Inspection on 07/07/05 for Herondale

This inspection was carried out on 7th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Herondale 19/11/08

Herondale 21/02/08

Herondale 10/10/06

Herondale 28/11/05

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Herondale 175 Yardley Green Road Yardley Birmingham B9 5PU Lead Inspector Ann Farrell Unannounced 7th July 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. Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Herondale Address 175 Yardley Green Road Yardley Birmingham West Midlands B9 5PU 0121 753 1653 0121 771 4188 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) Methodist Homes for the Aged Vacancy Care Home 36 Category(ies) of Dementia (36) registration, with number Mental Disorder (36) of places Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can accommodate up to 36 people over the age of 65 years with dementia or who have a mental illness and may also be infirm (DE(E)) and (MD(E)). 2. That the home can accommdate one named service user under 65 years of age with dementia. Date of last inspection 17th November 2004 Brief Description of the Service: Herondale is a purpose built; two storey home that is registered to provide care to 36 residents for reason of mental health problems, predominantly dementia. It is situated in a residential area within the boundary of Heartlands Hospital and is close to shops, local amenities and is accessible to public transport systems. There is adequate parking to the front of the building with and large enclosed garden to the rear with patio and seating for use by residents when weather permits. The garden is accessible from the ground floor lounges. The home is divided into four wings or house groups spread over the ground and first floors. The first floor can be accessed by the stairs or a passenger lift. Each house group has it’s own lounge, dining area, kitchenette, a bathroom, a communal toilet and nine en-suite bedrooms. The en-suite facilities consist of a toilet and shower facility. There is a main kitchen and laundry area situated on the ground floor, which are staff separately. The first floor can be accessed by the stairs or a passenger lift. The home has recently been taken over by Methodist Homes. The staff group reamin fairly stable and are in the process of changing some of the working systems and documentation within the home. Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over one full day on an unannounced basis on 7th July 2005 commencing at 8.15 am. This was the first statutory inspection for 2005/2006. The manager was present for the duration of the inspection. During the inspection process the inspector toured the home, sampled residents files and other documentation. The manager, four members of staff, two residents and two relatives who were visiting the home were spoken to. A number of the residents were unable to communicate verbally with the inspector. What the service does well: What has improved since the last inspection? Staff felt there had been an improvement in morale since the time of the last inspection and they felt they worked as a team. The call bell system has been replaced, some new equipment has been provided and some re-decoration of the environment has been completed. Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 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. Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 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 Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 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) 3,4,5,6, The home has information available enabling prospective residents or their relatives to make an informed decision about moving into the home. The home has good procedures for admission and assessment of residents, however some records need developing to ensure all resident’s needs are identified and met. EVIDENCE: Herondale provides specialist mental heath nursing care for older adults on a long-term basis and aims to meet their needs in a creative way following normal life patterns. They have been involved with research projects with the Bradford Dementia Group and are continually looking at ways to improve the quality of life for residents. The home is managed and run by suitably qualified nurses, who appeared enthusiastic and committed. The home does have written information for prospective residents and their families, but this was not inspected. Upon receiving referrals the new manager appoints a member of the management team to visit the prospective resident in order to assess their needs. Where it is felt that the prospective residents needs can be met their Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 9 name will be placed on the waiting list and it will be confirmed in writing by the manager. Following admission to the home comprehensive assessments are undertaken and a care plan drawn up. The manger stated that they will be developing the assessment process further prior to admission to enable further information to be obtained from relatives and encouraging them to take a more active part in the care if they wish. A small sample of resident’s files were inspected and found to be of varying detail. Some provided good detail, but others were lacking in detail and some of the areas had not been recorded clearly. The home have a range of equipment to meet resident’s needs. On discussion with some relatives who were visiting the home they praised the home and the staff stating they were happy with the standard of care and cleanliness. It was noted that they were involved with aspects of care if they wished. Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 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 There are good systems in place to meet resident’s health care needs. Although staff have a good understanding of residents needs and there are positive relationships the shortfalls in the recording system cannot guarantee consistency. EVIDENCE: Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 11 The home draws up care plans for individual residents. On inspection of a small sample of them they were found to be of varying detail. Some were found to provide good detail, but others were lacking in detail regarding the actions to be taken by staff to meet needs. Some areas of care had not been included in the care plan and the care plan had not been updated to reflect changes in residents care. Nutritional assessments were not available in some cases and daily records did not consistently demonstrate follow up to areas of concern. Residents are registered with a G.P in the area who visits the home twice a week and is available at other times. At the time of inspection he spoke with the inspector and stated there was a good relationship with the home and staff acted appropriately to meet the health care needs of residents. The home also liaise with other members of the primary health care team as required such as the chiropodist, optician etc. However, records were not always available to demonstrate this. The home stores medication appropriately and uses a monitored dosage medication system. On inspection there were noted to be discrepancies in a number of audits, there was no record of the disposal of some controlled medication, recording of codes was not clear and the fridge temperature was not recorded regularly. All rooms have en-suite facilities, doors have locks and a lockable facility and keys are available to residents or their relatives. Staff were noted to respect residents privacy and treat them with respect. Residents are able to get up and go to bed as they wish as the home operates a system of natural waking. Staff were noted to interact with residents appropriately and were aware of their needs. A portable telephone is situated on the ground floor and rooms have telephone sockets enabling telephone calls to be made in private. Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 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) 13,14,15 There is a relaxed flexible atmosphere and residents are free to do as they wish. There is a range of opportunities in the home for occupation. Catering and meals are well managed with a choice and variety of nutritious food available. EVIDENCE: The home has flexible routines allowing natural wakening and resident’s are supported by staff in making choices about various aspects of life. The home employs a trained nurse as a “locksmith” following a research project with Bradford Dementia Group. He is continually looking at ways of improving the quality of life for residents and they are currently working on developing areas in respect of social stimulation and occupation in a person centred manner with residents. Snoozlam equipment is available and is now used in residents rooms. The home employs a volunteer co-ordinator, who has recruited a number of volunteers. She works with the locksmith who has arranged training for them in order to develop specific skills enabling them to work with the residents. Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 13 The garden provides a potting shed, raised flower beds and garden furniture for use when the weather permits. The home has an open visiting policy and on discussion with relatives they stated staff were very good and they could visit at any time. At the time of inspection it was noted that some relatives were involved with care and were providing assistance with feeding. The manager stated they like to involve relatives and educate them about the resident’s condition etc. The home holds a relatives forum approximately every six months. The home employs separate catering staff who provide three full meals per day, with a light lunch and main meal in the evening. There is a four-week rotating menu with choices. Recently the chef has introduced themed events such as Chinese and Indian meals, which have proved to be popular. Birthdays are celebrated and he makes a cake. On the day of inspection a light lunch was served and the inspector had lunch with the residents. Staff were available and provided assistance where required. The meal was unhurried and residents were treated with dignity and respect. Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 14 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 The home has very few complaints. No concerns were voiced and relatives felt confident that any concerns would be addressed. EVIDENCE: The home receives very few complaints. They have a complaints procedure and maintains a record of complaints. At the time of inspection two complaints had been recorded for the past 12 months, which had been addressed appropriately by the manager and records were available. Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 15 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) 19,20,21,23,24,25,26 The standard of décor in the home is improving and it provides a relaxed and comfortable environment to live. EVIDENCE: Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 16 The home is purpose built and is divided into four units/house groups. Each house group has nine en-suite rooms with a lounge, dining area and small kitchenette. The home was clean, odour free and generally well maintained. Some re-decoration has been undertaken since the last inspection and this is ongoing. There is a large enclosed garden to the rear of the building with a patio, garden furniture and a potting shed to be used when weather permits. The garden can be accessed by the ground floor lounges and provides an enclosed wandering space with a telephone box, sewing machine and beach area for residents to explore. Baffle locks were fitted to all doors leading to staircases and rooms that may be hazardous to residents, had coded keypads to ensure residents safety All rooms have a lock provided to doors and lockable facilities. En-suite facilities