Inspection on 18/11/05 for Bournville Grange

This inspection was carried out on 18th November 2005.

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

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

Other inspections for this house

Bournville Grange 26/11/08

Bournville Grange 30/01/07

Bournville Grange 14/06/05

Bournville Grange 10/02/05

Bournville Grange 28/07/04

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 Bournville Grange 168 Oak Tree Lane Bournville Birmingham B30 1TX Lead Inspector Brenda O’Neill Unannounced Inspection 18th November 2005 10:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bournville Grange DS0000044748.V263705.R01.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. Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bournville Grange Address 168 Oak Tree Lane Bournville Birmingham B30 1TX Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 445 5896 0121 472 4552 Adam Barwell Ms Claire Brown Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. The category of registration is OP (older people, over 65) and the type of home is care home only. The number of residents shall not exceed 27 Staffing levels are maintained at 3 care assistants plus a senior throughout waking day. Two waking nigh care assistants with one person on call. The former office is refurbished to form an assisted shower and wc for resident use, completed by December 2003. The second rear lounge area is part-partitioned off to extend and improve the wc and make it accessible for people needing support In conjunction with this a corridor is created to the fire exit and the boiler is protected. By 1st October 2003 a proposal is submitted for a permanent staff room on the second floor to be finalised and resolved within 12 months of registration. finalised and resolved within 12 months of registration. Bedroom 16 is improved by reducing the en-suite and repositioning the door Bedroom 30 (second floor) is increased to a shared room. The WC off the laundry is designated for use by kitchen staff. The ponds located in the garden are made safe and secure in order to prevent accidents. That the patio area is made safe from tripping hazards, the severe drop in gradient, the path is made safe and handrails installed. The access and egress from the front of the Home to the rear is made safe and secure. Mrs Brown must provide evidence of completion of a management and care qualification at NVQ level 4 or equivalent by April 2005 Mrs Brown to access up to date training re: vulnerable adults and local procedures for reporting alleges of abuse. 8. 9. 10. 11. 12. 13. 14. 15. Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 Page 5 Date of last inspection June 14th 2005. Brief Description of the Service: Bournville Grange is a large detached property situated in the conservation area of Bournville. The home is within walking distance of local churches, parks and Bournville Village Green, which has a variety of local shops and a post office. Public transport is also within a short distance. The home offers accommodation to 27 elderly people over three floors. All but one of the bedrooms are singles and most have en-suite facilities. Residents have a choice of 3 lounges and there is one dining room. All are very comfortable and furnished in a homely style. There are three assisted bath/shower rooms and adequate numbers of toilets throughout the home. Aids and adaptations include a ramped entrance and shaft lift, giving easy access to the first and second floors for those who experience difficulties with mobility. The ground floor of the home also houses the main kitchen, laundry and office space. There is parking space at the front of the home and there are extensive, mature and well maintained gardens to the rear. Many of the rooms have a good view of the gardens. There is a patio with an ornamental pond and seating for residents. Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over half a day in November 2005. This was the second of the two statutory visits for this home for 2005/2006. To get a full overview of all the standards assessed during this inspection year this report should be read in conjunction with the report written following the inspection on June 14th 2005. During this inspection a partial tour of the premises was made, two resident files were inspected as well as other care and health and safety records. The inspector spoke with the manager, the proprietor, two senior care assistants and seven of the twentyseven residents. What the service does well: What has improved since the last inspection? The care plans had been further improved and included more detail of the residents’ individual needs. The manual handling risk assessments had been improved and detailed the size of sling to be used with the hoist. All residents had documented personal risk assessments. Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 Page 7 The reports written by the responsible individual, on the conduct of the care home, following her monthly visits to the home were being sent to the CSCI more regularly. 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. Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 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 Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5. The assessment procedures in the home were good ensuring the needs of the residents were known and could be met by staff. EVIDENCE: The files of two of the residents who had been recently admitted to the home were inspected. Both files evidenced that social workers had undertaken the assessments and drawn up the initial care plans. The home had received copies of the full assessments however there was evidence of their own pre admission assessments which were adequately detailed and included all the necessary information. The assessments ensured that prospective residents met the criteria for the home and that the home could meet their needs. Once admitted to the home further assessments were undertaken and these informed the first care plans that were drawn up. There was also evidence that prospective residents were able to visit the home prior to admission. The statement of terms and conditions of residence at the home was not viewed however the manager informed the inspector that the requirement made following the last inspection in relation to the complaints procedure had been made. Bournville Grange DS0000044748.V263705.R01.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 and 8. The care planning system in the home was good ensuring staff knew the individual needs of the residents and how they were to be met. There were comprehensive risk assessments for residents that included strategies for minimising any risks. The health care needs of the residents were being met. EVIDENCE: Two care plans were sampled. The care plans included very good detail of the residents’ needs and how these were to be met. Staff were commended for their attention to detail in the care plans. The care plans detailed residents’ needs in several areas of their lives including, communication, personal hygiene and social needs. The plans included details of what the residents were able to do for themselves and what their preferences were. There were also completed nocturnal needs sheets which gave details of any needs the residents had when retiring to bed and throughout the night. Any areas of high importance in the care plans were highlighted in red, for example, in relation to the diet of a diabetic. The care plans were being reviewed on a monthly basis. Both files sampled had well detailed manual handling risk assessments and well detailed personal risk assessments. Tissue viability and nutritional Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 Page 11 screenings were being undertaken however it was noted that one of the nutritional screenings had not been completed. It was also noted that on one of the risk assessments in relation to a resident’s diabetes and the risk of eating inappropriate food it stated the resident would become unwell however there was no detail as to what staff should be observing for. This detail needed to be included to ensure staff knew when to alert senior staff. There was good documented evidence of health care needs being identified, followed up and monitored by staff. There was evidence that referrals were made to appropriate health care professionals as appropriate, for example, diabetic clinics, doctors, chiropodists, opticians and dentists. The weights of the residents were being monitored on a regular basis. All the residents spoken with were very happy that their medical needs were being met. Bournville Grange DS0000044748.V263705.R01.