Inspection on 25/07/07 for Bearwood Nursing Home

This inspection was carried out on 25th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Bearwood Nursing Home 12/02/10

Bearwood Nursing Home 29/09/09

Bearwood Nursing Home 02/06/09

Bearwood Nursing Home 06/11/06

Bearwood Nursing Home 16/01/06

Bearwood Nursing Home 22/08/05

Bearwood Nursing Home 28/09/04

Bearwood Nursing Home 19/05/04

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 Bearwood Nursing Home 86 Bearwood Road Smethwick West Midlands B66 4HN Lead Inspector Mrs Amanda Hennessy Key Unannounced Inspection 25th July 2007 09:45 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 DS0000052879.V337775.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. DS0000052879.V337775.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bearwood Nursing Home Address 86 Bearwood Road Smethwick West Midlands B66 4HN 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) 0121 558 8509 0121 555 5182 Bearwood Nursing Home Ltd Chiedza Edith Ndoro Care Home 74 Category(ies) of Dementia - over 65 years of age (42), Old age, registration, with number not falling within any other category (60) of places DS0000052879.V337775.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user (male) identified in the variation report dated 21.1.2005 may be accommodated at the home in the category of LD. This will remain until such time that the service users placement is terminated. Two service users (male and female) identified in the variation report dated 21.1.05 accommodated at the home in the category of OP may be 60 years and over. This will remain until such time that the service users placements are terminated One service user (female) identified in the variation report dated 21.1.05 may be accommodated at the home in the category of MD(E). This will remain until such time that the service users placement is terminated. Service users to include up to 60 OP and up to 42 DE(E), not exceeding the total number registered for. Service users in the category DE(E) may be 60 years and over. One service user (male) aged 55 years and over, identified in the variation dated 17.11.05 may be accommodated at the home in the category of OP. This will remain until such time that the service users placement is terminated. 6th November 2006 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Bearwood Nursing Home provides nursing care for up to 74 elderly people. The home is a two-storey building with the second floor accessed by a passenger shaft lift. Bedrooms are on both floors with a mixture of double and single bedrooms some of which have ensuite facilities. There is a large lounge and dining room on the ground floor and two lounges/ dining rooms on the first floor. The home also has laundry and kitchen facilities. There is a large car park at the front of the home and patio/gardens to the rear. The home is close to local shops and amenities and is on a local bus route. The fees at the home range between £405 and £525 per week and are dependent on the needs of the residents and the room that they occupy. Hairdressing, toiletries, newspapers, Non National Health Service chiropody and physiotherapy are not included in the fee but are available at the home for an additional charge. DS0000052879.V337775.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection undertaken without any prior notice by two Inspectors. The inspection was carried out between 9.45 and 17.00. The inspection included a tour of the building, talking to people who live at the home, relatives, staff and the Manager, a review of records including information forwarded by the Manager before the inspection and survey comment cards that were completed by residents and their relatives. Care records were reviewed as part of the “case tracking” of seven people who live at the home and four staff records were also looked at. The home is owned by Bearwood Nursing Home Limited and is managed by Edith Ndoro. Six of the previous seven requirements have been addressed, or removed as they are no longer applicable; No new requirements were made as a result of this inspection. What the service does well: Bearwood Nursing Home is clean, homely and welcoming. The home prides itself on representing the local community and is a multi-cultural home. The home has an experienced manager and proprietor who provide effective and competent leadership for their staff. The Manager and Proprietor have a genuine wish to constantly improve and develop care and services that the home provides and listen and act on advice that they are given by other professionals. There is good information about the home for people who would like to live and who already live at the home. All prospective residents have a comprehensive assessment of their needs and can visit the home and have a meal before they come to live at the home. Residents have appropriate access to health care and the health care needs of the residents are identified and followed up by staff. The home has appropriate and safe administration and storage of medicines. There are no apparent rigid rules or routines in the home. Residents enjoy the activities and entertainment sessions that take place and appreciate the newsletter that informs them of what forthcoming activities and events at the home. There are no restrictions on visitors to the home within reasonable hours and visitors say that they are always made welcome. DS0000052879.V337775.R01.S.doc Version 5.2 Page 6 Residents say that the homes staff are very good, comments received included: ‘Staff are very good.’ “The carers are genuinely caring with the residents.” “ they have a good understanding of the needs of the ethnic residents”. 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. The summary of this inspection report can be made available in other formats on request. DS0000052879.V337775.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 DS0000052879.V337775.