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Inspection on 16/06/05 for Ilsom House Residential & Nursing Home

Also see our care home review for Ilsom House Residential & Nursing Home for more information

This inspection was carried out on 16th June 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The accommodation is extremely comfortable in this Home and residents can take their own belongings in with them on admission. Therefore some bedrooms look personalised and homely. Staff aim to `fit in` with the residents` routines and their individual choices and preferences are very much listened to. Residents and their visitors are afforded the level of privacy that they specifically wish to have. The Home offers a high standard of care and attention.

What has improved since the last inspection?

A lot of bedrooms have been decorated and ensuite facilities improved by removing low baths and installing walk in showers. Corridor carpets have been replaced throughout and new lighting installed, to include an upgrade of emergency lighting.

What the care home could do better:

Due to a lack of Deputy Manager and therefore a key member of the qualified nursing team, certain systems have fallen behind. The Manager explained that the care delivery has been the priority. The system for staff supervision is behind at present and will be the responsibility of the new Deputy Manager or will require reallocation to get back on course. The Home must be able to demonstrate that all staff are receiving adequate supervision. The care plan reviews are behind, however, the Manager has begun to do this and each resident or family is having the opportunity to review their care. The Manager is also aware that the staff files require re-organisation and some filing is required. This will be one of the new administrator`s first tasks. Two requirements under the Care Home Regulations 2001 remain outstanding.

