Inspection on 23/06/05 for Inglewood Residential Rest Home

This inspection was carried out on 23rd June 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 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

Inglewood Residential Rest Home 03/03/08

Inglewood Residential Rest Home 25/10/06

Inglewood Residential Rest Home 04/01/06

Inglewood Residential Rest Home 23/02/05

Inglewood Residential Rest Home 15/10/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE 330a Chester Road Streetly, Sutton Coldfield West Midlands B74 3LD Lead Inspector Maggie Bennett Unannounced 23rd June 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. 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Inglewood Residential Rest Home Address 330 Chester Road, Streetly, Sutton Coldfield, West Midlands, B74 3LD 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) 0121 352 1113 0121 352 1486 Mrs Janet Beecroft Mr Craig Chance Mrs Janet Beecroft Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2005 Brief Description of the Service: Inglewood is a detached extended two storey mock-Tudor house, which provides accommodation for twelve residents for reason of old age. Next door to the building are four flats providing accommodation for eight residents – four on the ground floor and four on the first floor. Each flat comprises two single bedrooms, a lounge/dining area, a kitchen and a bathroom. Residents are able to join the residents in the large home for the main meal of the day and also join in the social activities. The buildings are situated on the main Chester Road and are within walking distance of local amenities such as shops, places of worship and public transport, enabling easy access to Birmingham and Sutton Coldfield. There is adequate parking to the rear of the property with a south facing patio and gardens, which are well maintained. Planning permission has been granted for the home to be extended to provide care for 31 people. It is hoped that work will commence in July 2005. 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday between the hours of 9.00 a.m. and 6.20 p.m. During the course of the inspection 7 residents were spoken to, as well as 2 visiting relatives. Discussion took place with 2 care staff, the cook, the Deputy Manager and Manager of the home. The care plans of a sample of residents from the main home and those living in the maisonettes were seen and the care and support “tracked” for these residents. A tour took place of several areas of both buildings and various documents were inspected. What the service does well: What has improved since the last inspection? The manager and deputy manager constantly strive to improve their care planning systems, which are of good quality. The main areas of improvement 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 6 are yet to come and are eagerly awaited. The present system of the home being split into two sites does pose difficulties for residents and staff. 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. 330a Chester Road E55 S20855 330a Chester Road V235305 230605 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 330a Chester Road E55 S20855 330a Chester Road V235305 230605 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 All new residents to Inglewood receive a proper assessment to ensure that their needs will be adequately met. EVIDENCE: The assessment information on the two most recently arrived residents was seen at the inspection. This documentation showed that residents moving to Inglewood only do so following a proper assessment. The assessment information was found to be clear and comprehensive, providing the basis for the residents’ initial care plans. Inglewood does not offer intermediate care or rehabilitation. 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9 There is a comprehensive care planning system in place, which ensures that residents’ personal and social care needs are met. There is good liaison with healthcare professionals in order to meet healthcare needs. Medication administration was not up to standard in some areas and improvements are needed to ensure that residents’ medication needs are met. EVIDENCE: A number of residents’ care plans were seen at the inspection. The plans seen were comprehensive documents, giving clear details of the social, personal and healthcare needs of each individual and how these needs were to be met. All care plans contained a risk assessment. There was evidence of monthly reviews and of formal six monthly reviews. Where possible, care plans are signed by the resident. One resident spoken to was aware of her care plan and said that she had been involved in a review meeting. Healthcare plans are similarly comprehensive, containing evidence of good liaison with healthcare professionals. The Dentist, Optician and Chiropodist visit when needed. Equipment to prevent pressure sores (pressure relieving mattresses and cushions) is provided and the Continence Promotion Nurse 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 10 visits regularly. Opportunities for light exercise take place. Residents’ weights are taken on a monthly basis. It was noted that where the home had a concern about one resident, a fluid and food chart was in operation. It is recommended that a similar record is kept for two other residents. There is a policy in place for the receipt, recording, storage, handling, administration and disposal of medicines. The home uses a monitored dosage system and none of the present residents wish to self-administer. An inspection of the administration records and cassettes showed no discrepancies, but the home is recommended to use a code to indicate when “as needed” medication has been offered and is not needed by the resident. It is understood that when the extension work is carried out in the home there will be a new medication room and a drugs trolley will be purchased. This will be a great improvement on the current arrangement, which requires staff to return to the medication room to record when medication is taken. The home is reminded that when a new cupboard is purchased for controlled drugs it must meet the requirements of the Misuse of Drugs (Safe Custody) Regulation 1973 as amended. 