Inspection on 29/06/06 for Byker Hall

This inspection was carried out on 29th June 2006.

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 05/12/05

Byker Hall 22/04/05

Byker Hall 09/12/04

Byker Hall 27/07/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

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 Tyne & Wear NE6 2SB Lead Inspector Suzanne McKean Key Unannounced Inspection 29th June 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Byker Hall DS0000000396.V294761.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. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Byker Hall Address Allendale Road Byker Newcastle Upon Tyne Tyne & Wear NE6 2SB 0191 224 0588 0191 276 3080 Byker.Hall@fshc.co.uk www.fshc.co.uk Tamaris Healthcare (England) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Elizabeth McAffery Care Home 48 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) Category(ies) of Old age, not falling within any other category registration, with number (48) of places Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three named service users under the age of 65 years can be accommodated. Any changes to the named service users must be notified to the Commission. 5th December 2005 Date of last inspection 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 en-suite 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. The fees charged range between £355 and £505 per week. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection and took place over one day and involved two inspectors. Residents care records, staff rota, recruitment/training files plus additional statutory records were examined. The inspectors had informal and formal discussion with the manager, six staff, and two ancillary staff. Twelve residents and four relative were spoken to during the visit. There were nine requirements identified during the last inspection six of which have been fully met. Three requirements are outstanding however there is evidence that they will be addressed as planned. There has been one additional requirement and three recommendations made. What the service does well: What has improved since the last inspection? The standard of care planning has improved significantly as well as the record keeping and evidence of quality assurance. The staff are getting advice from other professionals regarding tissue viability, wound care as necessary and specialist training has been provided for the qualified staff. Although NVQ level 2 training has not been in place, additional training has been given to the care staff. The refurbishment and redecoration programme is now almost complete and the home is now being kept in a sound state and is comfortable for residents to live in. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 6 Residents’ views are being sought and acted upon more to help develop the service. 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 DS0000000396.V294761.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Satisfactory pre-admission assessments are undertaken and this is reflected in the care plan. The home is not registered for, and therefore does not provide intermediate care. EVIDENCE: Four care plans were inspected and showed that the manager carries out comprehensive assessments before any resident is admitted to the home. The care managers and the nurse’s assessments were also available. These records form the basis of the care planning process for the resident. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. The health and social care needs of service users are being met and there are records to support this. Medicines are managed effectively and residents receive their medication safely as prescribed and in line with safe practice guidance. The recording of disposal of controlled medicines should be improved. Residents feel they are treated with respect and their right to privacy is upheld. EVIDENCE: There has been a vast improvement in the record keeping since the last inspection. The manager has carried out an audit of the care plans and has made sure that the qualified nurses have reviewed and up dated the plans according to the changing needs of the residents. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 10 Each resident has a care plan, which is based on the admission assessment. The care plans inspected were completed to a good standard. There was evidence of relevant risk assessments for the prevention of falls, pressure sore and wound care, moving and assisting, catheter care, continence promotion, nutrition and mental health status. Risk assessments were available for the safe use of bedrails. Monthly health observations including weights are recorded and any changes acted upon. The care plans inspected showed that the nursing staff accurately document changes in residents conditions and review the care plans in a clear, concise style. The residents have access to all NHS facilities. There are regular visits from GP’s and other health professionals including dentists, opticians and chiropody services. There are appropriate pressure reliving devices and other aids available to support the staff and residents in daily activities. Advice is sought from tissue viability specialists, speech therapists and continence advisors. Visits from the multi disciplinary team are recorded in individual care plans. All personal care was given in private. Staff were observed to use residents preferred names and to knock on doors before entering. The relationships between the staff and residents were professional and based on mutual regard. Residents said the “staff are nice”, “I am looked after”, “everything is alright here”, and “they always help me”. There are policies and procedures available for safe receipt, recording, storage, handling, disposal and administration of medicines. These were being followed. The treatment room and medicine store cupboards were tidy, and more organised than at the last inspection although changes to the room are still required to ensure that adequate cleaning can be carried out. Controlled Drugs were examined were being recorded effectively. Medications receipt administration and disposal are recorded effectively. Medicines for disposal are now being removed using a nominated waste management supplier, however the recording of the Controlled Drugs could be made more robust by recording the medicines going into the de-naturing kit and its removal from the home. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 11 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, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Resident’s social needs are being met and the home helps residents maintain contact with family/friends/representatives and the local community as they wish. Residents are helped to exercise choice and control over their lives and this is evidenced in care plans. Residents receive a wholesome appealing balanced diet in a pleasant environment. EVIDENCE: The home now benefits from an activities organiser. Activities are now displayed and evidence is available to support what events have taken place both inside and outside the home. Residents enjoy spending time with the activities organiser on a one to one basis, enjoy board games, and relaxation sessions. A few of the residents were invited to the Lord Mayors Reception and those letters are on display. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 12 On the day of the visit several residents and their visitors spent the day in the garden chatting to each other and the staff were readily available to chat and bring them drinks. Some preferred to stay in their own rooms and have newspapers, books, television and jigsaws to keep them busy. Residents can choose to entertain their visitors in the lounges in addition to the privacy of their own room. The home encourages visits from the local community including the local school and churches. Where possible the residents are encouraged to manage their own money for as long as they are able. The residents are encouraged to bring personal possessions with them, making their own rooms individualised and reflective of their lifestyles and interests. There has been a vast improvement in the quality and choice of food. The home has a four-week menu displayed in both dining rooms. There was a choice of liver and onions or cheese flan with roast potatoes, swede and cauliflower. Residents could also have salads or sandwiches. Dessert was rice pudding with further choices of yoghurt, ice cream or fresh fruit. The kitchen staff served the lunchtime meal from a hot trolley. The staff offered a choice of drinks throughout the meal and gave assistance in a sensitive manner. Residents have the choice of eating meals in the dining room or in their own rooms. Regular drinks were served throughout the day and fresh fruit was easily available in the dining rooms. Five residents said that “the meals have improved”, “I have plenty to eat”, “they will always get me something I like”, “sometimes there is too much on my plate”. There are dining rooms on both floors. The tables were appropriately set with cutlery and crockery. The registered manager confirmed that the kitchenette units were to be replaced as part of the refurbishment programme. The tea trolleys have been replaced since the last inspection. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 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): 16 & 18 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Complaints are managed satisfactorily and the necessary action taken. The records of complaints and Protection of Vulnerable Adults referrals are kept to ensure that audits can be carried out. EVIDENCE: The home has a complaints policy and staff are clear about the procedure to deal with complaints, which is available in a number of places in the home. Residents and visitors said that they knew who to talk to if they were unhappy and had confidence that these would be dealt with, one had made some concerns known and had felt that these had been resolved to their satisfaction. The staff are aware of the whistle blowing policy and how to inform the Manager of any incidents or issues of which there are concern. Staff confirmed this on discussion. It was unclear from the training records which staff had completed Protection of Vulnerable Adults training. The complaint record was examined. There have been four complaints made since the last key inspection two of which were upheld. The records show the company policy is being followed and there is a good record of the process and the outcome with the necessary action taken regarding any identified problems with the service. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 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, 21, 24, & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents now live in a generally safe and well maintained environment with only a few items of redecoration and replacement of furniture being needed. There are good communal areas. There are suitable toilets and baths although some replacement of the flooring must be completed. The bedroom areas are personalised and comfortable but need some furniture and carpets replaced. The home is clean and odour free. EVIDENCE: The homes location and layout is suitable for the current needs of the residents. There is easy access to the garden area from the downstairs dining room and the main reception. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 15 A refurbishment and redecoration programme has been put in place since the last inspection. The corridor carpets have been replaced resulting in an odour free home. Communal areas are being redecorated and refurbished as necessary. The kitchenettes on both floors are to be refurbished. All of the bedrooms have an en-suite facility and there are bathrooms, shower rooms and toilets close to all resident areas. The following was noted during a tour of the home: • The bathroom opposite room 36 is used as storage for bedrails, unused zimmer frames, wheelchairs and scales. The bathroom opposite room 12 is also used as storage for scales, hoist slings, wheelchairs, Zimmer frames, bedrails, air mattresses and a fold up bed. This results in them being unable to be used or cleaned effectively. The tiles in the shower rooms still have not been repaired or replaced. One shower room had a torn shower curtain and there was evidence of use of communal toiletries. The flooring in both downstairs toilets next to the lounges remains worn and difficult to clean. • • • The bedrooms are all for single occupancy. Residents have brought small items with them making their rooms personalised and homely. Some of the bedroom furniture is showing signs of wear and several of the rooms have wheelchair damage to doors and walls. On the day of inspection the home was clean, bright and fresh smelling. The sluices were locked and there are disinfectors on both floors. The laundry is on the lower ground floor. There are separate areas for clean and soiled linen. Both areas were generally clean and organised. Staff were observed to follow infection control procedures throughout the day. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 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, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. The manager ensures there are adequate numbers of staff on duty that have appropriate skills and experience to care for the residents. The recruitment processes, POVA and whistle-blowing procedures are in place for the protection of residents and the support of staff. EVIDENCE: Seven staff files were inspected. All of them showed that the recruitment and selection process was being followed. There was evidence of two references, Criminal Record Bureau checks, POVA First checks, and medical references, proof of identity, completed application forms and contracts of employment. The staff spoken with confirmed that they have received training in safe working practices. Specialist training for staff includes care planning, record keeping, infection control, wound care, and adult protection. The registered manager confirmed that NVQ 2 training had been on hold and as a result 50 of staff are not trained to this level, a plan is in place to achieve this. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 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, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. The Manager has recently been registered and is showing that she his of good character, and is improving the standards. The quality systems are being established and developed and are now adequate to show that the resident’s needs and wishes are taken into account in the operation of the home or that there is a robust quality assurance system in place. Resident’s financial interests are safeguarded. Staff are not appropriately supervised. EVIDENCE: Residents personal allowance records were examined and were being completed appropriately. Two people sign all transactions and descriptions of Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 18 purchases are provided. There is good recording of their balances with personal accounts in place for some residents. Most residents moneys are being held in a central non-interest bearing account. The Company is planning to change this system to enable residents with accumulating amounts to get interest on their own money. This has not happened yet. The Manager is not up to date with staff supervision although the annual programme has begun. The registered manager has carried out yearly appraisals. The staff have received training in safe working practices including first aid, moving and handling, food hygiene, fire and infection control. Fire training and fire risk assessments were up to date. The practice of holding open fire doors with wooden chocks, wheelchairs and footstools has stopped. Accident recording is satisfactory with weekly audits carried out. Contract maintenance certificates were available and in house weekly tests are carried out with records kept. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 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 3 X X X X 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 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X 2 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 20 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 OP21 Regulation 23 Requirement The tiling in bathrooms and shower rooms must be replaced. The vinyl flooring in the two downstairs toilets must be replaced. The home must ensure that there is suitable furniture, fitting and floor coverings in residents’ bedrooms. Redecoration of walls in bedrooms is required where there has been wheelchair or other damage. Kitchen units in the small kitchens on both floors must be replaced. The home must ensure that 50 of care staff have completed NVQ level 2 training. All staff must have formal supervision at least six times a year. Timescale for action 01/11/06 2. OP24 16,23 01/11/06 3. OP28 18 01/01/07 4 OP36 18 (2) 01/08/06 Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP21 OP26 Good Practice Recommendations It is recommended that the home have a more robust system for recording the disposal of Controlled Drugs into the de-naturing kit and its removal from the building. The Manager should regularly tour the building to ensure that staff are not using bathrooms as temporary storage areas. It is recommended that the home has liquid soap, disposable hand towels and foot operated, lidded bins in all of the on suites / bedrooms. Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Cramlington Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Byker Hall DS0000000396.V294761.R01.S.doc Version 5.2 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. 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