Inspection on 29/10/05 for Bluebrooke Residential Care Home

This inspection was carried out on 29th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 28/07/05

Bluebrooke Residential Care Home 02/03/05

Bluebrooke Residential Care Home 14/09/04

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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 Catshill Residential Care Home Catshill Residential Care Home 242 Stourbridge Road Catshill Bromsgrove Worcs B61 9LE Lead Inspector R McGorman Unannounced Inspection 28th October 2005 11:30 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 Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 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. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Catshill Residential Care Home Address Catshill Residential Care Home 242 Stourbridge Road Catshill Bromsgrove Worcs B61 9LE 01527 877152 01527 557409 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) Oldfield Residential Care Limited Mr Anastasis Kayiatou Mrs Maria Hogg Care Home 46 Category(ies) of Dementia - over 65 years of age (46), Old age, registration, with number not falling within any other category (46), of places Physical disability over 65 years of age (46) Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The four bedrooms on the top floor of the home are not used for service users with mobility needs. Staffing levels are increased to match the Residential Forum`s recommended levels which are that seven staff are on duty throughout the waking day. 28th July 2005 Date of last inspection Brief Description of the Service: Catshill Residential Care Home is registered to provide personal care for up to forty six older people who are frail, who may have a physical disability, or who may have a mental health problem. The home has a high proportion of service users who have a dementia illness. The large, detached property, standing in its own grounds, is situated in a pleasant residential area, approximately two miles from Bromsgrove town centre. There is an enclosed garden which is accessible to service users. The home had been under the same ownership for many years, until purchased by Oldfield Residential Care Limited in April 2004. The need for development in several areas was identified, and progress has been evident, during the past eighteen months, in service delivery, and in the upgrading of the premises. The care manager has recently resigned, and the responsibility for the day to day running of the home currently lies with the deputy manager, who is being assisted by the manager from Oldfield Residential Home. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this unannounced inspection was to follow up previous requirements and recommendations, and to monitor the care provision in relation to the stated aims and objectives of the home. A complaint received by the Commission was followed up during the course of the inspection. The inspection took approximately five hours, and time was spent talking with service users and staff, and checking the care documents. A tour of the building was undertaken, and the records kept in respect of the maintenance of equipment and safe working practices were also seen. The Acting Manager and other staff at the home were open and co-operative, and made themselves readily available to assist with the inspection What the service does well: What has improved since the last inspection? Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 Page 6 The ongoing upgrading of the premises is providing a pleasant environment in which to live and work, and the improved facilities have enhanced the quality of life of service users. There has been some progress in providing activities for service users, although further development is needed. Further compliance by the management of the home in meeting the requirements and recommendations made at the last inspection, demonstrates their commitment to providing a good standard of care. The National Vocational Qualification training is in place at the home, and some additional training has been organised for staff. 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 DS0000057561.V262262.R02.S.doc Version 5.0 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 Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 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): 1&3 Prospective service users are provided with some information to assist them in making a decision about living at the home, although this needs to be more extensive. The assessment procedures should be more detailed, to enable staff to fully understand the needs of the prospective service user. EVIDENCE: A Statement of Purpose and a Service Users Guide have been produced, and provide residents with some of the information they need to make an informed choice about their future care needs. Further review of these documents is needed to ensure they contain all the appropriate details. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 Page 9 An assessment is undertaken prior to a service user being admitted to the home, but those seen had not been completed in sufficient detail. A thorough assessment will enable staff to determine if the home is able to meet the identified needs of each service user. The records also need to show how these needs will be met. The assessment will then form the basis for the care plan. A Community Care Assessment is not available for all service users who are funded by the Social Services Department, and some do not provide adequate information to the home about the care needs of the service user. Service users should not be admitted without a current and detailed assessment. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 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 the following standard(s): 7,8 & 9 The plan of care contains relevant information, although rather limited, therefore more detail is needed, to ensure that the personal and healthcare needs of residents are fully met. Risk assessments that are comprehensive and cover all possible eventualities, will be more effective in encouraging independence and protecting service users and staff. EVIDENCE: A plan of care is produced for each service user based on the initial assessment undertaken prior to admission. The information provided is relevant, but rather limited, and therefore further development is necessary. Some comments are very subjective, and care should be taken by staff to ensure that only factual and accurate information is recorded. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 Page 11 The need for much more detail to be recorded for all interventions with service users was identified, to ensure the appropriate delivery of care. The records should describe how the care is to be implemented, the outcomes that are intended and the future proposals. The care plans should be reviewed at least monthly, and signed by the service user or their representative, to confirm their involvement and agreement. Information is also recorded in the daily log, although these comments were found to be repetitive, and not very informative. Risk assessments are completed with regard to the moving and handling of service users, and occasionally other areas of care provision, but the need for further development is evident. A body map should be completed for any service user who sustains an injury, or where there is any evidence of bruising. Risk assessment should be undertaken for all the activities of daily living, for each service user, and should be regularly reviewed. The need for more detailed and accurate recording was again identified. Training for staff to increase their awareness of the importance of care planning and risk assessment is needed. Staff were observed administering medication to service users, and the correct procedures were being followed. The Medication Administration records were checked, and had been completed to a satisfactory standard. The care records of a service user contained written information from the hospital regarding a change in medication, about which all senior staff were not aware. The acting care manager acknowledged the need for improvements in communication to be implemented. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 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 the following standard(s): 12 & 15 The absence of a programme of social and cultural activities, which is suited to the individual needs of service users, limits the opportunities available to them, and also their quality of life. Nutritious and wholesome food is provided, with a varied menu, but a record of the food provided to each individual service user is not maintained, therefore it is not possible to determine whether the diet is satisfactory for everyone. EVIDENCE: There has been recent consideration given to the recreational needs of service users, with some time given by care staff to providing activities during the afternoons. A committee is now in place to assist with developments, but there needs to be a more structured approach, which is responsive to the individual needs of service users, and is able to provide a flexible and varied programme. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 Page 13 The leisure needs of service users with dementia, and other cognitive or sensual impairment, requires a specific understanding by staff, to enable a more appropriate and effective response to be provided, therefore training would be beneficial. The appointment of an activities co-ordinator would further enhance facilities for service users. Comments from service users and staff, in regard to the meals, were all very positive. Conversations with the cook and the acting manager confirmed that a choice is offered, and alternatives are always available. Special diets are catered for, and individual preferences recorded. A record of the food provided to individual service users is not being maintained at the home, and the importance of this was discussed with the acting care manager. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 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 the following standard(s): 16 The complaints procedure is implemented at the home, in an open and efficient manner, to ensure the protection of service users. EVIDENCE: A satisfactory complaints procedure has been produced and is accessible to residents and their families. Further development should be undertaken to include a record of all comments and compliments received by staff at the home. A recent complaint is being investigated under the Adult at Risk procedures, and the management have responded in a professional manner to assist with the inquiry. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 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 the following standard(s): 19,20,21,23,24 & 26 The standard of cleanliness is satisfactory, the décor and furnishings are in good condition, and the building is well maintained, providing a comfortable and homely environment for service users The ongoing development in relation to the facilities provided at the home, is effectively improving the quality of life of service users. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 Page 16 EVIDENCE: Catshill residential home is a large, detached property, situated in an elevated position, approximately 2 miles from Bromsgrove. The building has been upgraded and extended, over several years to provide accommodation for up to 46 service users. There are 24 bedrooms in the original house, situated on three floors, 8 of which are shared rooms. The new wing has 13 bedrooms, 1 of these being shared, and all having en suite facilities. The home complies with the National Minimum Standards in many respects, although further consideration needs to be given to the ratio of single to double bedrooms, and also to the provision of screening in shared rooms. Service users in double rooms should have made a positive choice to share with each other, and a record kept of this arrangement in their individual care plans, but no evidence of this was found. Door locks are being fitted to bedroom doors as part of the upgrading programme, and lockable furniture is also provided for service users. Two fire escapes are accessed through shared bedrooms on the first and second floors of the original house. The Fire Safety Officer should be consulted about the options that may be available, as this is not a satisfactory arrangement. The fabric of the building is generally well maintained, and a programme of improvements to upgrade the bathrooms and toilets is currently being implemented. A new assisted bath has been provided recently, and the communal areas of the home have been decorated. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 & 30 Adequate staffing levels are maintained at the home, to provide for the identified needs of service users. The training provided for staff is helping to ensure the appropriate delivery of care to service users, although a training programme needs to be developed to ensure that each member of staff is competent, and has a clear understanding of their role. EVIDENCE: The staff rotas indicated that staffing is maintained at the levels agreed as a condition of registration, and it was confirmed by the acting manager, that these are adequate for the needs of service users. A list of recent training organised for staff has been submitted to the Commission, and a programme is being developed. Two members of staff are doing the National Vocational Qualification Level 2 in Care, and one person is doing Level 3. The deputy manager is taking Level 4, together with the Registered Managers Award. Further training is needed in respect of communication, specifically for senior staff, together with Fire Awareness and the Full First Aid at Work Course. In addition the need for specific care related training, for all care staff, was identified, to include, dementia care, person centred care planning and risk assessment. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 Page 18 Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,37 & 38 The health and welfare of service users at the home are promoted, although the failure to follow procedures on some occasions does not ensure that residents are fully protected in regard to all safe working practices. Development of the quality assurance system will enable the views and opinions of service users to have a greater influence in how the home is run. The safety of service users is being compromised by the failure to ensure that appropriate checks of the fire safety equipment are undertaken, and that staff are adequately trained. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 Page 20 EVIDENCE: The Registered Manager resigned recently, and the responsibility for the day to day running of the home currently rests with the deputy manager, who is coping well in this difficult situation. Support is being provided by the Manager from Oldfield Residential Home, another home in the group, and also by the Directors of the Company. A quality assurance system is yet to be implemented at the home. The Mulberry System is to be introduced, but the management situation has inevitably delayed its development. The Commission has not received a recent report on the conduct of the care home, from or on behalf of the Responsible Individual, in respect of the monthly visits to the home, under Regulation 26. The Fire Log book has not been completed for the last 4 weeks, which is considered to be a very serious omission, and fire awareness training has not been provided for staff during the past 6 months. The acting manager was reminded of the implications, and the need to ensure the safety of service users at all times. Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 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 2 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 2 X 2 2 X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X X 1 1 Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 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 OP1 Regulation 4 Requirement The statement of purpose must be amended to include all the information detailed in Regulation 4 and Schedule 1. (Timescale of30/09/05 not met) A service users guide which reflects the current service provision and includes all the information detailed in Regulation 5 and Standard 1, must be available in the home, and copies must be given to all current and any prospective service users. A detailed written assessment must be completed before the admission of any service user and in accordance with the requirements of Regulation 14 and Standard 3 A care plan must be drawn up with each service user in accordance with the requirements of Regulation 15 and Standard 7, and must cover all aspects of care as set out in Standards 7.2 and 3.3. The service user plan must be detailed and provide clear DS0000057561.V262262.R02.S.doc Timescale for action 31/12/05 2 OP1 5 31/12/05 3 OP3 14 31/12/05 4 OP7 15 31/12/05 5 OP7 15 31/12/05 Catshill Residential Care Home Version 5.0 Page 23 6 7 OP7 OP8 15 15 8 OP15 16 9 10 OP24 OP30 13 18 11 OP31 8 12 OP33 24 13 OP37 26 14 OP38 23 15 OP38 23 guidance to staff on the actions to be taken to meet the changing personal and health care needs of service users. All service user plans must be reviewed by care staff at the home at least once a month. Risk assessments must be undertaken in respect of all the activities of daily living relative to the individual circumstances of service users, and must be regularly reviewed and updated. A record of the food provided for service users must be maintained in the home in accordance with the requirements of Regulation 16, Schedule 4 and Standard 15. The exposed pipe-work in bedrooms and toilets must be guarded A staff training and development programme must be introduced which meets the National Training Organisations specification A manager must be appointed at the home and an application for registration submitted to the Commission A quality assurance system must be introduced in accordance with the requirements of regulation 24 and Standard 33. (Timescale of 30/10/05 not met) The person carrying out the monthly visit must prepare a written report on the conduct of the care home, and a copy must be submitted to the Commission (Timescale of 30/09/05 not met) Arrangements must be made for staff to receive regular training in fire prevention and the procedure to be followed in the event of fire. The registered person must take DS0000057561.V262262.R02.S.doc 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 30/11/05 Page 24 Catshill Residential Care Home Version 5.0 adequate precautions against the risk of fire - the fire alarm must be tested each week and a record maintained. 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 4 5 6 7 8 Refer to Standard OP3 OP12 OP16 OP19 OP21 OP23 OP23 OP30 Good Practice Recommendations A current and detailed Community Care Assessment should be obtained prior to the admission of a service user funded by the Local Authority Consideration should be given to appointing an Activities Co-ordinator to take responsibility for organising a programme of recreational activities for service users The record of complaints should also include comments and compliments received at the home The Fire Safety Officer should be consulted about the fire escapes which require egress through service users bedrooms The upgrading of bathrooms and toilets should be maintained Consideration should be given to the provision of 80 of places in single rooms Service users in shared bedrooms should have made a positive choice to share with each other, and a record made of this decision Arrangements should be made for senior staff to undertake the Full First Aid at Work Course Catshill Residential Care Home DS0000057561.V262262.R02.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Worcester Local Office 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 DS0000057561.V262262.R02.S.doc Version 5.0 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!