Inspection on 18/03/06 for Heyberry House

This inspection was carried out on 18th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Heyberry House 21/08/07

Heyberry House 06/03/07

Heyberry House 05/08/05

Heyberry House 09/02/05

Heyberry House 29/09/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Heyberry House 3 Ashville Road Birkenhead Wirral CH41 8AU Lead Inspector Beate Roth Unannounced Inspection 18th March 2006 10:00 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 Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 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. Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Heyberry House Address 3 Ashville Road Birkenhead Wirral CH41 8AU 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) 0151 653 3225 Anchor Trust Mrs Joan McKevitt Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th August 2005 Brief Description of the Service: Heyberry House is a purpose built three storey residential home that is registered to provide personal care for 41 older people. All bedrooms are single occupancy with en-suite facilities. There is one large lounge/dining room and a conservatory on the ground floor. In addition, there is a seating area off the corridors on each floor of the home. Specialist bathing facilities are provided in the home and a passenger lift services all floors. There is a garden/patio area at the rear of the home, which overlooks Birkenhead Park. Parking is available at the front of the building. The home is situated in the Birkenhead Park area of Wirral close to Claughton village and Birkenhead town centre, it is serviced by both rail and bus services. Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over half a day. During the inspection time was spent in the office examining records and policies and procedures and talking to senior staff. A tour of the home was undertaken. Staff were observed delivering care to residents. The inspector spoke to residents and to staff. What the service does well: What has improved since the last inspection? What they could do better: Improvements need to be made to the management of medication in order to fully safeguard residents. Medication must be administered in accordance with the homes medication procedure. A risk assessment is needed for the storage heaters in the communal areas of the home as these can become hot and are not guarded. A monthly written report on the conduct of the care home is to be provided to CSCI. Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 Page 6 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. Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 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 Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 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): 2, 3 and 5 New residents are fully assessed before they are admitted to the home in order to ensure their needs can be met. Opportunities to visit the home are provided and residents have a contract, which ensures they have information to assist in making a decision as to the suitability of the home. EVIDENCE: The records relating to three residents who have come to live at the home since the last inspection were examined. Each resident has a contract that contains all the required information. Residents are admitted on a 6-week trial basis. The records provided evidence of appropriate assessments being carried out before new residents move to the home. There was also evidence that information is gathered from social workers and health professionals to inform the assessment. The manager, deputy or senior carers, undertake the initial assessment of prospective residents. During the first 6 weeks at the home further assessment of residents’ needs takes place, which provides the basis for ongoing care planning. A review of the service provided and whether it is suitable takes place after the first 6 weeks of living at the home. Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 Page 9 Inspection of records and discussion with the care staff and a senior carer confirmed that prospective residents are able to visit the home on an introductory basis. During these visits they can meet staff and current residents and view the home. Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10 The needs of residents are well supported by the care planning processes in place at the home. Residents feel they are treated with respect. Improvements need to be made to the management of medication in order to fully safeguard residents. EVIDENCE: A sample of residents records were looked at and indicated that residents have a care plan in place to ensure that staff are able to meet their identified needs. Care plans are produced on admission, and are reviewed after six weeks. At six weeks an individual lifestyle agreement plan is produced which provides the staff team with detailed information with regard to the care needs of the resident. The individual lifestyle agreement is produced with the input and cooperation of the resident. Risk factors are identified and when required management plans are put in place. A sample of risk management plans were seen and provided sufficient information for staff to refer to. A discussion took place with the senior carers around improvements that could be made to the format to make the risk assessments easier to refer to. Residents spoken with were very positive about the care they receive. Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 Page 11 The records at the home indicated that referrals are made to health professionals in accordance with the needs of residents. A record is made of visits by health professionals and the outcome is documented. Residents spoken with said that their health needs are well met. An appropriate record of accidents is maintained. The medication management system in place at the home has changed since the last inspection and there is a revised medication procedure available. The home provides secure medicine storage facilities. Staff who administer medication have received appropriate training. A sample of medications for 5 residents and the corresponding records were examined. This indicated that some medication had been signed for but not administered and that there was no record to indicate whether two types of medication, that were not in their container, had been administered. Following a discussion with the senior carers it was evident that the procedure for administering medication was not being followed. The procedure indicates that medication is to be taken to the resident and signed for once it is clear that the resident has taken it. Senior staff reported that they are not taking the medication administration record sheets with them when they give out medication. Medications are being signed for on return to the medication room when several medications have been administered. Medication must be administered in accordance with the homes medication procedure. Controlled drugs are appropriately stored. Records were checked against stock held and were found to tally. Staff receive training and guidance around how to meet a residents needs in a dignified manner and how to respect their privacy. The staff were observed to address residents in a respectful and polite manner. The residents spoken with said staff are “kind,” “polite” and that “ staff respect my privacy.” Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 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 the following standard(s): 13, 14 and 15 The home maintains community links, encourages visitors and encourages residents to make choices, which ensures that the social and emotional needs of residents are promoted. Residents receive appealing, well-balanced meals in pleasant surroundings. EVIDENCE: The individual lifestyle agreement details the key relationships residents wish to maintain and the community based activities they were involved in prior to living in the home. The home operates an open door policy to visitors. This visiting policy was displayed in the entrance hall and in the service users guide. During this inspection, the residents who were spoken with said they felt their visitors were made to feel welcome. A number of visitors were observed visiting the home during the inspection and were greeted warmly by the staff. Discussion with residents and staff indicated that the home encourages residents to make decisions about their day-to-day lives at the home, such as when they will get up and go to bed and what they will do each day. Each of the residents’ bedrooms seen had been personalised with items brought in from their own homes. The contact details for advocacy services are available. Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 Page 13 Observations of the dining area indicated that a pleasant environment is provided for residents to have their meals. Residents were appropriately assisted to eat their meals by staff as necessary. Liquidised food was available to residents in accordance with their needs and was very well presented. There is a choice of meals. The food prepared looked appetising. Menus are displayed in the main reception for residents and their visitors to view. Visitors may eat with the person they are visiting as long as sufficient notice is provided. The records of menus indicated that a variety of meals that would provide a balanced diet are available. Any special dietary needs are written in to a residents care plan. A dietician is consulted where necessary. When asked about the food provided, residents described the food as “excellent” and said it is of a “good quality and that “a variety is offered.” A number of residents commented very positively about the variety of deserts available on the sweet trolley. The record of a recent residents meeting said “all residents agreed that the sweet trolley is gorgeous.” Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18 The home has a satisfactory complaints system which residents know how to access. The procedures at the home and training provided to staff around adult protection safeguard residents. EVIDENCE: The home has a detailed complaints’ procedure. On admission to the home, each resident is given a copy. A record is made of any complaints received. An examination of this record indicated that there had been two complaints since the last inspection, which had been responded to in a timely and satisfactory manner. A discussion with the senior carer indicated that any complaint made by a resident is taken seriously and handled in a sensitive, thorough and non-biased manner. During the inspection, the residents who were spoken with confirmed that they would be confident to approach the registered manager or other senior members of the management team, if they had a complaint or concern about the service. Since the last inspection a number of staff have attended adult protection training. Arrangements have been made for the remaining staff to attend this training. Staff spoken with were aware of the procedure to follow in order to protect older people from abuse. A copy of Wirral Borough Council’s adult protection procedure is available at the home. Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 Page 15 Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 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, 24, 25 and 26 The home is well maintained and there is a good standard of cleanliness and hygiene, providing residents with a pleasant environment to live in. EVIDENCE: A tour of the home was undertaken. This included an inspection of the communal areas and a sample of the bedrooms. This indicated that the home is well maintained and decorated to a high standard. There is a rolling programme of re-decoration and refurbishment. The bedrooms seen were suitably furnished. All bedrooms are single with en-suite sink and toilet. Residents have personalised their bedrooms. Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 Page 17 The water accessible to residents is maintained at a safe temperature. Covers have been fitted to electric storage heaters in bathrooms and bedrooms to prevent any possible risks to residents. The senior staff reported that radiator covers are to be fitted to the storage heaters in communal areas. In the meantime a risk assessment is to be recorded for the storage heaters in the communal areas, as at the time of the inspection, some of these heaters were hot and could pose a possible hazard to the well being of residents. All areas of the home seen were clean and fresh smelling at the time of the inspection. It was evident that the domestic staff are working hard to maintain good standards. Appropriate laundry facilities are provided by the home. Preferred laundry routines are discussed with residents and documented in the individual lifestyle agreement. Procedures relating to COSHH and protective clothing are available for domestic staff. Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 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): 28, 29 and 30 The needs of residents are met by the numbers of staff and the training staff have received. The recruitment practices at the home safeguard the welfare of residents. EVIDENCE: The rota and a discussion with the staff and residents indicated that there are sufficient numbers of staff to meet the needs of the residents living at the home. There is a clear staff structure in the home that includes the manager, deputy manager, senior care staff, care staff and ancillary staff. The records of 1 new member of staff who has been employed since the last inspection were examined. These records were very well maintained and contained all the required information. Residents are involved in the recruitment of new staff and form part of the interview panel. An induction and foundation training programme are provided to all new staff. This training meets the National Training Organisation specification. A new member of staff was interviewed and reported that they had received the training and guidance they needed to be able to appropriately care for the residents. New staff work alongside existing staff until they have been assessed as competent. Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 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 and 35 The management systems promote the wellbeing of the residents. EVIDENCE: The registered manager has managed the home for several years. The manager has completed the registered managers award and has attended training to keep her skills and knowledge up to date. The staff interviewed were clear about the lines of accountability at the home. Staff meetings and residents meetings are held on a regular basis. Staff and residents spoken to said that their views about the day-to-day operation of the home are sought. There is an equal opportunities policy available. All staff have access to the General Social Care Council’s Code of Practice and staff have been made aware of the standards expected of them. There are comprehensive quality assurance and monitoring systems in place at the home. The views of service users and other stakeholders are sought Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 Page 20 regarding the operation of the service. The regional manager undertakes monthly regulation 26 visits which includes discussions with the staff and service users. A copy of these reports are to be sent to CSCI. The records and the home environment are regularly inspected by the manager and senior managers. The senior carer reported that the home does not look after any money for residents. The financial affairs of residents are managed by the residents themselves, or by their family or a solicitor. Residents are able to bring personal possessions to the home Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 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 X 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X 3 2 4 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X X Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 Page 22 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. Standard OP9 Regulation 13 Requirement The registered persons must ensure that medication is administered in accordance with the homes medication procedure The registered persons must ensure that a risk assessment is available for the storage heaters in the communal areas that can become hot and are not guarded. The registered persons must ensure that a monthly written report on the conduct of the care home is provided to CSCI. Timescale for action 18/03/06 2. OP25 13 18/03/06 3. OP33 26 18/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Heyberry House DS0000018894.V286699.R01.S.doc Version 5.1 Page 24 - 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!