Inspection on 03/03/06 for Digby Manor

This inspection was carried out on 3rd March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Digby Manor 03/12/08

Digby Manor 18/12/06

Digby Manor 31/08/05

Digby Manor 15/02/05

Digby Manor 10/08/04

Digby Manor 03/03/04

Digby Manor 16/12/03

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Ravenhurst

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Inspirations

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

CARE HOMES FOR OLDER PEOPLE Digby Manor 908 Chester Road Erdington Birmingham West Midlands B24 0BN Lead Inspector Debby Railton Unannounced Inspection 3rd March 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 Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 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. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Digby Manor Address 908 Chester Road Erdington Birmingham West Midlands B24 0BN 0121 373 2333 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) janet.alrubaie@shonali.co.uk Mrs Janet Al-Rubaie Mr Jafar Safar Al-Rubaie Mrs Janet Al-Rubaie Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2005 Brief Description of the Service: Digby Manor provides accommodation for 26 elderly people. The home is made up of two detached houses that have been tastefully converted and linked together. It is situated on the Chester Road, near all local amenities. On the ground floor there is a large comfortable lounge/dining room and a conservatory for residents who smoke. There is also a smaller lounge, laundry facilities and kitchen. Some of the bedrooms and bathrooms are also on the ground floor. There are rooms and bathroom /toilet facilities on the first floor. The home has two passenger lifts. The staff room and office are situated on the top floor. In total there are 18 single rooms and 4 double or twin, some having en-suite facilities. All rooms are well furnished and have been personalised to individual residents choosing. To the rear of the home is a beautifully landscaped garden with flowerbeds and large patio areas with garden furniture for service users use. Car parking is in front of the home via a driveway. Residents are able to access a range of activities in the home including pet therapy. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector was in the home for six hours between the hours of 9.30am to 3.30 pm. The inspection was assisted by the senior care on duty at the time and was completed with the homes manager. The inspection started with assessing the medicine management and then a tour of the building followed. Lunch was eaten with the residents during the inspection. Randomly selected care plans, staff files were reviewed and three members of staff were interviewed in private. Throughout the inspection the residents views and opinions were sought. This latest inspection report should be read in conjunction with the last report to obtain a complete overview of the service offered. What the service does well: What has improved since the last inspection? All the requirements from the last inspection had been met within a short timescale. There is a rolling programme installed to ensure that all enhanced CRB checks are undertaken when the CRB has expired. The recruitment procedures now meet the standards and all new staff have and an enhanced CRB and POVA check. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 Page 6 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. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 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 Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 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): None of these standards were assessed during this inspection. EVIDENCE: Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 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, 10 Residents’ health and personal care needs are regularly assessed and identified in their own personal healthcare plan. The service users are able to make full decisions about the care they wish to receive and are fully supported by the care staff to maintain their autonomy. The systems for medicine management remain at a consistent high standard. Clear comprehensive arrangements had been installed to ensure service users medication needs are met. EVIDENCE: Each resident has their own care plan updated on a regular basis to reflect their needs. This is discussed with each individual resident and their key worker to ensure their needs are fully met. Service users are encouraged to maintain their independence and are fully supported by the trained care staff to maintain this. Care plans sampled were comprehensive and fully reflected the service users needs. A range of risk assessments were regularly carried out and appropriate action was taken to ensure the needs of the resident were fully met. External healthcare professionals, such as the doctor, district nurse, optician, chiropodist and dentist, visit the home on a regular basis. Specialist equipment to promote their well being and meet personal needs is purchased if necessary. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 Page 10 The medicine management remained at a high standard. All audits undertaken demonstrated that the medication had been administered as prescribed. Systems were in place to check the medication received into the home. Regular audits took place to ensure that the medicines are administered as prescribed and the records reflected practice. Staff were polite and considerate during the drug round and safe practice was observed. Residents are encouraged to self-administer their own medication and regular risk assessments are carried out to ensure their safe administration. Policies and procedures were in place and fully supported the medicine management. Unlabelled creams were found in communal bathrooms, which were removed during the inspection. The residents were treated with the utmost respect by the staff and their needs were the priority. All the residents looked well cared for and their own clothes are laundered to a high standard. Residents spoke highly of the staff. One resident stated, “The staff are good to me and look after me well”. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 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 Residents’ expectations were well met. Various activities were offered on a regular basis contributing to their quality of life. Social relationships within the home were met. Residents’ personal autonomy and choice were maintained. A wholesome balanced diet was offered and the residents’ choice and preferences respected. EVIDENCE: Various activities and social events are planned on a regular basis. Posters advertising events were placed around the home. External trips to the local park were encouraged and the garden offered beautiful surroundings for events such as BBQ’s to take place. A minister visits on a regular basis and a local choir sings each week at the home. Exercise classes are available to those that wish to take part. An extensive library was available to those wishing to read. Family and friends are able to visit whenever they wish either in one of the lounges or the resident’s own room. An extra visiting room was planned to be added in the near future providing tea and coffee making facilities for the residents to entertain their guests. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 Page 12 Residents are encouraged to bring their own furniture and personal belongings into the home and all the rooms were personalised to suit the individual personal needs. The inspector ate lunch with the service users. A choice of salad or fish and vegetables was offered with a selection of side orders followed by a freshly made hot desert with custard. Menus are provided offering a limited choice. However if the service user dislikes what is on offer an alternative is always prepared. The care staff knew individual preferences. The food was nutritious and well presented. Special dietary needs were catered for. Discreet help was offered to the residents and they could either eat with the other residents or in their own room. A supper menu was on offer and an assortment of freshly prepared sandwiches were provided on three days each week and a supper offered on the remaining four. One service user spoke to me and said, “There are many things to do in the home such as the exercise class that I enjoy and the choir come in each week to sing to us”. Another service user praised the quality of the food on offer; “All the food is lovely to eat. I have never had a bad dinner whilst I have been here”. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 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): 17 The residents’ legal rights were fully protected and they were able to participate in civic processes if they wished EVIDENCE: Liaison with the local MP enabled the residents to vote at the local election. Taxis were provided to take the residents to the poling station if they wanted to personally vote and alternative arrangements were made if they did not want to leave the home. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 The service users live in a well maintained home, which is safe and comfortable to live in. The garden is outstanding. Specialist equipment is provided to meet the residents’ needs. The residents’ rooms are personalised and very comfortable. The home was scrupulously clean. EVIDENCE: Digby Manor is well maintained with a rolling redecoration programme. The home is comfortable and a pleasant environment to live in. The manager was active in complying with any guidance from the local fire service. Residents are able to meet their friends and family in either of the two lounges, dining room or smoking lounge or their own room. A further room with kitchen facilities was also planned. All the furniture was in a good condition and residents are encouraged to personalise their own room. Many rooms had ensuite facilities and two assisted bathrooms were also offered. Further aids were provided to meet the needs of the residents. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 Page 15 All rooms had a call system installed. The garden is outstanding and extremely well kept. Ramps and garden furniture enabled any resident to fully enjoy it. The home has a separate laundry, which complies with the cross infection procedures. The room dedicated to storing excess food was clean and tidy and well organised. The fridge and freezer temperatures are monitored daily to ensure the food stored within meets all health and safety standards. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 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 There is a high resident to staff ratio and the majority of staff are trained to at least NVQ level 2. All residents are protected by the recruitment procedures. Training is important to the managerial staff and all staff are actively encouraged and supported to improve their practice further by additional training. EVIDENCE: The care manager is full time and supernumery. The provider employs a high number of staff above the minimum required standards. Additional staff are employed during peak times in the day. Three random staff files were selected and all met the national minimum standards for recruitment. All staff had been police checked and a rolling programme had been installed to identify when these police checks had expired. All staff receive regular supervision and the manager encouraged any training need. Staff are able to express any concerns with the manager at any time and three members of staff were interviewed during the inspection. These staff spoke very highly of the management team and all felt fully supported by them. They felt the residents’ needs were the main focal point in their job and they were all enthusiastic about meeting their health and social needs. The provider operates a key worker scheme so each resident has a dedicated key worker, which is commended. Male and female carers are employed. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 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, 32, 33, 36 The registered manager is qualified and competent and very experienced in running the home. The home certainly meets its stated purpose, aims and objectives and is run in the interests of the residents’. Both the residents’ and staff benefit from the leadership and management approach. Staff are regularly supervised and work experience placements are offered. EVIDENCE: The registered manager has successfully completed NVQ Level 4 in management. She is extremely familiar with the needs of the residents who live in her home and is in control of the day to day running of the home. The residents certainly benefit from her hands’ on approach, as do the staff she employs. Her leadership skills were demonstrably good and all the staff spoken with during the inspection all had a very high regard for her. The registered manager had a clear direction and strove to meet the needs and enhance the lives of both the residents’ and staff. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 Page 18 Digby Manor uses a quality assurance system to monitor the progress objectively and had scored very well at the last assessment. There is an annual development plan for the home. The views of the residents and staff are considered and the residents’ wellbeing is promoted in every way. Regular resident forums are held in addition to occasional forums for family and friends visiting the home. Information from these forums is used to enhance the residents’ lives further. All the requirements at the last inspection had been met in a very short time scale. Recommendations to improve practice further are taken in a positive light and actioned immediately. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 3 3 3 3 3 3 3 4 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X X 3 X X Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations All creams should be resident specific and it is advised that these are kept in their own rooms and not left in communal bathrooms. Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Digby Manor DS0000016745.V285389.R01.S.doc Version 5.1 Page 22 - 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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