CARE HOMES FOR OLDER PEOPLE
67 Birch Avenue Nursing Home 67 Birch Avenue Chapeltown Sheffield S35 1RQ Lead Inspector
Janis Robinson Unannounced 31 August 2005 08:50am
st 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. 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service 67 Birch Avenue Nursing Home Address 67 Birch Avenue Chapeltown Sheffield S35 1RQ 0114 2453727 0114 2454015 None South Yorkshire Housing Association 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) Mr John Scott McCaffrey N Care Home with Nursing 40 Category(ies) of DE(E) Dementia - over 65 (40) registration, with number of places 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 15th March 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 J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 8.50 a.m. to 1. 30 p.m. A deputy manager was in charge of the home at the time this inspection took place. The majority of staff were spoken with, and interactions between residents and staff were observed. A sample of records was examined and a partial inspection of the building was carried out. What the service does well:
A relative support booklet was available to give prospective residents and their representatives information about the home. Visits to the home prior to admission were encouraged, and the deputy managers carried out assessments to ensure all assessed needs could be met before residents moved in. Each resident was provided with a contract to inform them of their rights and obligations. Each resident had an individual plan of care, which set out identified needs, and the staff action required to ensure needs were met. Residents’ health care was monitored and access to relevant professionals was available. Staff were observed to respect residents privacy. All of the interactions between residents and staff appeared patient and respectful. A varied menu was provided. A complaints procedure and adult protection procedure were in place to inform and ensure residents safety. The majority of the environment was very clean. Residents’ bedrooms were individual and contained personal belongings. The central garden was well maintained. Agreed levels of staff were being maintained. Staff undertook a range of training to equip them with the skills needed to carry out their duties. Health and safety systems were in place and equipment was checked and serviced. 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI 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.
67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI 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 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI 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) 1,2,3,4 and 5. standard 6 does not apply to this home. Prospective residents and their relatives were provided with information that they needed. Residents were not admitted to the home without their needs being assessed. Residents and their relatives were given the opportunity to visit the home prior to their admission. Contacts were undertaken with each resident. EVIDENCE: A relative support booklet was available to provide residents and their relatives with the information that they needed to make an informed choice about living at the home. Each resident had been provided with a contract, statement of terms and conditions, to inform them of their rights and obligations. A full needs assessment was carried out prior to admission by the deputy managers, which provided staff with the information needed to formulate a individual plan of care.
67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 Page 9 Staff undertook periodic training to equip them with the skills needed to carry out their duties. Staff confirmed that residents and their relatives were given the opportunity to visit the home prior to their admission to meet the staff and view the bedrooms that were available. 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 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 standard(s) 7,8,10 and 11 Residents’ individual needs were assessed. Care plans did not contain all of the required information and had not been completed in full. Plans were reviewed regularly. Service users had good access to health care services, which met their assessed needs. Residents’ wishes regarding death and dying were not recorded in all plans. EVIDENCE: Care plans set out in some detail the action that was required by staff to ensure that all aspects of residents care needs were met. The plans had been reviewed on a regular basis to ensure they were up to date. One plan had not been completed in full. The residents preferred funeral arrangements were not 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 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. 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 Page 11 Residents were observed to be receiving personal care in a manner that respected their privacy and dignity. Staff reported a problem with lack of continence supplies on occasion. The deputy manager stated that sufficient supplies were in place, however, some staff were not following guidelines stating specific aids to use, as set out in care plans. As a consequence some supplies were used sooner than anticipated. As a matter of priority care plans must be audited to ensure relevant information on meeting personal care needs are recorded. Staff must be instructed to follow the guidelines as set out in individual plans. Sufficient supplies must be provided to meet assessed needs. 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 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 standard(s) 12,13 and 15 The daily routines within the home were flexible and promoted residents choice. A programme of leisure and social activities was available. Contact with residents family and friends was supported and maintained. A good choice of menu was offered and special dietary needs were catered for. EVIDENCE: Residents were able to spend their day as they wished and move freely around the home. The majority of residents were unable to express a preference, however, staff were observed interacting with residents in a patient and respectful manner. 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. Contact with residents family and friends was encouraged, staff stated that they were welcome at any reasonable time. 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 Page 13 A good choice of menu was offered and special dietary needs were catered for. The cook was aware of the likes and dislikes of residents, and alternatives to the menu were always offered. The majority of residents were unable to communicate their preferences verbally, the cook always offered an alternative meal if a resident did not appear to be enjoying or eating their meal. Since the last inspection discussions had taken place with the staff team to ensure assistance with eating was given discreetly. Care plans did not specify how assistance with eating was to be provided, or if a specific need identified that sitting with a resident was not appropriate. 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 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 standard(s) 16,17 and 18 The complaints procedure was clear and accessible. Complaints made by residents and their relatives were listened to and action was taken to deal with complaints promptly. Access to advocacy services was provided. There was an adult protection procedure in place. EVIDENCE: The complaints procedure ensured that residents and their relatives were aware of how to make a complaint and who would deal with them. No formal complaints had been made to the home since the last inspection. Information on advocacy service was on display and available to residents and their relatives, to ensure they received appropriate support. The adult protection policy contained relevant information. The staff spoken with were aware of the procedures to follow if they suspected abuse. 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 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 standard(s) 19,20,21,22,23,24,25 and 26. The home was in the main well maintained and well decorated. Some furniture required replacing and some decoration was worn. The majority of the environment was clean. Residents’ bedrooms appeared comfortable and individual. Equipment in the laundry was not in full working order and did not meet residents’ need. EVIDENCE: A rolling programme of redecoration was in place. Since the last inspection the homes corridor areas had been redecorated and a patio door provided to one unit. A large proportion of furniture provided in communal rooms was in need of replacement. Armchairs were ripped and worn. Whilst the home was very clean in all other areas, some communal carpets were badly stained. The inspector acknowledges that the homes carpet cleaner had broken, however, sufficient equipment must be provided to ensure standards are maintained. Resident’s bedrooms were well decorated and individual. Some rooms contained personal belongings. Each bedroom had en-suite facilities.