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home, prospective residents and their supporters are provided with good sources of information about the home and are invited to spend time at the home prior to admission to enable them to make an informed decision about coming to live at the home. EVIDENCE: The home has a statement of purpose and service users guide that provide good sources of information about the home from which to make informed decisions about the suitability of the home and the services they offer. A copy of the service user guide is available in each residents bedroom. Each case file includes a contract and a letter confirming that the agreed assessed needs can be met by the home, the letter also invites prospective service users to take the opportunity to visit and trial the services offered. DS0000052879.V337775.R01.S.doc Version 5.2 Page 9 People who wish to live at the home have a comprehensive assessment of their needs based on activities of daily living which they are involved in and this is recorded. The home reflects the cultural diversities of the local community by its residents, staff and facilities that are on offer and meets their needs. The home does not offer an intermediate care service. DS0000052879.V337775.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home have a plan of care that identifies all their care needs and instructions required to meet them. There are safe systems in place for the management and storage of people’s medicines. EVIDENCE: People who live at the home have a detailed plan of care that identifies their needs, preferences and choices and give staff instructions how their needs should be met. Care files include records of the individuals stated preferences for their daily routine such as rising, retiring and bathing. The Manager has been working hard to ensure that care plans reflect people as individuals which is termed “person centred care” and she will continue to develop this. Risk assessments identify when there is concern about peoples risk of developing pressure sores, their moving and handling needs and their DS0000052879.V337775.R01.S.doc Version 5.2 Page 11 nutritional status with actions being undertaken by staff to safeguard residents. All service users are registered with a GP and are seen regularly seen by other health professionals such as Chiropodists, Dentists, Opticians and when required Dieticians, Speech and Language Therapists and Tissue Viability Nurses. Medication administration is undertaken by nursing staff using the NOMAD monitored dosage system. Discussion with staff and observation of practice confirms that medication administration record (MAR) charts are completed at the time of administrating the medication. The MAR charts examined were completed accurately and are subject to weekly internal audit. Arrangements for all aspects of medication management are robust. Records identify the name that people prefer to be called by. Staff were seen to knock on bedroom doors and were seen to respect residents and their cultural differences. DS0000052879.V337775.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People find that the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. EVIDENCE: The home has an activities programme that is displayed on the main notice board Activities available include exercises, music and movement, entertainers, individual shopping trips and singalong sessions. Hairdressing, aromatherapy, manicure and pedicures are regularly available. The spiritual needs are met with frequent church visits and services and a number of residents attend the temple close by. The home has an open visiting policy, which was observed in action with visitors arriving and leaving during the inspection. Visitors spoken with said they felt they are welcome at any time. DS0000052879.V337775.R01.S.doc Version 5.2 Page 13 Care plans identify residents individual likes and dislikes and choices about their individual routines, these are carried out flexibly to provide for choice of the moment. A number of service users continue to handle their financial affairs although most are handled by their families. Residents are able to personalise their rooms and it was lovely to see that many had taken this opportunity with treasured possessions. Residents say that “food is very good” and “there is always a choice” . One family also commented that is was good that there is an extensive ethnic menu available. It was lovely to see the extent of choice available with options of sausage casserole, homemade steak and onion pie, cheese and potato pie, traditional Asian vegetarian curry with rice and chapattis all with a choice of vegetables and potatoes if required whilst other residents opted for sandwiches and baked potatoes. Pudding were home made apple pie or rice pudding. Staff were seen to offer assistance where necessary. One member of staff was seen to mix up the pureed diet which would have been unappetising for the resident and also served milk already in a jug with the tea- The proprietor also observed this practice has since addressed it with the member of staff concerned. DS0000052879.V337775.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe environment and has appropriate systems in place in which people can voice concerns and are confident that they will be listened to and responded to appropriately. EVIDENCE: The home has an appropriate complaints procedure and maintains a detailed record of the complaint investigation and the outcome, Seven complaints were recorded and resolved to the complainants satisfaction two of these were investigated under adult protection procedures. Residents and residents said when they had raised any concerns: “ The response is very good. The Manager will always find time to discuss any issues raised and give satisfactory answers”. Service user meetings are held monthly and are a good platform for developing ideas whether in respect of planning events or adapting the menus. The home has robust procedures for responding to any suggestion of abuse and training is given to staff in adult protection procedures. Staff spoken to were clear of actions that they should take if any allegations of abuse were identified. DS0000052879.V337775.