CARE HOMES FOR OLDER PEOPLE
Hasbury 154 Middleton Hall Road Kings Norton Birmingham B30 1DN Lead Inspector
Zeta Joseph Unannounced 9 May 2005 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. Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Hasbury Address 154 Middleton Hall Road Kings Norton Birmingham B30 1DN 0121 458 5336 0121 243 5336 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) Mrs Rajwantee Chundoo Mrs Rajwantee Chundoo Care Home 24 Category(ies) of Older People registration, with number of places Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25 January 2005 Brief Description of the Service: Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was conducted on an unannounced basis starting at 1.45pm. The Registered Manager and Deputy were present for the duration of the inspection. During the inspection the Inspector toured the home, examined residents and staff records and other relevant documentation. The Managers, three staff, five residents and one relative who was visiting were spoken to. Residents’ views were very positive and varied they welcomed the inspection. And spoke about the temperature in the home, the food, the staff and preference. What the service does well: What has improved since the last inspection?
In response to the previous inspection conducted on 25 January 2005, a hands free telephone will be fitted to the telephone system once repairs are completed. Residents will then be able to make and receive telephone calls in private. Residents’ bedrooms were individually furnished and contained comfortable sitting chairs. Plastic chairs that were in residents’ bedrooms have been removed; all bedrooms contain a comfortable chair. The Manager has replaced the communal items that were found at the last inspection with liquid soap and paper dispensing boxes are being replaced with sturdier ones. There are reminders on bathroom walls to remind staff to refrain from leaving service users personal items in bathrooms. The Registered Manager showed the Inspector a work schedule that double sockets are to be fitted to seven bedrooms and a light to be fitted to the entrance to the cellar to improve lighting and aid the safety of staff accessing the cellar. Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 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. Hasbury E54 S16907 Hasbury V225248 090505 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 Hasbury E54 S16907 Hasbury V225248 090505 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) 3,6 The Registered Manager has implemented a comprehensive admission procedure that is based on the care plan information received from the referring Social Care and Health Department. A detailed plan of care is written to include all aspects of caring for the service user. There were no residents’ admitted for intermediate care at the time of this inspection. EVIDENCE: Individual records are maintained for each resident. Four residents’ files were examined and these contained assessment records of relevant information about residents to enable the staff to safely provide permanent care for older people. The Manager had recently reported an incident to the Commission using the required Regulation 37 form regarding a resident who had been admitted to hospital. Records were examined relating to this, the daily reports, medical notes and care plan were on file and these were well documented; however the risk assessment although on file, must be updated to reflect the residents’ safety. The Inspector found similarities within the four residents’ files examined. Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 Page 9 Residents’ family and or representatives are included at the initial trial visit stage to ensure they are satisfied with the arrangements to provide care for the prospective resident. Records of trial visits are maintained. The staff members on duty were spoken to and they knew about the residents’ care needs and the importance of maintaining records Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 Page 10 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 The health care of residents were identified and met by the home. The inspector observed interaction between staff and residents when in the lounge, dinning area and during the tour of the home, these were positive. EVIDENCE: Service users’ files examined by the Inspector revealed that residents’ health, personal and social care needs were assessed and recorded within the care plan; these were divided into separate records of daily, risk assessment, health care, medication, doctors notes, service user preferences and diet. Risk assessments needed to be reviewed. The Manager said that she ensures that staff seeks professional advice from health care professionals to ensure that each residents health care needs are fully met. A risk assessment taken from the Primary Care Trust ‘Self-Medication Scheme Protocol for Care Homes’ has been incorporated within the policies and procedures for the home for residents who are responsible for their own medication. The Manager confirmed that there were no residents who were responsible for their own medication.
Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 Page 11 Staff interacted well with resident and showed a good understanding of their needs. Discussion with staff revealed that they were knowledgeable about residents needs through care plans, training and guidance provided by the Registered Manager and or senior staff. Residents spoken to were happy with the care they received and were able to describe some of what the staff provided for them. At the time of inspection the telephone system was being repaired and upgraded to include a portable telephone for residents to use in private. Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 Page 12 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) 13,14, Residents’ are encouraged to maintain contact with relatives and friends and visit the home. Staff interaction with residents’ helps them to exercise choices. EVIDENCE: The Registered Manager encourages residents’ relatives and friends to visit the home within set visiting times. Visitors sign in when arriving and leaving and are encouraged to comment about the management of the home or any aspect of care for their relative or friend. Confidentiality is upheld as far as possible. Residents can exercise their choice to be involved in social activities, when to get up and when to go to bed. Staff respect this and do not try to enforce regimented rules. Hasbury E54 S16907 Hasbury V225248 090505 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 There is a complaints procedure, the Registered Manager is responsive to complaints and manages complaints and concerns. The Registered Manager investigates these to a satisfactory conclusion. EVIDENCE: There is a comprehensive complaints procedure; a summary of this is within the Service User Guide displayed on the notice board. At the time of inspection there were two formal complaints that had been forwarded to the Commission. The Registered Manager had implemented the procedure, liaised with relevant people, co-operated with the Commission and kept comprehensive records with action taken and outcome to ensure the complaints are resolved. From discussions with residents, informal complaints/concerns are dealt with as and when these arise to the satisfaction of the resident concerned. A numerical complaints log has been implemented with the complaints policy. Hasbury E54 S16907 Hasbury V225248 090505 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) 19,22,23,24,25,26 Residents’ live in a safe, well maintained home with their personal belongings and they will be provided with a specialist assessment should they require specialist equipment. Infection control is controlled; however clinical waste must be managed more robustly. EVIDENCE: The Manager confirmed that she would contact an Occupational Therapist to be involved as and when resident’s mobility deteriorates and specialist equipment is necessary. Infection control audits must be implemented within the home. Bedroom furnishings must provide residents with safe, comfortable surroundings. The Inspector examined residents care plan files. Plastic chairs seen at the previous inspection have been removed from resident’s bedrooms and replaced by comfortable chairs. Residents’ bedroom furniture appear comfortable and meet the furniture standards. Resident’s bedrooms are individually decorated and furnished with their own personal possessions. However, the carpet in room 10 will need to be replaced because it is badly stained and has an odour, there was a slight odour in room 6 and
Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 Page 15 this will need to be managed. The plastic chair from the shower room has been disposed of. A new belt has been fitted to the hoist and the plastic chair fitted to the hoist is to be replaced as recorded on the invoice relating to the servicing of it. All bins in the toilet and bathrooms have been fitted with lids. All communal soaps have been removed from bathrooms and liquid soap and paper towels are used where fitted, a programme of fitting paper dispensers has been implemented within bathrooms and toilets, and the owner hopes to complete this by December 2005. There are notices to staff displayed on bathroom and toilets walls regarding the non-use of shared toiletry items. The paper dispenser in the laundry has been replaced to reduce infection control within the laundry area. The Inspector noticed that disposable gloves had not been discarded as clinical waste. The Inspector examined four residents care plan files; two of these contained risk assessments that will need updating so that a safe system of care practice is operated by the staff. The home was otherwise clean and pleasant. Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 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 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) 27,29 The numbers and skill mix of staff meets residents’ needs; however the person in charge of each shift must be clearly recorded. The content of recruitment files have improved to ensure the protection of residents; however not all recruitment files met the standards. EVIDENCE: The duty rota indicated that no clear record was made of who was in charge of each shift and whether the rota was worked. The layout of the duty rota must clearly show that the home is adequately covered in relation to the needs of service users. The staff file examined contained gaps in the employment record; the Registered Manager must investigate this. The Inspector has raised this at previous inspection visits. Hasbury E54 S16907 Hasbury V225248 090505 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) 31,33,38 The home is well managed, however the Manager must complete the minimum qualification standard of NVQ 4 and the Registered Managers Award. The Inspector examined the record keeping for the home. Health and safety must be managed effectively. EVIDENCE: A fit and competent person manages the home in the best interest of the residents. The Manager was not able to show that she had enrolled on a programme of professional studies to ensure she meets the minimum qualification standards. The Inspector observed a number of health and safety issues. These included wheelchairs being used without a fitted lap belt and footrests must be fitted to the correct position. Food items in the fridge must be rotated to ensure they are used before the manufacturers use by date. Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 Page 18 One of the bedrooms is designated a fire exit; although this has been written into the Statement of Purpose for the home, the risk assessment for the resident occupying the home must detail that the fire escape can be accessed. The Inspector at previous inspections has highlighted this. The Manager must consider the use of this bedroom as the opening onto the fire escape can easily be accessed. Record keeping was examined by the Inspector, residents photographs are stapled to care plan folders; these were found to be comprehensive and meet the standards. Hasbury E54 S16907 Hasbury V225248 090505 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 x x 3 3 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 x 13 3 14 3 15 x
COMPLAINTS AND PROTECTION 2 x x 2 3 2 3 2 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 3 3 x x x 3 2 Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 Page 20 yes Are there any outstanding requirements from the last inspection? 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 OP10 Regulation 16(2)(b) Requirement The Registred Manager shall ensure service users privacy is paramount and provided with facilities to ensure their telephone converations are not overheard. THIS IS OUTSTANDING FROM 30TH APRIL 2005. The Manager shall ensure residents risk assessments are reviewed and updated with relevance to residents needs. The Manager shall ensure the hoist chair in the shower room is replaced. The Manager shall ensure the carpet in room 10 is replaced. The Manager shall ensure odour is controlled and managed especially in rooms 6 and 10. The Manager shall ensure clinical waste is managed throughout the home and that staff are made aware of this. The Manager must ensure the rota includes all staff on duty, who is in charge of the shift and whether the rota was worked. The Manager shall ensure a minimum ratio of 50 NVQ trained staff are employed at the Timescale for action 30th April 2005 2. OP19 14(2)(a)( b) 14(1)(a) 23(2) 16(k) 16(k) 30th September 2005 30th September 2005 31st August 2005 31st July 2005 31st July 2005 31st July 2005 30th September 2005
Page 21 3. 4. 5. 6. OP22 OP24 OP26 OP26 7. OP27 17(2) Sched 4 (7) 18(1)(i) 8. OP28 Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 home. 9. OP29 19 The Manager shall ensure that gaps in the employment histories of applicants are explored and recorded as discussed with the Inspector. The Manager must ensure she has obtained a recognised qualification in Care Management to NVQ level 4 by 31st December 2005. The Manager shall ensure the home established a quality assurance system appropriate to the home. The Registered Person shall ensure policies and procedures are reviewed on a regular basis and are appropriate to the care given in the home The Manager shall manage health and safety at the home and ensure compliance with the Manual Handling Operations Regulations 1992 that wheelchirs used for residents are fitted with apprpriate lap safety belts and the footrests are fitted correctly. The Manager shall ensure that foodstocks are rotated so that perisable food is not store beyond the manufacturers recommended use by date. The Manager must consider the future use of Room 11 as a fire exit. 31st July 2005 10. OP31 10(1-3) 31st December 2005 31st December 2005 31st July 2005 11. OP33 35 12. OP36 18(1) 13. OP38 13(5) 31st July 2005 14. OP38 16(2)(i) 9th May 2005 15. op38 18(1) 31st October 2005 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.
Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 Page 22 Refer to Standard Good Practice Recommendations Hasbury E54 S16907 Hasbury V225248 090505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Birmingham and 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
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