Inspection on 02/11/06 for St Bathens

This inspection was carried out on 2nd November 2006.

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.

Other inspections for this house

St Bathens 25/02/09

St Bathens 18/04/07

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Bathens 88 Newbridge Hill Bath Bath & N E Somerset BA1 3QA Lead Inspector Jon Clarke Key Unannounced Inspection 2nd/6th November 2006 09:30 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 St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 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. St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Bathens Address 88 Newbridge Hill Bath Bath & N E Somerset BA1 3QA 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) 01225 319293 M & J Care Homes Ltd Mrs Juliette Denise Grier Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14/03/06 Brief Description of the Service: St.Bathens is a care home owned by M&J Care Homes Ltd and provides accommodation for up to 16 older people. There was a change of ownership of the home in May 2006 however the new owners have retained the former owner and registered manager to act as the registered manager. This has provided valuable continuity for the existing residents and staff. The home is situated in the Newbridge area of Bath with bus access to the city centre it is also conveniently located close to the local Health Centre where most of the residents are registered. St.Bathens is a converted older property and the home is two properties made into one. It is on two floors with some of the rooms only being accessed by stairs however there is a lift to the first floor. There is a large lounge area at the front of the house, a dining room and conservatory with access to attractive gardens and patio area. St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection the first since ownership of the home changed. The registered manager was present throughout the inspection and the inspector was also able to meet the new owner on the second day of the inspection. A focus of the inspection was to discuss with residents, staff and registered manager the impact if any of the change in ownership of the home. As part of the inspection a number of documents were looked at including care plans, recruitment, training, medication and those relating to health and safety practice in the home. There was also an opportunity to meet with a number of residents individually and a small number of staff. What the service does well: What has improved since the last inspection? Since the previous inspection changes have been made in the systems of the home in recording information this is now more structured, a new format for care plans has just been introduced. This provides a more detailed and structured way of recording the social and health needs of residents. Following St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 6 comments from residents at the last inspection some efforts have been made to improve lighting in the lounge. 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. The summary of this inspection report can be made available in other formats on request. St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 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 St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good arrangements for assessing the health and social care needs of perspective residents so that the home is able to make sure that those needs can be met. EVIDENCE: A new format for pre-admission assessments has been introduced providing comprehensive details about care needs. Included is information about daily care needs such as dressing and undressing, mobility, social contact and interests. Where individuals are supported by the local authority copies of assessments are obtained. St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care Planning and arrangements for meeting health care are generally good providing staff with the necessary information so that the health and social care needs of residents are met. The home’s practice makes sure that resident’s health needs are protected. The practice of staff and policies of the home help to make sure that residents are treated with respect and their dignity is upheld EVIDENCE: A number of care plans were looked at and showed good information about the care needs of residents with the necessary risk assessments in place and regular reviews taking place. Moving and Handling assessments are completed. The new format for care plans is to be welcomed in that this will provide a more through and comprehensive picture of residents needs and arrangements for meeting those needs. St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 10 Residents have full access to local health service and there is visiting district nurse service available where individuals need such support. Other services such as chiropody, dental and optician are all arranged by the home and will visit the home or where able residents may use local services. The home has good links with GP surgeries and residents can choose to remain with their GP if they are still in the catchment area. Storage of medication is satisfactory with separate secure storage for controlled drugs. Returns of medication are recorded and their receipt signed for by pharmacist or their representative. All residents had their medication reviewed in January 06 by the pharmacist. The pharmacist also provide Patient Intervention Record which gives recommendation about the safe and effective administering of drugs particularly where certain drugs have a detrimental effect because of their re-action with other medication being taken by the individual. In one instance looked at the home had not followed the recommendation. Administering records were examined and had been completed satisfactory and as recommended. Residents are able to selfadminister medication and a risk assessment is completed so any potential risk of harm are identified and changes made if necessary. Staff who administer or have responsibilities around medication have all received the required training. In talking with residents they confirmed that they always “feel staff treat me with respect” “I have no complaints about the staff they are all very good and caring”. Staff were observed talking and assisting residents in a caring and sensitive way. Staff were also observed knocking on residents doors and importantly waiting for a response before entering and a resident confirmed that this was always what they did before entering their room. Since the previous inspection and following a comment form a resident the home has reenforced the right of residents to have a key to their room. Their wishes about this are recorded in the individual’s care plan. St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for meeting the social and recreational needs of residents are good and there are opportunities for residents to maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable residents to exercise choice and have control over their lives. The home provides meals, which are balanced and meet the dietary needs of individuals in the home. EVIDENCE: There is no structured activities programme however in speaking with residents they spoke of the regular coffee mornings, bingo, beetle drive, scrabble and exercise session which take place regularly. There is a monthly “Songs of Praise”. One resident continues to attend a community based social club where she is able to maintain her contact with friends. Another was being taken to visit an old friend. A visitor to the home spoke of how they were always made to feel welcomed and said they “couldn’t fault the home” always St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 12 felt they were fully informed about how their relative was and staff always “friendly and can always speak to them”. In talking