CARE HOMES FOR OLDER PEOPLE
Hasbury 154 Middleton Hall Road Kings Norton Birmingham West Midlands B30 1DN Lead Inspector
Zeta Joseph Unannounced Inspection 10th July 2006 09:00 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 Hasbury DS0000016907.V303899.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. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hasbury Address 154 Middleton Hall Road Kings Norton Birmingham West Midlands B30 1DN 0121 458 5336 0121 243 5336 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) Mrs Rajwantee Chundoo Mr S.V. Chundoo Mrs Rajwantee Chundoo Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th February 2006 Brief Description of the Service: Hasbury is a large, extended, detached house, which is set back from the road with car parking spaces to the front of the building. Located on Middleton Hall Road between the shopping centres of Cotteridge and Northfield, public transport passes the front of the home. Accommodation for the service users is on two floors with a passenger lift to enable access. There is a mixture of five double and fourteen single bedrooms. There is a dining room, and a sitting area that is divided into two by a dividing wall. The garden is large, with covered patio, lawn, plants and shrubs. There is a path around the garden. The property is well maintained and decorated to a high standard. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was conducted on an unannounced basis and took three hours. The owner/manager and deputy manager was present for the duration of the inspection. The inspection included talking to some residents after they had finished their lunch, a tour of the premises, examination of residents’ and staff records and other relevant documentation. There were twenty-one residents at the home and staff was seen interacting with residents and assisting a few to eat their meal. The Inspector spoke with four residents about life in the home and five staff about their duties for the day. The rota confirmed that four staff was on duty including the deputy; additional staff includes a kitchen assistant, two cleaners and the manager. There are two night staff on duty and one of the two deputy staff rotate on a weekly basis. The key standards and requirements from the last inspection were used to measure outcomes for this service. What the service does well:
The quality assurance system is now implemented and is based on continuous improvement at the home so that residents’ benefit and development of staff care practice skills. The Quality assurance system has been verified and complies with the requirements of its standards and has resulted in an improved status for the home. The Manager and staff are to be commended for their hard work to improve the status of the home. The management team responds well to the inspection process and completed action points from the last inspection; outstanding from this is the managers NVQ level 4 Care Management qualification that she is working towards. The manager confirmed that there is a low turnover of staff and that sickness levels are low, this means that residents benefit from continuity of care. All residents’ care plans have been reviewed and residents’ relatives are actively involved. Residents are encouraged to participate in activities of their choice such as attending cricket matches and family weddings. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 6 Staff were seen to interact well with residents and were able to relate how well they understood the care needs of residents, this was also evident in the accuracy of. The Records maintained by the manager and staff includes daily occurrences, contact with health care professionals, manual handling and risk assessments; the numbers on the telephone used by residents is in large print. The manager has made improvements to five communal toilets fitted with raised toilet seats and integrated hand rails so that residents can use these safely, and with greater independence. Results of infection control audits and continence management reveals where replacement of carpeting, decorating and beds takes place so that residents live in a clean home. The Primary Care Trust (PCT) conducted a review in March 2006 of medication administration records and medication returns; these were found to be managed well. The atmosphere in the home is relaxed, clean and friendly. A comprehensive quality assurance system has been implemented so that a high level of care is always provided to residents. There are ‘thank you’ cards and complimentary letters retained in a folder. What has improved since the last inspection?
