CARE HOMES FOR OLDER PEOPLE
Zetland Court 128 Alumhurst Road Westbourne Bournemouth Dorset BH4 8HU Lead Inspector
Debra Jones Unannounced 6 September 2005 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. Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Zetland Court Address 128 Alumhurst Road Westbourne Bournemouth Dorset BH4 8HU 01202 769194 01202 764980 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) Royal Masonic Benevolent Institution Miss Tina Beament CRH N - Care Home with Nursing 63 Category(ies) of OP Old age (58) registration, with number MD(E) Mental Disorder -over 65 (5) of places DE(E) Dementia - over 65 (5) Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home may accommodate a maximum of 13 service users who require nursing care. 2. The home may accommodate up to 5 service users in either category DE (E) or MD (E) at any one time. Date of last inspection 31 January 2005 Brief Description of the Service: Zetland Court is a large care home for older people registered to accommodate up to 13 people who require nursing care and up to 5 people who have past or present mental health disorders or dementia. The home has 63 places altogether. The home is one of 18 run by the Royal Masonic Benevolent Institution (RMBI) and provides accommodation and care for older freemasons and their dependants. The home receives substantial support from their Association of Friends. Zetland Court is situated in the Westbourne area of Bournemouth, close to local shops and transport links to the centre of Bournemouth. The home was originally a summer home for a local landowner and has landscaped gardens leading down to the cliff tops. The communal areas of the home are on the ground floor and include a large and a small lounge, a library and a billiard room as well as a large dining room. The lounge and library overlook and provide access to the rear garden. The home has two pet cats, 2 cockatoos and 2 budgies. The building is on 4 floors with a passenger lift enabling easy access around the home. A call system is installed in all rooms. Meals are prepared on the premises. Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over 4 hours on the 6 September 2005 and was one of the two anticipated inspections of the year. The requirements and recommendation made at the last inspection were followed up to see if they had been addressed. The Inspector looked around some of the building and a number of records and related documentation were inspected. Tina Beament - registered manager assisted the Inspector along with the staff on duty at the home. The Inspector met and chatted with some residents and their visitors in order to get a feel for what it is like to live at Zetland Court. One resident said ‘I’d thoroughly recommend it!’ No new requirements or recommendations were made at this inspection, although a few are repeated. What the service does well:
Zetland Court provides a service for older people in a well decorated home that is furnished to a high standard. The home has a tranquil and relaxed atmosphere and residents are clearly at ease. The home is well organised and the care and contentment of residents is at the heart of the way the home is run. The complaints and adult protection procedures reassure residents and their representatives that the well-being and comfort of residents is important to the home and that any concerns raised will be properly investigated and resolved. The home and grounds are very well maintained, comfortable and safe for the residents living there and anyone visiting. The home is kept clean and smells pleasant. The numbers and skill mix of staff are sufficient to meet the needs of residents. Systems are in place and records kept, that demonstrate the homes commitment to keeping residents safe. Residents and their relatives were full of praise and thanks to the home. One commented that Zetland Court is a ‘lovely place’ and said ‘the girls are very kind’. Another said ‘ there’s always something on to interest you’.
Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 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. Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 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 standard(s) EVIDENCE: These standards were not inspected on this occasion. Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 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 standard(s) EVIDENCE: Representatives from the Royal Masonic Benevolent Institution (RMBI) make regular visits to the home and carry out audits of the home’s documentation, and meet with staff and residents to talk about life at the home. Reports of these visits are sent to the Commission for Social Care Inspection. These reports show that the organisation has identified themselves that there is a need to improve care planning at the home and staff and managers are working hard to raise their standards in this respect and are getting good feedback as improvements are made. The Inspector and Ms Beament agreed that it would be appropriate to inspect these standards at the next inspection when it is anticipated that the home will have finished addressing their own concerns. Three requirements were made at the last inspection that relate to care plans, continence assessments and wound assessment charts. Through discussion the Inspector was happy that these concerns are being addressed in the work that the home is doing. It was agreed that these requirements would be repeated at the end of this report as an aide memoire to the next inspection.
Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 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 standard(s) EVIDENCE: During the tour of the premises the Inspector met with residents and their visitors all expressed satisfaction with the home. However these standards were not fully assessed on this occasion and will be properly reported on at the next inspection. Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 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 standard(s) 16 and 18 A system is in place to deal with complaints that are made by residents and their representatives. The home’s adult protection policy and ongoing staff training demonstrates the homes commitment to understanding abuse and of protecting residents. EVIDENCE: The home has a complaints procedure and keeps a record of any complaints made, the investigation of the complaint and the outcome to the complainant. No complaints have been received by the Commission for Social Care Inspection since the last inspection. Some complaints have been received by the home. Records demonstrate the home takes complaints seriously, conducts full investigations in a timely fashion, looks to resolve complaints and learn from them, changes general practice where necessary and feeds back to the complainants. Residents spoken to said that they could not think of anything to complain about and that they would talk to the manager / or staff about any worries that they had. The home has an adult protection policy and there is ongoing staff training in this subject at the home. Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 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 standard(s) 19,20,21,22,23,24,25,26 Ongoing investment in the upkeep of the home maintains the comfortable and safe environment for the residents living there and anyone visiting. Bedrooms are well decorated, well furnished and personalised to suit the residents. Adequate facilities are available to meet the number and needs of the people living there. The home is kept clean and smells fresh thereby making daily life for all in the home more pleasurable. EVIDENCE: The home has a warm and relaxed atmosphere. The home is well decorated throughout. Lounges and dining areas are comfortably furnished. Since the last inspection work has continued around the home to keep the environment up to its high standard. Improvements have been made to make the building even more accessible for the residents such as the automatic openers on the front doors, this has made a big difference especially for those in wheelchairs as the doors were previously very heavy and this weight made them difficult to open.
Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 Page 13 Plans are in place for further refurbishment e.g. the hairdressing room. The grounds are glorious, providing an outstanding outlook for the home. Residents can enjoy walks around the gardens and plenty of seating is provided. A new summerhouse has been purchased and is nearly ready for use. There are a number of communal bathing areas in the home. The majority of bedrooms are single occupation. About half the single rooms and all 5 double rooms have en suite facilities Aids and adaptations are available throughout the home e.g. raised toilet seats, grab rails etc - and some residents with particular needs have their own personal equipment to assist with their independence. Residents are able to personalise their rooms with furniture and general belongings as they wish and in agreement with the home. There is a passenger lift in the home, enabling easy access between the floors. There are emergency alarm bells throughout the home – in each bedroom and in communal areas. The home was clean and there were no unpleasant odours. The laundry was clean and tidy. At previous inspections concerns had been raised about the temperature of the hot towel rails. These have now been risk assessed and all have been turned off and they cannot be used. Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 Page 14 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) 27,28,29 and 30 Sufficient, well trained care staff are employed and deployed to ensure that the care needs of residents can be met. Robust recruitment procedures are in place to protect residents from the risk of unsuitable staff working at the home. EVIDENCE: Clear staffing rosters are in place that show who is on duty, where, when and what jobs they do. On the day of inspection 9 care assistants were on duty in the morning and 6 in the afternoon. A nurse is always on duty in the nursing area. Nursing and care staff are supported by kitchen staff, cleaning staff, maintenance men and gardeners, office staff and management. It is always clear who is in charge. Well ordered staff records/ personnel files demonstrate the homes’ recruitment procedure in action. The files of the latest members of staff to join the home were inspected. All documents that should be on file were. A good system is in place to check that all information is in place before staff begin working at the home. For example CRB disclosures and POVA 1st checks were applied for and received prior to the commencement of duties and appropriate references are obtained. Records are kept of training that staff undertake. These records showed that staff have access to a good range of basic training and receive their regular mandatory updates e.g. manual handling, fire and first aid. Recent training courses have included dementia and abuse.
Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 Page 15 On the day of inspection some staff were having appraisal training. The Royal Masonic Benevolent Institution is introducing a new appraisal system and training has been rolled out across the organisation. Staff in the homes are supported by staff who work across the organisation e.g. business organisation managers, human resources and welfare. The number of care staff with the NVQ level 2 in care qualification is in excess of the target set by the Department of Health of having 50 of care staff trained to this level. Some staff have also, or will be going on to do, NVQ level 3. The home also benefits by having some nursing students working there. Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 Page 16 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) 31,33,35,37 and 38. The home is well organised and the daily management and running of the home centres round the care and contentment of residents. Good management practice, systems in place, and records kept, confirm the health and safety of all in the home. EVIDENCE: Representatives regularly visit the home from the company that owns it – Royal Masonic Benevolent Institution - and reports are made of these visits and copied to the Commission for Social Care Inspection as required by law. During these visits a number of record audits take place including those that relate to health and safety. Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 Page 17 The manager – Tina Beament has successfully completed her NVQ 4 in management. Ms Beament is a qualified nurse and is registered with the Nursing and Midwifery Council. All records were available as requested at the inspection. An up to date insurance certificate was on display along with the home’s registration certificate. The home has extended their annual quality assurance survey, whereby they find out more what people think about the home, to relatives. The response was positive and the replies have been analysed. The manager had compiled a report and taken steps to address the few criticisms made. One relative commented – ‘I have the utmost respect for all staff. They are genuinely caring and thoughtful to residents and nothing is too much trouble’. Another said ‘ care is superb’. The next step will be to include other stakeholders in the home such as district nurses and chiropodists. The home keeps some money belonging to residents and an excellent system is in place to look after it. Clear records are kept of expenditure and balances along with receipts. Fire records were up to date and internal checks of fire safety equipment are being carried out at appropriate intervals. An external company carries out quarterly checks of the fire equipment. Fire training records for staff showed that all staff had had fire training at the required intervals. The last fire drill took place on 18 July 2005. A disaster plan for the home is in draft. Risk assessments are carried out on hazardous substances used in the home and data product sheets are available. Information about products is well presented and included eye catching pictures to ensure that staff use the right protective clothing when they need to. This information is kept on each floor for easy reference. Accident records were looked at. A new system is in place to record accidents. Accident forms seen were well completed – especially those completed in the nursing area. Records were clear about how staff came across accidents or if they had witnessed them, what they did and any follow up that was needed. Analysis of such records provides the home with important information as to the effectiveness of the emergency systems in operation and of any further measures that could be put in place to minimise risks to residents. An incidents and occurrences book is also kept and accident records cross referenced to this. Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 Page 18 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x
COMPLAINTS AND PROTECTION 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x 3 x 3 3 Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 Page 19 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 Requirement Timescale for action 1 12 05 2. 8 13 3. 8 14 The registered person must ensure that the information regarding residents needs gathered daily observations, reviews and assessments is reflected in the plan of care and acted upon. (previous timescale for action 30/6/04, 30/10/04 and 31/3/05). The registered person shall make 1 12 05 arrangements for residents to receive where necessary a continence assessment. (previous timescale for action 30/10/04 and 31/3/05). It is required that wound assessment charts be introduced 1 12 05 and used as appropriate. (previous timescale for action 31/3/05). 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.
Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 Page 20 Refer to Standard Good Practice Recommendations Zetland Court D55 S20457 Zetland Court V230891 060905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Unit 4 New Fields Business Park Stinsford Road Poole Dorset BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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