67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 Page 16 Bathrooms were provided with the aids and adaptations needed to meet residents needs. All of the staff spoken with reported a problem with the equipment in the laundry. A damaged dryer had been replaced, however, two industrial washing machines were not in working order, and laundry staff had been experiencing problems for some time. The one remaining washer was not in full working order and only domestic in scale. Laundry staff were prioritising, but were unable to fully undertake their duties and meet residents needs, as they were not provided with the equipment to do this. Some laundry was undertaken externally to address this ongoing problem. Staff stated that a new washing machine had been prioritised, and was due to be delivered the week after this inspection took place. 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 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 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 and 30. Agreed levels of staff were being maintained. However, agency and bank staff were being used on a large proportion of duties. A proportion of staff undertook NVQ training. A training and development programme was in place. Staff received regular training, which enabled them to meet the needs of service users. EVIDENCE: Staff were observed to be professional, caring and committed to the care of residents. Several staff spoken to confirmed that they had worked at the home for several years and it was evident that they had a good understanding of their role and individual needs of service users. Whilst numbers of staff met agreed levels, all staff reported a problem with the high level of agency staff used. The homes rota evidenced that agency staff were used to cover a high proportion of duties. Staff reported that this sometimes impacted on the quality of care offered to residents, as time had to be spent explaining duties to agency staff. Several staff were on long-term sick leave. The line manager external to the home reported a lack of sufficient funding to ensure sufficient permanent staff were employed to maintain agreed levels. The home had a commitment to NVQ training. The recommended 50 of care staff trained to NVQ level 2 by 2005 had almost been achieved. 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 Page 18 The manager had provided staff training manuals for induction training to new staff that met standards. The recent employees spoken with stated that this training had not commenced. 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 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 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) 34,36,37 and 38 Appropriate financial procedures were in place. A policy on staff supervision was provided. Staff supervision did not take place at the required frequency for all staff. The homes policies and procedures promoted the health, safety and welfare of service users and staff. Records of fire drills required some update. EVIDENCE: A business plan and insurance cover was in place. Whilst a policy of staff supervision had been introduced, some staff were not receiving supervision at the required frequency, to provide them with appropriate levels of support. The staff had received regular training, which promoted safe working practices and the health, safety and welfare of service users and their colleagues. 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 Page 20 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. However, the records of drills did not evidence the names of staff participating in the drill, as a consequence the monitoring of staff participation in drills was unable to take place. 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2
COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 1 STAFFING Standard No Score 27 2 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x x 3 x 2 3 2 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 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. Standard 7,11,15. Regulation 15,12 Requirement Timescale for action 31/10/05 2. 8 12 3. 19 23 Care plans must be completed in full and contain all of the required information; Residents wishes regarding funeral arrangements must be recorded. Where this information has been refused, this must also be recorded. Care plans must specifically detail the assistance needed with eating. Where it is not possible for staff to sit with residents in the interests of safety , this must be recorded. Discussions must take place with 31/10/05 all staff regarding the continence aids required to meet the needs of residents. Care plans must accurately reflect the assistance required with personal care. Sufficient, appropriate aids must be provided. The environment must be well 31/11/05 maintained; All damaged armchairs must be identified for replacement within the homes plan. The marked carpets must be cleaned to eradicate marks. The dining room with damaged decoration must be redecorated.
Version 1.40 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Page 23 4. 26 16 5. 27 12,18 6. 7. 30 36 18 18 8. 38 13 Sufficent laundry equipment must be provided to enable residents needs to be fully met. Written confirmation that new equipment has been provided must be forwarded to the local office of the CSCI. The number of agency staff used at the home must be reduced. Sufficient funds must be provided to ensure enough permanent staff are available to cover the homes rota. Staff must receive adequate induction training. (Previous timescale of 01/06/05 not met) Staff must receive formal supervision at least six times each year. (Previous timescale of 01/05/05 not met) Staff must receive fire instruction training at least once each year. (Previous timescale of 01/05/05 not met). Records must indicate the names of staff participating in a drill. a system must be put into place to ensure staff fire drills can be efficiently monitored. Within two weeks of this inspection date. 31/11/05. 31/10/05 31/10/05 31/10/05 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. 2. Refer to Standard 28 31 Good Practice Recommendations 50 of the care staff should NVQ level 2 in care by 2005 The registered manager should NVQ level 4 in management by 2005 67 Birch Avenue Nursing Home J55 S21769 BirchAvenue V242548 310805 UI Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 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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