registered person must confirm in writing that the care home is suitable for the purpose of meeting the service user’s needs. Botham Hall DS0000026266.V254404.R01.S.doc Version 5.0 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): 7 - 10 As there are no formal arrangements for service users 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: Staff have recently started to introduce new care documentation, and training is planned for all care staff. The documentation was comprehensive and it will be interesting to see how it develops over the next few months. Should a service user be admitted who wished to self-administer their medication, there was not a medication policy/ procedure or a risk assessment. Ms C Halonka said that none of the present service users wished to selfadminister their medication. Botham Hall DS0000026266.V254404.R01.S.doc Version 5.0 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, 13 & 14 Service users find the lifestyle experienced in the home matches their expectations and preferences. EVIDENCE: A dedicated activities person has been employed and she works approximately 14 – 16 hours per week. The carers also organise activities on a daily basis. Events and activities that are scheduled on a daily basis are displayed throughout the home, and forth-coming attractions are displayed on a notice board in the entrance of the home. At the time of the visit an entertainer had been booked to sing and service users commented on how they had enjoyed her songs. Staff also encouraged service users to play the organ, and a number of service users were seen playing dominos, and also sat talking with staff and other service users. A relative spoke positively about the staff and the care her relative receives. Seven relatives/ visitors comment cards were returned to the commission, and without exception they were happy with the care their relative/ friend is receiving. Botham Hall DS0000026266.V254404.R01.S.doc Version 5.0 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): 16 Without a complaints procedure, which includes the stages and timescales for the process, service users and their relatives and friends cannot be confident that their complaints will be acted upon in a timely manner. EVIDENCE: The complaints procedure should contain the stages and timescales for the process, with an assurance that they will be responded to within a maximum of 28 days. Mrs Halonka confirmed that although the procedure does not reflect the timescales, complaints are responded to within 28 days. Botham Hall DS0000026266.V254404.R01.S.doc Version 5.0 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 & 26 Service users live in a safe, and well-maintained environment. EVIDENCE: The decorative condition of the home was of a good standard, and the majority of bedrooms have been redecorated and had carpets replaced. The patio area to the front of the premises has been recently cleared, and is now a pleasant place where service users and their relatives can sit out. The proprietor is working with the fire prevention officer to ensure that the home meets fire regulatory standards. Botham Hall DS0000026266.V254404.R01.S.doc Version 5.0 Page 13 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 - 30 The staffing levels and skill mix were sufficient to meet the number and needs of service users. Staff are also trained and competent to do their job. EVIDENCE: There was a sufficient number and skill mix of staff on duty to care for the number of service users in the home. 62.5 of care staff have achieved an NVQ level 2 or equivalent. Botham Hall DS0000026266.V254404.R01.S.doc Version 5.0 Page 14 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): 35 & 38 Service users are safeguarded by the accounting and financial procedures of the home. Unless the required fire alarm checks are carried out, the health and safety of service users and staff could be potentially at risk. EVIDENCE: Service users personal finances were inspected and found to be correct. All staff have had fire lectures and drills, and the emergency lighting is checked and recorded monthly. The fire alarms have been tested and recorded weekly however, when the person who checks the alarms was on holiday the checks had not been carried out. Mrs Halonka and the Regional manager were both aware of the recording, and confirmed that steps would be taken to ensure that the appropriate check would in future be carried out. Botham Hall DS0000026266.V254404.R01.S.doc Version 5.0 Page 15 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 3 3 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 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 X X X X 3 X X 2 Botham Hall DS0000026266.V254404.R01.S.doc Version 5.0 Page 16 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. 1. Standard OP3 Regulation 14.(1)(d) Requirement The registered person shall confirm in writing to the service user that having regard to the assessment, the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. Timescale for action 31/10/05 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 OP9 OP16 Good Practice Recommendations Standard 9.1 – There should be a procedure and risk assessment regarding service users taking responsibility for self-administration of their medication. Standard 16.1 – There should be a simple, clear and accessible complaints procedure, which includes the stages and timescales for the process, and that complaints are dealt with promptly and effectively. Standard 16.2 – The complaints procedure should specify how complaints may be made and who will deal with them, with an assurance that they will be responded to DS0000026266.V254404.R01.S.doc Version 5.0 Page 17 Botham Hall 3. OP38 within a maximum of 28 days. Standard 38.2 – The manager should ensure that fire alarms are tested weekly and recorded. Botham Hall DS0000026266.V254404.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Brighouse Area Office 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. 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