Inspection on 22/03/06 for Bournedale House

This inspection was carried out on 22nd March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bournedale House 27/05/09

Bournedale House 03/06/08

Bournedale House 27/07/07

Bournedale House 25/07/06

Bournedale House 28/11/05

Bournedale House 21/03/05

Bournedale House 23/09/04

Bournedale House 27/02/04

Bournedale House 13/10/03

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

CARE HOMES FOR OLDER PEOPLE Bournedale House 441 Hagley Road Edgbaston Birmingham West Midlands B17 8BL Lead Inspector Monica Heaselgrave Unannounced Inspection 22nd March 2006 09:30 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 Bournedale House DS0000016740.V287725.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. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bournedale House Address 441 Hagley Road Edgbaston Birmingham West Midlands B17 8BL 0121 420 4580 0121 420 4580 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) Mr David Pangbourne Leah Robertson Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That Ms Leah Robertson provides evidence of completion of a management qualification at NVQ level 4 or equivalent at the earliest opportunity or Before April 2005. The category of registration is OP (older people, over 65) and the type of home is care home only. The resident numbers shall remain at 11. Date of last inspection 28th November 2005 Brief Description of the Service: Bournedale House is located approximately 3 miles from Birmingham city centre, and within walking distance of Bearwood shopping centre. Facilities such as churches, public houses, restaurants, library and parks are close to the home. Bournedale House is a large Victorian house providing accommodation to 11 older adults. Care is provided on the ground and first floors, a chair lift provides access to the first floor facilities. On the ground floor there is a main lounge, dining area and kitchen, with toilet and shower facilities within easy reach. The lounge is to the rear of the property, is spacious and provides nice views of the rear garden. There is a shared double room to the ground front of the property that provides accommodation for two service users who require ground floor facilities. This room has privacy screens. The first floor facilities consist of spacious single bedrooms with ample storage, some with original Victorian fireplaces. The bathroom has a bath hoist to assist persons into the bath; there is also a shower. There are grab rails located in toilets and around the home to aid service users. There has recently been an assessment of the environment and service users needs. This has led to the provision of aids and equipment suited to the needs of people who require assistance. Raised chairs, pressure cushions for chairs, and handrails at the top of the stairs have been provided. Individual service users have been provided with zimmer frames to enhance their mobility and independence. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over a two and a half hour period. Nine service users were in residence. A number of records were inspected to include care plans, staff meetings, service user meetings, daily records, service user finance records, staff files and staff training records. The arrangements for the quality assurance system were assessed. The inspector met a couple of service users to speak to individually, others, due to their dementia were observed. The deputy manager, care staff and cook contributed to the inspection. The inspector observed the lunchtime meal. This is the second of two visits. Readers of the report are advised to read both reports in conjunction in order to obtain a fuller picture of the service. What the service does well: Bourndale House continues to maintain good standards of care. There is a structured care planning process that has been developed further since the last inspection. Service users appeared happy, well and content, and staff interaction was positive and caring. There are systems in place to safeguard services users finances. Service users are supported in this area. Service users have access to safe and comfortable communal facilities. These were comfortably furnished, clean and well maintained. The staff team have the skills and training to ensure service users are in safe hands. The recruitment and selection process is thorough. This ensures service users are protected from anyone considered to be unsuitable to work with vulnerable adults. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 6 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. Bournedale House DS0000016740.V287725.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 Bournedale House DS0000016740.V287725.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): 1, 2, 3, 5 There is good information available to help Service Users make a choice about moving into the home. The comprehensive and well-established assessment and admission procedures ensure that the needs of service users are known, planned for, and service users know what to expect from the home. EVIDENCE: There has been a significant improvement in the information available to Service Users. Since the last inspection, the Statement Of Purpose and Service User Guide has been updated. These now provide excellent information for Service Users, are comprehensive in their detail, and are particularly well written. Copies of these were seen in service users rooms and the inspector was informed that families have been given a copy. Each Service User has a copy of the homes contract. There is a good system in place for welcoming and informing prospective service users. This includes giving them copies of these documents for them to read at leisure, and verbally explaining the process and procedures to them, should they decide to live in the home. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 9 There is a well established, pre- admission assessment process. This includes the service user, their family, and any relevant professionals involved with the care of the service user. Home visits can be undertaken to support this process. Service users were spoken with, but were not able to express their views on this process. Given that some suffer with dementia it was particularly nice to see the efforts made to include family members in the decision process. Families are encouraged to sign these documents to show that they are happy with the proposed care plan. The Care Plans viewed were comprehensive, and covered all aspects of needs, this included; mobility, health, risk of falls, continence, weight, manual handling needs, the use of aids or adaptations and social, religious and cultural needs. Trial visits have been a regular feature prior to moving in. Records are maintained and utilised as a resource for adding to the assessment process. This gives both the service user and the staff an opportunity to determine how suited the facilities are. