CARE HOMES FOR OLDER PEOPLE
Bywater Hall 1 Leeds Road Allerton Bywater Wakefield West Yorkshire WF10 2DY Lead Inspector
Hebrew Rawlins Unannounced Inspection 12th December 2005 10:00 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 Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Bywater Hall Address 1 Leeds Road Allerton Bywater Wakefield West Yorkshire WF10 2DY 01977 667878 01977 667879 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) Tri-Care Limited Mrs Susan Sharp Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44), Physical disability (1) of places Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The one place for Physical disability will be for the service user named in the NCSC letter dated 9 September 2003 25th August 2005 Date of last inspection Brief Description of the Service: Bywater Hall is a purpose built care home, located in Allerton Bywater which is east of Leeds City Centre. Care is provided for 44 older persons both male and female aged 65 and over. The bedrooms are located over two floors accessible by stairs or a passenger lift. There is easy access throughout the home for wheelchair users. All bedrooms have en suite facilities which offer privacy to the service users. There is a television and telephone point in each room and service users can have a fridge if they wish. The rooms are pleasantly decorated and service users can bring their personal possessions to help them feel “at home”. Bywater Hall has a modern in-house laundry, a hairdressing salon as well as Hydrotherapy baths. Support services are in place with a choice of GP, district nurses, chiropodist, dentist and optician. Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One inspector between 10am and 5.00pm carried out this unannounced inspection. Time was spent talking to residents, relatives, friends and staff. I also looked at records including duty rotas; residents’ care records, and assessments and observed the lunchtime meal. Some bedrooms and other areas of the home were checked. The manager was present for the inspection. Comment cards were left at the home for relatives and residents to complete. Three cards were returned from relatives and nine from residents. Generally feedback was positive. What the service does well: What has improved since the last inspection?
The pre-admission assessment has being developed to include further information. New care documentation has being introduced and care plans are now updated. Cleaning schedules have been revised to incorporate required changes. Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 6 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. Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, and 5. The home provides sufficient information to allow prospective residents to make an informed choice about moving in. All residents are assessed before admission to make sure that the home can meet their needs. EVIDENCE: People making initial enquiries are sent a letter, copy of the home’s brochure and other relevant information. The manager assesses all residents before they move into the home and offers a trial visit. Residents I spoke with said that they had been happy for their relatives to look round on their behalf. The home does not provide intermediate care. Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Care plans seen were informative. Residents’ health care needs are met and residents’ are treated with respect. EVIDENCE: Five care plans seen provided detailed and personalised information clearly showing how care needs are met. Arrangements are in place for residents to access health care services such as the dentist, chiropodist and optician. Residents said that they felt well cared for and said that staff treated them with respect. Residents said that they could get up and go to bed when they wanted and felt that staff respected the choices they made. One resident said, “staff are very good and all seem to get on well together which creates a nice, happy atmosphere”. Administration charts are generally well completed. Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, and 15. The level of recreation varies between residents ability. The manager must review its activities to make sure that residents have meaningful and fulfilling daily lives. Contact with relatives and friends is encouraged and supported. Residents enjoy the food and the same standard of service was good. EVIDENCE: Activity provision differs on which staff are on duty. Staff plans activities on a weekly basis. Residents said how much they look forward to the entertainers who visit the home. Many residents choose to stay in their own rooms and said that they were content entertaining themselves by watching television, reading or listening to the radio. Two regular visitors said that there were few activities and felt that more stimulation was needed. The manager acknowledged that the activity level could be improved and would like to employ an activity co-ordinator. Most residents said that they had control over their daily lives in relation to how they spent their days. Some residents who needed assistance from staff said that they try their best to be helpful. Residents praised the food and made the following comments “the food’s very good”, “lots of choice”. Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected at this visit. However the manager stated she had received one complaint and an action plan was agreed with the family. EVIDENCE: Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, and 26. The home provides a clean and pleasant environment. Bedrooms and communal areas are decorated and furnished to a good standard. EVIDENCE: All areas of the home were inspected at this visit. Communal areas are furnished and decorated to a good standard providing light and spacious accommodation. At the time of the visit a new lock was been fitted on the door of the medication room. Externally there is a well-maintained accessible garden. Bedrooms seen were decorated and furnished to a high standard. Residents said that they were pleased with their rooms and were glad to have many of their own personal belongings with them. There are sufficient and suitable lavatories and washing facilities for residents and guests. All areas of the home were clean with no malodours. Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected at this visit. However on inspecting the building I spoke to several staff. They were concerned that the management are thinking of changing working shift pattern of the home. This is in the discussion stage. EVIDENCE: Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 and 33. The home is well organised and the manager provides effective leadership. Staff work well together as a team and in the best interests of the residents. EVIDENCE: The registered manager has many years care experience. She provides strong leadership and support to the staff team. The home is well organised. Staff I spoke with was clear about their roles and responsibilities. They said that they enjoyed working in the home and all worked together as a team. Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 4 4 4 X 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X X Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 16 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 OP12 Regulation 16 Requirement (The home’s given a date of 01/06/06 Timescale for action 01/04/06 2 OP18 13 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bywater Hall DS0000001624.V256050.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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