Inspection on 02/02/09 for Bywater Hall

This inspection was carried out on 2nd February 2009.

CSCI found this care home to be providing an Good service.

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

Bywater Hall 10/01/07

Bywater Hall 12/12/05

Bywater Hall 23/11/04

Bywater Hall 16/09/04

Bywater Hall 15/03/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Bywater Hall 1 Leeds Road Allerton Bywater Wakefield West Yorkshire WF10 2DY     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Frederick Rawlins     Date: 0 2 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 26 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Bywater Hall 1 Leeds Road Allerton Bywater Wakefield West Yorkshire WF10 2DY 01977667878 01977667879 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Tri-Care Ltd care home 44 Number of places (if applicable): Under 65 Over 65 44 0 old age, not falling within any other category physical disability Additional conditions: 0 1 The one place for Physical disability will be for the service user named in the NCSC letter dated 9 September 2003 Date of last inspection Brief description of the care home 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 people. There is a television and telephone point in each room and people can have a refrigerator if they wish. The rooms are pleasantly decorated and people 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. Care Homes for Older People Page 4 of 26 Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is two star (2*). This means that people that use the service experience good quality outcomes. A visit was made on 2nd February 2008 from 09:00 to 17:00. The home did not know that this was going to happen. The inspection was conducted in the company of the manager. Feedback was given to her at the end of the visit. The purpose of the visit was to assess what progress the home had made and the impact of any changes in the quality of life experienced by people living at the home. Before visiting the home we asked for information from the manager (the Annual Care Homes for Older People Page 6 of 26 Quality Assurance Assessment - AQAA) which asks about what policies and procedures are in place and when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, staff details and training provided. The methods used during the inspection included talking to people who live in the home, staff, manager and relatives visiting at the time. Care records were looked at and a tour of the home was carried out. At the time of writing this report, the fees charged for care provided were 515 pounds to 545 pounds per week. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the care home does well: What has improved since the last inspection? What they could do better: Care plans reviews should show who was involved in the care planning process, this should shows that people and their relatives are consulted about how they want their care and support to be provided. Once a month the provider should visit the home and look at the general conduct, these visits are called Regulation 26 visits. Care Homes for Older People Page 8 of 26 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 26 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to make an informed choice about whether to move into the home and can be confident Bywater Hall will be able to meet their individual needs. Evidence: The information about the service is good and gives people the opportunity to decide whether or not the home can meet their needs. Five people we spoke to said they felt well informed before they moved into the home. Positive comments made were I was not sure if I would have settled in so quickly but I have. The others and staff have made me welcomed. The manager explained everything to me. The home has a statement of purpose and service user guide both are continually reviewed. The five people said they had all been given written information about the Care Homes for Older People Page 11 of 26 Evidence: home before they moved in. They also said they had received a contract, records examined confirmed this. People are always invited to visit the home before admission. This gives people the opportunity to experience at first hand the standard of care and facilities provided and it also give them a chance to meet other people in the home. Staff spoken with said people considering moving in the home are always supported through the admission process and once admitted care is taken to make sure that they are happy in their new environment. Care Homes for Older People Page 12 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health care and personal needs are met in a way that maintains their dignity and independence. Evidence: Case tracking was done for five people living in the home. This involved looking at their care records and medication charts. The care plans provided useful information about how care needs were met. The care plans we reviewed were completed to a satisfactory standard although in some instances they did not always show who was involved in the care planning process, which means people and their relatives may not be consulted about how they want their care and support to be provided. The home is in the process of introducing a more comprehensive care planning system, which covers all aspects of peoples social and health care needs. The new format is good and gives staff the information they need to provide people with quality Care Homes for Older People Page 13 of 26 Evidence: care. Everyone living at the home is registered with a General Practitioner and are supported in having access to the full range of NHS services. The input of other healthcare professionals is clearly recorded in the documentation available, which shows that staff are seeking advice if they have concerns about an individuals health. The administration of lunchtime medication was observed and this was administered appropriately. Medication and medication records were looked at and the amount of medication and the records corresponded. Risk assessments had been completed people that self medicate and they had appropriate storage to keep their medication safe in their room. Staff were observed to be treating people in the home with kindness and respect when speaking with them. People looked to be clean and well cared for. One person who was fairly new to the home said your able to maintain independence and the staff are friendly and there when you need them. Care Homes for Older People Page 14 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are encouraged to make choices. They also benefit from a good, healthy and varied diet. Evidence: Relatives and visitors said that they could come at any time and they were always made to feel welcome. The manager confirmed that daily routines of the home are flexible and people are encouraged to be as independent as possible and they can choose how to spend their time. Activities are done daily by staff and outside entertainers, and are recorded in people files. People have a choice in what activities they would like to do, therefore the activity plan is changed on their request. A full weekly program of activities are listed on the notice board and leaflets of the days activity is put on the dining room table on a morning so people can see what activity is for that day. There are some people who dont like to join in group activities so staff try to make Care Homes for Older People Page 15 of 26 Evidence: time to engage with them on a one-to one basis. People said you can do things if you want