with staff it was clear how they respected the rights of residents around their ability to make choices recognising “its up to them its their home”. Residents confirmed to the inspector that they felt there was “no real restrictions on us” “we choose what we do and when” were typical comments. The inspector joined the residents for lunch on one of the days of this inspection. The meal was well presented and appetising and residents said how they “always enjoyed the meals” “can’t fault the food”. This had been a topic discussed in a recent resident’s meeting and the cook in the home was well aware of some of the comments made about the food. The menus were looked at and showed a variety of meals being offered though there is no second choice offered or a menu board showing the meals for the day. In talking with a resident about the option of having two choices daily she said “they will always do something different if I ask” however this could be made clearer to residents if a menu board showed the choices available. It would not then be dependant on residents asking but be part of the normal meal arrangements. St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place and this enables individuals to make a complaint and voice their views about the service they receive and to know that they will be listened to and actions taken where necessary. The home makes sure that as far as possible residents are protected from harm by having policy and procedure about the Protection of Vulnerable Adults and providing training to all staff in this area EVIDENCE: No complaints have been made since the previous inspection. In talking with residents they spoke of how they “always” felt able to say if they were unhappy about anything “I would certainly tell one of the staff”. Residents were aware of their right to make a complaint “I have never needed to” “I would always say”. One resident had made a suggestion about improving the environment and this had been acted upon. The home has a Vulnerable Adults policy and some staff have received the required Adult Protection Training however from training records looked at there remains a number of staff who have not completed this mandatory area of training. St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe, well-maintained and hygienic environment for the residents and staff. EVIDENCE: In walking around the home it was evident that there is a good standard in the maintenance of the home and it is in good decorative order. An improvement would be the providing of a hearing loop system this would assist those residents who have hearing impairment. Further improvements in the lighting would also benefit residents particularly those with visual impairment. Residents said that the home “is always clean” “have no complaints about how they look after the home always clean”. On the days of this inspection the home was clean and free from offensive odours. St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 15 St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements in the home are good so that the needs of residents can be met in an efficient way. Training of staff could be improved to make sure that all staff complete the mandatory areas of training so that all staff have the necessary skills and knowledge. The recruitment and selection of staff is undertaken to make sure that as far as possible the health and welfare of resident is protected. EVIDENCE: Staffing rotas were examined and showed 3 staff on duty 8-4, 2 4-10, domestic 8.30-1 Mon-Fri with 1 member of staff on duty at night and sleep-in. There is a nominated senior on duty at all times. Recruitment records showed that as required staff have had Criminal Record Check and Protection of Vulnerable Adults list check. In addition two references are obtained and application form provides full information about the applicant including full employment history. Training records showed that not all staff had completed Vulnerable Adults and First Aid (night staff) however staff had received Fire Safety, Moving & St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 17 Handling, Food Hygiene. The inspector was unable to look at records for two members of staff. St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are opportunities for residents to express their views about the service they receive. The health & safety practices of the home need improvement to make sure that the health, safety and welfare of residents and staff are fullyprotected. The arrangements for staff supervision need improvement so that staff receive the appropriate and required level of supervision. EVIDENCE: The manager of St.Bathens has extensive experience in caring for older people and for 11 years was the previous owner. She has the Registered Manager St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 19 Award NVQ 4. She has a very open approach to the management of the home and makes every effort to have a real understanding of the needs of the residents in the home. Residents spoke of her as being “approachable” “someone you can always talk to”. Residents meeting are held twice yearly providing an opportunity for residents to make comments and suggestions about the care they receive. Minutes of the last meeting were seen and residents had voiced their views about the quality of food as well as make suggestions about the menu. The manager and cook were making efforts to address these issues. Resident’s questionnaires surveys are used as a more formal way of getting the views of residents. However only 6 residents completed the last questionnaire and the manager needs to try and involve a greater number of residents. These should be used to get views of relatives (particularly where individual resident chooses or is unable to complete the questionnaire) and professionals about the quality of the service. In discussion with the manager she recognised that staff are still not receiving regular formal supervision and records confirmed this. It is recognised that there is good informal supervision however this doesn’t replace the need for formal supervision. Records relating to fire safety practice of the home were looked at and showed that there is no record of staff receiving fire drills this only taking place when there is a “false alarm”. There are weekly fire alarms tests and monthly emergency lighting tests. Annual servicing of Fire Alarm system the last being 13/5/06, Gas Safety certificate 10/01/06. The manager has completed a Fire Risk assessment as required by Avon Fire & Rescue service. St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 20 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 2 St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 21 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. 1 Standard OP38 Regulation 23 (4) (E) Requirement Ensure all staff undertake fire drill as stipulated by Avon Fire & Rescue Service. (Requirement from previous inspection not met) Ensure all staff receive regular supervision. National Minimum Standard is at least 6 times a year. (Requirement from previous inspection not met) Timescale for action 31/12/06 2 OP36 18 (2) 31/03/07 3 OP22 23 (2) (a) 4 5 OP30 OP30 18 (1) (i) 13 (4) Undertake an assessment as to 31/03/07 the suitability of communal areas for individuals who have communication difficulties (hearing impairment, visual or dual sensory impairments) Ensure all staff completes Adult 30/06/07 Protection training. Ensure there are suitable 31/03/07 arrangements for the training of staff in First Aid. (This relates to having a member of staff on duty at all times who is first aid trained) St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 22 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 St Bathens DS0000067143.V317533.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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