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: At the previous inspection all of these standards were assessed, and met. These were not assessed at this visit, however the inspector observed that good practice is maintained in this area. The care plans and daily records confirmed that service users benefit from care that is planned and structured around their needs, which ensures the needs of particularly vulnerable people are met in a caring manner. Staff were observed to interact positively with service users offering support that responded well to their individual characters or idiosyncrasies. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 11 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, 15 There has been good development in providing planned activities for service users to enjoy. Consultation with service users has been very effective in providing meal choices, which are clearly enjoyed by the service users. EVIDENCE: At the previous inspection these standards were assessed. Two were met. Requirements were made in relation to social activities and meals. Service users have access to a weekly progressive mobility activity. Informal activities take place on a daily basis such as bingo, and sing-along. The hairdresser visits weekly and the catholic priest visits occasionally. There had been four choir concerts this year, which service users particularly enjoyed. Care plans viewed showed the activities that individuals enjoyed and engaged in. Whilst there are examples of activities taking place, the manager was required to develop a programme of planned activities and a means of communicating these to service users, and monitoring them. A list of planned Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 12 activities is available, and staff now record in service users daily notes, which activity is engaged in. A quality assurance system has been implemented which has included questionnaires for service users and their relatives to express their opinion on all aspects of care. Family members now see the daily records and can read and sign them to say they are satisfied or not. These are all good initiatives which will enable staff to monitor their provision and tailor it to service users needs. There has also been significant improvement in relation to providing a choice of meals, and varying the menu. Since the last inspection there has been consultation with service users, which has led to menu changes. Service users requested grapefruit and orange juice for breakfast, more fresh fruit, an extra roast dinner in the week and a ‘soup with sandwiches’ option. This appears to meet the needs of service users in that they have the choice of meal they want, not necessarily two cooked choices at each meal which was said not to work well previously. On the day of inspection, service users were observed to be enjoying a mid week roast chicken with peas, cauliflower new potatoes stuffing and gravy. Pudding was prunes and custard. Service users were seen to have their meals nicely presented with good portions. Assistance at the table was particularly nice to see. Two ladies informed the inspector that they have always enjoyed the food, but really like the new menu changes made, particularly the roast dinner during the week. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17, 18 Service users are informed as to their legal rights, and have benefited from participating in elections. There have been developments, which will ensure that a proper response to any allegation or suspicion of abuse is responded to quickly. EVIDENCE: Standard 16 was met at the previous inspection. Since the last inspection, new policies and procedures have been implemented. This includes adult protection, and the whistle blowing policy. Staff has yet to commence formal training in adult Protection, this is planned and was on the training list seen. The inspector was advised that staff would also go through these procedures in their formal supervision once the training is completed. These developments will ensure that a proper response to any allegation or suspicion of abuse is responded to quickly. Service users can participate in the civic process if they wish, and are enabled to vote in elections either via postal votes, or attending polling stations. One service user voted with her family member and another via proxy. Service users are given information as to their legal rights. This is included in the Service User Guide which they have a copy off in their rooms. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 There has been some improvement in providing service users with a safe environment. However there are a number of corrective measures that need to be taken in relation to fire safety. EVIDENCE: At the previous inspection, six standards were assessed, three of these were met, and three had minor shortfalls. At the previous inspection the fire department had requested the roof void be opened in order to assess the fire safety in this area. This was planned for 13/1/06. The Commission has not been advised that any action was necessary as a result of this assessment. The Responsible Person was required to clarify the fitting of cold seals to fire doors. The Commission was advised that this was a recommendation, and that due to the cost involved, a programme of fittings would commence in April 06. At the time of this inspection this work had not commenced. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 15 Since this inspection, the Commission received a copy of the fire report highlighting corrective measures needing to be taken in order to improve fire safety precautions. These are summarised as follows: *Records show that fire training is not being carried out at the required frequency. The inspector was advised that fire training was planned, but waiting a date. This training must commence at induction, and at least twice yearly. *The fire officer advised that the fire risk assessment was not comprehensive, and that a new one should be carried out and a record made of significant findings. *Fire resisting doors to bedrooms 3 and 9 require adjustment to fit to the rebate on closure. *The laundry fire resisting has been compromised by pipe work that now requires filling using fire resisting filling. The Responsible person must ensure that the points raised in relation to fire safety are addressed. Since the last inspection the Responsible Person has ensured that service users will be provided with bedroom door keys unless their risk assessment states otherwise, or it is recorded that this is not their preference. This standard is now met. The Responsible Person was required to ensure that checks for Legionella are carried out on the water supply. This has now been addressed. