CARE HOMES FOR OLDER PEOPLE
Southway 290 London Road Bedford Bedfordshire MK42 0PX Lead Inspector
Dragan Cvejic Unannounced Inspection 25th November 2005 08:00 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 Southway DS0000014971.V269503.R01.S.doc Version 5.0 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.V269503.R01.S.doc Version 5.0 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.V269503.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th February 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.V269503.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection. It started in the morning and went on throughout the day for 4.5 hours, providing an opportunity for the observation of care practices and a general overview of every-day life in the home. The inspector spoke to 7 service users, 3 staff and the management team. Two service users were case tracked in order to check the accuracy of the records and documents held about service users. The living environment was checked for the case tracked service users. The homes’ documents inspected on this occasion were: the statement of purpose, service user’s guide, generic risk assessment, two service users’ files, medication records and survey results with the business plan. The deputy manager presented the home during the inspection. What the service does well:
The home provided a very homely environment. The atmosphere was friendly and relaxed. All staff knew their roles and worked in a relaxed, approachable and inclusive way. Service users looked and felt comfortable. A cat, the home’s pet, walked from the inspected files to the lap of a service user and the passionate relationship created a smile on the user’s face and purring from the cat. Service users enjoyed their breakfast in smaller lounges and dining rooms in each unit. A visitor commented: “The food is excellent. My wife is very well looked after. This is a very good home.” She confirmed this statement together with her friends, other users, who sat together with her and chatted over breakfast. A service user was very pleased to use her mother tongue language with Polish staff. A staff member that spoke to her in Polish stated how important it was to her to be able to use her language as well as English. Care plans were well written and reviewed. Service users signed their plans and knew the goals set in them. Care plans were created from the comprehensive admission assessment carried out by the manager and the deputy. Two recent emergency admissions demonstrated that the home followed the precise and clear procedure. Full staff complement ensured consistency of care and no agency staff were used. The cleaner explained how she managed to get rid of an unpleasant smell in one of the rooms in less than one hour and keep the room and the home clean and pleasant. Southway DS0000014971.V269503.R01.S.doc Version 5.0 Page 6 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.V269503.R01.S.doc Version 5.0 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.V269503.R01.S.doc Version 5.0 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): 1,2,3,4, The home had very good written information that allowed service users to make an informed choice before moving into the home. EVIDENCE: The home had reviewed their statement of purpose and the service user’s guide and kept these documents up to date. Service users and their representatives could make an informed choice from these well-presented documents. Service users were asked to sign the standard contract form issued by BUPA that contained all the required elements. The manager and the deputy were assessors for all new referred service users. The assessments inspected were comprehensive and were used as a base for creating care plans. Service users admitted to the home were ensured that their needs would be met. This applied to emergency admissions too, as two recent assessment forms showed that process was carried out completely before offering the place to potential service users. Trial visits were arranged whenever possible, according to the admission procedure described in the statement of purpose and in the user’s guide.
Southway DS0000014971.V269503.R01.S.doc Version 5.0 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, Well organised and appropriately written service users’ files provided a good source of information for carers to get to know service users and carry out their duties as well as they did. EVIDENCE: Two care plans were inspected and both service users checked stated that they knew their goals. The care plans were signed and reviewed monthly. A new form for risk assessments was introduced and, the examples inspected were filled in very well. Service users healthcare needs were met. Different charts were used to help staff monitor and take actions when necessary to ensure any potential health problem was dealt with. Weight charts corresponded to the entries in care plans, daily records and risk assessments. Another inspected file showed the successful management of pressure sores. Inspected medication and records of it were accurate. All controlled drugs were inspected and found to correspond to records. The home had a pill cutter to administer half a tablet as prescribed and the syringe for measuring liquidised medication accurately. Service users privacy and dignity were respected. The evidence was collected from the notes from the meeting about the care of a lady service user that did not want male carers to help her with personal hygiene and whose confusion
Southway DS0000014971.V269503.R01.S.doc Version 5.0 Page 10 created a potential risk if she was helped by male carers. The home created an action plan and dealt with the case. However, there was a complaint relating to the care of a confused service user with high care needs who used respite care from time to time. The home investigated and responded with the outcome of the investigation. Service users’ files contained the last wishes of service users and their relatives recorded to help staff deal appropriately with terminally ill service users. Southway DS0000014971.V269503.R01.S.doc Version 5.0 Page 11 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): 12,13,14,15 The home provided various and stimulating activities and service users had a choice of which ones to join to fulfil their aspirations. The home needed to ensure that the food provided is suitable for each individual in regards to their health conditions and staff were asked to produce information for kitchen staff immediately. EVIDENCE: Each file contained activity records and demonstrated an active life for service users that they could choose. The activities listed were: Attending church services, music therapy, reminiscence and a visiting entertainer’s programme. The home celebrated birthdays and significant public days. The Christmas party was advertised on the board. A service user commented on activities: “There are a lot of people around. We are never bored.” Staff were observed chatting to service users and patiently listening what they had to say. The home facilitated religious services, either in the home by inviting church denominations to visit, or arranging for service users to attend services in local churches. Visitors were welcome. During the inspection staff escorted the visitor to their relative and left them together showing respect for privacy. No service users had the capacity to handle their finances, but the home and BUPA offered support and help to those that did not involve their relatives into their financial affairs.
