Inspection on 12/06/07 for Bournbrook Manor

This inspection was carried out on 12th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Bournbrook Manor 20/10/08

Bournbrook Manor 03/06/08

Bournbrook Manor 04/12/07

Bournbrook Manor 28/06/06

Bournbrook Manor 24/01/06

Bournbrook Manor 07/07/05

Bournbrook Manor 23/02/05

Bournbrook Manor 19/08/04

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 Bournbrook Manor 134a Bournbrook Road Selly Park Birmingham West Midlands B29 7DD Lead Inspector Jill Brown Key Unannounced Inspection 12th June 2007 08:25 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 Bournbrook Manor DS0000017006.V340203.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. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bournbrook Manor Address 134a Bournbrook Road Selly Park Birmingham West Midlands B29 7DD 0121 472 3581 F/P 0121 472 3581 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) Mr Rajen Odedra Usha Odedra Miss Tracey Leanne Harper Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Old age not falling into any other category (19). That the manager completes the Registered Managers Award by 30 April 2007 and a copy of the certificate be sent to the Commission. 28th June 2006 Date of last inspection Brief Description of the Service: Bournbrook Manor is located in a residential area of Selly Park in South Birmingham. The home is a large detached property, which offers care to nineteen elderly people. It is well situated and gives easy access to public transport and local amenities including shops, churches and park. Accommodation is offered over two floors with 15 single and 2 double bedrooms. All but one of the bedrooms have en-suite toilet and wash hand basins, two of the bedrooms also have an en-suite shower facility. The home has a shaft lift and a stair lift (although this is rarely used) giving easy access to the first floor for those with mobility difficulties. There is an assisted shower room on the first floor and a large assisted bathroom on the ground floor, which is also equipped with a shower. There are adequate toilet facilities throughout. Communal areas comprise of two large lounges and a dining room. There is parking space on the road to the front of the home. To the rear is a well-maintained garden with a patio area and garden furniture. Access to the lawned area of the garden is problematic from the rear of the home as there are several steps to negotiate. There is alternative access to the garden by a side exit of the home. The home stated that their previous fee level is £314.00 for a shared room and £346.00 for a single they did not disclose their top up charges new charges with social services had not been agreed. The home has a hairdresser that calls and they charge £6.50 for a shampoo and set, £5.00 for a trim, £21.00 for a perm and £16.00 for a tint Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector visited the home on a day in June without prior notice. A key inspection was undertaken which looked at all of the key standards. The inspection took place over 9 and half hours. The home was full on this inspection 17 of the residents were living at the home permanently another two had been temporarily placed there due to an incident at their residential home. During the inspection 3 residents were case tracked and records of another resident were looked at. This case tracking involved talking to the residents looking at all the records and information about them, looking at their medication, their rooms and talking to professionals and carers. This was to help the inspector make a judgement about the care given. A number of residents in this home were unable to express their opinions clearly because of dementia. Observations were made about these residents wellbeing during the inspection. The inspector also took information we had received from all sources since the last inspection. Information was given to us in an Annual Quality Assurance Assessment (AQAA), which the home completed. The AQAA shows how the home rates their performance in the areas set out in this report. We received this AQAA following the inspection. The home had received no complaints about their service. We received concerns about infection control following an outbreak of diarrhoea and vomiting at the home. However the home had made contact with the Health Promotion Agency and undertaken all their procedures to manage this outbreak. What the service does well: The home has a contract with the residents of the home and this updated on yearly basis. Residents were assessed prior to admission and there was detailed information about the skills the resident retained and this helps to ensure that residents can maintain some independence. The staff group is mainly female as is the resident population however there is a male member of care staff. There are procedures in place to ensure female residents have a say about how much intimate care they will allow the male member of staff to undertake and this is good practice. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 6 The relationships with health professionals were good health staff spoken to thought the staff knowledgeable and that they were aware of chances in the health of their residents and referred residents appropriately. Residents spoken to were happy with the food and the menu had recently changed after consultation with residents. Residents were only restricted in moving around or out of the home if it was to maintain their safety. The areas that were accessible to residents were well maintained and comfortable. Residents spoken to were happy about the care given to them from staff. One relative thought the home ‘was the best in the area.’ What has improved since the last inspection? What they could do better: Although assessments were carried out before residents were admitted there were not enough checks to determine whether residents with dementia had difficulties over and above what was usually associated with age. This could mean that the home is not in a position to provide appropriate care. Residents did not have plans of care plans to instruct staff how to care for new residents in a timely way. Risk assessments were not undertaken and plans made for residents that clearly were at risk for example of falling or that plans are now in place and we will be checking to see that these have been done. Medication administration processes were not robust enough to prevent errors and these deficiencies put residents at risk. The provider said changes to the medication practices have been made since the inspection. We will be checking that these changes are still in place. Although there were activities in place these needed to be improved upon to ensure residents with dementia had activities that were meaningful to them. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 7 Whilst the environment provided was good for residents the kitchen needed refurbishment and practices with the laundry needed to be improved to ensure that residents benefited from good infection control practices. A number of the residents had high needs, staffing levels and where staff worked needed to be reviewed to ensure residents were appropriately checked. Staff were recruited following checks but the process needed to show more evidence of interviews and checking of references. Induction did not follow the Common Induction Standards. Training for staff was about to lapse on key areas of training or had not been given and this could mean that staff are not aware of how to care for residents appropriately. The manager has been on maternity leave and had yet to complete the Registered Managers Award. A quality assurance system had been set up but was not fully working at this inspection. We will be asking the home to provide us with an improvement plan to ensure that the standard of care delivered improves and we will be monitoring this improvement. 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. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 8 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 Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 9 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): 2, 3 & 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents rights are protected by a contract detailing the terms and conditions of their stay. Assessments were undertaken but were not always used to ensure that the home stayed within their conditions of registration and this may mean residents are admitted that the home cannot adequately care for. EVIDENCE: Contracts of residence were found on the three care files of the residents’ case tracked. The provider updated contracts except for the residents who were funded by Social Care and Health. In this case it was expected that Social Care and Health would inform the residents of any changes to the fees charged. The contracts specified the room that residents were to occupy and some information such as the smoking and alcohol policies and the complaint Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 10 procedure. The home carries a low level of insurance for residents’ personal belongings and this is noted in the contract. Residents had assessments before being admitted. Where necessary assessments take place in the hospital or in residents own homes although the home would prefer that residents spend some time with them before deciding to be admitted. Assessments had details of residents’ health conditions and information on their abilities in areas such as mobility. The home had these rated from good to poor but written details to expand this information were needed in some cases to make it useful for devising a care plan. Information was recorded about skills the resident retained. One resident had been admitted with a diagnosis of Alzheimers disease and this appeared to be their primary condition. The assessment did not determine if the resident had any specialist needs and this may mean the home is acting outside its conditions of registration by the admission. Staff do not have adequate levels of training on dementia care. Residents’ religion and their ethnic origin is recorded on their care files in one care files a care plan was not written. The home need to monitor to ensure that emerging needs can be met. Residents sign to say whether they are in agreement to having a male carer there is one male care in the home at the present time. The male carer has on file information about the amount of care each resident is willing to accept from the male carer and this is good practice. Two residents were admitted as an emergency from another home they arrived with care plans and this enabled the staff to provide appropriate care. The home does not currently have any residents that smoke a previous requirement about risk assessing was removed. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 11 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): 7,8,9 &10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments were not in place quickly enough to ensure residents needs could be met consistently and residents safety assured. Medication was not administered in a safe way and this compromises the health and well being of residents. EVIDENCE: Two residents did not have care plans or risk assessments in place. This lack means that risks to residents cannot be minimised and residents cannot be guaranteed of consistent practice in how their care is given. One of the residents case tracked it was found that they had behaviour that was likely to put them at risk and had conditions and medication needs that needed monitoring. There was no assessment of their behaviour and no plans were put in place to minimise the risks of falls. An urgent letter was sent to Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 12 the provider about this shortfall; they have responded that the care plans and risk assessments are now in place for these two residents. Assessment information such as a resident ‘doesn’t like showers’ was not transferred to the care plan. A number of care plans were not specific and had comments such as needs ‘full assistance’ and ‘guidance in personal care encourage to do as much for self as possible.’ Others had information such as ‘will assist in own personal care if given short simple instructions’ and ‘forgets where the toilet is.’ Risk assessments where in place were too general. One physical health risk assessment had recorded right to request a GP visit, or GP weekly surgery and 999 in an emergency rather than instructions how staff can help to improve residents’ health or signs that show when a resident’s health condition is deteriorating. A behavioural plan seen stated ‘if unsettled give reassurance’ it contained no details of how this should be managed. There was no detail of a recent admission’s weight. Other resident weights were recorded. One resident had a change in weight of over a stone in a month and this had not provoked an investigation as to whether this was correct or if the resident required some intervention from a health professional. One resident that needed to increase weight managed an increase of 13lbs over a year and this is good. The food intake records were not in enough detail to determine whether residents were individually eating a varied and nutritious diet. There were good records of professional visits. A district nurse spoken to said the staff at the home were helpful that they ensure the resident is brought for treatment straight away, the staff appear knowledgeable and would contact the district nurses. Another said that they were very happy with the care in this home staff are available and they have no concerns in the care of the residents. A GP that visits thought that residents were referred appropriately when needed and that the home’s systems worked well. Residents were observed to be well dressed in ironed clothing and with their hair and nails attended to. Two residents with dementia were observed to have unsettled behaviour with verbal outbursts plans were not in place about how this was to be managed. The medication administration was poor. On the day of the inspection a member of care staff was observed to: Put up the medication into tots with a piece of paper with the name of the resident on this is unsafe as any time this medication can be spilt and residents medication become mixed up. Leave the medication unattended and this means residents can have access to potentially harmful medication. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 13 Not check that the resident had taken the medication at the time of administration. The Medication Administration Record (MAR) recorded that then resident had taken it. This means the resident could drop, not take, or save up medication to take later. A resident that needed pain relief by a patch every three days had a patch missed which potentially means the resident was left in pain. Carried forward medication at the end of the prescription month was carried forward incorrectly making the counts of medication incorrect. There were gaps in the in the Medication Administration Record and the counts of the medication suggested that both medication was administered and not recorded and medication was recorded as given that hadn’t been. Prescriptions had not been checked against the previous MAR to ensure changes can be checked and this could lead to the wrong medication being given. The service provider has altered the timing of medication administration to allow two staff to be available to administer medication to improve practice. We will be monitoring that this improvement is sustained. Consultations with the doctor are done in the dining area although examinations take place in the resident’s room this could be improved upon to maintain residents privacy. Residents said that the homes care staff are good and assist quickly when they ask for help. A resident said that when they had been disturbed through the night by another resident the staff had acted swiftly. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 14 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): 12,13,14 &15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities provided did not meet the needs of all residents. Residents were not restricted by the home’s routine and residents relatives could visit when they wished. The meals provided met the needs of residents. EVIDENCE: A number of residents were able to go out and organise some of their own activities. Activities provided by external providers recorded in the last the month were; an entertainer had visited to do a sing a long session, a clothes show and an exercise morning. There had been improvements to access of the garden and a few residents had sat out in there on occasions. A number of residents had also been taken for a walk up the road, and some residents had enjoyed games such as floor snake and ladders and bingo. The homes AQAA acknowledged that the home had work to do in this area and a more organised activities programme needed arranging. Residents’ daily records did not show that residents joined in activities. There was little information to show how residents’ previous interests were maintained and planned for especially for Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 15 residents with dementia. This is important as it can preserve residents’ skills and interests. Residents with dementia were not observed to be engaging in activities. A relative was spoken to and they were happy with their welcome in the home and can visit when they wish. During the inspection there were a number of visitors and the staff responded warmly and appropriately to them. The relatives spoken to were visiting in the resident’s room but relatives were also seen talking to residents in the lounge. Residents appeared to move around the home as they wished. The home does have a locked front door to protect vulnerable residents and has alarmed fire exits in response to these residents walking out when confused. Residents can lock their bedroom doors if they wish. The inspector arrived at 08.25 and a number of residents were having breakfast. However some residents were in lounges. There appeared to be food available as the residents wanted. Some residents were having a cooked breakfast other residents were having cereal and toast. The cook was knowledgeable about residents’ preferences and those residents that needed special considerations because of their health conditions or difficulties in chewing food. Residents spoken to said the food was good. At lunchtime residents were offered a choice of baked fish or quiche and treacle roly-poly and custard or ice cream. There was plenty of food available in the home. The inspector found good stocks of frozen, refrigerated, dry, and tinned foods. There was fresh fruit available. The cook only works during the week and from 8-1 and this means care staff are providing meals at other times. The AQAA and the cook informed the inspector that residents had been consulted about the menu and changes were to be made to it. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaint and adult protection systems needed to be improved by ensuring appropriate information was available for residents and appropriate information and training to staff. EVIDENCE: The home has received no formal complaints, the Commission received a concern about the infection control processes in the home during an outbreak of diarrhoea and vomiting but the home had taken all appropriate steps. The AQAA provided by the home recognised that there were improvements the home could make in making their complaints procedure more accessible to some of the residents. An independent agency was undertaking the statutory monthly visits to the home. We were advised by the manager and by a resident that this was no longer going to happen. A resident spoken to felt that they welcomed the visit from this person and saw it as part of their feedback on the home’s performance. The AQAA provided stated that they have introduced an outside agency to undertake these statutory visits and provide reports. No adult protection issues have been raised since the last inspection. Staff have yet to undertake Protection of Vulnerable adult training and this is important as it ensures that staff are reminded about good practice and their responsibilities to report poor practice. Staff have Protection of Vulnerable Adults and Criminal Records Bureau checks before starting work. There was no Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 17 record that staff are given individually a copy of the General Social Care Council Code of Practice. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 18 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): 19,21,22,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment was comfortable and homely for residents but further improvements were needed to improve the infection control in the kitchen areas and the laundry. EVIDENCE: A tour of the building was undertaken with communal facilities and assisted bathing facilities and a number of residents’ bedrooms being looked at. There have been improvements made to the garden space to the rear of the home. The owners have built an office in the garden but have improved the access to the outdoor space by building a large deck from the rear exit over the patio. This deck overlooks the garden. Prior to this build the access to outside seating was difficult for residents to negotiate because of steps. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 19 Residents with walking difficulties previously had to come out the front and round the side of the building if they wanted fresh air. They will still have to do this if they wish to go to the grassed area. The garden gate did not have a security system to ensure that staff know if residents have left the garden. Residents had managed to get out of the front of the building without staff knowing since the last inspection resulting in an exit having an alarm so this precaution is necessary. The home’s kitchen remained hot and in need of refurbishment. There is no dishwasher despite there being 19 residents and one cook. The kitchen surfaces are porous in places and hard to keep clean. Since the last inspection the home has had a period without a working oven. A food safety report in December 2006 found the ventilation in the kitchen inadequate and the fridge temperatures not within the recommended safety limits and this was also found on the day of the inspection. A previous requirement for details of when the kitchen would be refurbished remains outstanding. The providers have stated that they wish to ensure that a full catering kitchen is put in its place. The timescale offered was within a year of the last inspection this timescale has now lapsed. The AQAA provided has no details of this as an area of intended improvement. All areas of the building were clean and fresh on the day of inspection. There were new dining room chairs available for residents. These chairs had ‘ski runners’ on the bottom, which makes it easier for staff ensure that residents were in a good eating position at the table. There were a number of residents with poor memory and the inside of the building has few signs and symbols for residents to assist them find their way. This does not promote residents’ independence. The ground floor assisted bathing facility is clinical in nature being all white, having a manual sluice, the shower, toilet and hoist. A more homely feel would help residents relax more and enjoy these facilities. A bedroom had new carpet fitted before a resident was admitted. The home stated that a number of bedrooms had been recarpetted and decorated. Bedding and mattresses were checked in some bedrooms and these were found to be clean and of good quality. The infection control in the home could be improved. Carers were noted to wear blue aprons when they came into the kitchen as required and there were good infection controls in place for a resident with a specific health condition. However some of these good practices needed to be in place for all soiled linen. There were no dissolvable bags for soiled laundry and the open weave baskets are not suitable for transporting such laundry. Laundry seen in Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 20 residents rooms was clean and well ironed. The home had since the last inspection removed staff uniforms from the laundry area. The AQAA did not indicate that any staff had received training in infection control. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 21 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): 27,28,29 &30 Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels training and recruitment needed to be improved to ensure that residents’ needs are met. EVIDENCE: The home currently provides four care staff for the morning shift and three for the afternoon plus management through the week they are supported by a cook between 8-30 and 1pm. At the weekend there are four care staff on the morning shift one of whom acts as a cook and three in the afternoon. There are two night staff on duty throughout the whole week. The weekend staffing levels need to reflect that one member of staff is being taken off the floor to undertake cooking duties especially as there is no management support on site over the weekends. The manager and deputy manager take it in turns to be on call for any emergencies that may occur out of office hours. A resident thought that there was a difficulty getting the breakfast they wanted when the cook was not on duty. The numbers of residents’ vacancies has decreased recently the staffing has to reflect these changes in numbers and needs. The AQAA stated that the staffing level has increased to three in the afternoon. The home has stated that 6 of the 15 current care staff (excluding the manager) have achieved a National Vocational Qualification level 2 in care. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 22 This means that 40 of care staff have achieved the basic level in the care for the elderly. The target of 50 has not been met but will be if the current staff on the course achieve this qualification. Three staff files were looked at to determine the recruitment practices and qualifications of the staff. The application forms for three staff were completed. Staff had Criminal Records Bureau checks before employment and there was evidence of references being taken up. There were no details or records of the interview process. A minimal induction process that does not meet the Skills For Care recommended common induction standards was undertaken. The AQAA produced by the home stated that they were meeting this requirement. Staff records suggested that formal supervision of staff had lapsed whilst the manger was on maternity leave and this is of concern for newer staff. The manager of the home stated that the matrix showing the staff teams training was being updated and that a number of update training for key courses such as moving and handling were due for renewal in July. The staff files looked at indicated that one staff members Health and safety and moving and handling training needed to be renewed in July. There was nothing to indicate that the two newer staff had undertaken any courses. The manager stated that the provider was looking for a training company to rectify this training shortfall. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 23 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): 31,33,35,36,37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the majority of systems were in place to ensure that residents benefited from a well managed home these expectations were not kept to and this puts residents at risk. EVIDENCE: The manager of this home has the experience to manage a care home she has yet to undertake the Registered Managers Award as agreed due in part to maternity leave. She and the deputy are now to start this training this should give the home a stronger management lead to the staff group. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 24 The AQAA stated that there was a quality assurance programme but at the inspection this was still in development. The manager was unable to show an annual report of its findings and the AQAA showed a gap in this requirement. There were independent visits on behalf of the provider undertaken monthly and reports were submitted to us. These reports indicated that there had been ‘minor issues with medication’ and the home was looking to recruit a weekend cook. Three residents’ personal finances were looked at. Records were kept of any spending of residents money and receipts were kept. The money held matched the records. Money was usually held by relatives and given to the home to pay for services such as hair care. Staff files showed few supervision sessions had been undertaken. Supervision had lapsed due in part to the manager’s maternity leave. Supervision of staff is important as it allows staff the opportunity to raise concerns and for the manager to ensure good consistent care practices. The AQAA showed that there were gaps in policies in procedures about accidents, contact with families and friends, Common induction standards and individual planning and review. A number of these gaps were evident in the shortfalls in the home’s performance. A company specialising in health and safety was contracted to look at the home’s performance in this area. It outlined that work was needed in the homes moving and handling procedures and the inspector found this was evident in the moving and handling risk assessments of residents. A sample of records on the maintenance and inspection of services such as lifting equipment, gas, electrical and fire safety were looked at and found to be in place. There was no record of a thorough examination of the passenger lift although there was information about it being maintained. The passenger lift had a period of time out of service since the last inspection. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 25 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 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 2 X 3 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 2 2 Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 26 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 OP4 Regulation Care Standards Act 2000 Requirement Residents must only be admitted if they meet the Conditions of Registration related to the service user group. This is to ensure that residents have the care that meets their needs and to ensure the home is not acting outside its category of registration. a) All residents must have a care plan that shows how their needs are to be met within 48 hours of admission. Urgent letter sent provider has stated this is now in place. b) All residents must have care plans that detail their current needs in respect of health and welfare and how these are to be met by care staff. c) There must be evidence that wherever possible the residents have been consulted about the care plans. Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 27 Timescale for action 31/07/07 2 OP7 15(1) 26/06/07 Previous time scales of 14/08/05 01/04/06 and 31/08/06 not met. This is to ensure that residents have planned consistent care that meets their identified needs and secures their health and wellbeing. Risks to residents identified on the preadmission assessment must result in a plan to minimise these risks. 3 OP8 13(4)(c) 26/06/07 4 OP8 13(4)(c) Urgent letter sent provider has stated this is now in place. All risks identified to a resident 26/06/07 must have a risk assessment and result in a risk management plan. This is to ensure that residents are kept as safe as possible and free from harm. a) The manager must ensure 31/07/07 that any nutritional or tissue viability screenings are completed correctly to reflect the current needs of the residents and where needed ensure a nutritional plan is place. b) Residents that have unplanned losses and gains in weight that cause concern must have a nutritional plan. c)The home must record the amount and type of food eaten by residents. 5 OP8 12(1)(a) 16(2)(i) 6 OP9 13(2) A safe system of administering medication must be put in place that is audited for compliance Urgent letter sent provider has stated this is now in 26/06/07 Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 28 place. Medication must not be put in to tots for a number of residents before administration. Medication must not be left unattended. Medication must be recorded as given when the resident has been seen to take it. Medication must be given as prescribed. Prescriptions must be checked against the previous Medication administration record. This is to ensure that residents have the benefit of medication prescribed at the time they need, which has been stored properly. Residents should not be put at risk of incorrect, medication or medication that is inadequately secured. Residents that are unable to join group activities must have individual activity plan to show how they have one to one time with staff. Outstanding since 31/08/06 Activities ensure that residents remain mentally agile and enhance their daily lives. All staff must be given a copy of the General Social Care Councils Code of Practice. All staff must have training in the Protection of Vulnerable Adults. This is to ensure that staff are aware of how abuse of Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 29 7 OP12 12(1)(a) 31/08/07 8 OP18 18(4), 13(6) 31/08/07 9 OP19 23(2)(b) vulnerable adults can happen and their individual responsibilities for promoting good and reporting poor practice A full assessment of the kitchen 31/07/07 facilities must be undertaken and work carried out to improve facilities within a suitable time scale. This information must be sent to us. This is to ensure that the kitchen can reliably provide food that is well stored and cooked to maintain residents health and wellbeing. 10 OP19 13(4)(c) A risk assessment related to the residents exiting the garden gate must be completed and action taken if appropriate to minimise any risks determined. This is to ensure that vulnerable residents do not leave the premises without staff being aware. The infection control practices must be reviewed to ensure that soiled laundry is not a cross contamination risk. Staff must receive training in infection control. 31/07/07 11 OP26 13(3) 31/08/07 12 OP27 18(1)(a) 13 OP29 18(1)(a) (c)(i) This ensures that residents are not subjected to risks associated with cross infection. A review of the staffing levels 31/08/07 must be undertaken and suitable action taken to ensure that these meet the needs of the residents. Staff employed must have an 31/08/07 induction period and training to meet the Common Induction Standards. This is to ensure that staff are Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 30 14 OP30 18(1)(c) (i) aware of the needs of this resident group and have the basic skills needed to deliver the care needed. All staff must receive mandatory training and records demonstrating this must be available. This is to ensure that staff maintain the skills needed to care for residents in this home and are updated in developments in practice, 31/07/07 15 OP38 13(4)(c) Assessment and a safe system of 31/07/07 moving and handling individual residents must be undertaken and reviewed routinely. This is to ensure that residents are moved from place to place in a way that does not put them at risk. There must be a full examination of the passenger lift (LG1) and the certificate must be available for inspection This is to ensure that the home meets its legal requirements under the LOLER regulations and ensure that residents are not lifted in faulty equipment. 16 OP38 23(2)(c) 31/07/07 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 Refer to Standard OP1 Good Practice Recommendations The statement purpose should contain information about the numbers of staff, their experience and qualifications. DS0000017006.V340203.R01.S.doc Version 5.2 Page 31 Bournbrook Manor 2 3 OP10 OP15 Alternatives to interviewing residents in the dining area should be investigated. It is recommended that residents that are able are encouraged to serve themselves food. It is recommended that menus be available on tables for residents to remind themselves of the choices for the day. (Outstanding since the 28/06/06) Complaints procedures should be in a format that make it easy for residents to raise concerns or make comments on the service provided. The ground floor bathroom be redecorated to make it more domestic in character and that the sluice facility is removed from the ground floor bathroom The provision of signs, symbols and colour coding should be introduced to assist residents to find their way around the home. The home should improve its records of the recruitment process to ensure that a fair recruitment can be demonstrated. The manager must complete the Registered Managers Award. The home should improve the ways they collect residents views to improve the service and this should result in an annual report. Staff should receive 6 recorded supervision sessions in a year. 4 5 OP16 OP21 6 7 8 9 OP22 OP29 OP31 OP33 10 OP36 Bournbrook Manor DS0000017006.V340203.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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