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 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 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): 29 There has been good progress in determining and planning training for staff to ensure the care needs of service users are met, this is ongoing. Recruitment procedures are good and provide further safeguards for service users. EVIDENCE: At the previous inspection, three standards were assessed; one was met. Two requirements were made. The manager was required to provide information to demonstrate that 50 of the staff team are trained to NVQ Level 2. At this inspection staff training records show that three staff have NVQ Level 3, four have NVQ level 2, and since the last inspection five are currently undertaking NVQ training. There is good awareness of the needs of service users. Staff are competent in the roles they undertake which ensures that service users are in safe hands. A training matrix is now available, and training and induction is now following the Skills for Care requirements. Some mandatory training has commenced to include 1st Aid, and fire safety is planned. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 17 Specialist training in Dementia for both the manager and deputy is planned; this was a requirement from the previous inspection. The manager must ensure that care staff, also have access to training in this area, in line with the assessed needs of the service users, as required at the previous inspection. Staff records showed that 6 currently have manual handling training, 7, infection control, and 5, safe handling of medicines. This will further ensure that staff continues to develop the skills and knowledge to meet the assessed needs of services users accommodated. Staff files have sampled showed that two written references are taken, and a police and POVA 1st check is carried out. A complete application and work history is aimed for. Each had proof of identity, contracts and terms and conditions. Clearly a lot of work has been undertaken in this area, which will provide further safeguards for service users. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 18 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): 32, 33, 35 There is a quality assurance system in place to enable service users to express their views, and affect the way the service is delivered. The arrangements for service users finances ensure that where able they can control their own money, or their interests are protected where they are unable to do this for themselves. EVIDENCE: Four standards were assessed at the previous inspection one was met. Three requirements were made. The registered manager has enrolled on the NVQ Level 4 in management and care; the completion date for this training is 2006. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 19 Training for the manager in staff supervision and appraisal is being undertaken as part of the NVQ training. Training in first aid at the higher level, needs to be confirmed. Service users and staff spoke positively of the ethos of the home. There are many platforms in which service users felt they could contribute to the way the home is run, this included service user meetings and resident review meetings as part of the quality audits undertaken. The most recent meeting was said to be successful, relatives and service users were informed that they have access to daily records and care plans, ensuring they agree with what is recorded or planned for the service user. Questionnaires have also been utilised enabling service users and relatives to express their opinions on the service provided, it was positive to note that the suggestions made have been implemented, for instance the many changes to the menu which service users enjoy. The deputy stated that an annual development plan is being implemented in order to systematically review all aspects of the service. Whilst the plan was not seen, there are many examples evident that the service and it’s standards and procedures are being audited and that the manager is acting on the outcomes in order to improve the experiences of service users. There clearly has been a lot of work undertaken in this area, and staff should be rightly proud of their efforts. There are systems in place to safeguard services users finances. An audit of money and those records maintained was undertaken and confirmed this. One service user is supported to manage her own finances within a risk management framework. This person stated they were happy with this arrangement. Comments from individual service users confirmed that they have access to their money, as they require it. A staff supervision plan mapping out dates for the year was seen. The format in place encourages work objectives, which will provide a good sense of direction for staff in undertaking their role and responsibilities. This standard is now met Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 20 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 2 2 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 X X Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP18 Regulation 13(6) Requirement The Responsible Person must ensure that all staff receives training in adult protection procedures. The Responsible Person must ensure that those corrective measures highlighted in the fire officer’s report, are addressed. Timescale for action 01/07/06 2. OP19 23(4)(a)i (d) 01/06/06 3. OP30 4 OP30 Confirmation of this should be forwarded to the Commission. 19(5)(b) The Registered Manager must confirm that the planned mandatory training in first aid, health and safety and fire safety, has been undertaken with all staff. 18(1)(c, i) The Registered Manager must ensure staff have access to specialist training in Dementia to meet the identified needs of service users. Planned dates for this training should be submitted to the Commission. This is an outstanding requirement from the previous inspection. 01/07/06 01/06/06 Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 22 5 OP31 9(2)(b)(1) The Registered manager must complete their NVQ Level 4 in management and care. 01/09/06 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 OP15 Good Practice Recommendations Advice from the dietician should be sought to ensure menus are planned in a manner that provides wholesome and nutritious food, which is varied. This will further enhance the good quality assurance system already in place. Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 Page 24 Bournedale House DS0000016740.V287725.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!