Inspection on 19/07/05 for Andrew Cohen House

This inspection was carried out on 19th July 2005.

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

Andrew Cohen House 19/03/07

Andrew Cohen House 22/02/06

Andrew Cohen House 25/01/05

Andrew Cohen House 20/09/04

Andrew Cohen House 27/01/04

Andrew Cohen House 15/09/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Andrew Cohen House 1 Riverbrook Drive Stirchley Birmingham B30 2SH Lead Inspector Sean Devine Unannounced 19 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Andrew Cohen House Address 1 Riverbrook Drive Stirchley Birmingham B30 2SH 0121 458 5000 0121 458 4999 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) Birmingham Jewish Community Care Sheila Gold Care Home 59 Category(ies) of Dementia - Over 65 - Terminally Ill - Old Age registration, with number (59) of places Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate 50 service users over 65 yrs of age who are in need of nursing care (including 4 continuing care service users)for reasons of old age, dementia or terminal illness. 2. 9 service users over 65 years of age in need of residential care for reasons of old age. Date of last inspection 25 January 2005 Brief Description of the Service: Andrew Cohen is purpose built two-storey home set in its own grounds that was commissioned in 1993 by the Birmingham Jewish Community. The home provides both residential and nursing care for 59 service users for reason of old age, dementia and terminal illness. Accommodation is provided in single rooms and the majority have en-suite facilities. There are a number of communal rooms, a library, synagogue and snoozlem room for use by service users in the home. The home is well maintained both internally and externally. There is a pleasant garden to the rear with parking to the front of the building. The home has strong links with the local Jewish Community who provide support and there are a number of volunteers involved with social activities in the home. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted on an unannounced basis by two regulation inspectors over a period of one day. Inspectors were able to investigate concerns raised within a recent complaint whilst conducting the inspection. Details of findings and some subsequent improvements are detailed within this report. Many of the concerns raised were not upheld. The inspectors were able to meet with some residents and staff, view records pertaining to care provision, services and staff training and development. What the service does well: What has improved since the last inspection? What they could do better: The home needs to complete a comprehensive assessment including risks and written care plans for residents, this must include a period of consultation with residents and their representatives. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 6 The social and recreational activities of individual residents must be fully assessed and a programme of activity focussed upon these findings developed. A robust quality assurance system is in place, minor improvements are needed to involve persons from a nursing background when appropriate. 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. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- 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 Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- 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) 3 The home does not fully gather important information during the assessment of residents, this means that some residents’ abilities are not always realised. EVIDENCE: Sampled residents files all had a long term care needs assessment, some areas in respect of activities of daily living had not been completed. Other assessed information had been gathered utilising the Barthel index of activities of daily living. It is not clear how residents and representatives have been involved in the gathering of information for the assessments. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10,11 Many residents have their health and personal care needs adequately met by the home. Extensive risk assessments are in place to protect and promote residents safety, with only minor shortfalls. EVIDENCE: The complainant was concerned that the home does not meet the following needs of residents mobility, oral healthcare, toileting / elimination and tissue viability and that some staff have a poor attitude to the delivery of care. One element to this complaint was upheld, since inspection the manager has advised that improvements have been made. Written care plans are in place to assist and guide staff to support residents to achieve their needs, such as managing diabetes, personal hygiene, constipation and skin breaks and oedema. These plans were discussed with a nurse who was positive and knowledgeable in respect of care delivery. Two assessments for oral healthcare had no corresponding written care plan. Some residents who require input from a dentist as identified in assessments and written care plans had no records to support they had seen a dentist, the manager advised at the time of the inspection that there were difficulties accessing a dental service but after the inspection advised that a dental service was available. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 10 All written care plans are reviewed on a monthly basis or sooner when needed, however some information recorded within the review did not reflect on whether the plan was effective, entries such as ”no change” and “continue with plan” do not indicate progress or otherwise. The home has completed tissue viability risk assessments, residents with broken skin do have an in depth assessment and the home has involved a tissue viability nurse, details of treatment and condition are regularly updated. The home monitors the frequency of toileting for residents and records when stimulant laxatives are administered. Care plans for constipation include encouraging fluids, fresh fruit and relevant exercises. The home must ensure that risk assessments including nutrition and manual handling are reviewed frequently. Records confirming the input from GP’s, optician and chiropodist are well maintained. Some residents require the use of hoists, slings and lifting belts to aid mobility, some care plans are not specific and do not detail size of sling or type of hoist. One resident at times is reluctant to access other parts of the home and prefers to remain within the bedroom, this is documented as the individual choice of the resident and this resident continues to have all care needs met within the bedroom when needed. The home has some residents that need to use bedrails and rail protectors; specific risk assessments after consulting residents or their representatives were not available. The home has commenced quality audits into the care of terminally ill and dying residents, feedback from relatives who had previous contact with the home suggested they were content with the care afforded to these residents at this time in their lives. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 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 standard(s) 12 A variety of activities, resources and support is available for residents, but the home does not fully assess the social and recreational needs of residents, thus the home may not always be meeting their individual and specific lifestyles. EVIDENCE: Activity of daily living assessments do include sections to record the personal history, social activity, hobbies and interests of residents. Sampled residents files had all or some of this information missing and in turn no written care plans had been developed. The home has a standard activity record form that records activities such as using the garden, hairdressing appointments and visitors (homes visiting group). It is clear that as the assessment identified above had not been completed, the activity records are not based upon choice and preference of the residents. The form does not fully record all activity, planned and daily interactions with staff are not recorded. The home does engage with volunteers to assist and support residents with activities. