Inspection on 27/07/07 for Bournedale House

This inspection was carried out on 27th July 2007.

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 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 25/07/06

Bournedale House 22/03/06

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

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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 Brenda O’Neill Key Unannounced Inspection 27th July 2007 09:00 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.V338950.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. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bournedale House Address 441 Hagley Road Edgbaston Birmingham West Midlands B17 8BL 0121 420 4580 0121 989 6270 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 Vacant. Care Home 11 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (11) of places Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 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), DE(E) (Dementia over 65) and the type of home is care home only. The resident numbers shall remain at 11. Date of last inspection 25th July 2006 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 property 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 people 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 people into the bath; there is also a shower. There are grab rails located in toilets and around the home to aid people living in the home. The fees at the home range from £370.00 to £400.00 per week. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this key unannounced inspection over one day in July 2007. During the course of the inspection a tour of the premises was undertaken, the files for two staff and two of the people living in the home were sampled as well as other care and health and safety documentation. The inspector spoke with the proprietor, three staff members and four of the people living in the home. Prior to the inspection the acting manager had completed and returned to the Commission an Annual Quality Assurance Assessment which gave some additional information about the home. The commission had not had any complaints lodged with them about the home since the last inspection. The complaints log for the home showed that all complaints no matter how minor were recorded. Six had been logged since the last inspection. These included issues such as chocolate going missing from a bedroom which was found in the room, one of the people living in the home not being taken to bed when they wanted, another not being happy with a meal and a relative complaining about clothes not being ironed. All the complaints detailed the investigation and the outcome. What the service does well: Although it was a busy time of day when the inspection commenced the home was quite calm and relaxed. The people living in the home that were spoken with were generally very positive in their comments about the staff team and friendly relationships were evident. The needs of any people wishing to live in the home were assessed ensuring the staff could make an informed decision as to whether they could meet the needs of the individual. People wanting to live in the home could visit the home before admission to assess the facilities available. Assistance with personal care was offered discreetly and individuals were addressed by the name of their choice. There was some evidence that there were activities available in the home for those people wishing to take part. Visitors attended the home at various times and the people living in the home were able to go out with them if they wished. One of the people living in the home confirmed she had visits from her family on a regular basis. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 6 The complaints log showed that the people living in the home were listened to and any issues they raised were addressed. The home was generally well maintained and comfortable. What has improved since the last inspection? What they could do better: Care plans needed to include details of all the needs of the people living in the home and how they were to be met by staff to ensure they received person centred care. To ensure the people living in the home were not exposed to any unnecessary risks appropriate risk assessments needed to be in place for such things as, the use of bed rails, tissue viability and nutrition. There needed to be some improvements in the management of the medication system to ensure it was entirely safe for the people living in the home. There needed to be records of food provided to the people living in the home in sufficient detail to enable any person inspecting the record to determine whether the diet was satisfactory, in relation to nutrition and otherwise, and that any special diets were being catered for. This will show the nutritional needs of the people living in the home are met. Some issues needed to be addressed to improve the infection control procedures in the home and safeguard the people living there. To further improve the safety of the people living in the home staff needed to ensure that fire doors were not wedged open and that when using wheelchairs they attached footrests. Staff recruitment procedures needed to be improved to ensure they safeguarded the people living in the home. Staff training needed to be improved to ensure they had all the necessary skills and knowledge to care for the people living in the home. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 7 The home needed to have in place a development plan based on seeking the views of the people living in the home and the outcomes of the quality audits. This will ensure there are plans in place to continually improve the service offered to the people living in the home. The Commission needed to be notified of any events in the home that affected the well being of the people living there so that it could be assured they were managed in the best interests of the people living in the home. 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. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 8 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.V338950.R01.S.doc Version 5.2 Page 9 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 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment procedures ensured the needs of the people being admitted to the home were known to staff prior to admission. People wanting to live in the home could visit to assess the facilities before moving in. EVIDENCE: The file for one person admitted to the home since the last inspection was sampled. This evidenced that a social worker had been involved in the assessment however the information from the social worker was limited. The manager of the home had also undertaken an assessment of the individuals needs and this covered all the required areas and highlighted what the needs of the individual were. The home had also received some information from the hospital on the day the individual was admitted to the home. There was also evidence on the file that the placement had been reviewed after 28 days to see if the placement was suitable. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 10 People wanting to live in the home were able to visit prior to admission to assess the facilities available to them. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 11 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care and plans and risk assessments needed to be further developed to ensure staff knew how to meet all the needs of the people living in the home and minimise any risks. Management of the medication system needed to be improved to ensure it was entirely safe and the people living in the home received their medication as prescribed. EVIDENCE: Two care files were sampled. One was for an individual who was fairly independent and able to direct their own care, the other was for a person who was dependent on the staff for assistance in meeting the vast majority of their needs. Two different care plan formats had been used on the files sampled. One file included a personal profile, an assessment of daily living needs and a care plan. This included a good overview of the individual and some good detail of some of the needs of the individual and how these were to be met by staff, for example, communication due to a hearing impairment. However other Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 12 areas needed more detail, for example, the care plan stated ‘assist when getting up and going to bed’ but there was no detail of what assistance was needed. The individual’s social needs were detailed but there was no detail of how these were to be met. The other file sampled included some very good detail of how the individual’s personal care needs were to be met. However it was unclear from the file and talking to staff if the person was mobile or not. This individual clearly had dementia but there was no detail of this on the care plan or how it affected the person’s every day life. This file included a lot of information that was quite dated and it was difficult to ascertain what was current. It was strongly recommended that any information that was not current was archived. There was no evidence that the people living in the home or their representatives had been consulted about the care plans or that they were being reviewed monthly. The detail included in the risk assessments for the people living in the home varied. One of the files included adequate risk assessments for the individual in relation to smoking, falls and access to the medication trolley. However other areas needed more detail, for example, the manual handling risk assessment stated ‘needs assistance’ but the type of assistance was not detailed. There was clearly a mental health issue with one of the individuals. The care plan/risk assessment stated staff were to monitor, record and report any changes that may signify a relapse in the person’s mental health but it did not detail what staff were to monitor for. It was clear from one of the files that some restrictions had been put on the individual in relation to alcohol intake, locking their door at night and smoking. There was no detail of these decisions having been discussed with the individual. One of the people living in the home had bed rails but there was no risk assessment in relation to these just a mention in the daily records that they had been ordered to reduce the risk of the individual getting out of bed. There needed to be a full assessment undertaken that detailed why the person getting out of bed was an issue, how staff knew the individual would not climb over the bed sides, who had been consulted about this issue, what staff were to check for when fitting bed rails and so on. Neither of the files sampled had nutritional assessments and only one included a tissue viability assessment but his was very out of date. One file did include the details of the pressure care being received by one of the individuals. The files sampled did include details that the health care needs of the people living in the home were being highlighted by staff, followed up and monitored. This had improved since the last inspection. At times the professional health care visits were difficult to track as they were on daily records and this information got lost as the records built up. It was strongly recommended that one sheet was used for all professional health care visits and that this also included the outcome of the visits. There was evidence that the people living in the home received visits from G.Ps, chiropodists, opticians and attended Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 13 hospital appointments. District nurses were seen to visit the home on the day of the inspection. The people living in the home were being weighed on a monthly basis until earlier in the year but this had lapsed. The member of staff spoken with and the proprietor did not know why this had happened. Medication was being administered via a 28 day monitored dosage system. The inspector was informed that none of the people living in the home self administered their medication and no controlled medication was being administered. Only senior staff were administering medication. The medication coming into the home was not being recorded on the MAR (medication administration record) chart but on a separate sheet attached to the MAR charts. The inspector attempted to undertake a random audit of the medication in the home. There were discrepancies in all the medication checked. This appeared to be because there had been medication held at the end of the previous 28 day cycle and this had not been brought forward and added to the new supply. This had also been an issue at the previous inspection. It was also noted that there was medication in the trolley that should have been returned to the pharmacist at the end of the last 28 day cycle. There were also eardrops in the trolley that should not have been used after the end of May 2007. Medication that had been taken out of the blister packs and was refused by any of the people living in the home was being put in small plastic packets and kept in the trolley. These