Inspection on 22/02/06 for Andrew Cohen House

This inspection was carried out on 22nd February 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

Andrew Cohen House 19/03/07

Andrew Cohen House 19/07/05

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 West Midlands B30 2SH Lead Inspector Sean Devine Unannounced Inspection 22nd February 2006 10:10 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 Andrew Cohen House DS0000024818.V284635.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. Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Andrew Cohen House Address 1 Riverbrook Drive Stirchley Birmingham West Midlands B30 2SH 0121 458 5000 0121 458 4999 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) Birmingham Jewish Community Care Mrs Sheila Gold Care Home 59 Category(ies) of Dementia - over 65 years of age (59), Old age, registration, with number not falling within any other category (59), of places Terminally ill over 65 years of age (59) Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 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. 9 service users over 65 years of age in need of residential care for reasons of old age. 19th July 2005 2. Date of last inspection Brief Description of the Service: Andrew Cohen is a 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 residents for reason of old age, dementia and terminal illness. Accommodation is provided in large 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 residents 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 DS0000024818.V284635.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted by a regulation inspector and a regulation manager on an unannounced basis over a period of one day. The inspector was able to sample three records of residents regarding care provision, view health and safety documents and also meet with managers, trainers and the director. The regulation manager conducted a tour of the premises including, kitchens, laundry, communal areas and residents’ rooms and was able to meet some residents and observed residents being supported by staff. What the service does well: What has improved since the last inspection? Nearly all requirements from the last inspection have been addressed, these include for example: Improving how residents’ needs including risks are assessed and how their care is planned and reviewed. Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 Page 6 The inspector was advised that the quality assurance systems were now fully operational with a continuous cycle of audits involving detailed consultation. Staff are receiving good support and supervision, a focus for nurses is being developed to look at clinical aspects of care. 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. Andrew Cohen House DS0000024818.V284635.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 Andrew Cohen House DS0000024818.V284635.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): 3, 4, 6 Residents needs in respect of ensuring they can be cared for by the home are met, it is also evident that staff collectively have the skills and qualities to ensure these needs are met. EVIDENCE: Residents’ files included detailed reports gathered prior to admission, which detailed the needs of residents and possible risks to their health. Also included were details of how there personal, health, psychological and social care had been supported in the past. The training manager has developed staff both with regard to health and safety and specific care needs of residents but also with a focus on protecting them. Staff were observed supporting and interacting with residents, it was evident that residents are very comfortable with staff and present a state of well-being. The cultural needs of residents are embedded mainly in the Jewish faith and their needs are met through routine practices, staff development and a sharing of knowledge. The home does not provide an intermediate care facility. Andrew Cohen House DS0000024818.V284635.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): 7, 8, 9 The health and personal care needs of residents are met by the home, any concerns are quickly identified and effectively managed; medication practices are not adequate to ensure residents are provided with a safe service. EVIDENCE: Residents’ files contain detailed care plans written following an assessment of need, these plans reflect the individual needs of residents and are well written describing to all staff what they must do to provide the support needed. Sampled plans had been completed in consultation with advocates on behalf of residents, including signing care plans to confirm they are aware of the care being provided and that they have opportunity to take part and help plan the care. Care plans need to be written to identify how the social and lifestyle needs of residents are to be met. All care plans are routinely reviewed and reflect on whether the care plans are effective or otherwise. Risk assessments are routinely completed and reviewed monthly and include falls, moving and handling, nutrition and tissue viability. The personal care needs of residents are recorded upon a daily chart; this helps for quick reference and reflects what is written in care plans. Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 Page 10 The health care records indicate that residents when needed are able to see their GP, records also indicate that other community healthcare services visit the residents including tissue viability nurses, nutritional nurses, dieticians and chiropodists. The home manages all medication on behalf of the residents. A monthly supply of medicine in boxes and bottles is received from a local chemist. The medication administration records are thoroughly completed for when medicines are received, administered and disposed of, correct procedures for deactivating controlled drugs are in place. Audits of stocks of medicine indicate some are inaccurate. Medicines, including controlled drugs are safely and appropriately stored. The controlled drug register reflects current stocks. One medication was seen to be written on the medication administration records without the full directions for use as were recorded on the copy of the GP prescription and the dispensing label. Andrew Cohen House DS0000024818.V284635.