CARE HOMES FOR OLDER PEOPLE
67 Birch Avenue Nursing Home 67 Birch Avenue Chapeltown Sheffield South Yorkshire S35 1RQ Lead Inspector
Michael O’Neil Unannounced Inspection 23rd February 2006 08:40 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.V279379.R01.S.doc Version 5.1 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.V279379.R01.S.doc Version 5.1 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 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) None South Yorkshire Housing Association 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.V279379.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 31st August 2005 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 fourty bedrooms are single, all have en-suite facilities. A central kitchen and laundry serve the home. The home is near to the centre of Chapeltown, bus rotes and local ammenities. A car park is available. 67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 08:40 to 12:20. Elaine Biggins ,deputy manager was present during the inspection. Six residents and ten staff were spoken with. A sample of records were examined and a partial inspection of the building was carried out. The inspector wishes to thank the staff and residents for their time, friendliness and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection?
The standard of the care plans had improved significantly since the last inspection and the staff had clearly made an effort to meet the requirements made at the last inspection. Staff should be commended for their efforts. There was evidence that the activities coordinators had expanded the activities offered to the residents. Since the last inspection further refurbishment of the home has taken place. New chairs have been provided in some lounges and dining rooms and one bungalow has been redecorated. Refurbishment was continuing in other areas of the home as well, including the creation of a larger dining room between bungalows 1 and 2.This room, when completed, will also be used as a function room, which will be of benefit to the resident’s social lifestyle. Building work had also created additional space in the laundry room. Staff said staffing levels were adequate and that the high level of agency staff working previously at the home had been reduced. Staff said new staff had been recruited and staff previously off work due to on long-term sickness had returned to work.
67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 Page 6 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.V279379.R01.S.doc Version 5.1 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.V279379.R01.S.doc Version 5.1 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): None of these standards were checked as the key standards were checked and met at the last inspection. EVIDENCE: 67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 and 11. The residents’ health, social and personal care needs were generally well documented in the care plans. A range of health care professionals visited the home to assist in maintaining the health care needs of residents. Residents themselves said that they were “happy” living at Birch Avenue and said that the staff were “nice”. Residents’ privacy and dignity was maintained. Residents’ wishes regarding death and dying were recorded in care plans checked. EVIDENCE: Three resident plans of care were checked. The standard of the care plans had improved significantly since the last inspection and the staff had clearly made an effort to meet the requirements made at the last inspection. Staff should be commended for their efforts. The plans had been reviewed on a regular basis to ensure they were up to date. The residents preferred funeral arrangements were recorded, to ensure that their wishes following their death could be respected. Staff maintained daily records of residents’ health, to ensure that the specific needs and care
67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 Page 10 given to residents could be monitored. Records of healthcare visits were maintained and these evidenced that other healthcare professionals, e.g. general practitioner, chiropodist and optician, were visiting residents on a regular basis. Nutritional screening was undertaken on admission and weight-monitoring records were maintained. The only omission found in the care plans was the failure of all staff, not just the activity coordinators, to record all activities that the residents had participated in. Residents themselves said that they were “happy” living at Birch Avenue and that the staff were “nice”. Residents were well dressed in clean clothes and had received a good standard of personal care. Medication was administered in a safe and hygienic way. Medication procedures provided protection to residents. Medicines were securely stored in the home in locked cupboards. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. Staff were observed to be assisting residents in a positive and friendly manner, doors were closed where staff were helping with personal care. 67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15. Residents had a choice of lifestyle within the home and they were able to maintain contact with family and friends. Meals served at the home were of a good quality and offered choice. EVIDENCE: Two care staff had been employed as activities coordinators, and were improving the range of activities offered. These included trips out of the home to the local community. Activities were advertised around the home. Some activities that residents had participated in were recorded in the residents care plans. The inspector saw evidence that care staff were also undertaking simple 1 to 1 activities with the residents such as reading a newspaper with them or painting the female residents fingernails. Two residents were able to tell the inspector that they chose when they got up and went to bed and generally how they spent their day. All the residents interviewed said the meals served were nice and they always had enough to eat and a choice of food. 67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 Page 12 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): None of these standards were checked as the key standards were checked and met at the last inspection. EVIDENCE: 67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 Page 13 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): Standards 19,21,24,25 and 26. The environment within the home was on the whole well maintained and clean providing a comfortable, safe environment for residents. EVIDENCE: Since the last inspection further refurbishment of the home has taken place. New chairs have been provided in some lounges and dining rooms and one bungalow has been redecorated which has improved the aesthetics of this bungalow. Refurbishment was continuing in other areas of the home as well including the creation of a larger dining room between bungalows 1 and 2.This room, when completed, will also be used as a function room which will be of benefit to the residents social lifestyle. Building work had also created additional space in the laundry room. The wallpaper in the lounge of bungalow 4 is torn and needs redecorating and a carpet around the patio door in this lounge needs fitting. The corridor carpets in Bungalow 4 also need a thorough clean or ideally replacing.