could easily have fallen out and should be stored in a locked cupboard with any other medication to be returned to the pharmacist. All these issues were discussed with the senior staff member on duty and she was to audit the medication trolley and remove any unwanted medication. Staff interacted well with the people living in the home and friendly relationships were evident. Assistance with personal care was offered discreetly and individuals were addressed by the name of their choice. Bedrooms had locks on the doors so that the occupants have privacy if they wished. The double bedroom had appropriate privacy screening and all bedrooms had been personalised to the occupants’ choosing. The home had a cordless telephone for the use of the people living there if they wanted to make or receive any calls. It was noted that in two places around the home there were instructions for care staff in relation to one of the people living in the home. One of these was in full view of any visitors to the home as well as the other people living there. This is not acceptable and does not respect the privacy or dignity of the person concerned. The proprietor removed these at the time of the inspection. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 14 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, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were some activities available in the home but they did not meet the needs of all the people living there. There were no restrictions on visitors to the home within reasonable hours. It could not be evidenced that the dietary needs of the people living in the home were being met. EVIDENCE: When the inspector arrived at the home some of the people living there were having breakfast, others were in the lounge and some were still in bed. Despite being a busy time of day the home had a relaxed atmosphere and generally people were content. There were records of some activities taking place in the home and these included, exercise, hand massage, bingo, cards and sing a longs. There was nothing in the activity records for nine days prior to the inspection. One of the people living in the home described the activities as ‘basic’. No evidence was seen of any discussion with the people living in the home about the range of activities offered. Clearly some of the people living in the home had dementia and it could not be ascertained what stimulation they were getting. There was Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 15 no evidence in the records of any one to one time for the people living in the home. One of the care plans seen detailed the social needs of one of the people living in the home however there was no evidence in the activity records or the daily records that the individual had been enabled to meet these needs. The information received prior to the inspection stated that ‘a choice of activities are offered to each resident, which are appropriate to their needs abilities or expressed wishes’. This could not be evidenced on the day of the inspection. There was evidence on the daily records that visitors attended the home at various times and that the people living in the home were able to go out with them if they wished. One of the people living in the home confirmed she had visits from her family on a regular basis. There was some evidence that the people living in the home were able to make some choices, for example, when to go to bed and get up, being able to take part in or decline activities, personalise their own rooms to their choosing and when being decorated the proprietor stated they were consulted about colours and so on. As detailed previously there were some restrictions on one of the people living in the home and there was no evidence that these had been discussed with him. The home did have set menus in the kitchen but discussion with the cook and the proprietor showed that these were often changed. The records of food being served to the people living in the home had lapsed in May 2007 therefore it could not evidenced that the dietary needs of the people living in the home were being met. The inspector had lunch with the people living in the home. The meal was well cooked and nicely presented for most people. It was noted that two people were having their food liquidised and this had all been done together and looked very unappetising. It was strongly recommended that different foods were liquidised and served separately. These two individuals were being fed by staff and it was noted that one member of staff was using a very large spoon which was not appropriate. Also as there were only two staff available at this time they had to keep getting up and down to serve other people. It would be more appropriate if staff could sit with the people they are assisting throughout the meal. One of the people living in the home chose not to have the mid day meal and just to have a sandwich in the lounge. When speaking with one of the people living in the home they stated they did not know what they were having for lunch before it was served. They thought it would probably be fish that day as it was Friday when it was actually chicken. There needed to be system in place that ensured the people living in the home knew what was for meals before they were served in case they wanted an alternative. Many of the people living in the home did not eat their meal and as the cook had gone off duty by the time the meal was finished and Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 16 no food records were being kept it was difficult to know how this information was passed onto the cook and that maybe it was not an appropriate meal. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 17 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The views of the people living in the home were listened to and acted on. Staff needed to undertake training in adult protection issues to ensure the people living in the home were safe guarded. EVIDENCE: Information received prior to the inspection showed that all the people living in the home were issued with a service user guide which included a copy of the complaints procedure. No complaints had been lodged with the Commission since the last inspection. The complaints log for the home showed that all complaints no matter how minor were recorded. Six had been logged since the last inspection. These included issues such as chocolate going missing from a bedroom which was found in the room, one of the people living in the home not being taken to bed when they wanted, another not being happy with a meal and a relative complaining about clothes not being ironed. All the complaints detailed the investigation and the outcome. No adult protection issues had been raised at the home. There were policies and procedures on site in relation to adult protection but these were not viewed at this visit. There was no evidence on the two staff files sampled that they had received training in adult protection issues. The training matrix forwarded to the Commission after the inspection showed that not all staff had undertaken training in adult protection issues. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 18 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, 20, 21, 22, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean, comfortable and well maintained. Further improvements were needed to ensure the needs of people with dementia were met and that the home was safe. EVIDENCE: The proprietor informed the inspector that the home had been given a grant by Birmingham City Council to improve the facilities available for the people living in the home. The money was to be used to improve the bathing facilities in the home, to buy new carpet and curtains for four bedrooms, decorate three bedrooms and purchase a flat screen television. A tour of the home was undertaken with the proprietor. There had been no changes to the layout of the home since the last inspection and it was generally well maintained. The acting manager had attempted to improve the Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 19 signage around the home for the people living there who had dementia. However these were mainly written signs and some were quite small. Alternative signage was discussed with the proprietor, for example, appropriate pictures accompanied by words. He was to discuss this with the acting manager. During the tour it was noted that the window on the stairs was open and it was not restricted and could have been hazardous for the people living in the home. The communal space at the home comprised of a lounge and dining room. Both were comfortable and adequately furnished and decorated. New carpet had been fitted in the dining room since the last inspection. The home had adequate numbers of toilets, one floor level shower that allowed for assistance from staff and one bathroom that was being altered to give an assisted facility. On a shelf in the shower room there were creams, a razor and personal toiletries that were accessible to the people living in the home. In the bathroom and one of the toilets there were containers of bleach and toilet cleaner accessible to the people living in the home. Staff needed to ensure that any creams and personal items were returned to the appropriate rooms after use and that all COSHH substances were stored securely. The proprietor did ensure all these items were removed before the inspection ended. There were some aids and adaptations in the home and these appeared to meet the needs of the people living there. These included stair lift, assisted showering facilities, emergency call system and free standing hoist. There were also wheelchairs around for the use of the people living in the home. It was noted that none of these had any footrests attached. Using wheelchairs without footrests can cause injury and they should be used unless there is a specific reason not to. The reason for not using them for any individual needed to be detailed the corresponding care plan. Bedrooms varied in size and were generally comfortable. Some were in need of decoration and new carpets. This was due to be addressed with the grant money from the City Council. Not all the rooms contained all the furnishings and fittings detailed in the National Minimum Standards, for example, two chairs and a lockable facility. All the bedrooms needed to be audited against the Standards and any shortfalls discussed with the occupants or their representatives to ensure they were satisfied with their rooms. It was noted that the vast majority of the bedrooms had door wedges and although these were not in use at the time their presence implied that doors were wedged open at times. Bedroom doors are fire doors and must not be wedged open. This was discussed with the proprietor and he was to remove the wedges. The home was clean and odour free. It was noted that there was hard soap and cotton towels in some of the communal facilities and to ensure good Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 20 infection control these needed to be removed. Two bedrooms had worn and rusted commodes that needed to be replaced. The laundry was appropriately located and equipped. A lockable COSHH cupboard had been installed since the last inspection and staff needed to ensure that all COSHH substances were stored in this. The kitchen was clean and tidy. All the requirements made by the environmental health officer had been addressed including fly screens to the windows. It was noted that there were open jars of food in the kitchen fridge that had not been dated when opened which could be hazardous if the foods were used when out of date. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 21 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, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels met the needs of the people living in the home. Staff had not received all the required training to ensure they could work safely with the people living in the home. Recruitment procedures needed to be more robust to ensure they fully safeguarded the people living in the home. EVIDENCE: There were two care staff plus the cook on duty when the inspector arrived. Some of the people living in the home were having breakfast, others were in the lounge and others were still getting up. Although it was a busy time of day the home was quite calm and relaxed. The acting manager was on leave however the proprietor arrived shortly after. The staffing levels met the needs of the people living in the home at the time with two staff on duty at all times. The acting manager was usually on duty during the week and her hours were supernumery to the care rota. The people living in the home that were spoken with were generally very positive in their comments about the staff team and friendly relationships were evident. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 22 The files for two staff recruited since the last inspection were sampled. Although all the required documentation was included in the files and all the appropriate checks had been undertaken it was clear from the dates that some of the references and both the CRB checks had not been obtained prior to the staff commencing their employment. This was discussed with the proprietor when giving feed back to him three days after the inspection. He stated no staff started work at the home until a POVA first check had been obtained and would send proof of this to the Commission when the manager returned from leave. Information was received from the manager stating that she got verbal clearance of the POVA first checks from the umbrella body that carry out the home’s CRB checks. Details of this needed to be kept on staffs’ files for inspection. The manager also needed to ensure that two references were received prior to any employees commencing their employment. There was evidence on the files sampled that staff undertook some induction training but the manager needed to ensure that this complied with the specifications laid down by Skills for Care. A training matrix was sent to the Commission after the inspection this showed that staff had undertaken some training, for example, manual handling, fire awareness, infection control and dementia care. However there were several gaps in staff training, for example, adult protection and food hygiene and some staff had not had the required updates in topics such as manual handling. These shortfalls needed to be addressed. The information received prior to the inspection stated that over fifty percent of staff were trained to NVQ level 2. The training matrix showed that the home employed twelve staff three of these had NVQ level 2 and another three were undertaking this training which would then give the home the required fifty percent. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 23 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 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was running smoothly. Some improvements were needed to ensure the people living in the home were adequately safeguarded and lived in a safe environment. The home needed to have a development plan in place to show how the service was to be continually improved for the benefit of the people there. EVIDENCE: The acting manager was on leave at the time of the inspection. The proprietor was in the home for most of the inspection. He stated the acting manager had been in post since January 2007 and she had settled well. She had many years experience of caring for older adults and was very dedicated. She gets on very well with the people living in the home and visiting relatives are very happy Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 24 with the care. One of the people living in the home commented ‘she is golden’ another said ‘the owner is a very nice man.’ Clearly there were some areas that need to be improved, for example, the acting manager needed to walk the building and ensure the home was safe, medicine management and recruitment also needed to be improved. There was a quality assurance system in the home and some audits had been undertaken and some surveys had been completed by the people living in the home and their relatives. Some analysis of the findings had been undertaken but there was no evidence of any actions from the outcomes. The home needed to have a development plan in place, based on seeking the views of the people living there, that showed how the service was to be continually improved. There was evidence of some staff meetings and of one meeting with the people living the home in this year during which there was an in depth discussion about meals in the home. The home was managing some money on behalf of the people living there. The records for this were sampled. Generally these were adequate however it was strongly recommended that two staff signatures were obtained for any expenditure and that the acting manager and another staff member audited the system on a regular basis. The proprietor stated he did audit the system with the manager but the records did not evidence this. It was noted that the people living in the home were paying for activities such as hand massages and progressive mobility. There needed to be some evidence that there had been some consultation with the people living in the home or their representatives as to whether they wished to pay for this. There was evidence on site that the equipment used in the home was regularly serviced and that the water system had been checked for the prevention of legionella. The in house checks for the fire alarm were up to date but the emergency lighting appeared to only be checked every six months not monthly as required. No evidence was seen that fire drills were being carried out every six months as required. There were some premises risk assessments on site however these needed to be further developed and include such areas as use of gas equipment, burns and scalds, access to the kitchen, infection control and COSHH. Accident forms were being appropriately completed by staff when there were any accidents in the home however no notifications were being sent to the Commission. The manager needed to ensure that the Commission was notified of any events in the home that affected the well being of the people living there. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 2 2 X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15(1) Requirement Care plans must include details of all the needs of the individual and how they are to be met by staff. (Previous time scale of 01/09/06 not met.) Care plans must show that either the individual or their representative have been consulted about the plan. This will ensure the people living in the home receive person centred care. There must be appropriate risk assessments in place with corresponding management plans for any risks identified for: - Manual handling. - The use of bed rails - Tissue viability - Nutrition - Any personal risk to the individual. This will ensure the people living in the home are not exposed to any unnecessary risks. Wherever possible any restrictions placed on the people DS0000016740.V338950.R01.S.doc Timescale for action 30/09/07 2 OP8 13(4)(c) 30/09/07 3 OP8 12(2) 14/09/07 Page 27 Bournedale House Version 5.2 living in the home through the risk assessment process must be discussed with them. This will ensure the people living in the home receive care in a way suited to them. The registered person must ensure that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. (Previous time scale of 01/09/06 not met.) There must be a complete audit trail for all medication. All unwanted medication must be returned to the pharmacist at the end of each 28 day cycle. This will ensure the people living in the home are receiving their