CARE HOMES FOR OLDER PEOPLE
Annie Bright 6 Norfolk Road Edgbaston Birmingham West Midlands B15 3QD Lead Inspector
Jill Brown Unannounced Inspection 16th December 2005 10:00 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.V273970.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. Annie Bright DS0000016761.V273970.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Annie Bright Address 6 Norfolk Road Edgbaston Birmingham West Midlands B15 3QD 454 1289 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.V273970.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th July 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.V273970.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An unannounced inspection took place at the home over two and half hours in December. The home had received a full announced inspection in July with all but two of the core standards being assessed at that point. This report should be read with the report of the announced inspection that took place in July. Four residents were spoken to during the inspection and two staff. Care records for two residents were looked at. Some maintenance records were viewed, a number of employment records checked and the reports of the representative of the provider’s monthly visits were looked at. What the service does well: What has improved since the last inspection?
The home had acted on previous inspection requirements. The hall carpet had been replaced, the assisted bathing facility had been repaired and a radiator that had been missed had been covered to ensure a safe surface temperature. The home had recruited another senior care but the ill health of the existing senior staff had prevented the benefit of this being felt. Annie Bright DS0000016761.V273970.R01.S.doc Version 5.1 Page 6 Staff spoken to said that they had undertaken the management of medication course 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. Annie Bright DS0000016761.V273970.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 Annie Bright DS0000016761.V273970.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&5 The arrangements for the assessments of residents was good and this enables the home to meet residents needs. EVIDENCE: The homes records showed that prior to a resident’s admission they had an assessment of needs. This assessment was undertaken both by the relevant social services department and buy the home. The assessment provided appropriate information about the resident’s health and social needs. The home also admitted in emergency if necessary as part of the ethos of the home. The home was clear when a resident’s health needs were too much for them to manage and made appropriate referrals for reassessment. The home offers a contemplative religious placement and is suited for those residents that wish that type of environment. Annie Bright DS0000016761.V273970.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 arrangements for the care planning and meeting health needs were good and this keeps residents well. Medication administration needs regular and routine auditing to ensure that mistakes can be found. EVIDENCE: The home does extensive care plans that are reviewed when need changes. These care plans include a lot of detail on the medical condition of the resident the medication and the management of care. In addition further shorter term plans are drawn up and looked at on a more regular basis usually monthly. The home completes risk assessments and moving handling assessments and these are usually reviewed on a 3 monthly basis routinely. Residents appeared in good health and had their personal hygiene needs attended to. Residents at the home have few falls and have contact with health professionals when needed. The weights of residents suggested that residents’ nutritional needs were met. Residents spoken to were happy with the care that they received and said that they get help when they needed. One resident said ‘They give me help because my knees have gone quite stiff.’
Annie Bright DS0000016761.V273970.R01.S.doc Version 5.1 Page 10 Medication was generally well managed and staff administering medication had attended an appropriate course. A previous requirement to return excess stock had been acted upon. The home had to keep with auditing medication and a number of gaps were found on the medication administration record. Annie Bright DS0000016761.V273970.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): EVIDENCE: These standards were not assessed on this occasion. Annie Bright DS0000016761.V273970.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed on this occasion. Annie Bright DS0000016761.V273970.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The home was clean and fresh and this provides a good environment for residents. EVIDENCE: Although a tour of the building was not undertaken on this inspection the home had replaced the large carpet in the large main reception hall, which had some threads showing. Since the last inspection an uncovered radiator has now been covered. The home’s assisted bathing facility was now in working order. The areas of the home that the inspector visited were clean and fresh. The homes environment caused no concern on the last inspection. One resident said ‘My room is lovely.’ Annie Bright DS0000016761.V273970.R01.S.doc Version 5.1 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 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 Arrangements for employment of staff needed improvement to ensure the safety of residents. EVIDENCE: Staffing at the home had caused some difficulty since the last inspection due to long term sickness and the home hadn’t ensured that staff had all the required up to date checks prior to employment. The home must ensure it complies with new processes from the Criminal Records Bureau. Annie Bright DS0000016761.V273970.R01.S.doc Version 5.1 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 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): 33,35 & 38 The management of residents’ money was satisfactory. Some improvements could be made to the auditing of the homes service to improve the service provided for residents. EVIDENCE: The home manager was not present at this inspection and therefore immediate access to quality assurance paperwork was difficult. It appeared that the home was undertaking quality surveys with residents and their families about twice yearly. The home did not have an independent survey of the service it provides. Peer audits from the home’s sister nursing home may provide a suitable alternative. The home has regular visits from the representative of the provider and the inspector on this inspection saw reports of these visits. The home only manages small amounts of float to assist relatives and residents. The majority of the finance is managed by the resident themselves or by relatives. The home accounts for each amount of money well and
Annie Bright DS0000016761.V273970.R01.S.doc Version 5.1 Page 16 receipts are kept of this spending. The money spent is usually for items such as hairdressing and chiropody. The home stated that residents have access to their money when needed. The recommendation for the level of supervision to be improved was not inspected on this occasion and was brought forward. Maintenance records checked showed that the home was undertaking routine maintenance of the building. Annie Bright DS0000016761.V273970.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 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 X X 2 X 3 X X 3 Annie Bright DS0000016761.V273970.R01.S.doc Version 5.1 Page 18 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 OP9 Regulation 13(2) Requirement The home must undertake audits of staff competence in administering medication. (This requirement was outstanding since 31/07/05) Medication Administration Records must show why a medication is not given. The home must ensure that three care staff are employed from 7-10.30 every morning including weekends to provide care. (This requirement was not assessed on this occasion) The home must ensure that a senior member of staff is employed to ensure that the home can supply a senior member staff during waking hours. (This requirement was not assessed on this occasion.) All staff must have a relevant CRB check in place. (This requirement was outstanding since 30/12/04) Timescale for action 15/02/06 2. 3. OP9 op27 13(2) 18(1)(a) 15/02/06 15/03/06 4. OP27 18(1)(a) 15/03/06 5. OP29 19 (4) 15/02/06 Annie Bright DS0000016761.V273970.R01.S.doc Version 5.1 Page 19 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 OP33 OP36 Good Practice Recommendations It is recommended that the home increase its auditing to include peer auditing. It is recommended that supervision of staff occur no less often than six times a year. Annie Bright DS0000016761.V273970.R01.S.doc Version 5.1 Page 20 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
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