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 and 13. There were no rigid rules or routines in the home and residents were very satisfied with their lifestyles. EVIDENCE: The residents spoken with confirmed there were no rigid rules or routines in the home and that they could spend their time as they wished. Activities offered in the home were not assessed during this visit however residents were seen to wander freely around the home, spend time quietly in their bedrooms, watch television, listen to music and sit chatting together. Staff at the home were busy arranging activities for over the forthcoming Christmas period at the time of the inspection. Residents spoken with said they could have visitors when they wished and visitors were seen to come and go from the home during the course of the inspection and all appeared to be made very welcome by staff. Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 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 the following standard(s): These standards were not assessed during this visit however both of the key standards were met at the last inspection. EVIDENCE: Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21, 24, 25 and 26. The standard of the environment within this home was very good providing residents with an attractive, safe, comfortable and homely place to live. EVIDENCE: There had been no changes to the layout of the home which was suitable for the residents. The home was safe and very well maintained. All the requirements made by the fire officer at the most recent visit had been met. Only one minor requirement was made following the last inspection and this had been met. Communal space in the home was ample and offered residents a choice of three lounges. All communal areas were furnished and decorated to a very good standard. The home has extensive grounds to the rear that are accessible to the residents however these were not inspected during this visit. In the home there were two fully assisted shower rooms and one assisted bathroom. The majority of the bedrooms had full en-suite facilities including Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 Page 15 showers, others toilets and wash hand basins. There were also additional toilets on the ground and first floors. Some bedrooms were seen during the tour of the home. All were well furnished and decorated and personalised to the occupants choosing. All bedrooms had appropriate locks fitted and residents could have keys if they wished. The heating, lighting and ventilation throughout the home were safe and met with the needs of the residents. The home was clean and odour free with appropriate procedures in place for the disposal of clinical waste. The laundry was appropriately located and equipped. Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 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 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. Appropriate staffing levels were being maintained by a staff team that could meet the needs of the residents. EVIDENCE: The conditions of registration in relation to staffing levels were being met. At the start of the inspection the manager was not in the home however one of the senior care assistants was the designated person in charge and there were three other care staff also on duty. Also in the home were the cook and a domestic assistant. There had been more stability in the staff team since the last inspection which had improved the continuity of care of the residents. All the residents spoken with were very positive about their relationships with the staff and were happy with the service they were receiving. Staff were seen to address residents appropriately and friendly relationships were evident. Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 Page 17 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, 37 and 38. The manager ensured the smooth running of the home in a competent manner. The health and safety of the residents and staff was very well managed. EVIDENCE: The manager of the home had many years experience of caring for older people. She was undertaking her Registered Manager’s Award qualification. Throughout this, and previous, inspections she demonstrated her knowledge of the needs of the residents in her care and the running of a residential home. The decreasing numbers of requirements made following inspections reflects her commitment to the home and ensuring the residents enjoy a good quality of life. The home also has a deputy manager and a team of senior care assistants. The proprietor and the service manager were also frequent visitors to the home. Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 Page 18 All the records sampled during the course of the inspection were very well ordered and up to date. The service manager who was also the responsible individual for the home had been undertaking her monthly visits and producing the required reports on a more regular basis. Health and safety at the home were very well managed, with no requirements being made. The inspector was aware that staff had received training in safe working practices. There was evidence on site of the regular servicing and maintenance of all equipment and all the in-house checks on the fire system were up to date. There was an updated fire risk assessment that had been undertaken by an outside agency. The water system had been checked for the prevention of legionella. The premises were very well maintained and safe. Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 Page 19 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 X X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X 3 3 Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes but they were not assessed for compliance at this visit. 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 OP8 Regulation 12(1)(a) Requirement All residents must have completed nutritional screenings. Risk assessments must detail any known symptoms in relation to any illnesses that staff must observe for. Staff must record the activities residents take part in or decline to evidence their social needs are being met. (Previous time scale of 14/07/05 not assessed for compliance at this visit.) A minimum of 50 of care staff must be qualified to NVQ level 2 by 2005. (Previous time scale of 31/12/05 had not lapsed.) Induction training for staff must be completed within twelve weeks of them commencing their employment. (Previous time scale of 14/07/05 not assessed for compliance at this visit.) The manager must be qualified to NVQ level 4 in management and care or the equivalent by 2005. (Previous time scale 31/12/05 had not lapsed.) DS0000044748.V263705.R01.S.doc Timescale for action 01/01/06 2 OP12 12(1)(a) 01/01/06 3 OP28 18(1)(a) 31/12/05 4. OP30 18(1)(a) 01/01/06 5. OP31 9(2)(b)(i) 31/12/05 Bournville Grange Version 5.0 Page 21 6. OP33 24(1)(a) (b) 7. OP36 18(2) The home must have effective quality assurance and quality monitoring systems in place, based on seeking the views of the residents. (Time scale of 01/04/05 not met. Previous time scale of 01/09/05 not assessed for compliance at this visit.) The manager must ensure that staff receive a minimum of six supervision sessions per year. (Previous time scale given 01/08/05 not assessed for compliance at this visit.) 01/01/06 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Bournville Grange DS0000044748.V263705.R01.S.doc Version 5.0 Page 23 - 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!