6 members of care staff have successfully completed the Safe Handling of Medicines accredited training and only these staff administer medication. The home must take the following action: Only prescribed medication can be administered. The home has been acting illegally by administering admitriptyline on an “as needed” basis. Request the G.P. to review the administration of risperidone for one resident. Where medication is no longer required (in the case of a resident who was taken off morphine sulphate in Hospital) the home should request the G.P. to review. 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 The meals at Inglewood are of good quality, offering choice and variety and meeting dietary needs. EVIDENCE: The majority of the residents spoken to said that they enjoyed the food at Inglewood. The “good food” was mentioned a number of times. A visiting relative remarked that one of the reasons the home was chosen was because of the inviting smell of home cooking. The cook is very experienced and recognises the importance of attractive presentation. She is aware of individual likes, dislikes and nutritional needs. The menus demonstrate that a good variety of nutritional foods are offered, with alternatives provided. An inspection of the kitchen took place and adequate supplies of food were seen, including fresh fruit and vegetables. 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 12 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 and 18 There is a satisfactory complaints system in place to enable residents and their relatives to express any concerns they may have. Although staff appeared to be well aware of their responsibilities under the “Whistleblowing” policy, the Adult Protection Procedure needs to be updated to ensure that it is in line with local and national policies and procedures. EVIDENCE: There is a clear complaints procedure in place, a copy of which is given to all residents and their relatives. There is a system available for recording complaints, but no complaints have been received by the home. The complaints procedure includes information on how to refer a complaint to the Commission. The home do have a policy and procedure with regard to Adult Protection, but this is not in line with the local Social Services procedure or the Department of Health document, “No Secrets”. The home’s policy and procedure must be updated. Staff have not received training in Adult Protection and this must be arranged as soon as possible. 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 13 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 and 25 The home is comfortable, clean and well maintained. The practice of using wedges to prop open fire doors poses a risk to residents and must cease. The planned extension and refurbishment should significantly improve the environment to the benefit of the residents. EVIDENCE: Inglewood is situated on the Chester Road in Streetly, within easy access to Walsall, Sutton Coldfield and Brownhills. The main home accommodates 12 people and the maisonettes next door accommodate 6. 5 of the residents from the maisonettes spend their day in the main home. Building work is due to commence in July to combine the two buildings, making a large home with accommodation for 31 people. It is hoped that this will be completed in January 2006. One resident from the maisonettes commented that the change could not come quickly enough for her. She said: “I’ll be glad when the move has taken place. It was very cold coming over in the winter – it’s too much for me.” 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 14 There are safe and attractive grounds, which were being enjoyed by the residents at the time of the inspection. Several fire doors were found to be wedged open. This practice must cease. If residents wish their bedroom doors to be open, automatic closures must be fitted. The new build will eradicate the present problems with regard to access to toilets (the ground floor toilet is difficult to access for those using zimmer frames). A separate sluice facility is also to be provided. It was found that several of the commodes need replacing with more up to date, hygienic models. Not all radiators are covered at present, but will be when the building work is completed. Water temperatures at outlets accessible to residents were measured in some areas and were satisfactory. The temperatures are checked and recorded on a regular basis. 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 15 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 and 29 The numbers of staff on some afternoon shifts has been insufficient, particularly bearing in mind that these staff cover the maisonettes in addition to the main home. When this occurs, residents may be at risk. There are good recruitment procedures in place. The home must make sure that up to date CRB and POVA checks are carried out so that residents are fully protected. Staff morale is high resulting in an enthusiastic workforce who work positively with the residents. EVIDENCE: The staff rota showed that during the morning shift there are usually 3 members of care staff on duty from 8.00 a.m. From 2.00 p.m. to 4.00 p.m. there are, at times, only 2 members of care staff, with an additional member of staff coming on duty at 6.00 p.m. The registered manager’s hours are supernumerary, but she does spend some hours working with the residents. The day-time shift finishes at 10.00 p.m. During the night there is one waking member of staff at Inglewood and one waking member of staff in the maisonettes. The majority of the residents from the maisonettes (5) spend their day at Inglewood, making the total in the main home, 17 residents. One resident prefers to remain in the maisonettes, but spends considerable periods alone, all main meals being taken by staff to the maisonette. The manager states that were any of the residents in the maisonettes to become