Inspection on 13/11/06 for 67 Birch Avenue Nursing Home

This inspection was carried out on 13th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

67 Birch Avenue Nursing Home 23/02/06

67 Birch Avenue Nursing Home 31/08/05

67 Birch Avenue Nursing Home 15/03/05

67 Birch Avenue Nursing Home 07/09/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE 67 Birch Avenue Nursing Home 67 Birch Avenue Chapeltown Sheffield South Yorkshire S35 1RQ Lead Inspector Michael O`Neil Key Unannounced Inspection 13th November 2006 08:30 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 67 Birch Avenue Nursing Home DS0000021769.V312446.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. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 67 Birch Avenue Nursing Home Address 67 Birch Avenue Chapeltown Sheffield South Yorkshire S35 1RQ 0114 245 3727 0114 245 4015 none None South Yorkshire Housing Association 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) John Scott McCaffrey Care Home 40 Category(ies) of Dementia - over 65 years of age (40) registration, with number of places 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2006 Brief Description of the Service: 67 Birch Avenue is a one-storey purpose built home, which provides nursing care for older people with dementia. The home has four, ten bed units with an interlinking corridor surrounding a large garden and patio area. Each unit has a communal lounge and dining room. All of the forty bedrooms are single and all have en-suite facilities. A central kitchen and laundry serve the home. The home is near to the centre of Chapeltown, bus routes and local amenities. A car park is available. Copies of the last Commission For Social Care inspection reports were available for service users and their families to read. The weekly fees range from: £441 to £489. This information was provided on the 18th September 2006. The home charges extra for chiropody, toiletries, clothing, telephone, holidays and hairdressing. 67 Birch Avenue Nursing Home DS0000021769.V312446.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 undertaken by Janice Griffin and Mike O’Neil; it took place from 08:30am to 14:00 pm. As part of the inspection process the inspectors spoke to, six relatives, five staff, three residents and the manager. One inspector spent a period of time sitting with a group of residents in a lounge. The inspector was able to observe the residents experiences of living in the home and their interactions with each other and the staff. The inspectors would like to thank, the relatives, the staff and the manager for their openness and for their commitment to the inspection process. The inspectors were pleased to note that all the relatives spoke highly of the ongoing support provided by the staff. Observations confirmed that service users were extremely comfortable and at ease in the company of the manager and staff who were approachable, supportive and appeared sensitive to the needs and feelings of the service users. The relatives described the service as “excellent”. A number of records were examined which included, the managers preinspection questionnaire, medication records, three service users care plans, three weeks menus and three weeks staff rotas. Records relating to staff recruitment, service users finances, staff training and the homes quality assurance systems were also checked. Several areas of the building were also inspected. Since the last inspection the Commission for Social Care Inspection have received no complaints about this home. The home has a system for displaying information and bringing attention to community events and activities. Feedback on the inspection was given to the manager. What the service does well: The home was very well decorated, very clean and cosy. All the relatives said the service users were well cared for by the staff. They described the staff as being “very good” and very hard working. Service users were able to visit the home for trial periods. The staff said that the manager considers carefully the needs assessment for each prospective service user before agreeing to their admission to the home. Service users were only admitted once it had been determined that the home could meet their needs. Clear information about contracts/terms and conditions, fees and extra charges were available in a format appropriate to each individual service user and their families. Feedback was being sought on a regular basis from the service users families. Staff interacted well with each service user and it was obvious from discussions with them and the relatives that staff had developed positive relationships with them. An inspector saw staff consistently treating service users in respectful and friendly way. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 6 The inspector observed staff generally interact very well with the service users. The cook was familiar with the dietary needs of service users. The inspectors observed the lunch offered to service users the food provided was of good quality, well presented and a good choice of food was offered. Documentation and discussion with five staff showed that they have had training in the specialist area of work that they work in. 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. 67 Birch Avenue Nursing Home DS0000021769.V312446.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 67 Birch Avenue Nursing Home DS0000021769.V312446.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 6. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with five relatives, five staff, the manager and a visit to the home. The statement of purpose has been reviewed and contained all the required details. No service users have moved into the home without having his or her needs assessed, this ensures that care needs can be met. Service users were able to have informal introductory visits to the home at the time of their admission. Relatives confirmed that this helped service users to get to know everyone at the home, which made them feel less anxious. Intermediate care is not provided at this home. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 9 EVIDENCE: Detailed full needs assessments had been completed by the referring social worker for all service users admitted to the home. Families had been involved in the assessment process as appropriate. The relatives spoken to said at the time of the service users admission they were able to have informal introductory visits to the home and they had been provided with a contract containing the relevant information. Records checked and discussion with five relatives confirmed that service users families had been involved in decisions regarding the arrangements. An up to date contract/statement of terms and conditions had been provided to service users and signed copies were retained on individual files. These clearly detailed the fees, including any extra charges, and the services and facilities provided by the home. