Inspection on 11/10/06 for Annie Bright

This inspection was carried out on 11th October 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

Annie Bright 10/07/08

Annie Bright 16/12/05

Annie Bright 07/07/05

Annie Bright 11/10/04

Annie Bright 06/05/04

Annie Bright 25/11/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Annie Bright 6 Norfolk Road Edgbaston Birmingham West Midlands B15 3QD Lead Inspector Kulwant Ghuman Unannounced Inspection 11th October 2006 09:00 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 Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Annie Bright Address 6 Norfolk Road Edgbaston Birmingham West Midlands B15 3QD 0121 454 1289 0121 454 1301 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) Sisters of Charity of St Paul Claudine Buchanan Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th December 2005 Brief Description of the Service: Annie Bright Weston is a residential home for fifteen elderly women. It also accommodates some Sisters from the order at Selly Park Convent. The Sisters have their own facilities within the home and assist in the work of the home. Annie Bright Weston is situated in a large house that became dedicated to the care of elderly women via a legacy through the Catholic Church. It stands in a residential area of Edgbaston, set back from Norfolk Road. The home has its own drive with small car parking area. Whilst not a main bus route it is a ten minute walk to Harborne shopping area and in the other direction to the main Hagley Road by both routes one can access Birmingham city centre. The home provides an environment where women in their care can continue with their faith on a daily basis, however it does admit women from other faiths. The home has been converted from a large roomed mansion house and therefore has some small bedrooms. However the home has large living, dining and quiet areas as well as its own chapel. It is set in beautifully maintained gardens. It has a large well-equipped kitchen and has separate laundry facilities. There is an assisted bathroom on the first floor of the home. Access to the first and second floors of the home is via passenger lift. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this key, unannounced inspection over one day in October 2006. Prior to the inspection the inspector had received ten resident comment cards that all stated that they were happy with the food, care and activities provided in the home. Two professional comment cards stated that they found the home to be a good home. Three relatives comment cards were received, two were very happy with the home but the other was unhappy about the level of fees charged. During the inspection the inspector was able to take lunch with the residents, tour the building, speak with the majority of the fifteen residents and sample three resident files, two staff files and health and safety documents. All the residents spoken with said they were happy with the services provided in the home. What the service does well: What has improved since the last inspection? Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 6 More of the staff had completed their NVQ level 2. Some staff had been employed but unfortunately some had left therefore negating the positive aspects of having more staff available for duty. There was a senior member of staff on duty during the day. The home was carrying out audits of the medication and recording why medicines had not been given. 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. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The assessment process gathers some good information about the residents before admission; however, the assessment carried out at the pre-admission visit must be documented to ensure that the residents needs can be met. EVIDENCE: Three resident files were sampled. The files included some very good information on them about the residents’ past history and current needs. There was evidence that a pre-admission visit was carried out however, there was no written assessment of the residents needs carried out during the visit. The files did include some admission details but these were very brief. It is important that this assessment is carried out and documented, as the social workers assessment is not always received before admission and the information available to the home is minimal. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 9 One of the residents had needs over and above those that could be met at the home and appropriate referrals had been made to find an alternative placement. There was evidence on the files that where the residents were not able, or not willing, to offer much input into the care provided there was liaison with relatives to ensure that the care was appropriate and the resident was happy. The manager wrote to the residents confirming that needs could be met at the home and the fees to be paid and by whom. There were contracts available in the service user guide however. One of the files was without a contract, as the relative had not returned it after signing it. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The care planning system in the home was good. Further development was needed in relation to detailing personal care needs to ensure staff knew how to meet all the needs of the residents. The resident’s health care needs were being met and the systems for medicine management were generally good ensuring resident’s medication needs were being met. EVIDENCE: The care files for three residents were sampled. The care plans were well detailed and individualised in most areas. The care plans covered issues such as medical needs, deafness, skin integrity, personal care, hair care, dental/chiropody, activities and cultural needs, sleeping, toileting, death and funerals. They were discussed and signed by the resident. The personal care section needed to be more personalised, as it appeared that all three care plans had exactly the same needs. The care plans needed to be individualised with details such as preference for times of bathing, what toiletries are used, flannel used etc. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 11 Discussion with the manager about the use of creams was discussed. There was no clear indication on the care plan of when and where the creams were to be applied. The nutritional assessments for two of the residents had not been completed. One of these was because the individual had gone to hospital and the other because they were waiting for input from the relative. It is recommended that these were completed as soon as possible after admission and updated later. There was a skin integrity section in the care plan but there was no assessment to show how this had been arrived at. There were pressure cushions in place for some of the residents. There was evidence that medical needs were identified and followed up with appointments at hospitals, with GP and nurses where required. The chiropodist was also visiting the home on a regular basis. A 28 day monitored dosage system was in use in the home. There were a few issues that needed to be addressed. There were some medicines in the home that were not accounted for on the Medicines Administration Record (MAR) charts, medicines carried over from one month to the next had not been recorded on the MAR charts and the amount of medicine recorded on the box was recorded on the MAR charts rather than the actual amounts received into the home. Residents’ privacy and dignity were respected. Keys to bedrooms were available, there was a lockable piece of furniture in their bedrooms, there were appropriate locks on toilet and bathroom doors and residents had access to their bedrooms and small lounge when they wanted. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Residents were afforded a lifestyle that met their needs, maintained contact with family and friends and provided choices and nutritious food at mealtimes. EVIDENCE: The home provided care in a quiet, contemplative atmosphere where pastoral care was available from the sisters or priest on a daily basis. Mass and rosary were held every day for those wanting to attend. Activities available in the home included bingo, talking about the old days, sitting in the garden and St Patrick’s, Georges and David’s days celebrations. The music man came into the home for birthdays if the resident wanted. Residents were taken to the pantomime, botanical gardens, local church, for coffee and to the local shops if they wanted. Physiotherapy was also available on a regular basis. There was involvement with the local school children. One resident stated she did not like activities but preferred to read. Daily newspapers were available in the quiet lounge. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 13 Choices were available to residents. They were able to bring in some of their own furniture; choices were available at meal times and in daily activities. Menus were varied. Residents were happy with the food available. On the day of the inspection three courses were available at lunchtime including soup, pasta chicken or gammon, Swede, broccoli and roast potatoes. Staff were observed to offer the residents seconds. Residents were able to serve their own potatoes and vegetables that were placed on the table. Sauces were available at the table. Napkin rings had the resident’s names on them. The main alternative on the menu to the main meal was fish but this was at the request of the residents. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were protected by the policies and procedures in the home. EVIDENCE: No complaints had been made to the home directly and none had been lodged with the CSCI regarding the home. There were appropriate policies in place for the management of complaints and protection of the residents. The residents spoken to during the inspection stated that they were happy at the home. Staff were being appropriately recruited and training provided in adult protection. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home was clean and fresh creating a comfortable and safe environment for the residents living there. EVIDENCE: The home was clean, fresh and well maintained. There was ample communal space available in the home in the form of two lounges, a dining room and garden area. The furniture in the communal areas was of a good standard. Bedrooms were comfortable and most were personalised and had the appropriate furniture included in them. Some bedrooms were smaller in size and couldn’t accommodate all the furniture in them. One of the bedrooms had the wardrobe placed outside the bedroom, as there was not enough room to include it in the room. It was advised that the resident was given a choice as to whether she preferred to have the wardrobe in the bedroom rather than a chair that could be kept outside and taken into the bedroom when required. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 16 All bedrooms had either bedside lighting or a pull cord that enabled them to switch off the light from the bed. Bedrooms had star locks on the doors that needed to be made inoperable. There was a passenger lift that connected all three floors of the home. There were other adaptations in place including emergency call system and handrails. There was equipment available to help residents maintain their mobility including wheel chairs, zimmer frames and tripods. There was no hoist available in the home. There were sufficient numbers of toilets throughout the home and there were commodes available in bedrooms where required. There was a sluice machine available in the home. The flooring in the sluice room was due to be changed but as an interim measure the edges needed to be taped down for the health and safety of the staff. A separate hair dressing room was available for residents to have their done. There were three bathrooms available in the home, however; only one of these was adapted. Mainly the sisters who lived at the home used the domestic type baths. The emergency pull cord was not available from the toilet in the assisted bathroom. The emergency system needed to be available from both the facilities in the home. The home was centrally heated with radiators guarded and hot water temperatures appropriately controlled. There was a laundry room that housed the sluice cycle washing machine. The dryer and other equipment was located in the utility room. The home was found to be clean and fresh. There were no offensive odours throughout the home. There were no concerns regarding infection control procedures in the home, however, although residents had insisted on keeping a cotton towel available in one of the toilets, the staff toilet must have paper towels available to minimise the risks of cross infection. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The residents were cared for by staff who were trained and had the appropriate abilities however, staffing levels and the recruitment procedures needed to be improved to ensure that residents were safeguarded. EVIDENCE: Staffing levels were being maintained at three staff during the morning between 7.30am and 9.30am from Monday to Thursday and two members of staff for the remainder of the day. However, the other days of the week there were only two members of staff throughout the day. The manager must ensure that there are sufficient staff on duty during the early mornings to assist the residents. Staff receive the appropriate training. The majority of staff have achieved NVQ level 2 and one has started NVQ level 3. Staff undertook induction however; the manager was directed to the Skills for Care Induction training records. Two staff files were sampled. One of the files indicated that the CRB and references had not been returned to the home until after the person had started work. There was only one reference on this file and there was a gap in the employment history and there was no evidence on the file that the gap had been discussed with the member of staff. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home was managed so that a safe environment was provided and residents’ needs were attended to. EVIDENCE: The registered manager was a qualified nurse and kept her training updated to maintain this qualification. She has a qualification in management. She was an experienced manager of older persons care homes. The staff team worked well together and the manager encouraged the staff to take up training and developed their skills in all areas. There were good interactions noted between the staff and with the residents. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 19 The home was having monthly visits from its sister nursing home, questionnaires were undertaken with the residents to ascertain their satisfaction with respect to the services they received. The manager had then prepared a report showing the views of the residents. The manager stated that she intended to develop this further. The records of the monies held on behalf of the residents were sampled and all found to be in order. There were two signatures for all transactions however; the receipts for recent expenditures had not been put with the residents’ individual records. The manager was undertaking supervision with the staff but had not quite reached the required levels. There was some work outstanding following the fire officers visit to the home. This work was being planned but had not yet taken place as planning permission may be needed for some of it. All other maintenance records and fire records were in place providing the residents with a safe environment. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 20 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 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 2 3 2 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X 2 X 2 Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 21 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 OP3 Regulation 14(1) Requirement The home must ensure that the assessment carried out at the pre-admission visit is documented. The home must ensure that the care plans are personalised to the individual residents to ensure that the needs of the residents’ are met in the way they want. The home must ensure that there are skin integrity and nutritional assessments in place for all residents. The home must ensure that: • all medicines in the home are accounted for on the MAR charts • that all medicines carried over from one medication cycle to the next are recorded on the MAR chart • the actual amounts of medicines received into the home are recorded on the MAR chart. The emergency pull cord must be accessible from both the toilet and the bath in the assisted bathroom. DS0000016761.V314413.R01.S.doc Timescale for action 01/12/06 2. OP7 15 01/12/06 3. OP8 17(1)(a) Sch 3 (3) (m) 13(2) 01/12/06 4. OP9 01/12/06 5. OP22 13(4)(c) 01/01/07 Annie Bright Version 5.2 Page 22 6. 7. 8. OP24 OP26 OP27 13(4)(c) 13(3) 18(1)(a) The star locks on bedroom doors must be made inoperable. The cotton towel must be replaced with paper towels in the staff toilet. The home must ensure that three care staff are employed from 7-9.30 every morning including weekends to provide care. (Previous timescale of 15.03.06 not met.) All staff must have: • a relevant CRB check in place before they start work • two references • any gaps in employment history discussed and documented. 01/12/06 01/12/06 01/01/07 9. OP29 19(4) 01/12/06 10. 11. OP38 OP38 23(4)(c) (i) 13(4)(c) The CSCI must be informed how 01/12/06 the requirements of the fire officers visit are to be addressed. The flooring in the sluice room 01/12/06 must be made safe until it is replaced. 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. 3. 4. Refer to Standard OP23 OP28 OP35 OP36 Good Practice Recommendations The manager should discuss with the residents what furniture they would like in their bedrooms where there is limited space. The manager should access the Skills for Care website for induction training guidance. The manager should ensure that receipts are put with the financial records as expenditures take place. It is recommended that supervision of staff occur no less DS0000016761.V314413.R01.S.doc Version 5.2 Page 23 Annie Bright often than six times a year. Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 24 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 Annie Bright DS0000016761.V314413.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!