Inspection on 06/07/05 for Butterley House

This inspection was carried out on 6th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Butterley House 19/04/07

Butterley House 24/04/06

Butterley House 25/01/06

Butterley House 09/11/05

Butterley House 22/03/05

Butterley House 29/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Butterley House Old Coach Road Ripley Derbyshire DE5 3QU Lead Inspector Brian Marks Unannounced 6 July 2005 1.15pm The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Butterly House Address Old Coach Road Ripley Derbyshire DE5 3QU 01773 745636 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Patricia Diane Smith Colleen Deacy (appointed but not registered), job share with Jean Fountain PC Care Home only 37 Category(ies) of 37 places - OP Old age registration, with number of places Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Plus five (5) Day Care Places. 2. 1 PD place. On a named person basis for the person named in the notice of proposal letter dated 9 August 2004. Date of last inspection 22 March 2005 Brief Description of the Service: Butterley House is a detached building, which has been adapted and extended as a care home. The home is situated on the outskirts of Ripley, set back from the main road, bus route and local amenities, and in a semi-rural location. The home provides personal care for up to 37 people aged 65 years and over. The home is also approved for up to five-day places. All bedrooms are single rooms with ensuite facilities. The facilities are on two floors and access to the first floor is by stairs and a stair lift. The three lounge areas, conservatory and dining room are on the ground floor. On-site laundry services are provided. The home has well set out garden areas, which are accessible to service users. Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over an afternoon. Additionally, time was spent in preparation for the visit, looking at previous reports and other documents. At the home, apart from examining documents, care files and records, time was spent looking around the building and speaking to 5 of the residents and 2 visitors. The 2 managers and staff were also spoken to, and they were observed throughout the visit, looking after and dealing with residents and visitors. What the service does well: What has improved since the last inspection? What they could do better: Work is still required on the way that information about residents is obtained, recorded and in the way the care plans are laid out, so that staff work in consistent and safe ways. There must be a system to encourage the plans to be regularly looked at, and revised if necessary, and service users must be encouraged to be involved in this process where it is appropriate. Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 6 Instruction in matters related to the protection of residents from harm has not been given to all staff and full safety in this matter is not assured. It is not clear from examination of the staff records about what training has been achieved and what still needs to be done. As mentioned above the records of staff recruitment to the home have been improved but this programme of updating needs to be completed to provide a completely robust system. This includes a clear record of application for checks by the Criminal Records Bureau. Now that the Fire Officer has inspected the home, all of his recommendations should be carried out in order to achieve complete safety. 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. Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4 and 6 People do not come to live at the home without the services they need from the home being identified. However, this is not comprehensively written down and the care that is needed may not be right as soon as they move in. EVIDENCE: The home provides a range of written information to prospective residents that describes the home, its staff and the services it offers. Key documents required by law have been amended to ensure that they give information that is accurate and up-to-date. All service user files examined contained a range of information but not all had enough detail about all aspects the person’s needs and preferences. Areas of particular concern and risk had been completed (risk assessments) and these had been updated since the last inspection. These included nutritional assessments, moving and handling assessment and one file contained a specific assessment in relation to a swallowing problem. Whilst these assessments were linked to the daily care plan (see next section), the overall package of documents lacked clarity and detail about how needs were to be met and how proper services were to be provided by staff. Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 9 The manager described plans to provide training for staff in the specific needs of people with sight and hearing problems and the considerations that had been given to individuals with specific needs, in order to make sure that the home did not offer them any obstacles in their daily lives. The home does not provide an intermediate care service so Standard 6 does not apply. Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 10 Individual residents had their care arrangements described in a care plan but they were not documents that efficiently supported care activities and resident welfare. The privacy of residents was effected by the lack of locks in some bathrooms and bedrooms. EVIDENCE: As reported above all residents have their own file containing care records and plans, and 3 files were looked at in detail during the inspection. The quality of the care plans was varied and discussions were held with the managers about how they could be improved, possibly by following a completely new format. The managers agreed that the style of current care plans does not encourage a comprehensive service being designed for each resident and that because of this they are not efficient for staff to use. They do not describe clearly how different needs are to be met and not all aspects of care are being reviewed regularly and updated, as the law requires. This could mean that service users are being placed at risk or that their welfare is not being properly maintained. Whilst those residents and relatives spoken to felt that their privacy and dignity was being respected, some of the home’s bathrooms and bedrooms still do not offer full privacy through being able to be locked. It is recognised that Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 11 the law in relation to standards of care provision and fire safety may be in conflict over this issue. Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards was specifically examined at this inspection. EVIDENCE: Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 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 standard(s) 18 The home makes sure that all of its residents are protected from harm by having robust policies and procedures in place and by a programme of staff training and awareness. EVIDENCE: The home has a clear written procedure for staff to follow if they suspect that people who live at the home are being placed at risk or being abused, and this had been recently improved to make sure that any steps that are taken are in line with the requirements of the law. Staff have been trained in the general aspects of this subject, so that they are more aware of their responsibilities and can behave properly should they have to. However the manager reported that not all staff had received this training and untrained staff doing the wrong thing could affect the welfare of residents. A clear picture of staff progress in this area was not obtained from the training records as they had not been completely updated. Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 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 standard(s) 19 and 26 The home is clean, hygienic and offers good standards of comfort to residents in both their bedrooms and communal areas, although the need to replace carpets in important areas of the home gives a bad impression to residents and visitors. EVIDENCE: Observations made during the inspection and comments from residents indicated that the home was routinely maintained and decorated. The front garden and seating areas provide a pleasant aspect from the home and a number of bedrooms open directly on to them through double doors. A resident and his wife commented favourably about the convenience this provides. All residents are accommodated in single rooms with en-suite facilities. The issue of the condition of the carpet had been raised at the last inspection and it remained in need of urgent replacement due to discoloration by sunlight. Carpets in the adjacent corridors and the dining room had been cleaned since Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 15 the last inspection. Those areas of the home visited were very clean and tidy, and free from odours at the time of this inspection. Residents spoken to had no complaints about the laundry service of the home and all residents observed in the home wore clean and well-presented clothing. From observation of the laundry room, issues around the organisation of the laundry, raised at the last inspection, had been resolved and soiled and clean laundry was systematically arranged and properly managed. Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 and 30 The home recruits new staff in a systematic way but not all the information required by law has been sought, potentially putting residents at risk of being looked after by the wrong sort of person. Staff training has continued but the systems to monitor whether the training activities are the right ones have not been put in place. EVIDENCE: Individual files are retained for all staff employed at the home and from examination of a sample it was evident that the manager had taken steps to improve their quality and obtain all the information about staff that is required by law. However the manager agreed that this job was not complete and certain items such as photographs and the availability of certificates form the Criminal Records Bureau (CRB) were still being obtained. These are required to make sure that the right people are employed at the home and that residents are not exposed to people who may cause them harm. Similarly, the files in relation to staff training had been improved but the manager agreed that further work was needed so that they had a good system to monitor training and development activity and to support the right activities being provided to improve staff skills. Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38 The home is well managed by 2 experienced managers and safety has been improved following a visit by the Fire Officer. This job requires still requires some activities to be carried out to ensure complete safety. EVIDENCE: The home is managed jointly by 2 managers, with the most recently appointed planned to register and take on the role fully. Both managers have a wide range of experience operating care homes and residents will benefit from the application of that experience. From observation of the physical environment of the home it was hazard free on the day of the inspection. The Fire Officer had recently visited and was generally satisfied with improvements made but has extended the deadline for the completion of all required improvements, to make the home as safe as possible. The practice of wedging open fire doors had actively been discouraged and suitable equipment was being installed to make this practice Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 18 unnecessary. Discussions with staff and managers indicated that training in safe moving and handling had taken place and staff practices in this area had improved. From observation footrests on wheelchairs had been replaced as required at the last inspection but 1 resident still insists that she doesn’t like to have them. The manager confirmed that a risk assessment had not been completed in respect of this to make sure that residents are not experiencing unnecessary hazards. Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 3 x x x x x x 2 Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14 Requirement The registered person must ensure that all resident needs are appropriately assessed. All essential information must be recorded.(Previous timescale of 30/06/05 not met). Care plans must clearly show how service users needs are being met, including identified risks. They must be kept updated and regularly reviewed and must show the involvement of service users/relatives. (Previous timescale of 30 June 2005 not met). Fit approved locks to all bedroom and bathroom doors without locks. Records of the food provided for service users must be in sufficient detail to determine whether the diet is satisfactory. All staff must receive training on prevention of abuse and adult protection procedures. Staff training records must provide evidence of training attended. (Previous timescale of 30 June 2005 not met). Replace the carpet in the conservatory and the adjoining Timescale for action 30/09/05 2. 7 15(2) 30/09/05 3. 4. 10 15 12(4) 17(2) Schedule 4 13(6) 31/08/05 30/09/05 (revised) 30/09/05 5. 18 6. 19 16(2) 30/09/05 Page 21 Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 7. 29 19 Schedule 2 8. 29 19 Schedule 2 9. 30 18(1) 10. 30 18(1) 11. 38 13(4) 12. 38 23(4) lounge area.(Previous timescale of 30 June 2005 not met). The registered person must obtain all information and documents listed in Schedule 2 of the Care Homes Regulations in respect of staff working in the home. The home’s recruitment and selection procedure must be available. (Previous timescale of 30 June 2005 not met). The Registered Persons must ensure that all person’s applying to work in the home have a satisfactory check against the Protection of Vulnerable Adults list. (Previous timescale of 30 June 2005 not met). Personnel files must contain documentary evidence that staff have received induction and foundation training in line with national training requirements.(Previous timescale of 30/06/05 not met). Personnel files must contain documentary evidence of training that staff have attended.(Previous timescale of 30/06/05 not met). A written risk assessment relating to use of footrests on wheelchairs must be completed for service users. Where use of footrests are assessed unsuitable, service user’s care plan must clearly state how they are to be transferred in a wheelchair. (Previous timescale of 30 June not met). The registered person must comply with the requiremnst of the inspectioncarried out by the Fire Officer. 30/09/05 30/09/05 30/09/05 30/09/05 30/09/05 30/09/05 Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 22 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 1 Good Practice Recommendations The registered person should combine the current documents entitled Statement of Purpose and Welcome to Butterley House as the new Statement of Purpose for the home. The registered person should continually review arrangements that ensure that service users needs relating to hearing and sight impairment are fully met. The registered person should review the format of care plan documentation and consider its replacement. Inexperienced staff should receive further training to develop their skills. Put arrangements in place to ensure that relatives are consulted in regards to their family members care. Establish regular meetings with residents/relatives to obtain their views about the care and services. Include procedures relating to prevention of abuse and whistle blowing in the staff handbook. Provide a suitable thermometer in all bathrooms for checking the hot water temperature of the baths and showers. Create a domestic appearance in the toilets and bathrooms. Staff personnel files should clearly show when references and documents had been requested and obtained. Completed application forms should provide:Sufficient information relating to the persons experience and a specified period of employment history. Any gaps in employment should be explored. Staff should be employed in accordance with the code of conduct and practice set out by the General Social Care Council, and receive a copy of the code. Personnel files should contain documentary evidence that staff have received written terms and conditions of employment. All staff should have an individual training and development file. Develop a written annual development plan for the home. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 4 7 4 7 16 18 21 21 27 27 12. 13. 14. 15. 16. 29 29 30 30 Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 23 Butterley House C52-C02 S19955 Butterly House V237107 060705 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby DE1 3QT 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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