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, comfortable and homely and is a pleasant place for people to live. EVIDENCE: Bearwood Nursing Home is a large converted two-storey building. Lounge and dining rooms are provided on both the ground and the first floor. There is a choice of double or single occupancy rooms with some having en-suite facilities on both floors. The home has had a major refurbishment which is ongoing since it has been owned by its current proprietors. All rooms and corridors are painted on an annual basis and the planned replacement of all carpets is ongoing. New bed linen has been purchased and had recently been delivered, although had not been put on beds at the time of the inspection. The proprietor has also recently DS0000052879.V337775.R01.S.doc Version 5.2 Page 16 ordered new bedroom furniture for twenty of the bedrooms and this will be ongoing until all bedroom furniture has been replaced. One relative commented that the iron hospital beds were like “prison beds” and it was good to hear that these beds have also been identified for replacement with some beds already replaced with variable height beds. A proportion of bedrooms were viewed and these meet standards for space, furniture, heating and lighting with hot water subject to control by mixing valves and monitored frequently. Several lounge chairs were seen to be marked and had some upholstery damage and require refurbishment, which the Proprietor said was being planned as part of the homes refurbishment plan. There is a large car park at the front of the home and patio/gardens to the rear. The exterior patio areas have patio furniture but would be more attractive with the addition of plants and flowers in the patio pots. The home was found to be clean, hygienic and free from odours, each floor has sluice disinfection facilities. The Proprietors have invested in a new “State of the Art” laundry that minimises the risk of infection to people at the home. DS0000052879.V337775.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient staff to meet residents needs. Recruitment and selection procedures are robust and safeguard the service users. Staff training opportunities are good. EVIDENCE: The home employs a culturally sensitive, diverse range of staff who are suitably trained to meet the needs of people who live at the home. The number of staff is dependent upon the service user needs with additional staff available at peak activity times. Staff have good training opportunities available and there are 50 of the care staff with a care qualification. The training matrix identifies good progress in achieving mandatory targets for moving and handling, fire safety food hygiene, adult protection and health and safety. Other training includes pressure care, care planning, administration of medicines, infection control, dementia awareness and continence management, wound care and nutrition. A training file indexes all training given with copies of certificates issued. Staff spoken to during the inspection were very positive about their rolekitchen staff were eager for the Inspectors to sample the food provided at mealtimes. Care staff spoke positively about training opportunities they had DS0000052879.V337775.R01.S.doc Version 5.2 Page 18 and how much they enjoyed working at the home and caring for people who live at the home. Recruitment and selection procedures at the home are robust and protect the service users with all required checks in place before the new employee commences work. New staff receive induction training when they start employment at the home. DS0000052879.V337775.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager of the home provides effective leadership to ensure the smooth running of the home. Systems are in place to continuously monitor the service on offer with a view to continuous improvement and ensure that people who live at the home are listened to. Residents’ health and safety is safeguarded at the home. EVIDENCE: The manager is a registered nurse with extensive experience in care home management and holds the NVQ level 4 award in care management. Staff said that the senior staff are very approachable and work closely with them. There are also regular staff meetings that assist communication at the home. DS0000052879.V337775.R01.S.doc Version 5.2 Page 20 People who live at the home are regularly surveyed for their views with a range of questionnaires that between them cover all aspects of service. A quarterly surgery is held for relatives to proactively seek their views about the service and notes and actions / responses are also kept. The home does not act as appointee for service users but have in place good accounting practice to assist service users in keeping their personal allowance safe. Supervision notes demonstrate an effective formal supervision process for staff of at least six times per year. Annual appraisals have also been undertaken. Policies and procedures are available for staff to read. Health and Safety is given appropriate priority with an extensive range of monitoring and maintenance in place. During the tour of the building it was observed that all corridors and fire escape ways were clear. An inspection of the monitoring records shows these to have satisfactory results and kept in good order. Staff training in health and safety and fire safety training is satisfactory. DS0000052879.V337775.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 3 x 3 DS0000052879.V337775.R01.S.doc Version 5.2 Page 22 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 OP24 Regulation 16(2)(c) Requirement The registered person must ensure that furniture is maintained in good order and replaced when damaged in a timely way. Timescale of the 31/12/06 not fully addressed Timescale for action 31/12/07 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 Refer to Standard OP7 OP12 OP16 Good Practice Recommendations Person centred care is developed. The manager should broaden the range of activity provision and opportunities for outings. All information pertaining to complaints is kept together DS0000052879.V337775.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000052879.V337775.R01.S.doc Version 5.2 Page 24 - 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. 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