Care Home: Bathurst House

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What the care home does well What has improved since the last inspection? The person in charge had obtained the necessary qualifications to become the registered manager. CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Bathurst House 7-11 Bathurst Street Blackburn Lancs BB2 1DB Lead Inspector Mr Graham Oldham Unannounced Inspection 25th June 2008 09:30 X10029.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 Bathurst House DS0000005811.V362744.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 and Care Homes for Adults 18 – 65*. 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. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bathurst House Address 7-11 Bathurst Street Blackburn Lancs BB2 1DB 01254 51538 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) Mr Terence Paul Eastwood Mrs Julie Eastwood Manager post vacant Care Home 11 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (2), Mental disorder, excluding of places learning disability or dementia (2) Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The home is registered for a maximum of 11 service users to include :Up to 7 service users in category LD - Learning disability under 65 years of age Up to 2 service users in category LD(E) - Learning disability over 65 years of age Up to 2 service users in category MD - Mental disorder under 65 years of age 15th August 2006 Date of last inspection Brief Description of the Service: Bathurst House is a property converted from three terraced houses to form one home. The home is maintained as one building situated very near to the town centre of Blackburn. Blackburn has a full range of leisure, business and commercial facilities. It is a family run business and there are currently eleven residents accommodated. There are private yards to the rear with seating for residents. The area around the home has recently been developed and is quite attractive. All bedrooms are single with all but one en-suite. There are separate dining and lounge areas, including smoke free areas. Parking is available at the front and rear of the property. A statement of purpose and service users guide is available for residents or their families to be informed of the facilities and services the home provides. The fees for Bathurst House range from £278 to £376 per week. Not included within the fees are hairdressing, toiletries, transport and outings. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection, which included a visit to the service, took place on the 25th June 2008. Much of the information gained was obtained from talking to the person in charge (who was the proposed registered manager). Two residents were case tracked. Case tracking gave the inspector an overall view of the specific care for the individual resident by checking the plans of care, other documentation and talking to the proprietors. Two staff were questioned about the residents case tracked to ensure they were familiar with the care required for each individual. The inspector took detailed notes during the inspection, which have been retained as evidence. Paperwork examined included plans of care, assessment documentation, policies and procedures or documents relevant to each standard. A tour of the building was conducted. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Six staff members returned questionnaires to the CSCI All six said they received up to date information about the needs of residents. Comments included, • The manager always tells me how important it is to read and fill in any information in the care plans. • We are informed at all times and when I first came to Bathurst I was told everything about each service user and their needs. • I was told how to use the care plans and how to find out about the different up to date needs of service users. All six said robust employment checks had been undertaken. All six said the induction process covered what was needed. All six thought training was relevant to the role, helped meet residents needs and kept them up to date with new working methods. Comments included, • I think I am getting training, which is relevant to my role as a carer and this helps to meet service users individual needs. • I am currently working on NVQ3 and our manager encourages us to do as much training as we can. All six thought the manager was supportive. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 6 All six knew who to speak to if they had any concerns. Five thought information sharing always worked well and one usually. All six thought the home was well staffed All six thought they were equipped to meet the diverse needs of residents. Comments included. • If I have any worries or issues I always consult my colleagues or immediate superior. • I feel I have been given the right support and experience to meet the different needs of service users. • We are well trained. Staff said the service does well by; • The service is fantastic for all staff and service users. They meet all the service users needs in the best possible way. • We support service users emotionally and help them feel wanted and part of an extended family. We work well in building service users selfesteem. • All the service users and staff have a very close family and get on very well and I believe we give a high standard of care. Four thought the service could not be improved and two thought more one-toone care would be even better. The information supplied by staff showed they have a committed staff team and are proud of what they have achieved. Four residents returned questionnaires to the CSCI. All four had been issued with a contract. Three thought they had enough information to make an informed choice to enter the home and one did not and said I came here as an emergency. All four always received the care and support they needed. All four thought staff listened to them. All four thought staff were available when needed. All four thought they received good medical support. Three thought there were always suitable activities and one usually. Comments included; • I don’t like to join in. • I like to go to the pub, library, bookies, play pool, watch television and go on holiday. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 7 Three thought food was always good and one usually. Comments included; • I go to the chip shop and Father Jims shelter for food because I like to • I don’t like to eat the vegetables. All four knew who to go to if they were unhappy and knew how to make a complaint. All four thought the home was always fresh and clean. The positive response from residents demonstrated they were satisfied with the care given at Bathurst House. What the service does well: The assessment process ensured the needs of residents could be met at the home. Residents were able to take calculated risks, which enabled them to lead a more independent lifestyle. One resident case tracked and a visitor confirmed there were no restrictions to visiting. Visiting was promoted for the benefit of residents. Two staff questioned during the case tracking process said, “I still enjoy working here and have been here four years here now. I am getting the support and training I need” and “.It’s really good. I enjoy it more than the other place. You can bond with them here. You do much more here. I have four weeks left to finish NVQ3. I want to work in the health care industry. I get support here from the management and staff. I think there is a good team”. Staff felt supported and enjoyed working at this care service. Resident’s case tracked said, “I like the food. Some of it is good. You can choose what you want. I make my own breakfast. I like sugar puffs” and “The food is OK. I like it”. A visitor said, “She has better meals than she did before. She likes her meals here. She has a good appetite”. Another resident said, “I like the food. If there is something I don’t like I tell them and they change it”. The choice and quality of food met resident’s expectations. Evidence showed residents had access to many leisure or work opportunities. A resident case tracked said, “I like to do my embroidery”. Another resident said, “I like my room. I have some things of my own like some photographs. I have my own CD and television. I prefer to go to my room and watch television. I went out to the bank with the owner and to Morrison’s”. Residents were able to attend many activities to help fill their days. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 8 All residents spoken to felt safe. Policies procedures and staff training for the protection of adults safeguarded residents at the care service. Resident’s case tracked said, “I like it here. Staff treat me very well and help me with reading and writing. I think this home is good I enjoy it here” and “I am still settled here”. Another resident said, “The staff treat me well. I am happy here”. Residents were contented with the care and services offered at this home. Resident’s case tracked said, “I like my room. I have my own television and music. I have my own tapes” and “I like my room. I have some of my own things in that room”. Residents could personalise their rooms to help retain some independent living. Two visitors met the inspector together and said, “We cannot believe how fine she is – she is a different person since she came here. It is hard to believe just how good she is. We expected something to happen – I am more content because she is so much better. The home is beautiful. Her room is very nice and it is bigger. She has enough furniture and a television in her room. She listens to music. Staff are brilliant and they are trained. Staff are friendly”. The two visitors spoken to were satisifed with the care given to their relative. What has improved since the last inspection? What they could do better: The registered person must ensure documentary proof that all checks necessary for recruitment is retained for any new member of staff employed at the home to comply with current regulations. The registered person must retain documentary evidence of each staff member’s qualifications and be available for inspection. The registered person should ensure there are no gaps in the medication administration charts to record why a medication has not been given. The registered person should ensure all hand written prescriptions are witnessed by staff to help minimise errors. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 9 The registered person must ensure members of staff are issued with the terms and conditions of employment and a copy is retained at the home to meet current legislation. The registered person should retain copies of the induction process carried out by new staff to provide documentary evidence at inspection. The registered person should ensure quality assurance questionnaires are sent to residents and produced as a summary for interested parties. The registered person should inform the CSCI and return a completed application form for the person designated to become registered manager. 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. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): YA2 and OP3 The quality outcome for this standard group was good. This judgement has been made using available evidence including a visit to this service. Prospective residents were assessed and offered trial visits to make an informed choice to enter the home. EVIDENCE: Two residents were case tracked during the inspection. One new resident had been admitted as an emergency and the assessment process was ongoing. Two family members were at the home helping the manager to gain knowledge to help develop a plan of care. One family member said, “We are satisfied with her care and the manager talks to us about her care. He keeps us updated. We can talk to him about the care”. The second resident case Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 12 tracked at been at the home for some years and the assessment was not relevant to care given now. The assessment of residents allowed staff to gain sufficient knowledge to care for residents. The service did not provide intermediate care. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): YA6, YA7, YA9 and OP7 – OP10 The quality outcome for this standard group was good. This judgement has been made using available evidence including a visit to this service. Each resident had a plan of care, which was up to date and reflected the care each individual required. Residents were able to make decisions to maximise their independence. Residents undertook risks to help maximise their choices. Resident’s health care needs were met. Medication administration needed to be improved to fully protect the welfare of residents. EVIDENCE: Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 14 Two plans of care were examined during case tracking. One plan of care was detailed and contained up to date information. The other plan was being developed with the assistance of the resident and her family. Six monthly reviews had been conducted for residents. There was a good daily record maintained to inform staff of any changes. Residents were aware of their care plans but had limited knowledge of what they contained. Plans of care informed staff of the needs of residents. Risk assessments, personal to each resident, were observed during the case tracking process. Risk assessments allowed residents to take calculated risks to allow some independence. Risk assessments were undertaken for the protection of residents. Residents said they retained choices within the routine of the home. During case tracking residents said they chose when to go to bed and get up, went out independently and attended various day centres and clubs if they wished. Residents were able to make decisions to maximise their independence. Medication policies and procedures met current guidelines. Drugs were stored securely. Staff had attended accredited training for the administration of medication. The medication administration records showed some gaps and two staff had not witnessed hand written prescriptions. No controlled drugs were being administered at the home at the time of the inspection. Two residents administered their own medicine and their capability had been risk assessed. Medication entering the home was recorded. The manager said they were able to get help from the local pharmacist. There was a copy of the British National Formulary. The good administration of medication protected the health and welfare of residents. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA12, YA13, YA15, YA16, YA17 and OP12 – OP15 The quality outcome for this standard group was good. This judgement has been made using available evidence including a visit to this service. Residents were able to access the community and take part in suitable activities to maximise their fulfilment. Residents were able to remain in contact with their families and friends to remain socially active. Residents were treated as individuals to protect their rights. Meals were satisfactory and met residents nutritional needs. EVIDENCE: Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 16 Residents were able to attend leisure activities or go to work if they wished. One resident was working on the day of the inspection. The manager said, “They are going to the cinema on Thursday to see the new Narnia film in the evening”. Residents spoken to were looking forward to seeing the film. Residents also go to pubs and bowling at night. Take lunch out, play darts, board games, cards and bingo. Playing the keyboard, attending karaoke, or watching videos and DVD’s were others preferred activities, Residents go out shopping - both with staff and on own. One resident goes bike riding. Residents who wish go on holiday each year and they are going to Bognor Regis later this year. Both group and individual trips are held. Some residents like to go swimming. Two residents attended a church of their choice on a regular basis. The varied activities helped residents lead a fulfilling lifestyle. Two visitors were present and spoke to the inspector about the home. The visitors said, “We cannot believe how fine she is – she is a different person since she came here. There are no problems with visiting and my daughter says she likes it here”. Open visiting allowed residents to feel socially included. Residents case tracked said they were able to exercise choice within the routine and went about the home as they wished. Residents were allowed choices to maximise their independence. Residents helped choose what they ate and accompanied staff to buy groceries. Resident’s case tracked said the meals were good and they could choose what they want. Environmental health checks had been completed and there was a rota to keep the kitchens clean. The dining area was sufficient for the residents accommodated at the home. There was a cooked option at least twice a day. Resident’s weights were recorded if necessary. Residents went out for a meal on a regular basis. No residents needed a different cultural or religious diet. Food served at the home was enjoyed by residents and met their nutritional needs. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA22, YA23, OP16 and OP18 The quality outcome for this standard group was good. This judgement has been made using available evidence including a visit to this service. Residents were able to voice their concerns if they wished. Policies and procedures for the protection of vulnerable adults helped safeguard residents from possible abuse. EVIDENCE: Residents were able to talk to staff formally and informally to voice their opinions. No complaints had been made about the service to the CSCI since the last inspection. There was a satisfactory complaints procedure. Resident’s case tracked said they had no complaints. Residents were able to access help if they needed to complain. There were policies and procedures for the protection of vulnerable adults. The home had a whistle blowing policy and a copy of the ‘No Secrets’ Document. The home used the Blackburn with Darwen Adult Abuse procedures to follow a local initiative. Staff had attended training for the protection of vulnerable adults. Staff questioned during the inspection were aware of abuse Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 18 issues. Resident’s case tracked said they felt safe. Policies, procedures and staff training protected residents from possible abuse. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA24, YA26, OP19 – 26. The quality outcome for this standard group was good. This judgement has been made using available evidence including a visit to this service. The environment met the needs of the residents accommodated at the home. EVIDENCE: A tour of the building was conducted on the day of the inspection. The home was warm, clean and tidy. Furnishings were comfortable and suitable in style for the resident group accommodated. Furnishings and fittings were domestic Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 20 in character and of a good standard. Each resident had their own room, which had been personalised to their tastes. Rooms contained a good amount of furnishings and equipment. Residents case tracked were happy with their private space. Local facilities could be assessed by public transport. The home had transport for group or individual outings. Toilets and bathrooms were suitable for residents needs. There was sufficient communal space. Residents had a lockable space and could lock their bedroom doors. There was good access to outdoor space and the town centre is a short walk away. The windows of the home had a suitable device fitted to protect residents from falls and radiators were of a type to not cause scalds. The homely environment provided good living accommodation for the resident group accommodated at the home. There were policies and procedures for the control of infection. The laundry contained washing machines and dryers, which met current specifications. The laundry was sited away from any food preparation areas and was easily washable. There was a sluice. Residents said the home was clean and tidy. Infection control policies and procedures protected the health and welfare of residents. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA32, YA34, YA35 and OP26 – OP30 The quality outcome for this standard group was adequate. This judgement has been made using available evidence including a visit to this service. Residents were supported by sufficient numbers of well-trained staff. Documentary evidence was not available to prove recruitment policies and procedures protected residents from possible abuse. EVIDENCE: Two staff files were examined during the inspection. Two new staff had been employed since the last key inspection. The files for the two staff members had not been completed to a satisfactory level. Both staff confirmed they had been CRB checked but no copies were retained by the home. Copies of any induction were not available. Other documents such as training records and the terms and conditions of employment were not contained within the files. Recruitment procedures protected residents from staff who may not be suitable to work with vulnerable adults but did not contain documentary proof of training, induction and terms and conditions of employment. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 22 Two staff members questioned during the inspection confirmed they had completed core training such as moving and handling. Over 50 had completed NVQ2 training or above. The staff rota showed the numbers of staff were employed to ensure staffing levels were sufficient to meet resident’s needs. There was a training profile for each individual and the home as a whole. Resident’s needs were met by a well-trained staff team. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA37, YA39, YA42 and OP31, OP33, OP35 and OP38 The quality outcome for this standard group was good. This judgement has been made using available evidence including a visit to this service. The views of residents were obtained to ensure management could react to their needs. Health and safety policies, procedures and staff training protected the health and welfare of residents and staff. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 24 EVIDENCE: The home was managed as a family business. One of the sons of the registered persons has been proposed to become the registered manager and had completed the registered managers award. It was recommended the application for manager be submitted to the Commission for Social Care Inspection as soon as possible. The person in charge of the home had updated his knowledge in mandatory subjects such as moving and handling for the benefit of staff and residents. There was an annual development and business plan. The home had attained the Blackburn with Darwen quality assurance benchmark. The person in charge said residents did not respond well to survey forms and had not been completed for the current year but planned to undertake one. All policies and procedures had been reviewed. The quality assurance systems at the home allowed management to react to the needs of residents. Staff had undertaken training in all aspects of health and safety. Staff questioned during the inspection said they had undertaken training for “moving and handling, health and safety, fire awareness, first aid, food hygiene, infection control, the administration of medication and protection of vulnerable adults”. Both members of staff confirmed training for NVQ3 in care. There was a health and safety policy and procedures. The person in charge was aware of health and safety legislation. Electrical and gas installation and equipment had been maintained. Health and safety policies and procedures protected the health and welfare of residents and staff. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 25 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 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 ENVIRONMENT Standard No Score 19 3 20 3 21 3 22 3 23 3 24 3 25 3 26 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 2 34 X 35 3 36 X 37 X 38 3 Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 26 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 OP29 Regulation 19 Schedule 2 Requirement The registered person must ensure documentary proof is retained for any new member of staff employed at the home. The registered person must retain documentary evidence of each staff member’s qualifications. 30/08/08 Timescale for action 30/08/08 2. OP29 19 Schedule 2 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. 2. 3. Refer to Standard OP9 OP9 OP29 Good Practice Recommendations The registered person should ensure there are no gaps in the medication administration charts to record why a medication has not been given. The registered person should ensure all hand written prescriptions are witnessed by staff to help minimise errors. The registered person must ensure members of staff are issued with the terms and conditions of employment and a copy is retained at the home. DS0000005811.V362744.R01.S.doc Version 5.2 Page 27 Bathurst House 4. 5. 6. OP30 OP33 YA37 The registered person should retain copies of the induction process carried out by new staff. The registered person should ensure quality assurance questionnaires are sent to residents and produced as a summary for interested parties. The registered person should inform the CSCI and return a completed application form for the person designated to become registered manager. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection 2nd Floor, Unit 1 Tustin Court Port Way Preston PR2 2YQ 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. Extracts may not be used or reproduced without the express permission of CSCI. Bathurst House DS0000005811.V362744.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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