to activities were better when someone did it, now all the staff are trying and some are not good at it. The manager said people are asked what they would like for their meals the evening before. This was confirmed by people spoken with. She said the cooks always make extra just in case they change their mind. There is a selection of choices eg breakfast choice of cereals porridge full cooked or bacon or sausage sandwiches. Lunch is two hot choices a meat dish or a fish, baked potatoes, choice of topping, omlette or salad. One person is a celiac and dairy free, so her meals are done separate and some of her food is brought in separate or ordered by prescription. Supper is offered now at 7pm and again at 9pm snacks and drinks are available throughout the day. People spoken with said the meals are nicely presented we get good meals some days its better than some its to plain needs some spice. During the visit we observed the lunchtime meal being served in the dining rooms, staff were seen supporting people with their meal, by cutting up their food and helping those who needed it. Several people spoken with said the problems they had with clothes going missing when sent to the laundry has now been resolved. Care Homes for Older People Page 16 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable systems in place to make sure that complaints are dealt with appropriately and people are protected from abuse. Evidence: The home has a complaints policy, which informs staff what action to take if a complaint is made. People living at the home said that they were aware of the complaints procedure and would have no problem at all in approaching the manager or registered provider if they had any concerns. Discussion with staff indicates that they are aware of the homes policy on whistle blowing and knew what to do if they suspected that people were being abused or working practices at the home were not in the best interest of the people living there. Care Homes for Older People Page 17 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home continues to provide people with a pleasant, safe and comfortable environment in which to live. Evidence: All areas of the home were visited. The home offers a very comfortable and safe place for people who lives there. There is a good garden to the rear of the property with a pleasant patio area, which is accessible from the conservatory. There is a range of communal space where people can meet with their families. The bathrooms have the appropriate aids and adaptations to support staff and people who use the service. Staff have made sure that the peoples bedrooms reflect their needs and suit their choices and preferences. Bedrooms were clean and free from any unpleasant odors. Relatives visiting made positive comments about the cleanliness of the home. Feedback from people lining at the home shows that they are very pleased with the standard of accommodation. They said the home is always kept spotlessly clean and tidy the communal rooms are always kept tidy and nicely decorated. Care Homes for Older People Page 18 of 26 Evidence: There is an ongoing programme of refurbishment and renewal at the home and since the last inspection the providers have made sure the home has its own maintenance person located at the home. They have added to their external security lighting in excessively dark and concealed areas to provide further safety to staff and people living in the home. There is a 24 hour out of hours emergency help line direct to key suppliers should key equipment need servicing immediately. The laundry facilities are well equipped to meet the needs of the people in the home. The kitchen was clean and tidy throughout and the cook said all equipment was in working order. Care Homes for Older People Page 19 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Proper recruitment checks are made to make sure that people are safe and staff are suitable to work with older people. Staff are supported in developing the skills and knowledge they need to care for people. Evidence: All staff are provide with job descriptions, which outlines their roles and responsibilities. The home has a thorough staff recruitment and selection procedure, which includes obtaining at least two written references and a Criminal Record Bureau (CRB) before new staff start work. This makes sure only people suitable to work in the caring profession are employed. The manager confirmed that all new staff receive induction training. Following on from that there is an expectation that staff will study for a National Vocational Qualification (NVQ) at level two or above depending on the post they hold. The manager said currently 98 of the care staff have achieved a NVQ at level two and all senior staff and some carers have now completed NVQ level 3 and level 4. Staff spoken with said training was good. Records confirmed that staff had received Care Homes for Older People Page 20 of 26 Evidence: training in areas such as infection control, health and safety, food hygiene, in-depth first aid and dementia training. People spoken with said they felt safe and staff treat them with respect. A relative spoken with said I come often and have always observed staff dealing with people kindly. Care Homes for Older People Page 21 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management structure in place makes sure that the home is well managed and run in the best interest of the people living there. Evidence: The pre inspection questionnaire stated that policies and procedures are available and regular maintenance and health and safety checks by external agencies are completed at the home. People said that the manager was approachable and helpful. Meetings are held with relatives and people living in the home and records kept. Regular staff meetings are also held. Staff said the management team was supportive and people worked well together. Formal one-to-one staff supervision also takes place, which gives staff the opportunity to discuss their training and personal development needs. People talked with during the visit explained how the manager has responded to any Care Homes for Older People Page 22 of 26 Evidence: concerns they had about the quality of the service. If somebody wanted the home to hold money in safekeeping for them there are systems in place to do this and appropriate records is kept. Only senior staff deal with peoples personal finances and receipts are obtained for any items purchased on their behalf. We checked a number of transaction and no concerns were raised. This means that people can be confident that the system is safe and well managed. There are quality assurance monitoring systems in place to asess how well the home is meeting stated aims and objectives. Once a month the provider should visit the home and look at the general conduct, these visits are called Regulation 26 visits. However these visits have not been completed regularly. It was agreed with the manager that this would be addressed. Care Homes for Older People Page 23 of 26 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 Reviews should show who was involved in the care planning process, which shows people and their relatives are consulted about how they want their care and support to be provided. Once a month the provider should visit the home and look at the general conduct, these visits are called Regulation 26 visits. 2 32 Care Homes for Older People Page 25 of 26 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 26 of 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!