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 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 standard(s) 16 Residents and their representatives are supported to raise their concerns, these complaints are investigated and considered improvements made where shortfalls in the services are identified. EVIDENCE: The complainant was concerned that the home did not fully consider complaints and that concerns raised were not acted upon. This element of the complaint is not upheld. The home has a complaints policy that is accessible to residents and their representatives. A log of complaints is maintained at the home, recording details of complaints received, time frames for investigation, letters in response to concerns and also details of subsequent actions to improve services where complaint is upheld. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 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 standard(s) Standards pertaining to the environment were not inspected. EVIDENCE: Standards not assessed at this inspection. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,30 The staffing compliment, their skills and competencies are adequate to meet the ongoing and specific needs of the residents. The residents are cared for by a team of staff that are well trained and competent. EVIDENCE: The complainant was concerned that staff do not have the skills, competencies and qualifications to fully meet the needs of residents. The home maintains an adequate staffing compliment to meet the needs of residents. The home has an allocated training officer who is a qualified RMN and RGN nurse. As well as providing in house training the training officer has involved training organisations and companies to assist with staff training and development including tissue viability and infection control through the health protection agency. Staff training files are available and reflect compliance with TOPSS induction and foundation standards. Training files for nursing staff are detailed and record evidence of post registration education and practice, courses and training include care planning, wound care, palliative and the role of radiotherapy and supervisory management. Staff training in protecting vulnerable adults from abuse, fire safety training and wound care updates has recently been completed, the staff are awaiting certification. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 15 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) 33,36 The home is run in the best interests of the residents, which ensures they are consulted on the quality of service and care provided. The home has introduced a quality assurance system to check on all aspects of performance. No reports or feedback have as yet been provided. EVIDENCE: The complainant was concerned that the home did not have an adequate system of quality assurance in respect of clinical practice audits, that the individual responsible for the clinical audits was not competent to undertake them. The quality assurance manager does not have a clinical nursing background. However systems are in place to involve nurses as described further below. The complainant was concerned that nursing staff are not being adequately supervised in respect of their clinical practice and development, this element of the complaint is upheld. The manager advised that plans have been discussed to introduce such a system, which are also detailed below. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 16 The home as identified at the last inspection has commenced quality monitoring and audits. At the inspection the manager advised that not all groups of staff have been fully involved within the cycle of audits, since the inspection CSCI have been advised that this has recommenced. Some audits in respect of clinical practice at the home have been conducted however the quality assurance manager was clear that this section of the quality monitoring had not been fully completed however a great deal of work had commenced. It was evident to the inspector that the gathering of some information in respect of clinical practice would need to involve a qualified and experienced nursing practitioner. Since inspection CSCI have been advised that appropriately qualified nurses are involved within the process. Clinical supervision for nursing staff is due to commence in the home to enable them to reflect on current practice, to update their professional knowledge and skills thereby improving on the quality of the service provided. Since the inspection the CSCI has been advised by the manager that the clinical supervision for nursing staff had already commenced. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 2 x x 1 x x Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 18 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(c ) Requirement A full and detailed assessment of need must be completed for all residents, this must include personal histories, pastimes, social and recreational support. The home must ensure that the resident and or their representative is involved in the gathering of information at assessment. The registered person must include an assessment in respect of continence and mental health where appropriate. Not assessed and is carried forward. Written care plans must be available to meet the assessed needs of residents including where dental and oral health needs are identified. The home must ensure that the residents and or their representatives are consulted about all written plans of care. Reviews of care plans must inform how effective the plan has been. Timescale for action 30/9/05 2. OP3 14 30/9/05 3. OP7 15(1) 30/9/05 4. OP7 15(2)(b) 30/9/05 Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 19 5. OP8 15(2)(b) All risk assessments including nutrition and manual handling must be regularly reviewed. 31/10/05 6. OP8 13(4)(c ), 12(1) Riskassessments must include specific actions to reduce risk, e.g. manual handling risk assessments must include type of hoist and size of sling to be used for each individual resident. Residents who are in need of bed 31/10/05 rails and protectors must have a risk assessment completed in consultation with the resident and or their representative. Written care plans must be developed to support residents lifestyles from the assessment identified in Requirement 1. The home must develop an individual activity programme for each resident. The registered person must undertake a review of the heating to ensure it is satisfactory in all areas of the home. Not assessed and is carried forward. The registered person must ensure that at least 50 of care staff are trained to NVQ 2. Not assessed and is carried forward. The registered person must ensure that a POVA check is undertaken for all staff before employment commences. Not assessed and is carried forward. The home must ensure that audits of clinical practice are 30/9/05 7. 8. OP12 15(1) 16(2)(m)( n) 9. OP25 23(2)(p) 30/9/05 10. OP28 18(1) 30/9/05 11. OP29 19 30/9/05 12. OP33 24(1) 31/12/05 Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 20 13. OP35 20 overseen by an appropriately qualified and experienced person. The registered person must ensure that where money is held in a bank account for residents the account is in the name of the resident(s) to which the money belongs. Not assessed and is carried forward. The registered person must ensure systems are in place for all care staff to receive formal supervision at least 6 times per year. Previous timescale of 30/6/05 not met, this requirement is carried forward. The registered person must ensure the call bell system is serviced on a regular basis and records are retained in the home. Not assessed and is carried forward. 30/9/05 14. OP36 18(2) 18(1)(a) 31/10/05 15. OP38 13(4) 30/9/05 16. 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. Refer to Standard OP15 Good Practice Recommendations It is recommended that the dining arrangements are reviewed and the need for extra staff seating. Not assessed and is carried forward. It is recommended that the system of financial recording be reviewed to enable easier auditing. 2. OP35 Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 21 Not assessed and is carried forward. Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Birmingham & Soliuhull Local Office 1st Floor , Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Andrew Cohen House E54_S24818_AndrewCohen_V239465_180705- UI stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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