Inspection on 03/07/07 for Bybuckle Court

This inspection was carried out on 3rd July 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bybuckle Court 25/09/08

Bybuckle Court 27/06/06

Bybuckle Court 13/09/05

Bybuckle Court 14/04/05

Bybuckle Court 02/09/04

Bybuckle Court 29/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Bybuckle Court 5 Marine Parade Seaford East Sussex BN25 2PZ Lead Inspector Gwyneth Bryant Key Unannounced Inspection 07:45 3rd July 2007 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 Bybuckle Court DS0000021065.V336241.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. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bybuckle Court Address 5 Marine Parade Seaford East Sussex BN25 2PZ 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) 01323 898094 F/P 01323 898094 Mr James Lord Mrs Sylvia Lord VACANT Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is seventeen (17). Service users must be aged sixty-five (65) years or over on admission. Date of last inspection 27th June 2006 Brief Description of the Service: Bybuckle Court is an established home providing residential care for up to seventeen older people. It is a large detached property, overlooking the seafront in Seaford and within easy walking distance of the town centre shops, amenities and railway station. Service users accommodation comprises fifteen single rooms and one double room, situated on two floors. The majority of the rooms have en-suite facilities, including a toilet and washbasin and all are fitted with a call bell system. On the ground floor there is a large, light and spacious lounge and dining area. A shaft lift provides access to the first floor. In addition to Bybuckle Court, the proprietors own a second home in Seaford, Hillersdon Court, which also provides residential care for older people. Information about the service, including the Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The range of weekly fees from April 2007 is £310 - £400. Additional charges, not included in the fees, include hairdressing, chiropody, toiletries and newspapers. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site visit carried out over six hours and its purpose was to check compliance with shortfalls identified at the last inspection. Five people living in the home were spoken with on the day, in addition to the Acting Manager, the cook and one carer. A tour of the premises was carried out and a range of documentation viewed including staff recruitment records, care plans and staff training records. Two relatives were contacted by telephone following the site visit and comments were all positive, with both saying they feel that people in the home are extremely well cared for. Despite the there being shortfalls, outcomes for the people living in Bybuckle Court remain good with all those spoken with saying how happy they are living in the home. Comments from those living in the home included: ‘the staff are lovely’ ‘they do so much – I have no complaints’. Comments from relatives included: ‘I feel lucky to have found the place (for mum).’ ‘couldn’t meet nicer people I’d rate them 200 ’ ‘Always made welcome’. ‘All the girls are super and I have peace of mind while she is there’. ‘It’s small and friendly. Mum would always say if there were any problem’. ‘ I live in Seaford and never heard bad words about the place’. Prior to the site visit information was requested from the provider; this was given and information detailed is used in this report as necessary. What the service does well: What has improved since the last inspection? Improvements have been made to the external grounds and in particular the provision of potted plants and flowers to the rear car park area. A staff Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 6 training and development programme has been introduced and the Acting Manager has completed the required training. The good practice recommendations in respect of after death arrangements and staff supervision have been addressed. 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. The summary of this inspection report can be made available in other formats on request. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 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 Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4. Standard 6 is not applicable. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Satisfactory pre-admission assessments are carried out prior to people moving into the home, which ensures that their needs can be met, and they are provided with detailed information on services offered by the home. EVIDENCE: Pre-admission documentation was viewed for recent admissions and it is evident that these documents are used effectively to ensure the home is able to meet the needs of prospective service users. At the time of admission information is sought from social and healthcare professionals to ensure all needs are clearly identified and planned for. A copy of the service users guide and the last inspection is left in each person’s bedroom as a point of reference. Prior to admission people are invited to visit and stay for a meal if they wish. The pre-admission sheet was discussed with the Acting Manager who agreed that it could be improved by adding further information to ensure all needs are identified and she agreed to address this. People living in the home confirmed they were invited for a visit and had received a contract detailing their terms and conditions of residence. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 9 Intermediate care is not provided. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. All aspects of the health, social and care of those living in the home are met but improvements need to be made to all aspects of the care recording process to enable staff to deliver care in a structured and consistent manner. EVIDENCE: Four care plans were examined and found to contain most of the required information although recording was not always consistent with the information in the daily notes. There is a key worker system in place with associate key workers identified to ensure those living in the home always have a named person to deliver care. Not all care needs of those living in the home were identified although the Acting Manager and staff were knowledgeable in this respect. People spoken with said they felt looked after and that staff treated them with care and respect. It is important to record all care needs, as currently there is a reliance on good staff communication and good memory. This issue had been identified at the last staff meeting and needs to be put into practice to ensure all staff provide care in a consistent manner. Medication charts included a Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 11 photograph of each individual and in order to facilitate identification photographs also need to be added to care plans. Although staff take care to reduce risks detailed risk assessments need to be carried out for those at risk of falls, tissue breakdown and self medication to ensure all those working in the home are aware of the risks and how to reduce them. Relatives spoken with confirmed that people are well looked after and that care needs are met. There was evidence that people living in the home have access to healthcare professionals including opticians, dentists and chiropodists. Information provided prior to the site visit indicated that all staff have been trained in medication administration. Medication records and storage arrangements were viewed and systems are satisfactory. Medication administration charts were up to date and clear, however there were inconsistencies in the recording of ‘as required’ medication. This was discussed with the Acting Manager and it was agreed that a pharmacy inspector would visit to advise on all aspects of the handling of medication. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home need to have the opportunity to experience a lifestyle that matches their expectations, choice and preferences in respect of meals and leisure activities. EVIDENCE: Information provided prior to the site visit indicated that the home provides various activities including bingo, card games, exercises in addition to outings to shops and local attractions. However the activities programme needs to be expanded to ensure daily activities are provided, based on the preferences of those living in the home. One person in the home, along with a relative provides bingo sessions and those spoken with said they enjoyed these sessions. Others spoken with said they are able to go out either with relatives or independently, thus ensuring that contact with the wider community is maintained. Relatives spoken with said that they are made to feel welcome, are offered refreshments and are able to stay for meals if they choose. One relative takes his mother and another person living in the home out at least once a week. Discussion with the cook found that there is a four-week menu with alternatives offered at each mealtime. The cook confirmed that those living in the home are consulted on meals and this was further confirmed from the Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 13 minutes of the last residents meeting. All food served in the home is home made, including soup and fresh vegetables used whenever possible. People in the home all mentioned how good the food is and comments included: ‘food is very good- sometimes too much’ ‘its just like my own cooking’. The lunchtime meal was observed and the food was attractively presented and it was clearly enjoyed by those living in the home. Relatives spoken with said: ‘the food is marvellous’. ‘mum always wants to be back in time for lunch’. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a satisfactory complaints system with evidence that those living in the home, felt confident their views would be listened to and further protection is provided by robust adult protection procedures. EVIDENCE: The home has detailed policies and procedures on complaints and although there is a complaints book the daily notes showed that some complaints had been recorded as a daily comment. This was discussed with the Acting Manager who agreed that all complaints, however minor should be recorded in the complaints book and include outcomes and actions taken. Those people in home said they were happy to speak to staff or the Acting Manager if they were unhappy with anything. Relatives also confirmed that while they have never needed to make a complaint they knew who to speak to and felt that the manager would listen to their concerns and act upon them. The home has policies and procedures on adult protection and staff are expected to be familiar with this document. All staff in the home, except one has been trained in adult protection procedures ensuring that appropriate action is taken in the event of an allegation. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The standard of decor within the home is good, providing a homely, safe and comfortable for those living in the home but minor repairs need to be identified and carried out promptly. EVIDENCE: A tour of the premises was carried out and most parts of the home are now well maintained and attractively decorated. Improvements have been made to the rear car park with the addition of potted plants and flowers which make it a more attractive place. Individuals’ rooms were attractively decorated and it was evident that many had taken the opportunity to personalise their rooms with pictures and ornaments. Minor repairs need to be made in respect of some bedroom doors not closing fully, some paintwork needs attention, replacing the perished non slip pads in communal baths and the cleaning of the stair carpet. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 16 Laundry facilities are clean and hygienic. Systems are in place for the control of infection and all staff have been trained in this area and were observed to be working in ways that minimised the risk of infection, by wearing gloves and aprons when required. Comments from relatives included: ‘everything is clean’. ‘don’t think we could get better’. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are sufficient staff with the skills and knowledge to provide consistent care to those living in the home and recruitment practices are robust and offer further protection to those living in the home. EVIDENCE: Staff rotas indicated that there are two staff on duty for each shift in addition to the Acting Manager, cook and domestic staff. People living in the home said staff are often busy and do not always have time to spend quality time with them. This was discussed with the Acting Manager and it was agreed that a staff review could be carried out based on the needs of those living in the home and that key workers could spend time compiling care plans with individuals. This latter would ensure staff spend significant quality time with individuals in addition to ensuring they are involved in all parts of the care planning process. Recruitment records for the last two people to be recruited were examined and all had provided proof of identity and two written references in addition to satisfactory Criminal Record Bureau and Protection of Vulnerable Adults First checks. In order to fully comply with the regulations staff need to provide a fully employment history and complete a health declaration. The carer spoken with confirmed that she had an induction period and continues to shadow a senior carer until as she has yet to undertake moving and handling training. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 18 Information provided prior to the site visit indicated that of the ten care staff, four have National Vocational Qualification level 2 in care and two have recently started work on achieving this qualification. Therefore it is on target to meet the required 50 of staff with this qualification. This document also showed that all staff have been trained in infection control, Protection of Vulnerable Adults, manual handling, fire safety and health and safety. Comments from relatives included: ‘All the girls are super’. ‘staff seem to know their job - all very dedicated’ ‘Manager is very approachable’. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 19 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, 32, 33, 35 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from clear leadership and direction and most aspects of their health, safety and welfare are protected and promoted. EVIDENCE: The Acting Manager how has the required qualifications and continues to provide good leadership, in an open and approachable manner. Throughout the site visit it was evident that both staff and those living in the home are happy to approach her with any concerns demonstrating there is a relaxed and welcoming atmosphere. The home holds some monies on behalf of those living in the home and receipts are provided and all transactions recorded satisfactorily. Minutes from the staff and resident meetings were examined and it is evident that the meetings are used effectively to actively encourage input into the running of the home from both people living in the home and staff. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 20 The Acting Manager carries out a number of quality assurance procedures including providing, surveys for both relatives and those living in the home, staff training, resident and staff meeting and supervision. These need to be structured and collated to formalise the quality monitoring process to enable the Registered Providers to evaluate all aspects of the service and ensure it is run in the best interests of those living in Bybuckle Court. Comments from surveys sent out by the home included: ‘Thank you very much – mum loved staying with you’. ‘care rated as excellent’. ‘the home is first class’. ‘Thank you for looking after dad so well.’ Documents relating to Health and Safety were available and found to be satisfactory as were accident records. There were records showing the regular testing of emergency lighting and fire alarms and that fire equipment and systems are regularly serviced. The staff training programme ensures they are trained manual handling, infection control, fire safety, food hygiene and first aid. A fire safety risk assessment has been carried out on the premises and the subsequent report due to be made available with in the next few weeks. Although some doors were wedged open the Acting Manager confirmed that she is due to order additional self-closing devices and that wedges are not used at night. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 21 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 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 3 Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 (1) Requirement That the pre-admission document is expanded to include all the information as required under the standard. That care plans are further developed to include the personal, social, religious and healthcare needs of service users. That all activities undertaken by service users be risk assessed and include measures to minimise the risk. That a daily programme of activities based on service users interests be devised and implemented. That all complaints be recorded and include actions taken and outcomes. That all repairs within the home are carried out promptly. That quality monitoring practices are formalised. The Registered Providers must complete a monthly monitoring report that is made available to the Manager and to CSCI. Timescale for action 03/08/07 2. OP7 15(1)(2) (b) (c) 03/09/07 3 OP7 13 (4) (b) (c) 16 (2)(m)(n) 22 (3) (4) 23(1)(a) (2)(b) 24(1)(a) (b)(2)(3) 24(1)(a) (b)(2)(3) 03/09/07 4 OP12 03/09/07 5 6 7 8 OP16 OP19 OP33 OP33 03/08/07 03/08/07 03/09/07 03/08/07 Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 23 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 OP27 Good Practice Recommendations That staffing levels be reviewed based on service users dependency levels. Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Bybuckle Court DS0000021065.V336241.R01.S.doc Version 5.2 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. 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