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 10 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 and 10. Quality in this outcome area is: adequate. This judgement has been made using available written evidence, discussion with five relatives, five staff and observations made by the inspectors at the visit to the home. Discussions with relatives and observations made by the inspectors confirmed that the staff promoted the service users privacy and dignity. The information in the care plans was not adequate to ensure that the service users health and social care needs could be met. This does not protect the well being of service users. There was no evidence to show that relatives were involved in the care planning and reviewing process. This does not allow the relatives to have a say in how the service users needs are being met. Some medication practices could cause a risk to the service users health and welfare. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 11 EVIDENCE: The inspectors observed staff knocking on bedroom doors and waited to be invited in before entering. An inspector saw staff consistently treating service users in respectful and friendly way. The inspector observed staff generally interact very well with the service users. Relatives meetings had been held on a regular basis and minutes of these meetings were available within the home. Three service users plans of care were checked. Two of the care plans did not give any details about the service users last dental and optical check or activities they participated in. Service users weight was being checked on a regular basis. Care plans detailed the service users religious and cultural needs but did not detail the gender of staff that they wished to support them with their personal care. Relatives were aware of the care plan and that they could have access to it when they wanted. Ranges of aids to assist service users with mobility problems were provided; these included lifting hoists, assisted baths, walking frames and wheelchairs. Records were kept of medication received, and disposed of. Medication was insecurely stored in several rooms and one service users prescribed medication for external use was being used for other service users. Some medication recording charts had not been signed on some occasions to show whether medication had been given or not. A pharmacist had checked the home’s medication systems in June 2006 and no issues of concerns were reported. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 12 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 and 15. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with five relatives, five staff and a visit to the home. Service users had access to a range of leisure activities based on their individual choices and preferences. Relatives confirmed that the routines of daily living were flexible and suited the service users individual preferences. Service users were supported with maintaining and developing contact with their family and friends, and relatives said that they were always welcome at the home. Which creates a home that people want to visit. A good choice of food was offered to service users at lunchtime. Several service users were being offered special diets on a regular basis. This promotes the rights of service users. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 13 EVIDENCE: Relatives confirmed that staff were extremely supportive and always encouraged the service users to become integrated into the local community, when they felt able to do this and with the appropriate staff support provided. Staff confirmed that they were encouraged to support service users with discovering how to enjoy social situations and activities. The cook was familiar with the dietary needs of service users. The inspectors observed lunch offered to service users the food provided was of good quality, well presented and a good choice of food was offered. Several service users were receiving special diets. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 14 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 and 18. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussions with five relatives, five staff and a visit to the home. The homes complaints procedure was clear, accessible and contained the necessary information. This protects the rights of service users. Service users were protected from abuse by the awareness of staff through training and the homes procedures. EVIDENCE: The complaints procedure was available for visitor, relatives and staff. Relatives spoken to said that they knew that they could complain if they were not happy about anything and that they felt able to discuss any issues or concerns that they may have with the manager and staff. They also said that staff were always available and that they were encouraged to talk about anything that troubled them or caused them anxiety. Since the last inspection no complaints have been made to the Commission for Social Care Inspection about this home. The staff had received training on recognising and dealing with abuse. Staff had been made aware of the action to take in dealing with third party information 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 15 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 and 26. Quality in this outcome area is: good. This judgement has been made after discussion with five relatives and using available evidence including a visit to the home. On the day of the inspection the home was clean and smelt fresh. This made the home look well cared for. The bedroom doors were fitted with locks. This promotes the privacy of service users. Some areas around the home had stained carpets; this made the home look shabby in parts. The string lights cords in some bathrooms and toilets were dirty. This is not hygienic. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 16 EVIDENCE: Relatives said that the home was always clean but some areas had stained carpets. Bedroom doors were fitted with suitable door locks and lockable facilities were provided in all the bedrooms. The appropriate seating had been provided in the garden for those service users wishing to sit outdoors whenever the weather permitted. Toilets were easily accessible as they were close to lounge and dining areas. All the toilets had been adapted for service users with physical disabilities and a good supply of equipment was also available for those service users. Some string light cords were noted to be dirty. The home had a proactive infection control policy and they work closely with external specialists, e.g. the Health Authority, Environmental Health and their own staff to ensure infections are minimised. Clinical waste is properly managed and stored. Staff confirmed that they were provided with protective clothing if they needed it and that all the equipment was in good working order and that it had been serviced as required. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 17 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 and 30. Quality in this outcome area is: adequate. This judgement has been made after discussion with five relatives, five staff and using available evidence including a visit to the home. Care staff had a range of skills and experience, which effectively supported the service users. This will ultimately benefit the health and welfare of the service users. The homes recruitment procedures were not adequate, as they did not protect the service users from harm. The home had a training and development plan and all staff had completed a range of training relevant to their role. This allows the staff to ensure they meet the individual assessed needs of service users. 28 of the staff was trained to NVQ level 2.This shows the providers commitment to staff development needs to be improved. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 18 EVIDENCE: The staff and relatives said that there was always enough staff on duty. They said that the staff worked very hard and described them as “very caring, kind and understanding”. Staff were approachable and sensitive to the needs of service users. Three staff files were checked; the files demonstrated that the recruitment processes did not meet the standard as required by the Care Homes Regulations. Criminal record checks had been done for all three staff. Two references had been obtained but gaps were noted in staff’s employment history. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control. Staff files checked and discussions with five staff and the manager confirmed that all staff had completed detailed induction training. 28 of the staff team were qualified to NVQ level 2. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 19 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): 31,32,33,35, 36 and 38. Quality in this outcome area is: good. This judgement has been made after discussion with five relatives, five staff and using available evidence including a visit to the home. The relatives and five staff spoken to said the manager was approachable and very professional. Relative’s surveys are completed annually, which ensures that the home is run in the best interest of service users. Records were in the main up to date and well ordered to ensure the best interests of service users. The homes policies and procedures met the required standards. An external audit of service users money was not being carried out regularly. This does not safeguard the service users from abuse. A safe environment was not provided in all parts of the home (see standard 9). This does not protect the health and safety of the service users. Staff were not being formally supervised at the frequency required, this does not allow individual staff development and the monitoring of care practices. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager had a job description that clearly defined his roles and responsibilities and staff were aware of his role. Staff said he was committed to ensuring that the home provides a high standards of care, he completes regular internal audits on all aspects of the service provided by the home. He has completed his NVQ level 4 training. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control. Staff were not being formally supervised at the frequency required. There was a quality assurance system, which sought the views of service users and relatives. The manager said that the responsible individual visit the home on a regular basis a report is written following the visits. A safe environment was not provided in all parts of the home, as medication was insecurely stored in some rooms. The staff handle money on behalf of some service users, account sheets were kept, receipts were available for all transactions and a second individual witnessed all transactions. The accounts are not audited annually. All records were available for inspection up to date. 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 21 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 2 2 X 2 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 22 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. 2. Standard OP7 OP8 Regulation 12,13,15 15 Requirement Staff must record any activities that the residents participate in. Care plans must include details of the service users health care checks and the gender choice of staff assisting with personal care. The relatives should be involved with the care planning and review process. Medication for external use must be kept in a secure place at all times. Mar sheets must always be signed to show whether medication as been given or not. The medication of one service user must never be used for another. All areas of the home used by residents must be well maintained. (Corridor carpet) The dirty string light cords must be cleaned or replaced. 50 of care staff must be trained to NVQ level 2 or equivalent. DS0000021769.V312446.R01.S.doc Timescale for action 01/03/07 01/02/07 3. OP9 OP38 13 13/11/06 4. OP19 23 01/03/07 5. 6. OP26 OP28 12,23 18 01/03/07 31/05/07 67 Birch Avenue Nursing Home Version 5.2 Page 23 7. 8. 9. OP29 OP35 OP36 19 20 18 Gaps in staff’s employment history must be explored. Service users accounts must be audited annually. Staff must have individual supervision at least six times in one year. 31/12/06 31/08/07 28/02/07 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 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 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 67 Birch Avenue Nursing Home DS0000021769.V312446.R01.S.doc Version 5.2 Page 25 - 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. 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