Inspection on 22/04/05 for Byker Hall

This inspection was carried out on 22nd April 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

Byker Hall 27/10/08

Byker Hall 12/05/08

Byker Hall 26/06/07

Byker Hall 29/06/06

Byker Hall 05/12/05

Byker Hall 09/12/04

Byker Hall 27/07/04

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The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

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Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Byker Hall Allendale Road Byker Newcastle upon Tyne NE6 2SB Lead Inspector Irene Bowater Unannounced 22 April 2005 09.30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Byker Hall Address Allendale Road Byker Newcastle upon Tyne NE6 2SB 0191 224 0588 0191 276 3080 byker.hall@fshc.co.uk Tamaris Healthcare (England) Ltd (wholly owned subsidiary of Four Seasons Healthcare) Mrs Judith Goode CRH 48 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of OP - Old Age (48) registration, with number of places Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 9th December 2004 Brief Description of the Service: Byker Hall Care Home is purpose built and is situated in a residential area of Byker. The site is shared with another home owned by the same company. The Home is within easy reach of shops,public transport and all other amenities. Byker Hall provides general nursing care for up to 49 older people in single ensuite rooms. The home has communal lounges, dining rooms and smoking rooms on each floor. The laundry and kitchen areas are on the lower ground floor, from resident areas. All areas of the home are accessible and a passenger lift services all floors. Externally there is a garden and patio area and there is ample car parking. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 6.5 hours. The home manager was available and assisted throughout the inspection. Eight staff and eleven residents were spoken to throughout the day. Part of the day was spent in the office examining records and the majority of the time was spent touring the premises and spending time with the residents. What the service does well: What has improved since the last inspection? Since the last inspection the use of agency staff has decreased in the home. The staffing is now consistent and residents and staff are building good relationships. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 6 The majority of the requirements and recommendations from the last inspection report have been addressed within the timescales. Decoration and refurbishment of the home is improving and those areas are looking welcoming and homely. The results of the resident’s survey are now published and there is a suggestion box available in the main reception area for comments from residents, staff, relatives and other professionals about the care and service provided. 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. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3,5 The admission procedures are comprehensive and ensure that the staff can meet residents assessed needs. Pre-admission visits are arranged to enable potential residents and friends to assess whether the home is suitable. The Home has not yet produced a Statement of Terms and Conditions for residents who are self funding. Without this the rights and obligations of the resident and the provider is not clear. EVIDENCE: The home has detailed pre assessment documents that are completed prior to residents being admitted into the home. Evidence was available to confirm that the home receives appropriate assessments from Care Managers and other professionals to ensure that residents assessed needs can be met in the home. From these documents the residents have a care plan formulated. The care plans inspected showed that they were comprehensive and enabled staff to deliver the care required. The home encourages potential residents and their representatives to visit the home for a day or part of a day prior to admission. All residents have a sixweek trial period followed by a multi disciplinary review before deciding to stay in the home on a permanent basis. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 9 The Home has not provided residents with a statement of terms and conditions (or contract) when purchasing their care privately. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10 There is a clear consistent approach to the care planning system, which ensures that the staff has the required information to meet residents assessed needs. The staff adhere to the procedures to ensure the safe receipt, recording, handling, administration and disposal of medicines. The staff have an understanding of residents needs and endeavour to promote their rights to privacy and dignity in regard to personal care delivery. EVIDENCE: Each resident has a care plan, which is based on the preadmission assessment. The care plans use a recognised nursing model that covers all aspects of daily living. The care plans inspected showed an extensive range of risk assessments in place to ensure the staff meets resident’s needs. The plans are regularly reviewed and updated and there was evidence of residents and their representatives being involved in the six monthly care reviews. The care plans show that residents have regular access to all NHS services and facilities. There was an impressive range of information available for staff to follow regarding care delivery and ensuring best practice. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 11 The care plans inspected showed that residents at risk from pressure damage have appropriate care plans in place and nutritional screening is undertaken on a monthly basis with residents weights recorded. The home has comprehensive policies and procedures available to ensure safe administration of medication. An audit of the medicines showed clear recording and administration. The Controlled Drug Audit showed no discrepancies and the staff carry out weekly checks. The records inspected showed that GP’s review residents medication and there was evidence of pharmacy audits. Since the last inspection a further drug trolley has been provided. This trolley was not secured to the wall when not in use. Throughout the day it was evident that the staff respected residents right to privacy and dignity especially in regard to personal care giving. The staff were observed knocking on doors and waiting before entering, personal care was given in private and the staff used the resident’s preferred name. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 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 standard(s) 12,14,15 The social care needs of residents currently meet their lifestyles and personal preferences. The staff enable the residents to exercise choices and maintain control over their lives as far as they are able. The home provides a balanced diet, which offers choices and caters for special dietary needs. EVIDENCE: The home has a programme of activities, which is displayed, in the home. An activities coordinator is employed who is responsible for organising outings and entertainment in the home. One bedroom has been converted into a library, and reminiscence room. Residents spoken to said they were generally satisfied with the activities provided. They were pleased the warmer weather had arrived as they had enjoyed sitting in the gardens for the last two days. Residents had been to the local shops on an individual basis with staff, other residents spoken with did not want to join in any planned activity and preferred to spent time in their own rooms. Residents have a social assessment and care plan, which documents their preferences and choices. There is information available on the notice boards regarding access to Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 13 advocacy services within the local area. Residents spoken with confirmed that they are enabled to exercise their preferences regarding all aspects of daily living as far as they are able. Breakfast was being served on arrival at 0.9.30 am. Residents were enjoying a selection of cereals, juice, toast with butter and preserves and various cooked breakfasts. Several of the residents were served their meal in the privacy of their own room. The residents were provided with drinks mid morning, however it was disappointing to note that coffee nor biscuits were offered at this time. At lunchtime there was a variety of meals served according to individual preferences. Residents spoken with said they always were offered choices for each meal, however they said they were sick of soup and sandwiches at tea times. The care staff and kitchen staff were able to discuss the dietary needs for the diabetics and those whose nutritional status may be compromised. Supplement foods are prescribed and the home also provides milkshakes as further supplements. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18. The complaints process within the home is currently satisfactory. The staff have knowledge of Adult Protection and would be able to use the procedures if necessary. EVIDENCE: The home has comprehensive policies and procedures in place, which give details of how and to whom to complain should a resident or their representative wish to do so. Residents spoken with said they would be able to use the process if necessary. The records show that all concerns and complaints are taken seriously, are clearly recorded with actions and outcomes recorded. The Provider is currently investigating one complaint. All residents are provided with a copy of the procedure and it is readily displayed in the home. There are policies and procedures available for staff to follow to ensure the Protection of Vulnerable Adults. Currently twenty-four staff have received training. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,22,23,24,26. The home is suitable for the residents who live there. The standard of the environment currently does not provide a clean, odour free living place for the residents. EVIDENCE: The home has continued with the redecoration programme and is in the process of redecorating the upstairs corridors. The chairs in the dining rooms were generally scuffed with food debris and tea stained. There was no evidence that the breakfast tables or the dirty dishes and left over food were any priority to clear away in the dining rooms or kitchen areas until late morning. The seal to the fridge located in the downstairs kitchen is split. Several of the small coffee tables require cleaning due to constant spillage of drinks. One resident’s specialist chair was split, torn and shabby. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 16 There are grab rails throughout the home and there are suitable hoists, assisted baths, showers and toilets available for the residents assessed needs. The home supplies some nursing beds and there is a range of pressure relieving mattresses available. All resident areas have an accessible call system with alarm facility provided. All of the bedrooms are single with an en-suite facility. Many of the residents have brought their own possessions with them making their rooms comfortable and homely. The bedrooms inspected were found to be generally clean, however many of the bed tables were stained with food debris and liquid spillages and the bed rails and bed bumpers were all dirty and marked. There was an odour of urine on the upstairs corridor, which came from two bedrooms. By early afternoon this odour was evident along the corridor. One resident had been admitted to hospital, however the room had not been cleaned. A dirty suction machine had been left on the floor and other medical equipment had not been cleared away. One bedroom is being used as a storage area. This room was unlocked, and housed various pieces of obsolete or non-required equipment. The toilet in this room was broken, there was no cistern and there was a dirty dried paper towel wedged in the toilet bend. The floor was also covered in crisps and food debris. There were domestic staff on duty throughout the day and they were observed to be constantly working and cleaning home. The household rubbish and clinical waste bins are stored outside at the back of the lower ground floor. The household waste bins were overflowing and although the clinical waste bin that was in use was locked a secure bin store has not been provided. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,30. The home is adequately staffed with qualified nurses and care staff given the current numbers of residents. The number of staff deployed should be constantly reviewed following assessment of dependency levels. The provision of training continues to progress, however new staff need to gain care qualifications. EVIDENCE: The home has experienced recruitment problems for some considerable time. There is some evidence that the agency use is reducing and the ongoing recruitment of staff is successful. The shift patterns have changed and the staffing levels have reduced since the last inspection. The home is currently staffed as follows: 2 Qualified Nurses from 8am to 8pm 1Qualified Nurse from 8pm to 8am 5 Care staff from 8am to 2pm 4 Care staff from 2pm to 8pm 3 Care staff from 8pm to 8am On the day of inspection there were 3 domestic staff 1 laundry assistant, 1 cook, 2 kitchen assistants, 1maintenance person and an activities organiser. The administrator works Monday to Thursday each week. The staff said that the new staff needed further training and are undergoing their induction programme. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 18 The home manager confirmed that staffing levels are monitored in line with resident’s dependency levels. There is a training plan for 2005 to 2006.Evidence from the records inspected showed that staff receive statutory training and some specialist training including, Dementia Care, Infection Control, Wound Care, Challenging Behaviour and Palliative Care.24 staff have completed the Protection of Vulnerable Adults training. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36.38. The system for resident consultation is satisfactory. The staff receive suitable supervision support from senior staff. Residents, staff and visitors health and safety is promoted as far as is reasonably practicable. EVIDENCE: The records inspected showed that there are regular resident and staff meetings held with minutes recording the issues, following action taken and outcomes. Resident’s views have been sought and the results are published in the home. A suggestion box is now available in the main reception area for residents use. A sample of staff files inspected showed that supervision takes place at least 6 times a year .The sessions cover care practice, aims and objectives of the home and individual career developments. The staff receive training in safe working practices with records kept. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 20 Accident recording is satisfactory with monthly analysis completed. Contract maintenance certificates were current and a fire risk assessment has been completed. The flooring in two toilets is lifting, however the manager confirmed that the flooring is due to be replaced. The maintenance person carries out weekly tests and the home has a Health and Safety committee which meets quarterly. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 1 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 2 COMPLAINTS AND PROTECTION 3 2 3 3 x 2 x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x 3 x 3 Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 0P 2 Regulation 5 Requirement The home must provide a statement of terms and conditions(or contract if self funding). Timscale of 2003 not met. The new drug trolley must be secured to the wall when not in use. The tea time menu requires reviewing to ensure residents preferences are taken into account.Hot and cold drinks and snacks must be avalable at all times according to individual preferences. Clean,revarnish or replace the scuffed ,stained dining room chairs. Replace the torn,shabby indentified specialist chair. The seal on the fridge door must be repaired or the fridge replaced. A review of the housekeeping practices is required to ensure all areas are cleared of dirty dishes and food debris after meals. The bed side tables must be kept clean from food and drink stains. The bed rails and rail covers require regular cleaning. Timescale for action 1st June 2005. 2. 3. OP 9 OP 15 13 12,16 1st June 2005. 1st June 2005. 4. OP 20 16,23 1st June 2005. 5. OP 24 OP 26 13,23 1st June 2005 Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 23 6. OP 26 16 The identified bedrooms require cleaning,medical equipment is to be removed and the room prepared for the residents return. The other room which is used as a store room must be cleaned,the toilet repaired and the door to be locked The two identified bedrooms require the carpets to be deep cleaned or replaced .. The home must provide safe storage areas for the household and clinical waste. 1st June 2005. 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 OP 27 Good Practice Recommendations It is recommended that the staffing levels are monitored in accordance with the geography of the home,the dependency levels of the residents and the skill and experience of the staff. Byker Hall B53-B03 S396 Byker Hall V221646 220405 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Northumbria House Manor Walks Cramlington, Northumberland NE23 6UR 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. 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