medication as prescribed. Records of food provided must be kept in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and that any special diets are being catered for. This will show the nutritional needs of the people living in the home are met. The Responsible Person must ensure that all staff receive training in adult protection procedures. (Previous time scales of 01/06/06 and 01/09/06 not met.) DS0000016740.V338950.R01.S.doc 4 OP9 13(2) 14/09/07 5 OP15 17(2) schedule 4(13) 30/09/07 6 OP18 13(6) 31/10/07 Bournedale House Version 5.2 Page 28 7 OP19 13(4)(c) The window opening on the stairs of the home must be appropriately restricted. This will ensure the people living in the home are not exposed to any unnecessary risk. All personal items and toiletries must be returned to individuals’ bedrooms after use in communal facilities. All COSHH items must be locked in an appropriate facility. (Previous time scale of 01/09/06 not met.) This will enhance the infection control procedures in the home and ensure the people there are safe. Wheelchairs must not be used without footrest unless this is specifically detailed in the individuals’ care plans. This will ensure the people living in the home are not exposed to the risk of injury. Fire doors must not be wedged open. 14/09/07 8 OP21 13(3) 14/09/07 9. OP22 13(4)(c) 14/09/07 10. OP24 13(4)(c) 14/09/07 11. OP26 13(3) This will ensure that should there be a fire in the home the people living there are as safe as possible. Any worn or rusting commodes 14/09/07 must be replaced. Hard soap and cotton towels must be removed from communal facilities. Any foods stored in the fridge must be dated on opening. This will enhance the infection control procedures in the home. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 29 12 OP29 19(1) schedule 2. All the relevant checks and documentation must be completed prior to any new staff commencement their employment. (Previous time scale of 01/09/06 not met.) This information must be available for inspection. This will ensure the people living in the home are safe guarded. The registered person must ensure the induction training undertaken in the home is in line with the specifications laid down by Skills for Care. 14/09/07 13 OP30 18(1)(a) 14/09/07 14 OP30 19(5)(b) This will ensure new staff have the skills and knowledge to care for the people living in the home. The registered person must 30/11/07 ensure that all staff have completed the appropriate training in safe working practices to include: Manual handling Food hygiene Health and safety Infection control. Fire procedures. Up dates on these training topics must be undertaken in a timely fashion. (Previous time scale of 01/07/06 and 01/09/06 not met.) This will ensure the safety of the people living in the home. The home must have in place a development plan based on seeking the views of the people living in the home and the outcomes of the quality audits. This will ensure there are plans in place to continually improve the service offered to the people living in the home. 15 OP33 24(2) 30/11/07 Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 30 16 OP35 13(6) There must be evidence that the 14/09/07 people living in the home or their representatives have been consulted about any expenditure made on their behalf. This will ensure the people living in the home are safe guarded. Emergency lighting must be checked monthly and records of the checks retained. Fire drills must be carried out every six months. This will ensure the safety of the people living in the home. Any event in the care home that affects the well being of the people living there must be notified to the Commission. This will ensure the Commission have evidence that accidents and incidents are being managed appropriately. 17 OP38 23(4)(c) (i)(e) 14/09/07 18. OP38 37 14/09/07 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 OP8 Good Practice Recommendations It is strongly recommended that any information on care files that is not current is archived to avoid any confusion when consulting care plans. To make health care visits easier to track it is strongly recommended that one sheet is used for all professional health care visits and that this also includes the outcome of the visits. Wherever possible the people living in the home should be weighed on a monthly basis. To ensure the privacy and dignity of the people living in DS0000016740.V338950.R01.S.doc Version 5.2 Page 31 3. 4. OP8 OP10 Bournedale House 5. 6. 7. 8. 9. 10. 11. OP12 OP12 OP15 OP15 OP15 OP19 OP24 12. 13. OP28 OP35 14. OP38 the home are respected instructions for care staff should not be put on walls around the home. It is strongly recommended that the range of activities available be reviewed after ascertaining the preferred pass times of the people living in the home. To ensure the social needs of the people living in the home are met records should be kept of activities that they have undertaken including one to one time. Foods being liquidised should be done separately and served separately to make them more appealing. Staff should use appropriate utensils when assisting any of the people living in the home with food and try and remain seated with the individuals throughout the meal. There should be a system in place to ensure the people living in the home know what is for meals before they are served in case they want an alternative. To ensure the people living in the home with dementia can find their way around alternative ways of sign posting where facilities are should be explored. The bedrooms should be audited for furnishings and fittings against the National Minimum Standards and any shortfalls discussed with the occupants to ascertain if they are happy with their rooms. To ensure staff have all the knowledge and skills they need to care for the people living in the home fifty percent should be qualified to NVQ level 2 or the equivalent. It is strongly recommended that the system in place for managing the money for people living in the home is regularly audited and records are kept. This will ensure people are safeguarded and any errors are noted in a timely manner. To further enhance the safety of the people living in the home the premises risk assessments should be further developed to include such areas as use of gas equipment, burns and scalds, access to the kitchen, infection control and COSHH. Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Bournedale House DS0000016740.V338950.R01.S.doc Version 5.2 Page 33 - 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. 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