The quality assurance system is comprehensive and it includes reviews of policies, procedures, residents’ multidisciplinary care plans, managing risk, medication reviews, manual handling and infection control. Care practice has changed from existing procedures to the quality assurance system so that better outcomes are achieved for residents and this is measurable. The manager has reported incidents to the Commission that includes resident’s accidents due to falling; they have been referred to their GP for a medication review and to a falls prevention programme. Manual handling and risk assessments were up to date as are daily records and medication management is good. The risk assessment for the home includes room 11 as a fire exit and the manager is aware of the future limited use of this room as a bedroom. Residents sharing a double room are provided with screens so that their privacy and dignity is promoted. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 7 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. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 8 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 Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 9 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): 1, 3, 4, 5, 6 Quality in this outcome group is good. This judgement has been made by examining available evidence including a visit to this service. Prospective residents and their representatives are provided with information needed to make an informed choice. An admission procedure continues to be implemented including a care plan to ensure that needs are met. There are no residents admitted for intermediate care. EVIDENCE: Prospective residents’ are given the opportunity to spend time in the home. A member of staff is allocated to them so that the resident feels comfortable and their questions are answered in relation to life in the home. Staff has skills and experience to admit residents and work alongside professionals to ensure that cultural and personal needs are met. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 10 Each resident is provided with a statement of terms and conditions prior to moving to the home; these are reviewed on a regular basis. This document will be examined at the next inspection. A full needs assessment is always undertaken by either the Social Care and Health Department or by skilled and experienced staff for residents that pay privately. A copy of assessments was seen on files. Service User Guides were seen in residents’ bedrooms; where appropriate, the content of these were explained to residents and a record made of this on the multidisciplinary record. When asked, the manager confirmed that no service users have been admitted for intermediate care. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are assessed and recorded on a multidisciplinary care plan. Referrals are made for specialist advice when necessary. The home works to an efficient and well-managed medication policy supported by procedures and practice. This ensures service users get the required medication at the right time. Residents occupying a shard room are provided with a screen to ensure privacy during personal care. EVIDENCE: Residents are referred to specialists so that their specific health care needs are managed well; written daily records and updated risk assessments supports this; for example referral to the ‘falls clinic’. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 12 The Manager involves residents’ relatives in the six monthly reviews of residents care. This supports the policy and practice of the home and includes a very comprehensive review of the care plan with records maintained on the residents’ personal file. Comprehensive records are maintained relating to care and managing medication. There are no residents who self medicate and there are procedures in place to manage this if a prospective resident has the capacity to take their own medication. The home benefited from a medication audit undertaken by the Primary Care Trust in March 2006; the MAR sheets and returns were audited. The Manager conducted a further medication audit in May 2006 for fifteen residents who were being reviewed. The Manager confirmed that the supplying Pharmacist visits every three months this gives the opportunity for queries to be raised and staff benefit from this. Screens are provided for residents sharing a bedroom to ensure their privacy is not compromised during personal care or any other time. Staff were seen to interact well with residents and were able to relate how well they understood the care needs of residents. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 13 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 available evidence including a visit to this service. The home organises residents meetings and through this the views of residents’ has been sought for example choice of activities and meals, this is so that residents enjoy a better quality of life. The home supports residents to maintain contact with family or friends so that important relationships are maintained and information is shared about life in the home. EVIDENCE: The routines of the home are planned around the residents’ needs and wishes. Meetings take place where relatives are encouraged to attend and be actively involved. Staff listen to residents’ and make efforts to improve activities in and out of the home so that residents can enjoy a better quality of life. A recent agreed activity included a trip to Evesham blossom trail and a garden party where 70 people attended. There was food, tombola, raffle and entertainer/singer. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 14 Family and friends are made welcome and they know they can visit the home at any time. Residents can entertain their visitor in the privacy of their own bedroom. The home encourages visitors from the community to visit service users. Service users are made aware of information held and written by the home such as the Service User Guide, care plans, reviews of manual handling and risk assessments and outcomes of concerns, requests, or complaints. An experienced cook is responsible for providing nutritional meals that meets the dietary needs of service users. The cook and deputy staff share in preparing meals and snacks and at the residents meeting service users choices and suggestions are listened to. Specific requirements are recorded in the multidisciplinary record so that meals and snacks meet individual needs. Care staff were seen by the Inspector, discretely assisting those service users who found it difficult to eat. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 15 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 available evidence including a visit to this service. Residents’ are protected by the complaints procedure implemented; the owner/manager confirmed that she investigates these with the deputy managers’ assistance. Policies and procedures have been reviewed so that incidences such as adult protection are managed alongside current and local guidance. EVIDENCE: There were no complaints logged at the home and none received by the Commission. The manager uses the residents meetings to listen to concerns, suggestions and opinions so that these are addressed and do not lead to formal complaints. Investment in quality assurance meant that all procedures have been reviewed and updated so that residents’ benefit from a well-managed care service built on protecting residents. Residents spoken to about the home state that they are satisfied with it, they feel safe and supported. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Residents live in a clean and well-maintained home, residents’ bedrooms are individually furnished with their personal possessions around them. Specialist equipment can be provided for residents who need help with mobility with handling aids. EVIDENCE: Residents live in a tastefully furnished home; their bedrooms are individually furnished and decorated. Most bedrooms have en-suite facilities. Carpeting in some rooms will be replaced within four weeks of the inspection because of the needs of the resident occupying the room. There is a bedroom that is also a fire exit; there is a risk assessment in place for the occupant and their future suitability and this also recorded in the risk assessment for the building.
Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 17 Where rooms are shared it is by agreement and is reviewed when a single room becomes available and at residents reviews. Screening is provided in shared bedrooms so that privacy and dignity is promoted for the resident concerned. There are a number of communal toilets accessible to residents and sufficient bathing facilities equipped with handling aids. Five of the communal toilets have been fitted with raised toilets incorporating grab rails so that residents with mobility difficulties can use the toilets safely. The shower room is not being used because the hoist chair needs to be replaced with a more appropriate model. The management has a good infection control policy and staff implements this so that the home smells fresh and looks clean and tidy so that the risk of infection is reduced. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 18 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 area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff meets residents’ needs. The duty rota has been amended so that there is sufficient staff and someone in charge of the shift on duty at all times. EVIDENCE: The staff rota was examined; it includes four care staff on duty during peak times; this includes the mornings. It is clear from the rota the person who is in charge of the shift. In addition to the care staff, is there is the cook, a deputy and two domestic staff. The manager has implemented the new policies and procedures regarding recruitment practices so that these are measured against the quality assurance system for the home. Where recruiting discrepancies were found at the last inspection; examination of the file shows that it now meets the standards. Staff benefit from annual mandatory training so that staff care practice skills and competence is improved and residents benefit from this. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 35, 36, 37, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, however the Registered Manager must complete the minimum qualification standard in Care Management and the Registered Managers Award. The manager confirmed the practice in the home regarding financial management that the residents’ family/representative or Social Care and Health services is sent an invoice for any bills incurred. The manager confirmed that staff supervisions are undertaken every three months or sooner if necessary. The supervision records examined by the Inspector confirmed this. The manager ensures that Health and Safety checks are carried out and recorded; the Inspector examined the invoices for servicing and maintenance.
Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 20 Quality assurance has been implemented and it has been assessed and meets the standards of the system implemented, as a consequence of this record keeping is good as demonstrated through examination of documents. EVIDENCE: A competent person co-owns and manages the home. Record keeping has improved and examination of records demonstrates that the manager is committed to providing a service based on quality. The manager has implemented the quality assurance system so that policies and procedures are reviewed and that care practice is improved and residents’ benefit form this. The manager agreed to complete the NVQ level 4 course by 31 August 2006 and provide evidence to the Commission of its successful verification; the requirement for this remains outstanding. The manager confirmed that the home does not hold any money for residents. Financial transactions are discussed with the Social Care and Health Social Worker, the resident and or relative at the trial visit assessment so that agreements are made inline with the policy and practice of the home. Supervision records were examined and these met the standards. An Environmental Health Officers audit for June 2006 indicates that food trays used in the kitchen must be replaced and these were replaced prior to the inspection; also for an additional extractor fan to be fitted to improve ventilation in the kitchen. The manager intends to use the audit to assist in supervising the kitchen staff to ensure continuous compliance with regulations. Bedroom 11 is a designated fire exit; this is recorded in the Statement of Purpose, Risk Assessment for the building and for the resident. Records regarding tests for Legionella were undertaken. There are no hot water or surfaces that present a risk for residents or staff. Kitchen and laundry equipment are serviced; there are invoices to demonstrate this. Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X X 3 3 2 Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 22 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 OP31 Regulation 10(1-3) Requirement The Registered Manager must ensure she has obtained a recognised qualification in Care Management to NVQ level 4 including the Registered Managers Award by 31st December 2005. This requirement is outstanding from 31 December 2005 and 09 February 2006. The Registered Manager must complete requirements form the Environmental Health Report. The Registered Manager shall ensure the shower hoist is repaired. This requirement is outstanding from 09 February 2006. Timescale for action 31/08/06 2. 3. OP38 OP38 18(1) 18 31/08/06 30/10/06 Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 24 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 Hasbury DS0000016907.V303899.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