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): 13, 14, 15 The residents are supported to achieve positive outcomes based upon assessments, however plans are not written to describe the support needed and in this area the home is not meeting the contact with family and friends, social, cultural and religious beliefs and needs of residents. EVIDENCE: Residents’ files include an assessment of who is important in their lives, many visitors were seen to come and go visiting their relatives. The social activity plan does record the visits and the visits are also recorded within daily records. However as identified in standard 7 a care plan to describe how staff support residents to keep contact with family and friends and maintain their social needs and lifestyle is required. As described in standard 7, advocates are consulted and help in the development and review of written care plans and risk assessments. Advocates, mainly families and some volunteers are supported through regular meetings, notice boards and by staff of which external agencies can provide advice and act in their best interests and those of the resident. The kitchen design, equipment and processes are provided to ensure the Jewish faith is at all times maintained. Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 Page 12 The kitchen waste disposal is in need of repair; the registered manager confirmed this would shortly be completed. Records of all meals served are maintained, special diets are prepared in the kitchen, such as soft diets, and these were seen and appear appetising. The main dining area is spacious and light, residents are able to move safely and were also seen in conversation at dining tables. Meals at teatime were nutritional including hot dishes, fish, salads and sandwiches. Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 Page 13 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): 18 Residents’ needs in respect of being protected from abuse are met; the home if needed can act quickly and are aware of what constitutes a risk to the health and welfare of residents. EVIDENCE: The policy to protect residents from abuse is built around the framework of the Department of Health paper “No Secrets” and also reflects the good practices as detailed in the local Social Care and Health Multi-Agency Guidelines. There is a clear commitment to training and developing the skills of staff to ensure they can act responsible and effectively should any type of abuse be suspected. Formal training is completed frequently and all staff are contracted to receive training in protecting vulnerable adults from abuse. Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 Page 14 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): All standards. The environment meets the safety, care and individuals needs of residents. It provides good support for the individual and collective needs of residents and focuses upon their abilities including their social, religious and cultural needs. EVIDENCE: The premises appear modern and well maintained, it is evident that considerable attention is extended to maintenance of the building and ensuring it is kept tidy, safe and fully accessible for residents. All areas communal and within residents accommodation are comfortable and of a design that is spacious and homely. The grounds are extensive and also well maintained. There are large communal lounges on both floors and in addition there are smaller rooms throughout the home that are used for visiting, meetings and as quiet rooms. The uses of many rooms are flexible, for example the large downstairs dining room is used as a cinema and a smaller area of a corridor provides a library facility. A large prayer room is available for residents to use and for regular religious services. There is a hairdressers’ salon that is used weekly and more often when needed. Furnishings are of good quality and Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 Page 15 replaced when needed, for example new dining room chairs and tables have been ordered. Corridors and doors are wide, with good access for residents with a disability and for those who use mobility aids. The home is fully accessible for residents who use a wheelchair. Grab rails are available in corridors, bathrooms, toilets and en-suites and residents have the use of a range of equipment to help support mobility such as assisted baths, including a hydrotherapy room, specialised beds and hoists. Toilets have wide entrances and are all located close to residents’ accommodation. All areas of the home have clear signs, new larger signs for residents’ rooms have been ordered. Residents’ accommodation is all single rooms, the rooms are spacious, clearly in excess of national minimum standards; most residents have an en-suite facility, which includes toilet, hand basin and shower. One area of the home is identified for residents with more dependent care needs, these rooms do not have an en-suite facility as larger assisted bathing and showering facilities are needed and provided. The furniture and fittings in rooms is of good quality, many rooms seen had been personalised, and they were clean, fresh and light. Adequate facilities including, seating, storage and utilities such as dimmer controlled lighting and