Inspection on 30/11/06 for Bryony House

This inspection was carried out on 30th November 2006.

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

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

Other inspections for this house

Bryony House 08/05/08

Bryony House 04/06/07

Bryony House 17/03/06

Bryony House 16/11/05

Bryony House 22/02/05

Bryony House 26/08/04

Bryony House 20/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bryony House 30 Bryony Road Selly Oak Birmingham B29 4BX Lead Inspector Brenda O`Neill Key Unannounced Inspection 09:00 30th November 2006 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 Bryony House DS0000016895.V320723.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. Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bryony House Address 30 Bryony Road Selly Oak Birmingham B29 4BX 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 475 2965 0121 680 1300 Bryony House Committee Christine Hilton Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th March 2006 Brief Description of the Service: Bryony House is a purpose built residential home situated in a residential area within the Bournville Village Trust, providing care for up to 38 older people. There are shops and a church in the locality and easy access to the public bus service. Community facilities such as shops and churches are within walking distance. The home is a large three-storey building with a lower ground floor. The residents’ accommodation is situated on all floors of the home. There are toilets and assisted bathrooms on all floors and all the bedrooms have en-suite facilities. Lifts and stairs connect the separate floors. One shaft lift connects the ground floor with the lower ground floor and the other connects the ground floor to the first and second floors. There are also six flights of stairs throughout the home. On the ground floor are the main kitchen, laundry, office space, a dining room, two lounges and a large conservatory that leads out to the rear garden. A further lounge has been established on the first floor of the home and there is a hairdressing facility on the second floor. At the front of the home there are parking spaces for several vehicles and there is a very attractive large private garden to the rear of the property. The fees at the home are £460.00 per week. Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this key unannounced inspection over one day in November 2006. During the course of the inspection a tour of the building was carried out, five resident and five staff files were sampled as well as other care and health and safety documentation. The inspectors spoke with the manager, deputy manager, a care officer, nine residents and one visitor. Prior to the inspection the manager had returned a completed pre inspection questionnaire to the CSCI which gave additional information about the home. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. No complaints had been lodged with the CSCI since the last inspection. One complaint had been lodged with Birmingham City Council’s Customer Relations Service. A copy of this had been forwarded to the CSCI. The manager of the home had been asked to investigate the complaint. The complaint raised issues about the care received when an individual was at the home on respite care. The records of the investigation were seen during the course of the inspection. The investigation was robust and detailed records had been kept. The complaint was not upheld. What the service does well: All residents were issued with contracts and service user guide when admitted to the home ensuring they had all the information about the home that they may need. Prospective residents were able to visit the home to assess the facilities available to them. There was good documented evidence in the daily records of the residents’ personal and health care needs being met. Health care needs were being identified, followed up and monitored by staff. Residents were able to choose alternative therapies if they wished. Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 6 There was a programme of activities available in the home on the notice board and residents were also notified of these in the monthly newsletter. The newsletter also kept the residents informed of new residents admitted, forthcoming birthdays and any information in relation to staffing. There did not appear to be any restrictions on visitors to the home within reasonable hours. Residents spoken with stated they could have visitors at any time and they could go out with their relatives or friends as they wished. The menus at the home were varied and nutritious and although there were no stated choices at lunchtime there was an extensive list of alternatives available for the residents from. Residents were able to have their meals in their rooms if they wished. Residents said the food was ‘good’ and one stated ‘the roasts are particularly nice’. Staff turnover at the home was relatively low and many of the staff had worked there for a considerable amount of time which was good for the continuity of care of the residents. The health and safety of the residents and staff were well maintained. The home provided residents with a very good standard of accommodation that was safe and very comfortable. What has improved since the last inspection? What they could do better: A pre admission assessment must be completed prior to any residents being admitted to the home so that staff can decide if they can meet the needs of the individuals. All residents must have care plans in place that clearly detail how all their identified needs are to be met by staff. Residents must be consulted about their care plans and how they want their care delivered. All residents must have risk assessments in place for any possible risks they may be vulnerable to and include guidance for staff on how to minimise the risk. Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 7 Wherever possible residents must be weighed on a monthly basis to ensure they are remaining healthy. Staff must ensure they are mindful of the residents’ rights to privacy at all times. There needed to be systems in place so that residents were assured it was acceptable to ask for extra drinks or that after a risk assessment being undertaken they had the facilities to make their own drinks. Arrangements needed to be in place to ensure that the food and drinks served to residents in their bedrooms were of an acceptable temperature. There must be systems in place in the home to ensure the residents are able to raise any concerns that they may have without worrying about the reaction of staff. There must be evidence that residents who do not wish to take part in group activities are given one to one time. Staff must record how residents are spending their days to evidence their social needs are being met. The manager must ensure there are records on site that staff have had the necessary induction training to enable them to care for the residents. 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. Bryony House DS0000016895.V320723.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 Bryony House DS0000016895.V320723.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): 1, 2, 3 and 5. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Information was available for prospective residents to enable them to make an informed choice about the home. The pre admission assessment procedure did not ensure the residents’ needs were known by staff prior to admission. EVIDENCE: The home had a service users guide and this included all the necessary information for residents. The manager stated that all prospective residents are given a copy of the service user guide. One of the residents spoken with said that they had received the service user/guide another two were not certain but said they had had some information although a relative managed their affairs. All the residents’ files sampled included copies of contracts that included all the necessary information such as the room number and fees. Two of the residents Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 10 asked about their contracts were aware of them and their fees and were aware that fees were reviewed annually. The other two residents asked about this stated that a relative managed all their affairs for them. Residents spoken with said they were able to visit the home prior to admission and some went into the home for a short stay before being admitted on a permanent basis. Only one of the files sampled included a copy of a full assessment carried out by a social worker. One included a copy of a care plan that had been drawn up a social worker but no assessment. The other files where no social worker had been involved in the admission process did not include any pre admission assessment documentation. It could not be determined how the decision had been made that the home could meet the needs of the individual residents. Bryony House DS0000016895.V320723.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 and 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 needed to be further developed to ensure they included sufficient detail to enable the residents’ needs to be met and ensure all identified risks were minimised. The medication system was well managed and safe with only a minor issue being raised. Staff were not always mindful of residents’ privacy. EVIDENCE: Five residents files were sampled. Two included a needs assessment that had been completed two to three months after admission. The assessments were quite detailed and included the individuals’ needs in relation to comfort and mobility, communication, activities, personal care, hygiene, diet, continence, spiritual needs and so on. Some of the information was quite detailed and included the individuals’ likes, dislikes and preferences and what they were able to do for themselves. There was also a document entitled summary of support plan which gave a very brief overview of the needs of the individuals but there was no detailed support plan or care plan. The other three files Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 12 sampled had little or no information at all about individual needs or how staff were to meet them. The only information was some personal details, for example, next of kin and date of birth. The lack of adequate care plans has been an ongoing issue at the home and need to be addressed. It is difficult to see how staff can meet the needs of the residents without some clear guidance of how to do this. Care plans also need to include evidence that the residents have been consulted about them and that they are reviewed on a monthly basis. Two files sampled included manual handling risk assessments but these did not detail the actions to be taken staff in the event of a fall if the person was uninjured. The other files had no manual handling assessments. The same two files included personal risk assessments, nutritional assessments and pressure sore assessments the other three did not. The personal risk assessments were adequate and in relation to such things as mobility. One of the nutritional assessments was adequate the other was not detailed enough. The individual concerned was very underweight on admission to the home and the assessment stated ‘need to encourage to eat’. There was no specific guidance for staff as to how to monitor the individual’s progress or what to do if the weight loss continued. The individual had only been weighed once in six months. The pressure sore risk assessments gave a score but it could not be determined from them when a resident would be as at risk and when a management plan would need to be put in place. There was good documented evidence in the daily records of the residents’ personal and health care needs being met. Health care needs were being identified, followed up and monitored by staff, for example, one resident was noted as unwell by staff and the doctor had been called, another was having regular visits from the district nurse for an ongoing problem with her legs and this was also being monitored by the hospital. One of the residents spoke to the inspectors of choosing to pay for some private treatment and she had also undergone some alternative therapies. It was strongly recommended at the last inspection that visits by health care professionals were documented separately from the daily records to make them easier to track. This had been done for some residents but not all. If this is not done information quickly gets lost amongst numerous daily record sheets. The medication was being administered via a 28 day monitored dosage system which was generally well managed. Medication had been booked in and acknowledged as being received and administered appropriately. Controlled medication was being recorded appropriately. Eye drops and antibiotics were being dated when opened. Any residents wishing to self administer medication had a risk assessment in place. One discrepancy was found when auditing the system. Staff had administered only one antibiotic on four occasions when two should have been administered. Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 13 The inspectors spoke to some residents who chose to spend a lot of time of their bedrooms and staff respected this. The residents did not raise any issues in relation to their rights to privacy not being upheld. However two areas were of concern to the inspectors, a member of staff was seen to enter a resident’s room without knocking and another staff member left the toilet door open while being used by a resident. Staff must ensure they are mindful of the residents’ rights to privacy at all times. All the bedrooms in the home were of single occupancy and all residents could have keys to their rooms if they wished. There were several areas in the home where residents could meet their visitors in private if they wished. There was a telephone for the use of the residents in the conservatory and several residents had their own telephones in the bedrooms. Bryony House DS0000016895.V320723.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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were no rigid rules or routines in the home and there were activities on offer for residents if they wished to take part. Residents were able to exercise choice and control over their lives. The meals served in the home met with the needs of the residents. EVIDENCE: There were no rigid rules or routines in the home and the residents spoken with confirmed they could spend their time as they chose. There was a programme of activities available in the home on the notice board and residents were also notified of these in the monthly newsletter. Activities included games afternoon, visiting entertainers, keep fit, showing of DVDs and quizzes. Staff were documenting some of the activities the residents were taking part in but not all. This needed to be done to evidence the social needs of the residents were being met. It was also noted that some of the residents chose to spend a significant amount of time in their bedrooms. There also Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 15 needed to be evidence that these residents and those who could not or did not want to take part in group activities were given one to one time. Visitors were seen to come and go throughout the course of the inspection and all appeared to be made welcome by staff. There did not appear to be any restrictions on visitors to the home within reasonable hours. Residents spoken with stated they could have visitors at any time and they could go out with their relatives or friends as they wished. There was some evidence in the daily records that residents were able to choose how they spent their time and if they chose to take part in organised activities or not. Residents were able to choose to stay in their rooms and have their meals taken to them if they wished. Residents spoken with stated they were always consulted about what meals they wanted to eat and that they could choose what time to go to bed and get up. Where a needs assessment had been undertaken for the residents it was detailed how independent the individual’s were and where they were able to make choices. Some of the residents continued to handle some of their personal money and two were financially independent. Residents were encouraged to personalise their rooms to their choosing and personal effects were observed in all the bedrooms seen. The menus at the home were varied and nutritious and although there were no stated choices at lunchtime there was an extensive list of alternatives available for the residents to choose from. All the residents spoken with confirmed they were asked prior to meal times what they would like to eat. Residents were able to have their meals in their rooms if they wished. Several residents had breakfast in their bedrooms however those deemed as being at risk if left to eat their breakfasts on their own had their meal in the dining room. Residents said the food was ‘good’ and one stated ‘the roasts are particularly nice’. One issue raised was that the food and drinks for residents who chose to remain in their bedrooms were only luke warm by the time it got to them. Arrangements needed to be in place to ensure that the food and drinks served to residents in their bedrooms were of an acceptable temperature. There was also a reluctance by some residents to ask for extra drinks as they thought ‘staff were always too busy’. There needed to be systems in place so that residents were assured it was acceptable to ask for extra drinks or that after a risk assessment being undertaken they had the facilities to make their own drinks. Bryony House DS0000016895.V320723.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): 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents did receive a copy of the complaints procedure but were not always confident enough to raise any concerns they may have. Staff had received training in adult protection issues to ensure they were able to safe guard the residents. EVIDENCE: There was a complaints procedure in the home and residents received a copy of this in the service users guide and it was also included in the contract that was issued at the point of admission to the home. The relative spoken to at the time of the inspection was aware of who to raise any issues with and had done so in the past. The residents spoken with did know they had the right to complain but some were wary of raising any issues as they felt they might get an adverse reaction from staff. There must be systems in place in the home to ensure the residents are able to raise any concerns that they may have without worrying about the reaction of staff. No complaints had been lodged with the CSCI since the last inspection. One complaint had been lodged with Birmingham City Council’s Customer Relations Service. A copy of this had been forwarded to the CSCI. The manager of the home had been asked to investigate the complaint. The complaint raised issues about the care received when an individual was at the home on respite care. The records of the investigation were seen during the course of the inspection. Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 17 The investigation was robust and detailed records had been kept. The complaint was not upheld. There were appropriate adult protection procedures on site. The majority of the staff had received training in adult protection issues since the last inspection. Bryony House DS0000016895.V320723.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, 20, 21, 22, 24, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided residents with a very good standard of comfortable accommodation. EVIDENCE: The home had undergone extensive refurbishment and provided residents with a very comfortable place to live. A tour of the home was made and it was well maintained, safe and accessible. The home had ample communal space with two large lounges, a conservatory and a new smaller lounge had been developed on the first floor. The two lounges on the ground floor had been refurbished and new furniture had been purchased. There was adequate dining space, this had also been refurbished and had some new furniture. There were extensive grounds to the rear of the home that were very well maintained and accessible to the residents. Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 19 There were numerous toilets, bathing and showering facilities throughout the home. All bathrooms and some of the toilets had been upgraded and provided residents with a variety of facilities many of which allowed for full staff assistance. All bedrooms had en-suite facilities of toilet and wash hand basin and some had floor level showers fitted. The aids and adaptations throughout the home appeared to meet the needs of the residents and these included, shaft lifts, level entrances and exits, grab and hand rails, assisted bathing and toilet facilities, emergency call system and there were mobile hoists on site for use as necessary. Some bedrooms were sampled all had en-suite facilities, double glazed windows and adequate heating. During the refurbishment all rooms had had new flooring, curtains and linen. All bedrooms were lockable and residents could have keys if they wished. Residents spoken with were very happy with their rooms and were very comfortable. All rooms seen had been appropriately personalised to the occupants choosing. The home was clean and odour free. The laundry was well equipped with washing machines with sluice facilities and tumble driers. Laundry was nicely presented and all had been ironed. Appropriate systems were in place for the control of clinical waste. Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were being maintained by a stable staff team. Recruitment procedures needed to be consistent and appropriate induction training documented to ensure the residents were fully safe guarded. EVIDENCE: Staff turnover at the home was relatively low and many of the staff had worked there for a considerable amount of time. The rotas evidenced that good staffing levels were being maintained. The manager was in the process of increasing staffing levels during the evening as the needs of the residents had increased. The home also employed several catering, domestic, laundry and maintenance staff. Residents were generally very positive about their relationships with staff. Some issues were raised in relation to residents feeling confident enough to raise concerns and ask for extra drinks. These issues were discussed with the manager. It was strongly recommended that the key worker system in the home be developed. This would enable residents to have a named worker who could spend one to one time with them to build up a relationship and reassure them it was all right to raise concerns. This would also help avoid residents who preferred to spend a lot of time in their bedrooms becoming isolated. Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 21 The recruitment records for five staff were sampled. All the appropriate documentation was in place including, completed application forms, two written references, POVA first checks and CRBs. However it was noted that for one member of staff the CRB had not been obtained until after the person had been employed at the home for almost three months and no POVA first check had been obtained. The manager stated that this was because the person was an ancillary worker and would not be with the residents. The person did have access to the home and would have had contact with the residents and it would not be able to be guaranteed they would have been constantly supervised. A minimum of a POVA first check should have been obtained prior to employment being commenced. There was no evidence on site that any of the newly appointed staff had received induction training. The manager did have the required induction books on site but stated staff undergoing induction kept their own books. There needed to be a record maintained on site that the induction training undertaken by staff was in line with the specifications laid down by Skills for Care and completed within the given time scales. There was ongoing training in the home in a variety of topics including, fire training, adult protection and manual handling. Some staff had also undertaken training in care planning and supervision. The pre inspection questionnaire stated that 66 of staff were trained to NVQ level 2 or the equivalent which is in excess of the required level. Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 22 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 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was generally well managed but some improvements were needed to the upkeep of the records required by regulation to ensure the resident’s needs were being met. The health and safety of the residents and staff were well maintained. EVIDENCE: The registered manager demonstrated a good knowledge of the residents in her care and the running of a residential home. She had many years experience of caring for older people, was a registered nurse and was undertaking her Registered Manger’s Award which would give her the required qualifications when completed. It was stressed to the manager at the time of the inspection the importance of ensuring that all the residents had Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 23 appropriate care plans and risk assessments in place to ensure their needs could be met appropriately by staff. Tasks within the home were being appropriately delegated to other senior staff members. There was a quality assurance system in place in the home and the manager was gradually working her way through the audits. She stated that the system was not entirely appropriate for the home and she was going to adapt some of the documentation particularly the questionnaires for residents and their relatives, as they did not get the required information from these. Several in house audits were undertaken on an ongoing basis, for example, health and safety of the environment, medicines and meals. The home was managing money on behalf of some of the residents. The records for this were sampled. There was documented evidence of income, which was generally from family members for which they were given receipts, any expenditure made and two staff signatures for any transactions. Receipts were available for all expenditure. All the balances checked were correct. The manager did need to ensure that the hairdresser signed for any money received from the home. One of the residents continued to manage their own financial affairs and others managed some of their money. The manager was satisfied that the residents were getting the money they were entitled to. Health and safety in the home was well managed. Staff received training in safe working practices and the home was well maintained and safe. There was evidence on site of the up to date servicing of all equipment. All the in house checks on the fire system were up to date and fire drills were carried out regularly. The water system was regularly checked for the prevention of legionella. Accident and incident recording and reporting were appropriate. There were numerous premises risk assessments in place that were regularly reviewed. There were also risk assessments in place for COSHH substances however it was recommended these were reviewed to ensure they were all still in use and that no other substances were being used. Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 24 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 3 3 1 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 4 4 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 3 Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14(1)(a) (b) Requirement A comprehensive assessment of need must be undertaken for all residents prior to them being admitted to the home. Where applicable a copy of the social workers assessment must be obtained. All residents must have care plans that detail how all their current needs in relation to health and welfare are to be met by staff. (Previous time scales of 31/05/05, 01/01/06 and 01/05/06 not met.) Care plans must include evidence that residents have been consulted about them and that they are reviewed monthly. All residents must have personal risk assessments that detail how any identified risks are to be minimised. (Previous time scales of 01/01/06 and 01/05/06 not met.) All residents must have manual DS0000016895.V320723.R01.S.doc Timescale for action 01/01/07 2. OP7 15(1)(b) (c) 01/02/07 3. OP7 13(4)(b) (c) 01/01/07 4. OP7 13(5) 01/01/07 Page 26 Bryony House Version 5.2 5. OP8 12(1)(a) handling risk assessments that include details of the actions to be taken by staff in the event of a fall and any other handling methods to be used. (Previous time scales of 01/01/06 and 01/05/06 not met.) All residents must have: Tissue viability assessments that clearly identify when a resident may be at risk. Nutritional screenings that have a corresponding management plan for anyone deemed as being at risk. (Previous time scales of 01/02/06 and 01/05/06 not met.) Wherever possible residents must be weighed on a monthly basis. Staff must ensure they administer the prescribed doses of medication at all times. Staff must be mindful that the resident’s rights to privacy are upheld at all times. There must be evidence that residents who do not wish to take part in group activities are given one to one time. Staff must record how residents are spending their days to evidence their social needs are being met. Staff must ensure that the food and drinks served to residents is at an acceptable temperature. There must be systems in place so that residents are assured it is acceptable to ask for extra drinks or that after a risk assessment being undertaken 01/02/07 6. 7. 8. 9. OP8 OP9 OP10 OP12 12(1)(a) 13(2) 12(4)(a) 16(2)(n) 12(1)(a) 01/01/07 01/01/07 01/01/07 01/02/07 10. OP15 16(2)(h) (i) 31/12/06 Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 27 11. OP16 12(5)(b) 12. OP29 19(1) 13. OP30 18(1)(a) 14. OP31 9(2)(b)(i) 15. OP35 17(2) schedule 4(9) they have the facilities to make their own drinks. There must be a system in place to ensure that residents are able to raise any concerns they may have without worrying about the reaction from staff. Staff employed at the home must have a minimum of a POVA first check undertaken prior to them commencing their employment. The manager must ensure there are records on site that staff have completed induction training in line with the specifications laid down by Skills for Care. (Previous time scale of 01/06/06 not met.) The acting manager must complete her Care Manager’s Award. (Previous time scales of 31/12/05 and 30/06/06 not met.) The hairdresser must sign for money received from the residents. 31/12/06 01/01/07 01/02/07 31/03/07 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP27 OP38 Good Practice Recommendations It is strongly recommended that the key worker system is further developed. It is recommended that the COSHH risk assessments are reviewed. Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Bryony House DS0000016895.V320723.R01.S.doc Version 5.2 Page 29 - 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. 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