Inspection on 16/02/06 for Birkdale

This inspection was carried out on 16th February 2006.

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

Birkdale 21/10/08

Birkdale 15/12/06

Birkdale 15/06/06

Birkdale 24/05/05

Birkdale 03/12/04

Birkdale 01/07/04

Birkdale 12/02/04

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 Birkdale Station Hill Oakengates Telford Shropshire TF2 9AA Lead Inspector Keith Salmon Unannounced Inspection 16th February 2006 13:15 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 Birkdale DS0000049825.V275808.R02.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. Birkdale DS0000049825.V275808.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Birkdale Address Station Hill Oakengates Telford Shropshire TF2 9AA 01952 620278 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) The Keepings Ltd Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Birkdale DS0000049825.V275808.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 29 persons, whilst the person named on the attached schedule (not to be displayed) is resident. 24th May 2005 Date of last inspection Brief Description of the Service: Birkdale, one of two homes owned by The Keepings Ltd, is a Care Home providing accommodation and personal care for up to twenty-eight people over the age of sixty-five. Situated close to Oakengates Town centre it is accessible to a variety of local amenities and public transport. A large, two-storey, detached property it provides single and twin-bedded accommodation with communal sitting/dining areas. There is generous car parking space to the front and a sheltered garden to the rear. Access to the rooms on the first floor is facilitated by a passenger lift. Birkdale DS0000049825.V275808.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection, undertaken by one Inspector, commenced at 13.15 and lasted 3.0 hours. This Report is a product of observations made during a tour of the Home, through discussions with the Manger (Rebecca Lambourne), members of Staff and 3 Residents. In addition, a review was undertaken of care related documentation, staff recruitment/deployment records, and a range of documents/records reflecting the general operation of the Home. The Inspector had visited the Home as part of an Inspection in late 2003 at the time of change of ownership to the present owners. At that time the overall impression was of a Home which was shabby in appearance and lacking strong, clear, management. At the time of this Inspection the Home showed a marked improvement both in general appearance and management. What the service does well: What has improved since the last inspection? Since the previous Inspection, held in May 2005, the Management and Staff have continued to work well to meet the ‘Required’ improvements. In particular, efforts have been successfully directed at resolving issues in the following areas: - direct involvement of Residents in care planning, nutritional screening, care planning documentation – particularly ‘Risk Assessment’ processes, and infection control practices. Birkdale DS0000049825.V275808.R02.S.doc Version 5.1 Page 6 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. Birkdale DS0000049825.V275808.R02.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 Birkdale DS0000049825.V275808.R02.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): 2. Residents’ rights are protected by a written Contract setting out Terms and Conditions of Residency. The ‘Requirement’, cited at the two previous Inspections is now fully met. EVIDENCE: A random sample of Residents records showed evidence of written Contracts setting out Terms and Conditions of Residency, which had also been countersigned by the Resident or their Relative/Advocate. Birkdale DS0000049825.V275808.R02.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): 7,8,9,10,11 A Care Plan for each Resident’s is now drawn up, individually relevant, and modified as necessary with full involvement of the Resident or Relative/Advocate. Care planning documentation is now satisfactory in areas previously criticised, i.e. nutritional screening, consent for bedrails use, obtaining Resident’s wishes for arrangements following death. The storage, administration and disposal of medicines are in accordance with accepted good practice. EVIDENCE: A randomly selected sample of Care Plans demonstrated evidence which fully supporting the above judgements. Two ‘Recommendations’ from the previous Inspection have been fulfilled. These were:- a sample of the medication administrators signature (and initial used) is obtained and kept with the Medication Administration Records and a maximum/minimum thermometer has been purchased for the accurate recording of the temperature range within the medicines refrigerator. Birkdale DS0000049825.V275808.R02.S.doc Version 5.1 Page 10 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): 12,14,15. The routines of daily living at Birkdale appear flexible. Residents are afforded the opportunity to find a ‘lifestyle’, which matches their expectations, interests, preferences and abilities. Where Residents’ capabilities permit, the Home works with Residents to enable good contact with family and friends and the continuation of religious practices. The Home provides nutritionally balanced meals based on the type of food preferred by the Residents. EVIDENCE: Discussion with Residents, and review of Care Plans, demonstrated clear opportunities for Residents to partake in a range of leisure opportunities, consistent with their individual capabilities. Discussion with the Manager, Cook and Residents, together with a review of the published menu (four weekly cycle with seasonal variations), confirmed the meal regime is nutritionally balanced, interesting and continually open to change reflecting Residents’ preferences. Birkdale DS0000049825.V275808.R02.S.doc Version 5.1 Page 11 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. The interests of Residents are protected through ready access to the Home’s Complaints Procedure, and information relating to advocacy services. EVIDENCE: Complaints procedure details are included in the Service