Inspection on 28/07/05 for Bluebrooke Residential Care Home

This inspection was carried out on 28th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bluebrooke Residential Care Home 20/04/09

Bluebrooke Residential Care Home 04/12/08

Bluebrooke Residential Care Home 23/04/08

Bluebrooke Residential Care Home 23/05/07

Bluebrooke Residential Care Home 05/06/06

Bluebrooke Residential Care Home 29/10/05

Bluebrooke Residential Care Home 02/03/05

Bluebrooke Residential Care Home 14/09/04

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Heathlands

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Inspirations

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

CARE HOMES FOR OLDER PEOPLE Catshill Residential Care Home 242 Stourbridge Road Catshill Bromsgrove, Worcestershire B61 9LE Lead Inspector Annie OMara Unannounced 28 July 2005. 07:30 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. Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Catshill Residential Care Home Address 242 Stourbridge Road, Catshill, Bromsgrove, Worcestershire B61 9LE 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) 01527 877152 Oldfield Residential Care Limited Mrs Maria Hogg Care Home 46 Category(ies) of DE(E) Dementia over 65 (46) registration, with number OP Old age (46) of places PD(E) Physical disability over 65 (46) Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The four bedrooms on the top floor of the home are not used for service users with mobility needs 2. Staffing levels are increased to match the Residential Forums recommended levels which are that seven staff are on duty throughout the waking day. Date of last inspection 2 March 2005 Brief Description of the Service: Catshill provides personal care for up to forty-six people who have physical disability and/or mental health needs associated with old age. The home has a high proportion of service users who are mentally frail.The home is situated in a residential area approximately two miles from Bromsgrove town centre. The home is on a local bus route and there is a public house at the end of the road.The home is a converted town house with three floors and a purpose built wing which is in two floors. Access to the first floors is by two passenger lifts and a stair lift to the three bedrooms on the top floor. The twenty-four bedrooms in the old house do not have ensuite facilities with the exception of one room, and eight of the rooms are doublerooms. All thirteen of the bedrooms in the new extension have ensuite facilities and one is a double room. There are adapted bathing facilites throughout the home which are currently being up-graded. The home has an enclosed garden. Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the early morning to early afternoon. Observations were made of care practices and a brief tour of the buildings was undertaken. Residents care records were examined, including assessments and care plans. Staff records were also examined. The main focus for this inspection was checking on the requirements from the last inspection. What the service does well: What has improved since the last inspection? There were forty requirements and twelve recommendations made at the last inspection. The home has gone a long way towards meeting them including the following: The assessment and care planning systems have improved. The involvement of specialised primary health carers has supported the work of the home to help them move towards meeting the specialist care needs of the residents. The manner in which shifts are managed with staff now being given specific tasks for each day has improved the way in which care is provided. The way in which meals are managed has improved the maintenance of residents’ independence. Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 6 The environment continues to be improved and a specialist bath has been provided. Commode washers have been provided. Training for staff has improved especially in the care of residents with specialist needs. The majority of recruitment practices have improved and staff are receiving supervision. 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. Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 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 Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 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, 2, 3, 4, Information is provided about the home but does not show all of the services provided to help people make an informed decision about moving to the home. Assessment processes do not provide all the information needed to ensure that residents’ needs are fully understood at the point of admission. EVIDENCE: The statement of purpose and service users guide was available in the reception area and contained most of the required information. The contract of terms and conditions was available and in order. Two of the homes’ assessment forms were seen for residents’ admitted to the home that had not been completed in detail. It was not clear from one assessment why the resident was being admitted and there was no information available from a previous placement. There were special considerations for the resident which had not been recorded, nor was there any risk assessments in place for the protection of other residents. The other residents’ file had a community care assessment. There was no evidence that either resident had visited the home prior to admission or reason why they had not. Training in the specialist needs of the residents had taken place since the last inspection. Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 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 standard(s) 7, 8, 9, 10. Residents are not safeguarded through the current planning and record keeping systems. Medication systems have improved, but again, there remains shortfalls in recording. This places residents at risk. EVIDENCE: Care plans seen showed some improvements from the previous inspection and contained more detailed information, although there were still some shortfalls in recording. For example, the daily records for the newly admitted residents’ gave no information about their arrival at the home or their admission. There was no information as to how they had been supported during their first evening at the home. Care plans contained risk assessments that evidenced that other professionals had been involved as appropriate with specialist care needs. A risk assessment written for a resident with challenging behaviour gave clear instructions to staff as to how they would manage the behaviour. This had however, not been reviewed since the 21st March 2005. The care records indicated that the behaviour had escalated and that staff were being put at risk more frequently when providing personal care. Care records also indicated that on three occasions in one month unexplained bruising had been noted on the residents arm, in the same place. There was Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 10 no explanation for this, no investigation and it was not clear whether the bruises were the same one or new ones. No body map had been filled in, nor had a risk assessment been carried out for the type of medication being taken by the resident could have explained the bruising. It was noted that one resident had not received a bath for a period of three weeks. There was no explanation as to the reasons for this. Other daily personal care tasks had not been recorded although the deputy manager had noted this through her audit. Pressure relief aids were provided and a nutritional risk assessment was in place for one resident although there was no skin care risk assessment in place. The home has been working more closely with the specialist social work and primary health care teams to provide for the residents personal needs. It was observed that the senior carer giving out medications was signing the medication administration sheet before giving the medication to the resident. One handwritten medication administration sheet had only one signature on it. All others were double signed. Antibiotics received into the home had not been signed to say they had been checked. Observations made during the inspection indicated that staff treated residents with respect and helped them to maintain their dignity. Instructions were given to staff at the beginning of the shift as to the duties they were expected to carry out during the shift. This included two staff working with individual residents in shared rooms which improved the care being provided. Choices were heard to be given to the residents when they where being helped to get dressed. It was noted that a privacy screen was not available in one double room where two residents shared. Additionally, the arrangements for ensuring that residents were consulted and offered a real choice about sharing a bedroom were not clear. Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 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 standard(s) 12, 15. Whilst meals at the home are well managed and allow for individual choice to meet the specialist dietary needs of the residents, the arrangements for activities do not address individual or collective needs. EVIDENCE: Morning routines in the home were observed to be more relaxed than during the previous inspection. Residents were being given cups of tea when they came downstairs. There was no specific activities program available during the day although staff were assigned in the daily handover to provide them. Care records indicated that activities were sporadic and lacked variety. Activities was an area which needed development and a committee had been set up to look in more detail at how this could be managed. The reality orientation board was out of date. Residents were given a choice of meals to choose from each day. Additionally if they did not like the choices an alternative was offered. The quality of food served was seen to be good and residents who were able, served themselves at the table. The mealtime was relaxed and residents who needed help to eat received their meal slightly earlier so that staff had time to sit and help them. Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 12 Hot food was provided at teatime as well as sandwiches. The management of mealtimes is greatly improved. Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 13 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 The home manages complaints efficiently, openly and promotes the best interests of the residents. EVIDENCE: The home received a complaint which was investigated under the local Adults at Risk procedures. They acted in a responsive and pro-active manner to ensure the issues were appropriately dealt with and resolved. Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 14 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 24, 26 The levels of comfort for the residents is improving due to the environmental upgrade and good hygiene practices ensure that residents from infection. EVIDENCE: The registered providers are currently upgrading and decorating the home. There is already a great improvement in the general maintenance of the communal areas. The maintenance plan for the home indicated that bathrooms and toilets were the next areas to be upgraded. A new specialist bath has been provided in the bathroom on the first floor. Other bathrooms were in a state of poor repair although as stated this was being addressed. One bathroom was labelled out of action but had not been locked. The bathroom on the ground floor in the new extension was seen to contain various shampoos and soap products belonging to individual residents. Some pipe-work in bedrooms was not boxed in. Gloves and aprons were available throughout the home and staff were observed wearing them whilst undertaking care and catering tasks. Paper Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 15 towels and soap dispensers were provided in toilet areas. Commode washers have been installed in bathrooms. Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 16 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. Staffing levels are maintained at a level that ensures the needs of the residents can be met. Staff training in specialist care of the residents has improved and helps staff to address their health and welfare needs. Recruitment practices do not always ensure that residents are protected from risk of abuse from employees. EVIDENCE: There were six members of staff on duty plus the deputy manager at the beginning of the shift. The registered manager came on duty later in the morning. One carer had not arrived for work or communicated with the home the reason for their absence. Given that the home is operating under numbers this was not providing an immediate staffing difficulty. Staff training files indicated that the majority of staff had received up dated health and safety training, POVA training and person centred care training. One member of staff spoken to had not received infection