CARE HOMES FOR OLDER PEOPLE
Southway 290 London Road Bedford Bedfordshire MK42 0PX Lead Inspector
Dragan Cvejic Unannounced Inspection 25th January 2006 01:30 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 Southway DS0000014971.V280697.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. Southway DS0000014971.V280697.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Southway Address 290 London Road Bedford Bedfordshire MK42 0PX 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) 01234 345284 01234 360340 briggsde@bupa.com BUPA Care Homes (Bedfordshire) Ltd Deborah Briggs Care Home 42 Category(ies) of Dementia - over 65 years of age (42), Old age, registration, with number not falling within any other category (42), of places Physical disability over 65 years of age (42) Southway DS0000014971.V280697.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th November 2005 Brief Description of the Service: Southway residential care home was purpose-built in 1975 and is owned by BUPA. The home provides care for 42 people over 65 years old, who might have dementia, including those who are physically and mentally frail. Three beds are used for respite care. All bedrooms are single and individualised. The accommodation consists of five separate units across two floors, and each unit has its own lounge, kitchenette/diner, toilet and bathing facilities. A passenger lift links the two floors. In addition there is a large communal room, hairdressing room, main kitchen and laundry room and offices. The home had a beautiful sensory and herb garden. Other features included a pond with colourful fishes and a fountain. The home was located in a pleasant suburb to the south of Bedford town centre, on a main bus route and within walking distance of local shops, pubs and places of worship. Southway DS0000014971.V280697.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out during the afternoon for the duration of 3 hours. Only the key standards were inspected, as there were no significant changes and the home continued to provide very well organised, safe and appropriate care to service users. A senior staff meeting took place during the inspection and the inspector was invited and attended this staff meeting. As all service users were discussed, the inspector used information shared on that meeting for the inspection and for the report. A visitor and his relative were spoken to and provided comments for this report. Another service user also spoke of her feelings and the care she received in the home. A visiting aroma therapist also provided her positive comments about the home. What the service does well:
The home continued to provide very good care with full respect and high protection of service users. All comments were positive and illustrated how an open and inclusive atmosphere benefited service users and visitors and clearly demonstrated users’ satisfaction. A visitor stated: “This is a lovely home. All communal areas are nice. Staff is nice. Food is excellent, they invite me to eat with my relative, and this is very nice. I am putting my name on a waiting list, as I want to come to this home when my needs come to that stage. She is not my relative”, he explained his relationship with the user he visited, “but a friend. I have many friends here, among residents and staff. The manager is fantastic, she always picks the best staff to come to work here.” The manager explained the referral process for service user whose needs exceeded the home’s ability to meet them and was referred to a nursing home. Despite being given a notice, the home continued to care for her, even allocated one staff member to ensure one-to-one care was provided, while the bed became available in a nursing home. A day after the inspection the manager informed the regulation authority that this service user moved to a nursing home. All the staff attended relevant training and was up to date with all mandatory topics. A visiting aroma-therapist commented that she was informed about who was allergic and who would not benefit from her therapy. A service user from a different background stated how happy she was in the home, and when offered to speak to someone from her background in a different language, she replied: “Why? What for? I am quite happy and can Southway DS0000014971.V280697.R01.S.doc Version 5.1 Page 6 communicate all I want to in English to any staff member. They are all very good.” What has improved since the last inspection? 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. Southway DS0000014971.V280697.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 Southway DS0000014971.V280697.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): 3,4 The home carried out very detailed and comprehensive assessments of service users to ensure their needs could be met if they choose to move in. The manager extended the assessment to the area of financial protection too; ensuring service users were properly assessed and protected when the place was offered to them. EVIDENCE: The manager explained the assessment where there was a potential issue of financial abuse for the referred service user and took all necessary action to ensure a high level of protection. The assessment of the existing user indicated that the home could not effectively meet rapidly increased needs. Despite the written notice, the home continued caring for that user. They introduced 15 minute interval observation at night and one-to-one care for daytime, temporarily, until a bed in a nursing home became available. The day after the inspection, the manager informed the regulation authority that a bed was found and the referral and admission process was immediately arranged.
Southway DS0000014971.V280697.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 Even the handover process included all relative aspects of care, illustrating how well the home organised care and health care for service users. EVIDENCE: During the handover and discussion about service users on staff meeting, all aspects of care were discussed in detail, including personal, health related, emotional and cultural needs. The risks were also discussed, taking into account users’ wishes and preferences and the home’s ability to respect them flexibly but safely. A new medication supplier was found and the new delivery procedure was introduced. The manager ensured that all staff were aware of changes. The manager was exploring accredited medication training for night staff too. Apart from regular health care professionals’ visits, the home offered complimentary therapy to those that would benefit from it, while at the same time, by communicating relevant conditions, protected service users who would be exposed to risk if they took part in aroma-therapy, for example. The medication procedure was extended to cleaning and keeping medication trolleys clean. Southway DS0000014971.V280697.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, 14, 15 The home fully respected service users wishes and preferences when daily routine was considered, planned and implemented. Service users were regularly consulted about their daily life. EVIDENCE: The manager presented the case of a service user with a court protection order and how the home protected her and still respected her wishes. A visitor commented on a structured, supportive daily programme that “all service users he knew, were benefited from”. Autonomy and choice were fully respected, as stated by a service user and observed during the inspection. Personal possessions were better protected with newly introduced recording system where dates and signatures were introduced. The kitchen staff started to record if service users chose a meal outside a set menu, to ensure that the food monitoring process was effective. Southway DS0000014971.V280697.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): 16 The home considered all concerns very seriously and used them to improve service. All spoken to were aware of the complaint procedure and knew how to complain if they wished. EVIDENCE: A clear and concise complaint procedure was in place. The manager explained how the home invited relatives that expressed some concerns to discuss them in details and to take the most appropriate action. Three out of 5 service users confirmed that they knew how to complain and two others were only confused by their conditions, but the inspector felt confident that even they would complain if they wished so. The relevant people, for example, knew Service users’ conditions, the kitchen staff knew who was diabetic, while the aroma therapist knew who was allergic. Southway DS0000014971.V280697.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, 26 The home offered a clean, comfortable and pleasant environment where service users could enjoy and benefit from the domestic style of the setting. EVIDENCE: The layout of the home was appropriate to service users and their lifestyle. The home was clean and bright. A renewal programme was in place and offered further reassurance that the home was suitable for service users’ needs, but also appropriate for their expectations and preferences. All hygienic measures were in place and were respected, this ensuring safe and effective hygiene and infection control procedures. Southway DS0000014971.V280697.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): 30 The staff were appropriately trained according to the home’s plan and ensured that their training helped them in meeting the service users’ needs. EVIDENCE: The home offered structured and planned training to all staff. All staff was up to date with their mandatory training. Three staff had become fire trainers that cascaded fire training through the staff team. The home also benefited from two staff who was manual handling trainers and the manager who was a “Personal Best” trainer. One new staff member was on the Skills for Care induction training at the time of the inspection. Southway DS0000014971.V280697.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): 31,33 The home was run in the best interests of service users. They were safeguarded by good policies and working practices. EVIDENCE: The registered manager was experienced, skilled and qualified. She introduced the ethos where service users, staff and relatives-visitors felt empowered to express themselves in a creative and open atmosphere. The survey, as part of the quality assurance process, was just about to start another circle and the manager was determined to effectively use the findings to ensure services offered remained at a high quality level. Southway DS0000014971.V280697.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 X X 4 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X X Southway DS0000014971.V280697.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? yes 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. Standard Regulation Requirement Timescale for action 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 Southway DS0000014971.V280697.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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