Inspection on 31/08/05 for Digby Manor

This inspection was carried out on 31st August 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

Digby Manor 03/12/08

Digby Manor 18/12/06

Digby Manor 03/03/06

Digby Manor 15/02/05

Digby Manor 10/08/04

Digby Manor 03/03/04

Digby Manor 16/12/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Digby Manor Residential Home 908 Chester Road Erdington Birmingham B24 0BN Lead Inspector Jane Walton Announced 31 August 2005 st 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. Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Digby Manor Residential Home Address 908 Chester Road, Erdington, Birmingham B24 0BN 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) 0121 373 2333 Janet Al Rubaie Janet Al Rubaie Care Home 26 Category(ies) of Old Age (26) registration, with number of places Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 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 Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place between the hours of 10.00 and 19.45 on the 31st August 2005. The inspector was assisted throughout by the homes’ manager. There were 26 residents at the home, and the inspector spoke to twelve of them to obtain their views of life at Digby Manor. Other information was gathered from conversations with staff, visitors, examining care and medication records and by undertaking a short tour of some areas of the home. This report has been delayed due to the inspectors extended sick leave. Subsequently, any requirements made of the home that were not immediate at the time of the inspection, have necessarily been given extended time scales. This report should be read in conjunction with the latest inspection report in order to obtain a complete overview of the service offered by this home. What the service does well: Digby Manor provides a homely, well maintained and clean environment for residents to live in. There is a range of activities for residents to take part in, according to ability, including trips out and entertainers coming in to the home. There are beautifully landscaped gardens for the residents to enjoy that are fully accessible by people using walking aids. The home provides a service users guide for all residents and their families that gives clear information about the service that the home is able to provide, so that prospective residents are enabled to make an informed choice about whether they wish to live in the home. Assessments are made by the manager prior to admission to ensure that the residents needs can be met by the home. Residents are generally well supported by the staff of the home, to meet their health, welfare, and personal care needs, and the resident is involved in producing their care management plan. The dietary needs of the residents are well catered for, and special diets can be provided where needed, for example, vegetarian or diabetic. Residents’ preferences for food are included on the menu. Digby Manor has a high ratio of care staff who are trained to NVQ level2 in care, and are able to offer a good standard of care overall. Training of staff is ongoing, and the manager is pro active in identifying gaps in skills where further training will be of benefit. All staff have regular documented supervision. The medicine management within the home is of a good standard and several staff have undertaken training in the safe handling of medicines. The standard of record keeping is good, and all documents are stored securely. Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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 Residential Home E54 S16745 DigbyManor V228347 310805 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 Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 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) 1, 3, 5 Prospective service users are provided with clear and comprehensive information to allow them to make an informed choice of whether they wish to live at Digby Manor or not. All the practices and procedures surrounding the admission of new residents were adequate and appropriate to ensure needs are met. EVIDENCE: There was a very comprehensive Statement of Purpose available for all residents and their families, including a Service Users Guide. All prospective residents are invited to the home for a day, with their relatives, are assessed by the manager and eat a meal with other residents in the home. When the resident moves in, it is for a trial period of 28 days, which may be cancelled by either party, should the placement not work out. Completed pre admission assessments were evidenced in the residents’ care plans. Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 Residents are well supported by the care staff to ensure that their health and personal care needs are met appropriately. The medication is very well managed promoting good health. Residents are treated with respect and their privacy is upheld. EVIDENCE: Individual care plans were available for all residents. A sample of the care plans were examined, and were clearly laid out with the needs and care management for the individual easy to access. A range of risk assessments had been carried out and where a risk was identified the management was explained. There was evidence that the residents and/or their family had been involved in the production of the plans. The plans had been regularly reviewed and updated where necessary. The daily records were comprehensive and for one resident indicated their participation in a range of activities. There was evidence that residents are seen as necessary by other health professionals such as GP, District Nurse, Optician and a dentist. An audit of the medication management within the home indicated that there is a high standard maintained. All the audits carried out were correct, and one resident who self-administers his medicines had a risk assessment completed to ensure competency, and this had been regularly reviewed. The home uses a Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 Page 10 Monitored Dosage System (MDS) and also keeps copies of the prescriptions for ease of cross-referencing. Medicines were stored appropriately and there were policies and procedures in place for the administration and self-administration in place. Staff who are involved in administering the medication in the home demonstrated a good understanding of the medication, and any monitoring required. Conversations with residents indicated that they felt that staff treated them with respect, one resident said, “The staff are always polite to me, and also very friendly” A visitor commented “ The staff are always friendly and willing to help in any situation.” Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15 Overall, the dietary needs of residents are well catered for with a balanced and varied selection of food available, which promotes their well-being. The systems for consultation with the residents in the home are good; with their views both sought and acted upon. The activities provided for residents generally matches their expectations and preferences, thus contributing to their quality of life and independence. EVIDENCE: There were a variety of activities suited to the abilities and interests of the residents offered by the home. These included, a BBQ, coffee morning, cream tea, and quizzes. One resident said,” We have a coffee morning every month, I like to talk to other people and catch up with the news.” Individuals’ preferences are recorded in their care plans and what activities they participate in are documented. One visitor commented, “ Digby Manor staff and management arrange several trips outside of the home, which is great. They also book entertainers to come to the home. The garden facilities are excellent, very well laid out and user friendly, especially for those using walking aids.” The visiting arrangements to the home are very flexible, and several visitors were present at various times throughout the inspection. Residents are actively encouraged to bring personal items with them upon admission to personalise their bedrooms, and these were much in evidence in the bedrooms seen. Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 Page 12 Meals are served in the dining room at times to suit the residents. The inspector joined residents for lunch. As the weather was very hot the residents had unanimously requested that the hot meal on the menu be replaced by a salad. A selection of cold meats, cheese, egg, pork pie and salad was served. Cold drinks were provided in jugs on the tables. The meal was eaten in an unhurried manner, and staff in attendance offered second helpings to residents. Because of the hot weather a dessert of ice cream or yoghurt was offered, and this was followed by a cup of tea or coffee. Menus were examined and demonstrate that a varied and well-balanced nutritious diet is provided for residents. Although there is only one choice of main course, the likes and dislikes of the residents are very well known and so alternatives are always available. A supper menu also indicated that a good variety of food is offered, and it was pleasant to see that assorted sandwiches are offered on only three days per week. Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 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 standard(s) 16, 18 The home has a satisfactory complaints procedure that is accessible to residents and visitors so that they are aware of how to make a complaint ensuring the promotion of protection matters. EVIDENCE: No complaints have been received by the Commission for Social Care Inspection (CSCI) in relation to the home, and there were none recorded in the log. The complaints policy and procedure includes all the information required to enable a person to make a complaint if they should wish to do so. One resident said, “I would never feel frightened of making a complaint, but I have nothing to complain about.” The adult protection policy and procedure incorporated the Birmingham Multi Agency Guidelines. Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 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 standard(s) 19, 25, 26 The standard of the environment within this home is generally very good, providing residents with an attractive and homely place to live. EVIDENCE: A full tour of the premises was not undertaken at this inspection, however, the areas of the home that were seen were clean, pleasant and well decorated. The bedrooms seen were very homely and comfortable. One resident said, “ I have my own lovely room and my own bits and pieces around me.” The home has a rolling programme of redecoration and refurbishment. The home has it’s own laundry facility and complies well with cross infection procedures. All clinical waste is removed by a reputable company who are contracted by the home for a weekly collection. Waste is stored appropriately. In the sitting room there are a range of comfortable armchairs for residents. However, several of one type of chair have seat cushions that can slip forward and may pose a risk to the resident, of sliding out of the chair. The registered manager agreed to make an assessment of these chairs, and take appropriate measures. Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 Page 15 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, 28, 29, 30 Overall the arrangements for staffing the home are sufficient to meet the needs of the residents, to ensure health and wellbeing. The robust recruitment procedure protects the residents. Staff have received appropriate training to ensure that they are competent to perform within their role. EVIDENCE: Staff duty rotas indicate that there are 4 care staff on duty from 8am – 3pm with an extra carer from 10am-2pm every day. There are generally four care staff working from 3pm-9pm, and 2 care staff during the night. In addition, the care manager is full time and is supernumerary. An administrator is employed as are housekeeping staff. The levels of staff would appear to be adequate for the dependency levels of the current residents. The home does not use agency staff, but relies on their own staff to cover any sickness or absence. A very high number of the care staff are trained to NVQ level2 or above, which is commended. The recruitment practices of the home are generally of a high standard, however, the manager needs to be aware that CRB checks are no longer portable due to the need for obtaining a POVA check upon the employment of an individual staff member. One staff file examined did not contain any proof of identity. There was evidence that new staff members undergo a formal induction, and that the programme meets the TOPSS standard. The home maintains a matrix of training delivered to staff, and also identifies when individuals require updating in statutory training. Evidence was seen that all staff have undertaken statutory training, and individual records are also Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 Page 16 kept. Training in other areas applicable to the care of the resident group is provided. Topics include, safe handling of medicines and managing challenging behaviour. Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 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 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) 31, 32, 33, 35, 36, 37, 38 The home has good systems for consultation with residents where their views are both sought and acted upon. The management style of the home engenders an open and inclusive atmosphere The homes’ generally high standard of record keeping safeguards the residents’ rights and best interests. The high standard of attention to the health and safety issues for staff and residents help promote and protect their health and welfare. EVIDENCE: The registered manager is very experienced in running the home. She is currently undertaking her NVQ level 4 in care management, and hopes to successfully complete the course by the end of 2005. Residents commented that they find the manager very approachable and feel that she listens to them. An internal audit is conducted with residents and their families using a questionnaire that is distributed every two months. The results are analysed, and made available for the residents and families to see. A wider catchment Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 Page 18 quality assurance programme would enable the manager to obtain feedback from other areas, e.g. from outside health professionals and from the staff of the home. Several residents’ personal allowances are managed by the home and an audit of the accounts demonstrated that those sampled were accurate, and relevant receipts were present. All staff have regular formal supervision, which is documented. Records were seen, however, they are currently kept in one file, and it was recommended that they be kept on the individual staff members’ file together with their training information. The standard of record keeping in the home is good, and a range of policies and procedures were examined that ensure that residents rights and best interests are safeguarded. Maintenance records indicated that safety checks in relation to fire procedures are carried out regularly and documented. The fire officer carried out an inspection in June 2005, and recommendations were made in relation to the bedroom door leading onto the staircase enclosure landing. The management are currently in contact with the fire officer to resolve the issue. The gas safety inspection was due to take place the day following the inspection and the manager agreed to forward a copy of the latest certificate to the CSCI when it was available. Other maintenance records were up to date. Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 x 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 3 COMPLAINTS AND PROTECTION 3 x x x x x 3 3 STAFFING Standard No Score 27 3 28 4 29 2 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 3 3 3 x 3 3 3 3 Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 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 OP29 Regulation 19(1) Sch 2 Requirement The registered manager must ensure that all staff provide suitable evidence of identification and retain copies in their file. Timescale for action 1/9/05 2. 3. OP29 Care Standards Act S89 (1)(a)(b) This requirement was left as an immediate requirement at the time of the inspection. This requirement has been deleted after discussion. All new staff must have a current 1/9/05 enhanced CRB and POVA check carried out prior to employment. Portability of CRBs is no longer acceptable. This requirement was left as an immediate requirement at the time of the inspection. The seat cushions of the blue chairs in the lounge must be assessed for the risk to residents, as they have a tendency to slip forward off the base of the chair. 4. OP38 12(1)(a) 28/2/06 Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 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. Refer to Standard OP36 Good Practice Recommendations It is reccommended that the staff supervision records are kept on the individual staff members file, and not in a common file. Digby Manor Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Birmingham Solihull Local 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 Residential Home E54 S16745 DigbyManor V228347 310805 Stage 4.doc Version 1.30 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. 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