TV aerials are standard. Some rooms have a telephone call point. One room was seen to have additional heating, being a free standing heater, this needs to be fixed to ensure fire safety and only used as an interim measure. Some residents’ rooms at the front of the building are overlooked by local housing, improvements need to be made to ensure the privacy of residents is maintained at all times. The lighting and heating throughout was good, lighting in some corridors is being replaced to ensure it meets the needs of residents. The kitchen area was clean and hygienic, at present the waste disposal unit is not working, however a part needed to repair it is on order. Food items are labelled when needed and meat and milk are stored separately. There are appropriately sited sluice rooms and the laundry area is well organised to help reduce risks of cross infection, staff showed a good awareness of hygiene and were seen to wear appropriate protective clothing. All high-risk areas have good hand washing facilities. Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 Page 16 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): 29 Residents are not fully protected by the recruitment practices and they may be at risk from staff who have not been adequately vetted. EVIDENCE: Staff recruitment files seen all included a job description, a completed application form and evidence that interviews are conducted. Criminal records bureau disclosures (CRB) are available, however they are not always applied for by the home and some staff have provided their own CRB. References are not always in place prior to staff commencing employment, those files seen either had references missing or the last employer had not provided the reference. Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 Page 17 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, 35, 38 An experienced, well-trained and competent manager, who is supportive to both residents and staff, manages the home. This enables the home to progress safely and to improve services to residents in a skilled and effective manner. EVIDENCE: The registered manager was observed to give clear direction and information to many of the staff during the inspection. It was evident that she has a good knowledge of the care needs of residents and keeps informed of the day-today care and activities of residents. Residents responded with enthusiasm and friendliness when approached by the manager. The manager is well qualified, experienced in the homes category of nursing and care and competent to manage the service. The manager keeps up to date with training internal and external to the home and resides upon the South PCT committee where the next project she will be involved in includes Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 Page 18 working with GP’s in regard to the verification of death, where she will provide some guidance, knowledge and support in relation to the Jewish faith. The home does manage some money on behalf of residents; this is mainly deposited by relatives of residents and normally comprises of personal allowances. Records are available of all transaction in and out of individual residents accounts, these are signed and balances reconciled. These were all found to be accurate. It is a concern that some receipts are not available for money spent on hairdressing and that the system for invoicing the home for hairdressing services is not fully validated by staff. Health and safety practices including the service, testing and maintenance of utilities, equipment and the building are completed and records accurately maintained. Records of fire drills at the home are available, however it is unclear whether all staff attend a minimum of two annually. Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 Page 19 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 4 4 3 3 3 2 3 3 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 2 X X 3 Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 15(1) 16(2m,n) Requirement Written care plans must be developed to support residents lifestyles identified in assessments. Previous timescale of 30/9/05 not met this requirement is carried forward. Stocks of medicines must be audited, where discrepancies are found this must be investigated and corrective actions taken. Timescale for action 31/03/06 2 OP9 13(2) 10/03/06 3 OP24 13(4)(a,c) 4 OP24 12(4)(a) 5 OP29 19(1)(b) Sch 2 Medication administration records must always reflect the prescribing wishes of doctors and fully record directions of use. Mobile heaters where needed for 10/03/06 additional heating must be in a fixed position and not at risk of falling over. Appropriate action to ensure that 31/03/06 residents’ rooms at the front of the building that are over looked must be taken to ensure their privacy is maintained at all times. All staff must have required 31/03/06 checks completed by the home DS0000024818.V284635.R01.S.doc Version 5.1 Page 21 Andrew Cohen House 6 OP35 13(6) 17(2) Sch4(9) prior to commencing employment including, CRB’s and two written references (one from the most recent employer). All expenditure made from residents’ accounts on behalf of residents by the home must have a corresponding receipt. There must be appropriate safety measures in place to ensure that residents only pay for services they receive, for example hairdressing. All staff must attend a minimum of two fire drills annually. 31/03/06 7 OP38 23(4)(e) 31/03/06 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 Andrew Cohen House DS0000024818.V284635.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Birmingham 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 DS0000024818.V284635.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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