CARE HOMES FOR OLDER PEOPLE
Annie Bright 6 Norfolk Road Edgbaston Birmingham B15 3QD Lead Inspector
Jill Brown Announced 7 July 2005
th 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. Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Annie Bright Address 6 Norfolk Road Edgbaston Birmingham B15 3QD 0121 454 1289 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) Sisters of Charity of St Paul Claudine Buchanan Care Home 15 Category(ies) of Care Home registration, with number of places Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11 October 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 E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An announced inspection took place on a day in July. Nine residents were spoken to during the inspection and three staff. Thirteen comment cards were received nine from residents, two from relatives and two from health professionals. Three residents care records were seen as well as three staff records. All staff files were checked for Criminal Records Bureau checks. A tour of the building was undertaken excluding the kitchen and maintenance inspection records were checked. The inspector joined residents for a meal. What the service does well:
Comment cards from relatives spoke of the home’s care being excellent. Comment cards from health professionals indicated that the care was satisfactory. All of the residents spoken to were happy with the care given and this was true of the comment cards received from residents. The home had excellent care plans that indicated the care required for all the needs identified. There was evidence that the home were increasingly trying to involve residents and their representatives in setting up plans. Plans were reviewed monthly in depth for any changes in residents’ conditions and where necessary changes to the care plan were made. The home undertakes appropriate risk assessments for falls and a general risk assessment. The home had a Food Safety Department inspection recently, which stated that the kitchen facilities were excellent. The home produced a very good three course main meal at lunchtime and this was the usual practice. Residents were offered soup, a choice of either chicken or steak dinner with usual vegetables, and strawberries and cream or rice pudding and cheese and biscuits for pudding. The home manages the Health and Safety requirements of the building well. Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 6 Staff training was well organised and there was evidence of planning to ensure staff training remained in date. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 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 Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3, 4 & 5 Residents receive information about the service the home offers and this enables residents to make a choice about its suitability. The home assesses potential residents well and this ensures that the home can meet residents’ needs. EVIDENCE: The home has produced a statement of purpose and service user guide and these are sent to residents and their families. The home collects information about resident’s needs and where possible the potential resident visits the home prior to admission. The home has accepted residents as an emergency if the circumstances warrant this. Where residents have not visited the home prior to admission the home checks information as soon as possible afterwards. The assessment information covers all the areas required and also contains information about residents’ preferences in food, daily routines and so on.
Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 9 The registered manager was aware of the conditions of registration and all of the residents’ needs met with these conditions. The home provides a contemplative, quiet placement where women can practice their faith. One resident put in the comment card that staff were ‘well organised and respond to requests without fail.’ Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9, & 10 The home gives a high standard of care and health needs are met. The home has installed good practices in medicine management and the staff were keen to improve practices further. EVIDENCE: Residents’ care plans were excellent. As well as providing instructions on how care needs were to be met they contained plans around health issues such as angina. These plans contained information on signs and symptoms of angina and where pain-relieving sprays are kept. Plans on residents that wander had information on times when this was more likely as well as strategies to minimise risk. New residents had checks from the optician and chiropodist within a few days of admission. Falls were risk assessed and as far as possible prevented. From the accident records and notifications to the Commission residents at this home do not have a lot of falls. The home records resident’s weights these have become more accurate as the home has purchased a set of sit-on the scales. Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 11 Medication was generally well managed and residents were offered their medication discreetly and sensitively. One ‘as required’ medication looked at did not tally with the records. The home has some enemas in stock and these must be returned to the pharmacy. The inspector suggested that the home record when a new bottle of liquid medication is opened to ease audits. Audits of medication were undertaken but not of staff competence. Staff had not had accredited training in administration of medication although the inspector was informed that this was booked. Some medicinal creams did not have a date of opening and had been kept longer than a month. The senior care had been given dedicated time for clerking in of medication and to undertake checks and this must continue. Resident’s privacy and dignity was maintained at all times and the home maintains a serene environment. Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,& 15 A range of individual choices, good food and the welcoming of visitors have improved the residents’ lives and led to a high degree of satisfaction expressed. EVIDENCE: The home provides a gentle exercise session for the residents from a trained occupational therapist on a fortnightly basis. The residents take the Rosary every morning. Staff arranged activities but the residents sometimes do not wish to join in. Some residents are self-motivated and read or listen to music in their own rooms. Residents liked having time in the garden and residents said they had enough to do. One relative described the care as excellent. There were no undue restrictions on visitors. The home has a small conservatory where residents can receive visitors in private if they wish. The residents decided to come to this home because of the lifestyle it offered. This contemplative quiet environment with its set patterns would not suit all people requiring care. However all the residents in this home are happy with the choice they have made. One resident told the inspector ‘you couldn’t find anywhere better in the whole world.’
Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 13 The home provided very good meals for the residents. There was a three course meal of soup, dinner and pudding provided every day. There were choices of dinner and pudding. The food was well prepared and cooked. Meals were taken in a large dining room. Residents serve themselves vegetables, sauces and so on and in this way maintain some independence. The home had a recent inspection from the Food Safety Department that described their kitchen facilities and practices as ‘excellent’. Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home has appropriate polices and procedures in place to safeguard residents. EVIDENCE: The home did not have any complaints recorded and the Commission had not received any complaints since the last inspection. The Adult Protection procedure and restraint procedures had been amended since the last inspection and now meet the requirements. All staff had undertaken a course in adult protection and challenging behaviour recently. Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24,25 & 26 The home provided a homely clean and safe environment for residents. EVIDENCE: The Home was clean, fresh and well maintained. Some areas of carpet were becoming threadbare the home had programmed for work. The home has large comfortable main lounge, a small conservatory and a nice dining area and these meet the required standard. The home had some problems with the assisted bath, the registered manager informed the inspector that this had been reported to the supplying company and was in hand. This must be fixed without delay. The home had increased the partitioning between the toilets and the hairdressing unit to increase the privacy for the residents and the inspector welcomed this. The home had removed the sluice and installed a commode pan disinfector since the last inspection.
Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 16 Resident’s bedrooms were well decorated and residents had adequate levels of furniture. One bedroom had been missed for the covering of radiators as it had been used by one of the Sisters of the home. Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 & 30 Improvements are required on staffing and CRB checks to ensure the wellbeing of residents. Staff were well trained and this ensures good care for residents EVIDENCE: The home has two care staff on duty during waking hours. A Sister works from Monday to Friday from 7.30 to 9.30 am to assist with the busy morning duties this is required at the weekends too. The Registered Manager is on duty during office hours during the week and shares on call duties. The home had one senior care. The home employs kitchen and cleaning staff. There is one member of staff awake and on duty at night however, the resident Sisters if needed supply immediate practical help and the manager and senior care share on call duties. The home’s rota must reflect these arrangements. The home has tried to recruit to the senior care post but has been unsuccessful. The home stated in their pre inspection questionnaire that all care staff have an NVQ2 in care or above. This exceeds the required standard. Some staff are to enrol on the NVQ3. The homes staff records have improved. Some staff were found to have Criminal Records Bureau checks from other employment and the home must ensure that these are redone. A conversation with the Immigration Department about the status of a passport was not recorded on the staff member’s file.
Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 18 The home plans its training and a matrix of the staff team’s training was available for inspection. The home is on target for meeting all the training requirements for its staff. Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36, 37 & 38 The arrangements for the management of health in safety in the home were met. 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 registered manager was conducting appraisal meetings with staff but these meetings were not at the level of two monthly as recommended for supervision. The home kept good detailed structured records and information from these could be extracted easily. Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 20 The home maintained all lifting equipment and appropriate inspections undertaken. Fire records indicated that all necessary checks and drills were undertaken. The home had been rewired since the last inspection. There was an appropriate Gas Landlords certificate and the homes water supply had been tested and found to be clear of Legionella. Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 2 3 2 x x 3 2 3 STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x 2 3 3 Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 22 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 op9 Regulation 13(2) Requirement The home must undertake audits of staff competence in administering medication. A named as required medication must be checked to verify amount. The enemas in stock must be returned to the pharmacy. Timescale for action 31/07/05 23/07/05 23/07/05 Medicinal creams must have a 31/07/05 date of openign and be discarded after 28 days to prevent microbacterial infection. Any staff handling medication must seek accredited training in the safe handling of medicines. (this last requirement was oustanding since 30/12/04) The registered provider must ensure that carpets are kept under review and have a programme of replacement for those beginning to wear. (this requirement was outstanding since 31/12/04) The home must provide evidence of the assisted bathing facility being in working order 30/09/05 2. op19 23(2)(b) 30/09/05 3. op21 23(2)(c) 31/07/05 Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 23 4. 5. op25 op27 13(4)(c) (i) 18(1)(a) The radiator that is uncovered in a residents bedroom must be covered The home must ensure that three care staff are employed from 7-10.30 every morning including weekends to provide care. 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. (these requirements remain outstanding since 30/12/04 All staff must have a relevant CRB check in place. (this requirement was outstanding since 30/12/04) the registered manager must keep records with Immigration Department where this affects the employment of staff. 07/08/05* 31/08/05 6. op29 19 (4) 07/09/05* RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard op36 Good Practice Recommendations it is recommended that supervision of staff occurs no less often than six times a year. Annie Bright E54_S16761_AnnieBright_V233025_070705 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Birmingham and Solihull 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
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