CARE HOMES FOR OLDER PEOPLE Ilsom House Residential and Nursing Home Tetbury Gloucestershire GL8 8RX Lead Inspector Janice Patrick Unannounced 16 June 2005 11:15hrs th 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. Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 3 SERVICE INFORMATION Name of service Ilsom Residential and Nursing Home Address Tetbury Gloucestershire GL8 8AX 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) 01666 504131 01666 504308 pitcherja@bupa.com BUPA Care Homes Ltd Mrs Jan Pitcher Care Home 38 Category(ies) of OP old people (38) registration, with number TI Terminally Ill (38) of places PD Physical Disability (38) Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22nd November 2004 Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 5 Brief Description of the Service: Originally a 17th Century Farmhouse, Ilsom House has been sympathetically extended over the years to provide comfortable accomodation over looking the surrounding countryside. Situated outside of Tetbury and standing back off the A433 to Cirencester, it offers a substantial amount of parking and grounds. The ground floor accomodation is a mixture of single bedrooms, a substantial airy lounge, dining room and smaller quiet lounge. It also includes the reception area which is staffed from Monday to Friday. The second floor, which is accessed via a shaft lift and stair lift is predominantly single bedrooms. The Home does have some larger bedrooms that could be shared by a couple if prefered. The Home is staffed by qualified nurses at all times and offers predominantly private nursing care. Good relations are enjoyed with local Doctors and other external health care professionals and the Home is well integrated into the local community. Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over 3.5hrs by one inspector. The Registered Manager was present and was helpful throughout. Some residents and staff were spoken to, including the new administrator who was being inducted into her new role. A tour of the building took place, which included the laundry. The records of residents’ personal allowances were seen and one carer’s induction training records. What the service does well: What has improved since the last inspection? A lot of bedrooms have been decorated and ensuite facilities improved by removing low baths and installing walk in showers. Corridor carpets have been replaced throughout and new lighting installed, to include an upgrade of emergency lighting. Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 7 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. Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 4 A good assessment process allows the Manager to be sure that the staff group is able to meet the individual needs and allows the prospective resident to be sure that they like the Home. EVIDENCE: An assessment process for one resident who was in hospital was discussed. The Manager went to meet the resident and carried out a full assessment. Many physical needs were identified, but since admission several mental health needs are also suspected. These needs have been included within the care plan and an assessment by the Community Psychiatric Nurse has been requested. Two nurses from the day staff team and two night staff have just completed a course, which included an update talk on the care of those with dementia and anxiety related issues. Another member of the care team has been promoted to ‘nurses assistant’. This is to recognise her level of training NVQ Level 3, her experience in care and her keenness to extend her skills. She is able to utilise these skills in tasks Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 10 that the nurse feels her to be competent to do, such as taking a blood pressure. Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,10 & 11 An audit of all care plans is ensuring that residents are having the care they require, that any deterioration or change in their condition is being reviewed and that privacy and dignity is being upheld at all stages of that care. EVIDENCE: The Inspector did not read any care plans during this visit, but the Manager confirmed that she has begun to review all care plans with either the resident or their representative. A formal invite is sent to all representatives asking them to arrange a date with the Manager; two such appointments had been made on the day of this visit and the Inspector was present when one of these was altered to another date. One resident spoke about her involvement in her own care planning. The daughter of another two residents was very involved in the care planning of both. This meeting proved useful, as the needs of one of the residents were more clearly understood by the staff after this. The recent death of one resident, who the Inspector had met on a previous visit, was discussed with reference to the deceased person’s particular wishes Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 12 at the time. These went against any nursing or medical advise and staff had to work hard to uphold the individual’s dignity during this time. The deterioration of another resident had also been identified and appropriate referrals made to seek assessment and advise to ensure these changed needs were met. Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 13 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) 13 The Home actively encourages consistent contact with family, friends and the local community, which helps add to the quality of the residents’ lives. EVIDENCE: One resident explained that she sees her family at varying times of the day and enjoys having tea with them or occasionally going out. She did say she would like to get out more often. A resident from the independent living cottages that share the grounds, enjoys coming into the Home. She said that she has made friends with some of the residents. A resident confirmed that she enjoyed talking with someone from outside the Home. Some of the residents belong to local day centres and attend on a regular basis. The Manager described a situation where a resident’s family have decided not to visit much and have not brought any personal belongings in to help make their relatives bedroom look more homely. Encouragement and the positive reasons for doing this have been given to the family to try and improve the situation. Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 14 Information about forthcoming events is on the notice board for visitors to see and is also circulated in writing to each resident. Invitations are sent out within the local community when there are larger events held at the Home. Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 15 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) 16 The Home has a robust Complaints Procedure, which allows residents and visitors to be assured that their concerns will be investigated and dealt with. EVIDENCE: No complaints have been received by the Home since the last inspection. BUPA require a monthly report from each of their Managers as to the status and number of complaints. This review is part of the quality assurance system. The Complaints Procedure is clearly stated within the reception area and can also be found in the Statement of Purpose within reception and in the information pack in each bedroom. One resident said that she had no problem with voicing any concerns as: ‘The Manager always listens and sorts it out’. Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 16 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, 24 & 26 Residents live in a clean and safe environment that has the option of being personalised and made to feel very homely. EVIDENCE: Since the last inspection work has been carried out to improve the decoration of several bedrooms and the layout of many ensuites. All corridor carpets have been changed and look vastly improved, particularly those upstairs. The lighting has been improved and the emergency lighting upgraded. The environment was clean and airy. Many bedrooms have been personalised and have been made to look very homely and attractive. Residents are informed within the Homes contract that they will need to take out their own insurance if valuables are brought in. The Inspector was shown a bedroom where a resident’s family has chosen not to bring in any of their relatives personal belongings. Therefore various items Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 17 have been collected by the staff and placed in the room to make it a little more welcoming. In comparison another bedroom contained many personal pictures and furniture, clearly enjoyed by the resident of this room. The laundry was seen and the member of staff who runs this spoken with. She was well conversed with health and safety procedures and the area was clean and organised. Residents have their clothing returned at least by the next day. All residents seen looked well kept and smartly dressed. Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 18 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 & 30 Thorough training for all levels of staff ensures that they are able to perform the job they are recruited to carry out and therefore meet the needs of residents and the Home. EVIDENCE: All new staff undertake induction training which is based on The National Training Organisation for Social Care (TOPPS) standards. Care staff progress to a more in depth training and are then ready to undertake their NVQ Award in Care. A new carer showed the Inspector her induction booklet. She explained that she was working with her mentor, a NVQ Level 3 carer and that she had also completed Fire Safety and Manual Handling training. The booklet covers most areas of basic care, health and safety and the basic procedures of the Home. The Manager was due to appraise her progress soon. A requirement from the last inspection report pertaining to standard 29 was followed up. This involved staff files containing the required criteria as laid out in Schedule 3 of the Care Home Regulations. The Manager confirmed that this had not yet been met, but that it was one of the first jobs for the new administrator. The Inspector felt this to be reasonable, as all recruitment criteria is met by the Home but due to the recent vacancy, the filing was not up to date. This will be inspected during the next visit. Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc 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 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, 35 & 36 The Manager has a strong sense of leadership within the Home and communicates this effectively and residents clearly feel reassured by this. There are robust procedures in place to ensure the safety and correct organisation of residents’ personal allowances. EVIDENCE: The present Manager has managed this Home for several years and is knowledgeable about BUPA’s Policies and Procedures. She is also a nurse and is popular with residents and staff. She leads the Home effectively and keeps her skills updated. At the present time she does not have a Deputy Manager, which makes it hard for her to keep abreast with all the required paperwork. The Inspector met one of BUPA’s Senior Financial Administrators. She was in the Home inducting the new administrator. She was able to demonstrate that Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 20 all personal allowances held by the Home were recorded and managed effectively. The person who holds Power of Attorney was also recorded. Residents have access to their monies at anytime except the weekend. Plans are usually made in advance if money is needed or a loan from a small float can be accommodated. One lady explained that she organises her own finances with her daughter’s help. A requirement from the last inspection report pertaining to standard 36 was followed up. This involved the supervision process for all staff. This system has fallen behind in practice and it’s recording, although new staff are being adequately supervised. The Manager confirmed that the new Deputy Manager would recommence this when in post. The Inspector felt this to be reasonable and will inspect the system during the next visit. Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x 3 2 x x Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 22 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 7 Regulation 15(2)(b) Requirement Care plan reviews must be carried out on a regular or as needed basis (Timescale of 30.9.04 not met) The hours that a person works per week must be included within the staff file (Timescale of 30.9.04 not met). Adequate and appropriate supervision must be availble for all staff. Timescale for action 31st August 2005 31st August 2005 31st August 2005 2. 2 17 Schedule 4 (6)(e) 18(2) 3. 3 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 36 Good Practice Recommendations That at least 6 supervision sessions for each member of staff are recorded and kept within their staff file. Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 23 Commission for Social Care Inspection Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB 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. Extracts may not be used or reproduced without the express permission of CSCI Ilsom House Residential and Nursing Home Version 1.30 D51_D03_16483_Ilsom_V218631_270405_UI_stage 4.doc Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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