Southway DS0000014971.V269503.R01.S.doc Version 5.0 Page 12 Service users’ personal possessions were recorded, but neither original nor updated list were signed. The menu showed the variety of food, choice and ensured the combination of dishes met the nutritional requirements. The kitchen staff did not have an updated list of service users with special dietary needs, as two diabetic users were not recorded. The deputy was asked to rectify this matter straight away, during the inspection, to ensure that appropriate food is served for the protection of service users health. Southway DS0000014971.V269503.R01.S.doc Version 5.0 Page 13 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): 16,17,18 The home was taking all complaints seriously and used them constructively to improve services and provisions. The home protected service users from abuse. EVIDENCE: The home had received two complaints since the last inspection. One was resolved, the complainant was satisfied with the outcome and measures resulted from the complaint. The other complaint, recent, was also investigated and an outcome reached, but the action plan was still to be made and to be forwarded to the complainant. The home promoted service users’ legal rights. The home arranged for service users either to be taken to the polling station or to take part in the election by voting by post. The home did not have anyone referred to the POVA register. The policies and procedures were in place to protect service users. The company’s financial procedure was in place to support service users who needed help with their finances in a safe way. The balances inspected were correct. Southway DS0000014971.V269503.R01.S.doc Version 5.0 Page 14 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): 19,20,24,25, 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 home’s location offered a quiet surrounding and access to local facilities. Internally, the home offered an environment that matches the users’ lifestyle and was domestic in nature. Sofa and armchairs in the foyer illustrated the home’s style that was followed throughout. There was a nice view to the pond with fish that several service users emphasised when talking to the inspector. The home was in a good state of repair and had a programme for regular maintenance. The communal areas were clean, bright and comfortable. Service users could use all parts of the home. During the inspection, a service user sat comfortably in the admin office enjoying being in a working environment, without disturbing the administrator. Individual bedrooms were comfortably arranged with personal possessions, creating a homely environment for service users. The cleaner washed the carpet in one of the bedrooms to get rid of an unpleasant odour and to ensure
Southway DS0000014971.V269503.R01.S.doc Version 5.0 Page 15 the hygienic state of the bedroom. The cleaning staff ensured that the home was clean and well ventilated. Southway DS0000014971.V269503.R01.S.doc Version 5.0 Page 16 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): 27,28,29 Service users enjoyed and benefited from the stable, committed and skilled staff team, who were properly trained to meet the needs of service users. EVIDENCE: The home employed a sufficient number of skilled and experienced staff. The rota demonstrated who worked at which position and was created to show staff per unit, making it simple and understandable. The rota separately listed senior staff. A trainee student on a placement in the home was supervised at all times and had a mentor allocated each day. She stated that she learnt a lot and that the work was very well organised and structured. Fifteen staff members had completed their NVQ training and a further 7 were currently doing this programme. The home exceeded the requirement to have 50 of NVQ trained staff. Recruitment was organised and carried out according to the BUPA procedure. Staff recruited from outside the UK were double checked and their files contained their foreign and UK CRB disclosures. Two references were in all files. Southway DS0000014971.V269503.R01.S.doc Version 5.0 Page 17 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): 31,32,36,38 The home was run in the best interests of service users. They were safeguarded by good policies and working practices. EVIDENCE: The home was managed by the experienced, skilled and stable manager. She was managing this home only and was able to offer her full commitment to the home. She created an atmosphere where staff were encouraged to express their initiative and creativity. A strong senior team ensured the philosophy of the home remained focused and respected across the management areas. Service users that needed help with their finances were helped through the established BUPA system. A service user who was concerned about his money was given a statement of his balances in the account and his relatives were approached to supply information about his money that they had access to. Safe working practices were in place. Staff were observed using a hoist for one service user. Two other staff members were observed helping and encouraging a service user to walk and remain independent.
Southway DS0000014971.V269503.R01.S.doc Version 5.0 Page 18 Kitchen staff showed good knowledge of food hygiene procedure. A cleaner explained in detail how she handled unpleasant odours and maintained the homes cleanliness. Southway DS0000014971.V269503.R01.S.doc Version 5.0 Page 19 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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X X X 3 3 X STAFFING Standard No Score 27 3 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 X 3 Southway DS0000014971.V269503.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP14 Regulation 13 Requirement The service users’ possessions lists must be signed by service users, their representatives or at least by the staff member who made these records. Timescale for action 15/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations The sheet prepared to accompany a service user to hospital should contain the date of admission to the home. Southway DS0000014971.V269503.R01.S.doc Version 5.0 Page 21 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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