CARE HOMES FOR OLDER PEOPLE
Feniscliffe Bank Home for the Elderly Hillcrest Road Blackburn Lancashire BB2 5LF Lead Inspector
Mr Graham Oldham Unannounced Inspection 8th October 2005 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 Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 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. Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Feniscliffe Bank Home for the Elderly Address Hillcrest Road Blackburn Lancashire BB2 5LF 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) 01254 587554 Blackburn with Darwen Social Services Mrs Barbara Magee Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. A maximum of 29 service users requiring personal care who fall into the category of OP The home shall employ at all times, a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 11th August 2005 Date of last inspection Brief Description of the Service: Feniscliffe Bank is a purpose built two-storey local authority home. The home provides accommodation for 29 residents who require personal care. There are sepearate lounges, a large dining room and a conservatory. All bedrooms are single. The home is set within its own grounds, which has an accessible patio and looks over parkland. There is a car park to the front of the property. The home is situated on a local bus route with local amenities close by. Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 8th October 2005. Much of the information gained was obtained from talking to residents and staff members. The views of residents were obtained on a variety of topics. Two residents were case tracked. Case tracking gave the inspector an overall view of the specific care for the individual resident by checking the plans of care, other documentation and talking to residents and staff. Two staff members, the registered manager and two deputy managers were talked to about care issues. Some of the views have been reported collectively with specific comments contained within the body of the report. The inspector took detailed notes during the inspection, which have been retained as evidence. Staff were directly and indirectly observed carrying out their tasks and interacting with residents. Paperwork examined included plans of care, assessment documentation, policies and procedures or documents relevant to each standard. A tour of the building and grounds was conducted. What the service does well:
The assessment process at the home ensured residents were correctly placed. Visiting was open and unrestricted. Comments included, “visitors come and go all day”, “there are no problems with visiting and I can go and see my family at weekend” and “My two cousins visit on different days and there are no restrictions”. Visiting at the home enabled residents to enjoy their social life. Residents were satisfied with staff at the home. Comments included, “the staff are very good”, “the home is well run”, my key worker is really good” and “the staff are good at what they do but there have been too many changes lately”. Residents’ thought the care staff gave was good and made their stay comfortable. Residents said they were offered choices at the home. Comments included, “staff help me back to my room when I want. I have a choice in what I do and staff will wait for you if you are busy” and “I go up and down from my room when I like. I like to do a few things for myself. If you want you can stay in bed but I like to be up by 8am”. Choices offered to residents allowed some independence. Staff had achieved NVQ qualifications. 85 of staff were qualified. The registered manager had achieved the RMA award. Qualifications gained gave staff the confidence and knowledge to meet resident’s needs. Health and safety policies, procedures and training protected residents and staff from possible harm. Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 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. Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 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 Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 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): OP3 Each prospective resident was assessed prior to admission to ensure their needs could be met at the home. EVIDENCE: Two plans of care were examined during the case tracking process. Plans of care contained a social services assessment. A senior member of staff had visited the resident and assessed their suitability to reside at Feniscliffe Bank. Information was obtained from the resident, their families where necessary and relevant professionals. A plan of care was developed from the assessment. The assessment process ensured staff gained sufficient knowledge to care for each resident. Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 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): OP7, OP8 and OP10 Resident’s health, personal and social needs were set out in a plan of care. Resident’s health care needs were met. Resident’s were treated with privacy and dignity. EVIDENCE: Two plans of care were examined during the case tracking process. Each resident had two plans of care - a standex system and the authorities own system. Carers were responsible for one system and managers the other. Upon examination it became obvious that discrepancies occurred between the two plans when developed and upon review. It is the inspectors opinion that two plans are not necessary and causing the problem. Combined together the plans were detailed. However, both sets of plans must be accurate and be reviewed on a regular basis to ensure care given meets the needs of residents. Residents and staff accounts of care given matched the plans of care. Plans of care had been developed to enable staff to care for residents but need to be updated to be consistent to ensure the needs of residents are met. Plans of care contained evidence residents attended specialists and clinics. Two residents involved in the case tracking process confirmed they attended
Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 Page 10 specialists and said, “I attend the diabetic clinic, eye specialist, optician and my G.P.” and “my doctor came yesterday and I have seen the optician and chiropodist lately”. Specialists were accessed as necessary to ensure residents received appropriate treatment. Two residents case tracked said, “staff treat me privately and do not make me feel uncomfortable” and “I think staff are confidential and care is given in private”. Staff were careful to preserve residents dignity, which allowed residents to feel comfortable with personal care. Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 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): OP12, OP13 and OP14 Residents were offered leisure activities to match their lifestyles. Visiting was unrestricted and enabled residents to maintain contact with family and friends. Residents were able to exercise choice and control over their lives. EVIDENCE: Two residents case tracked said, “I read a lot. We don’t do many activities now. They play dominoes but I don’t like to join in. We used to have concerts occasionally but not as often as they used to” and “I watch television a lot. I come back to my room because there is nothing else to do”. The inspector was shown an activities book, which showed some residents did join in with the activities on offer. The registered manager said, “Activities are held upon a regular basis. We discuss activities at meetings. We have been short staffed lately but now we have employed more staff can offer more activities. A trip out has been planned to Oswaldtwistle Mills for residents who want to shop. The ladies case tracked were offered a place but did not want to go”. The inspector recommended recording the names of residents who were invited to attend leisure activities but decided not to attend. One resident case tracked said, “the best thing about living here is everything is done for you if you cannot manage, but the worst thing is being bored”. The registered manager should look at the activities on offer and try to provide suitable activities to enable residents to live a fulfilling life.
Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 Page 12 Two residents case tracked said they were offered choices within the routines of the home. Residents were satisfied with the choices they had for food and their daily routine and retained some independent living at the home. Both residents case tracked said there were no restrictions for visitors and staff were welcoming. Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 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): OP16 There was a complaints procedure for residents to voice their concerns. EVIDENCE: An amended complaints procedure met current timescales and directed residents to bodies such as the Commission for Social Care Inspection should they wish. There had been no complaints to the Commission since the last inspection. One resident said she would complain to “the manager” the other to “my social worker”. Neither resident’s had a complaint on the day of the inspection. The complaints procedure gave residents the opportunity to contact the legislative bodies if they wished. Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 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): OP19 – OP25 The home was warm, clean and comfortable. Furnishings and equipment was domestic in style and met residents needs and individual tastes. Suitable equipment such as hand rails or disability equipment had been provided where necessary. Toilets and bathrooms were of a type that met residents needs. Shared space was provided to give a variety of activities and uses for residents Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 Page 15 EVIDENCE: The inspector conducted a tour of the home during the inspection process. All communal areas and most bedrooms were inspected. Rooms had been individualised to resident’s tastes. Comments included, “I have a nice room and I like it. I have some of my own things” and “my room is nice and big. I have a lot of my own possessions and its very comfortable”. Residents also said, “the home is very clean and they also make my bed” and “the home is very clean and tidy” One bathroom continued to be used as a storage area. The bath should be available to residents although the registered manager said, “ plans are in place to alter the bath to provide a walk in shower which will be more appropriate for our residents”. Rooms were clean, tidy and contained sufficient equipment to provide residents with a stimulating environment. Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 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): OP28 More than 50 of staff employed at the home had completed NVQ training to meet the requirements of the CSCI. EVIDENCE: 85 of care staff had achieved NVQ2 or above to give staff the knowledge to care for the resident group accommodated at the home. Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 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): OP31, OP33 and OP38 The registered manager had completed training suitable to her role. Quality Assurance systems had been developed to enable stakeholders to air their views about the homes services and facilities. The health, safety and welfare of residents and staff were promoted and protected. EVIDENCE: The registered manager had completed the Registered Managers Award. Further training had been undertaken since the last inspection and included a course on the control of cross infection. The registered manager periodically updated her training to enable her to fulfil her role. Quality Assurance systems had been developed and questionnaires sent out to families, residents and stakeholders. The registered manager was awaiting a breakdown on the results of the surveys. When completed this standard will be met. There was a business plan. Regular recorded meetings were held with
Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 Page 18 residents. Quality assurance was ongoing at the home and enabled the service to react to the changing needs and aspirations of residents. Certification was observed for gas and electrical appliances and equipment. Fire equipment and records had been maintained. There was a health and safety policy and procedures. Staff had undertaken training in health, safety and related issues such as first aid, COSSH, moving and handling, food hygiene and fire awareness. Both staff questioned about the care of residents had undertaken training in health and safety topics. Health and safety policies and procedures safeguarded residents and staff. Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 2 3 3 3 3 3 3 X STAFFING Standard No Score 27 X 28 4 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X X X X 3 Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 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. 1 2 Standard OP7 OP7 Regulation 15(2)(b) 15 Requirement The registered manager must ensure plans of care are reviewed on a regular basis. The registered manager must ensure plans of care contain all the information required to meet the needs of each resident. Timescale for action 30/11/05 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP12 OP19 OP33 Good Practice Recommendations The registered manager should record the names of residents invited to attend any leisure activities. The registered manager should ensure the bathroom is cleared of hoisting equipment and wheelchairs. The registered manager should ensure the results of quality assurance surveys are published and available for inspection. Feniscliffe Bank Home for the Elderly DS0000034786.V254864.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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