unwell or require more assistance, then extra staff would be brought in. The manager is required to carry out an assessment of the needs of the residents and calculate staff numbers required in accordance with the guidance recommended by the 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 16 Department of Health, the Staff Calculation Tool. Particular attention must be paid to the risk to the residents in the maisonettes, especially those who are on the first floor and have to use stairs. It is recognised that all residents will ultimately be living in the same building and that a vertical lift will be installed. There are no separate domestic staff employed for cleaning and the manager is aware that additional staff will need to be brought in for these duties when the home is extended. The cook is employed on 5 days a week. When she is not on duty care staff undertake additional shifts to carry out cooking duties. The home does accept trainees under 18. Any such staff are supernumerary and do not undertake any personal care tasks. The home must ensure that the member of staff under 21 is not left in charge of the home at any time. There are generally good recruitment procedures in place, but the home has been operating under the misconception that Criminal Records Bureau checks and POVA checks are portable from one establishment to the other and they are not. No new staff must commence work until satisfactory CRB and POVA checks have been received. If the home needs to urgently employ a new member of staff a POVA First check must be carried out in addition to a risk assessment. Staff spoken to were enthusiastic and committed. One said: “I love my job”. Residents commented that the staff were good, one said: “They look after us well.” Another said: “They listen to us”. One relative commented that she was pleased staff encouraged her mother to retain some independence. 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 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) 38 There are good practices and procedures in place to protect the health, safety and welfare of service users and staff, with the exception of the use of door wedges noted in Standard 19. Night staff must receive the same training in health and safety areas as those staff employed in the day-time. EVIDENCE: Staff records showed that the majority of staff have received regular training in the core health and safety areas of: first aid, fire safety, moving and handling, food hygiene and infection control. The exception was a member of night staff, whose records showed no indication of training in these areas. There was evidence that fire safety checks are carried out at the required intervals. It is noted in Standard 19 above that several fire doors were found to be wedged open. Verification was seen of the regular servicing of equipment. The home’s COSHH assessments have recently be reviewed. The Accident Book was correctly completed and the CSCI are notified of any incidents, 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 18 accidents or illnesses under Regulation 37. It is recommended that the manager develop a checklist for all staff to ensure that all safe working practice topics are covered in induction and foundation training. 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 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 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 4 COMPLAINTS AND PROTECTION 2 x x x x x 3 x 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 2 x x x x x x x 2 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 20 no 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 9 Regulation 14(2) Requirement The registered manager must request the G.P. to carry out a review of the prescribed medication (risperidone) to one resident. Where medication is no longer required, the home must request the G.P. to review. Only prescribed medication must be administered. It is illegal to adminster any medication other than at the time and frequency prescribed in writing by the Doctor. The home must have in place robust procedures for responding to suspicion or evidence of abuse or neglect. These procedures must be in line with the local Social Services procedure and the Department of Health document, No Secrets. Staff must receive training in Adult Protection. Fire doors must not be wedged open. If residents wish their doors to be open, automatic door closures must be fitted. The manager must carry out an assessment of the needs of the residents and calculate staff numbers required in accordance Timescale for action 08/07/05 2. 9 13(2) 23/06/05 3. 18 12(1)(a) 31/07/05 4. 5. 18 19 18(1)(c)(i ) 23(4) 31/07/05 With immediate effect. 15/07/05 6. 27 18(1)(a) 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 21 7. 8. 27 38 18(2) 12(1)(a) with the guidance recommended by the Department of Health. Staff left in charge of the home must be at least aged 21. All care staff (including night staff) must receive regular training in first aid, fire safety, moving and handling and infection control. 23/06/05 31/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 8 9 Good Practice Recommendations It is recommended that food and fluid charts are put into operation where there is a concern about a residents weight. It is recommended that when as needed medication is not required by the resident, a code is used on the administration sheet. This indicates that the resident was offered the medication. It is recommended that an audit take place of commodes and that old and unhygienic commodes are replaced. It is recommended that the manager develop a checklist for staff to ensure that all safe working practice topics are covered in induction and foundation training. 3. 4. 24 38 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen B62 8DA 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 330a Chester Road E55 S20855 330a Chester Road V235305 230605 Stage 4.doc Version 1.40 Page 23 - 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. 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