67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 Page 14 Three bedrooms were checked in detail and many others seen, all were comfortable and homely. Bed linen checked was clean and in a good condition. The home was clean, with no unpleasant odours noticeable. The staff spoken with said that there were still problems with the equipment in the laundry. Two industrial washing machines were leaking water, thus providing a slipping hazard, and one was sited at a height the laundry staff said was a risk to their health. 67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 Page 15 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): Standards 27,28 and 30. Agreed levels of staff were being maintained. A proportion of staff undertook NVQ training. Staff received regular training, which enabled them to meet the needs of service users. EVIDENCE: The staff rota identified agreed staffing levels had been met. This will assist in making sure that service users needs are met. Staff said staffing levels were adequate and that the high level of agency staff working previously at the home had been reduced. Staff said new staff had been recruited and staff previously off work due to long-term sickness had returned to work. Fifty per cent of care staff had not achieved their level 2/3 NVQ qualification, although the deputy manager said a number of staff had enrolled or were undertaking their NVQ training. Staff said that there were good training opportunities available to them, which enabled them to feel competent to do their job. 67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 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 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): Standards 31,33,36,37 and 38. The homes policies and procedures promoted the health, safety and welfare of residents and staff. EVIDENCE: The CSCI have not received notification to confirm that the manager has completed his level 4 NVQ management qualification. The home did have a quality assurance system, which included the internal auditing of the homes environment, services and records. Recorded visits by the registered provider had been carried out. The inspector saw minutes of relative and resident meetings that had recently been held. This quality assurance monitoring will assist in ensuring that the home is run in the best interests of the residents. Records were securely stored around the home, which protected the residents’ best interests and confidentiality. Staff said they were receiving supervision and management support on a regular basis. Dates of these meetings were held on staff’s individual files.
67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 Page 17 Fire records were up to date and stated that weekly testing of the fire alarm system had occurred. A sample of records showed that staff were receiving fire safety and other statutory training. Staff interviewed said they were receiving this training. Fire drills were conducted on a regular basis, to ensure that all staff were fully conversant with the action that they needed to take in the event of a fire. The records of drills evidenced the names of staff participating in the drill. (Previous requirement met) The hot water temperature in one bathroom measured a safe temperature of 41 degrees centigrade. This will promote the safety and welfare of the service users. 67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X 3 X X 3 3 2 STAFFING Standard No Score 27 3 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 3 3 3 67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard OP7 OP19 OP19 OP26 Regulation 12,13,15 23 23 12,13,23 Requirement Staff must record any activities that the residents participate in. All areas of the home used by residents must be well maintained. (Corridor carpet) All areas of the home used by residents (décor/lounge carpet B4) must be well maintained. Sufficent and suitable laundry equipment must be provided to ensure that the health and safety of the staff is maintained. 50 of care staff must be trained to NVQ level 2 or equivalent. The manager must be trained to NVQ level 4 or equivalent in management. Timescale for action 01/06/06 01/07/06 01/07/06 01/05/06 5. 6. OP28 OP31 18 9,18 31/12/06 31/12/06 67 Birch Avenue Nursing Home DS0000021769.V279379.R01.S.doc Version 5.1 Page 20 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.V279379.R01.S.doc Version 5.1 Page 21 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
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