consist of a toilet wash hand basin and shower. A new call bell system has been fitted with pressure mats where required. Furnishings were domestic in nature and appeared to be meeting the needs of residents. A small sample of rooms were inspected and they were found to be of a good standard and had been personalised by residents and their families Each of the four house groups has an assisted bath facility, accessible from both sides and there are communal toilets. All areas are individually and naturally ventilated and windows are provided with restrainers. All areas are centrally heated with low surface temperature radiators to reduce the risk of scalding. Laundry facilities were sited on the ground floor. The home has just received a new roller iron and arrangements are to be made for it as the laundry area is rather small. The home has limited storage space, but the manager is making arrangements to increase this. Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 17 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 Staff morale was good and there was noted to be good relationships between staff and residents. The staffing levels are satisfactory to meets residents needs and the home employs robust recruitment procedures. EVIDENCE: Duty rotas indicated that there are two nurses and seven carers on duty during the day with one nurse and four carers overnight. Staff members are divided into teams who usually work together. The home employs ancillary staff to support the care staff and at the time of inspection the staffing levels appeared satisfactory for the current dependency of service users. A small sample of staff files were inspected and demonstrated a robust recruitment procedure. Currently the home is recruiting permanent staff and are utilising some agency staff to cover shifts in the interim. One of the visitors felt that communication was not as good when agency staff were on duty. The home is in a process of change having been taken over by a new organisation, which have a range of training material for induction of new staff. Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 18 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) 31,32,36,38 The manager, who is supported by the senior team, was enthusiastic and was working hard to implement new systems. The home is managed in the interests of the residents and their health, safety and welfare is protected. EVIDENCE: The new manager has been in post for a short period of time, but has had a number of years experience as the deputy manager in the home. She appeared enthusiastic and has applied to the Commission for registration. Staff were relaxed and friendly. They stated they enjoyed working in the home and found all the nurses approachable. They felt they worked as a team and communication in respect of the residents was good. It was felt that there had been an improvement in the atmosphere since the last inspection. The manager is in the process of commencing appraisals under the new organisations system, which follows on from the previous personal Performance Plans. Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 19 A sample of records were inspected in respect of maintenance and servicing of equipment, which was found to be up to date and satisfactory. The manager stated they were currently addressing the servicing of the wheelchairs and some of the areas identified by the fire officer. The home has a training programme for all mandatory areas such as fire prevention, first aid, infection control etc, which is on going. Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 20 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 2 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 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 x x x 2 x 3 Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 21 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 3 Regulation 14 Requirement The registered person must ensure all assessments of residents needs are comprehensive upon admission to the home and include full risk assessments. The registered person must ensure a comprehensive care plan is drawn up for all residents in the home outlining in detail the action to be taken by staff to meet their needs. The care plan must be updated when there is any changes. The registered person must ensure that records indicate follow up to all areas of concern. The registered person must ensure records clearly demontrate that residents have opportunity for visits from health professionals on a regular basis. The registered person must ensure a nutritional assessment is undertkaken on admission to the home and periodically for all residents in the home. The registered person must ensure: The correct administration and recording of all medication. All codes are Timescale for action 30/8/05 2. 7 15 30/8/05 3. 4. 7 8 17(2) 12(1) 10/7/05 30/7/05 5. 8 14 30/7/05 6. 9 13(2) 30/7/05 Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 22 7. 19 13(3) 8. 35 20 clearly explained. Two staff sign entries for all controlled medication. The minimum, maximum and current temperature of the fridge is recorded daily. The registered person must ensure the temperatures of all refrigeration equipment is recorded on a regular basis The Registered Person must ensure that where money is deposited in a bank on behalf of a resident the account is in the residents name. This area was not assessed at the time of inspection and has been carried forward. However the manager stated the issues have been addressed. 30/7/05 30/9/05 9. 10. 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 Good Practice Recommendations Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 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 © 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 Herondale E54 S63695_HerondaleNH_V238239_070705 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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