User Guide, and are displayed prominently for the benefit of visitors. Residents informed the Inspector they felt able to complain, should it be necessary, and felt assured the Home would investigate properly and productively. Birkdale DS0000049825.V275808.R02.S.doc Version 5.1 Page 12 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): 19,21,22,24,26. The physical appearance of the Home, both internal and external, is generally much improved. With the exception of an issue, identified below, Residents live in a safe, well-maintained environment, in which privacy is enabled and personal possessions can be securely stored. Specialist equipment is available to facilitate provision of care, e.g. hoists, wheelchairs, stand-aids and are consistent with the needs of Service Users. Infection control practices have improved and are now generally satisfactory. EVIDENCE: Recent painting of the stucco facia of the building, and the addition of a nicely furnished sun lounge, giving access to the rear garden, are distinct improvements to the accommodation. Also, a number of mature trees to the rear have been removed/trimmed allowing better light to permeate the rooms at the rear of the building. A ‘Requirement’ from the previous Inspection was that door wedges should not be used to hold open ‘self-closing’ doors. A tour of the Home demonstrated this ‘Requirement’ had been effectively addressed with the exception of the door entering one bedroom. It was explained to the Inspector it was the wish of the Resident for the door to remain open. Whilst it Birkdale DS0000049825.V275808.R02.S.doc Version 5.1 Page 13 is generally correct to follow Residents’ wishes in such matters in this instance the ‘fire risk’ remains unacceptable. The Inspector noted some doors within the Home have magnetic holding catches linked to the fire alarm – therefore, it is a ‘Requirement’ of this Inspection that if the wishes of this particular Resident are to be respected, the Home must either link the Resident’s room to the ‘magnetic catch/fire alarm’ system, or, with the Resident’s agreement, move the Resident to a bedroom which is linked to the system. All bedrooms do not have facility for Residents to lock their room if they wish. However, formal enquiry of individual Resident’s wishes in this matter, has been made/documented and appropriate ‘risk assessment’ undertaken, thus accommodating those that wish to have a key to their bedroom (and are safe to do so). It is ‘Recommended’ that the Home has suitable spare locks on site for fitting, at short notice, by the maintenance staff. It was also observed that all Residents now have a lockable storage facility in their bedroom and those who wish to may have a mini-safe installed. All hand-washing facilities now have liquid soap, disposable paper towels and waste bins. However, infection prevention/control would be further enhanced by the installation of an automatic sluicing disinfector, on each floor, for the safe disposal of bodily waste – if necessary on a phased basis. Birkdale DS0000049825.V275808.R02.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): 27,29,30. Staff numbers and skill-mix on duty were consistent with that shown on the rota, and appeared sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with safeguarding of Residents. EVIDENCE: The current staffing rota, and those from the immediately preceding weeks, were examined. Staffing numbers and skill-mix enable a service provision, which meets the care needs of the Service Users. A sampling of Staff Personnel Files demonstrated evidence of compliance with the Standard and Schedule 2 of the Regulations. Birkdale DS0000049825.V275808.R02.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): 31,33,38. Operationally, the Home is very well organised, with the central purpose being ‘the best interests of Residents’. Lines of accountability are clearly defined and observed. Staff are subject to effective support, with regular supervision, and appeared involved and happy in their work. Residents and Staff live and work in a generally safe environment. EVIDENCE: The recently appointed Manager has now been in post since the post became vacant in September 2005. Discussion with the Manager and Residents, plus observation by the Inspector, suggest that during the period since her appointment she has worked very effectively, with good support from the Responsible Person, to improve management practices and the overall ambience of the Home. It is understood the Manager will, during the coming weeks, be applying for CSCI approval to become Registered Manager. Since the previous Inspection, the Home has effectively addressed ‘Requirements’ relating to the safe storage of opened food jars, replacement of a food trolley Birkdale DS0000049825.V275808.R02.S.doc Version 5.1 Page 16 and replacement of a freezer. The Home’s operational practices in the context of health, safety and welfare of Residents, Visitors and Staff were seen to be in accordance with the Regulations. Birkdale DS0000049825.V275808.R02.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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X 3 Birkdale DS0000049825.V275808.R02.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 OP19 Regulation 23(4)(c)(i) Timescale for action Where particular Residents wishe 31/03/06 their bedroom door to be kept open this must be effected by an approved system (e.g. by linking the particular door into a ‘magnetic catch/fire alarm’ system). The Manager must apply to CSCI 31/03/06 for approval to become Registered Manager Requirement 2. OP31 9-(1)(2) 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 OP24 OP26 Good Practice Recommendations It is ‘Recommended’ that the Home has suitable spare locks on site for fitting, when Required by Residents (subject to ‘Risk Assessment’), by the maintenance staff. It is ‘Recommended’ that consideration be given to the installation of automatic sluicing disinfectors, on each floor, for the safe disposal of bodily waste. Birkdale DS0000049825.V275808.R02.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. 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