control training, food hygiene training or fire training after having worked at the home for seven months. She was able to confirm that she had covered these subjects in a two- day induction she received at the beginning of her employment. Induction training is provided by an external company and induction and foundation training are covered over a two-day period. The registered Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 17 manager needs to satisfy herself that this training adequately covers the Skills for Care requirements for foundation training. Staff members are being enrolled on NVQ training courses and the home is working towards achieving the required level of trained staff by 2005. Staff are receiving supervision. Four staff files were examined and they indicated that required information, references and relevant checks had been undertaken for all new staff prior to their employment. Where previous convictions had shown up on criminal records checks there was no evidence that this had been discussed with the prospective employee. Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 33, 37, 38 The lack of quality assurance systems in the home does not provide the registered manager with feedback on how the service is developing or not, to ensure that it meet the needs of the residents. Health and safety practices including fire safety, are not adequate and do place residents at risk of harm. EVIDENCE: Maintenance certificates were available on file. Risk assessments for the environment were being done it was stated but were not available for inspection. Up dated moving and handling training was booked in and was seen to last for two hours. The registered manager stated that she was due to attend a training course so that she could train staff. An up to date fire safety risk assessment had been carried out. The weekly fire safety checks had not been carried out since 12/7/05 and there was no Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 19 records of recent fire drills. Bedrooms numbered 2, 3, 5, were seen to have their doors wedged open. Immediate requirements were left in respect of these matters. Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 x x x 2 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 2 x x x 2 2 Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 21 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 1 Regulation 4 Requirement The statement of purpose must be up-dated and contain all the required information as set out in Regulation 4 and Schedule 1. All prospective residents must have a full assessment of needs prior to them moving into the home. Timescale not met 30/4/05. Assessments must cover all areas of care needs and any special considerations. Care records regarding personal care must be filled in consistently. Timescale of Immediate not met. When residents have unexplained bruising on them this must be recorded in detail, body mapped and an investigation carried out and documented. Risk assessments must be regularly reviewed and up dated as needs change. Timescale of Immediate not met. Skin care risk assessments must be put in place. Timescale of Immediate not met. Medication administration sheets must be signed after the resident Timescale for action 30/9/05 2. 3 14 Immediate 3. 4. 3 7 14 15 Immediate Immediate 5. 7 15, 13 Immediate 6. 8 15, 13 Immediate 7. 8. 8 9 15, 13 13(2) Immediate Immediate Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 22 has been given medication. 9. 10. 9 9 13(2) 13(2) Hand written medication administration sheets must be double signed. Receipt of all medication including antibiotics must be documented for auditing purposes. Timescale of Immediate not met. Privacy screening must be provided and used in all shared rooms. Arrangements for consultation with residents about sharing rooms must be clarified and formalised. The activities program must continue to be developed and records kept of when residents take part in them. Timescale of 30/4/05 not met. Bathrooms and toilets must continue to be maintained and upgraded as necessary. All shampoos and liquid soap products to be removed from the communal bathrooms. Residents must be provided with lockable furniture or the reasons for not providing it be recorded on their care plan. Timescale of 30/4/05 not met. Recommended door locks must be provided on residents bedroom doors. The outstanding doors must be fitted with a lock as they become vacant. All pipework in bedrooms and toilets must be boxed in. Where staff declare a prvious conviction this must be discussed, risk assessed and recorded The registered manager must ensure that the foundation and induction training provide meets the skills for care specification. Immediate Immediate 11. 12. 10 10 12 12 Immediate Immediate. 13. 12 16(2)(n) 31/10/05 14. 15. 16. 21 21 24 23 13(4) 38 12 ongoing Immediate 30/9/05 17. 24 12, 13 ongoing 18. 19. 24 38 29 13, 23 13, 17 31/12/05 Immediate 20. 30 18 31/10/05 Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 23 21. 33 24 22. 37 26 23. 38 13 24. 25. 38 38 23(4) 23(4) 26. 38 23(4) A quality assurance system must be introduced into the home in accordance with Standards33 and Regulation 24. Timescale of 30/6/05 not met. The registered provider must carry out visits to the home and produce a report as stipulated in Regulation 26. Timescale of 30/4/05 not met. Moving and handling training provided by the home must be scrutinised to ensure it is adequate for the needs of the residents. Timescale of 30/4/05 not met. All wedges in fire doors to be removed. All fire safety checks to be carried out at the required frequency. Timescale of Immediate not met. Regular fire drills must be undertaken with all staff. Timescale of Immediate not met. 31/10/05 30/9/05 30/9/05 Immediate Immediate Immediate 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 3 7 10 Good Practice Recommendations It is advised that a record of any visits to the home prior to a resident moving in is kept. Care records should show in more detail information about residents when they are first admitted to he home. The reality orientation board should be kept up to date Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 24 Commission for Social Care Inspection The Coach House, John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Catshill Residential Care Home E52 S57561 Catshill V238971 280705.doc Version 1.40 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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