Inspection on 03/03/08 for Inglewood Residential Rest Home

This inspection was carried out on 3rd March 2008.

CSCI found this care home to be providing an Excellent service.

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 25/10/06

Inglewood Residential Rest Home 04/01/06

Inglewood Residential Rest Home 23/06/05

Inglewood Residential Rest Home 23/02/05

Inglewood Residential Rest Home 15/10/04

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Ravenhurst

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Inspirations

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

CARE HOMES FOR OLDER PEOPLE Inglewood Residential Rest Home 330 Chester Road Streetly Sutton Coldfield West Midlands B74 3ED Lead Inspector Martin George Key Unannounced Inspection 3rd March 2008 09:20 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 Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Inglewood Residential Rest Home Address 330 Chester Road Streetly Sutton Coldfield West Midlands B74 3ED 0121 352 1113 0121 353 9005 inglewood@netscape.net Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Janet Beecroft Mr Craig Chance Mrs Janet Beecroft Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2006 Brief Description of the Service: Inglewood is a detached two storey mock-Tudor house, which has recently been extended and refurbished to provide accommodation for 31 residents for reason of old age. There have been considerable improvements to the physical environment and Inglewood now provides 25 single rooms, 20 of which have an en suite toilet and 3 double rooms, 2 of which have an en suite toilet. Communal space consists of 2 lounges, a conservatory, a visitors’ room and a large dining room. There is a car park to the rear of the property and an attractive, landscaped garden with a patio area. The building is situated on the main Chester Road and is within walking distance of local amenities such as shops, places of worship and public transport, enabling easy access to Birmingham and Sutton Coldfield. The fees charged at Inglewood range from £377 to £427 per week. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This unannounced key inspection was carried out by a single inspector between 09:20 and 16:00. As part of the inspection all National Minimum Standards defined by the Commission for Social Care Inspection (CSCI) as ‘key’ were inspected. Information about the performance of the home was sought and collated in a number of ways. Prior to inspection we were provided with written information and data about the home through their annual quality assurance assessment (AQAA). The views of a number of people living at the home, the manager and staff working there were also acquired, through a number of discussions during the inspection. Information was analysed prior to inspection and helped to formulate a plan for the visit and helped in determining a judgement about the quality of care the home provides. On the day of the inspection we checked several records, looked round the building, took lunch with the residents and observed practice. What the service does well: What has improved since the last inspection? The manager has significantly improved the needs assessment carried out prior to placement and evidence of reviews of care plans is now much clearer. There is evidence that leisure opportunities are more varied but residents remain reluctant to broaden their activity options in the wider community, but the home quite rightly respects this as their choice. Staffing numbers are at a safe level for the protection of residents. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 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 Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Quality in this outcome area is excellent. The needs of residents are assessed and met by a competent and committed manager and team of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both the service user guide and the statement of purpose were comprehensive, written in plain English and were relevant to the resident group. Each of the resident’s files contained a nicely worded letter confirming the placement following completion of the assessment of need. The Annual Quality Assurance Assessment (AQAA) submitted by the home prior to the inspection states that prospective residents are invited to spend a day at Inglewood where they are invited to meet current residents, look around the home and partake in mealtimes, at no cost to them. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 9 We checked files for residents who were self funded and for those who were Local Authority funded and found both to have very good pre-placement assessments of need. The manager told us that she completes assessments for all the residents (whether self funding or Local Authority funded) as she feels the assessments completed by social services and health often fall short of her expectations. Where possible the manager meets with prospective residents in a place of their choosing. This showed a commitment to finding out as much as possible about the residents to help provide them with the right level of care. We spoke to the daughter of one recently admitted male resident who explained how delighted she was with the care provided to her father. She had experience of other homes (her mother was in one during her final years) and told us that Inglewood far exceeded any other home she had knowledge of or had actually visited. One female resident we spoke to told us how she had been very reluctant to visit the home when her family were looking for somewhere for her but within a couple of hours of arriving on her trial day she knew she would be happy at Inglewood. She told us that the staff were so friendly and did everything possible to make her feel welcome. Another female resident who was on 2 weeks respite reinforced this view. She also made the point that staff treated her no differently from long term residents, which made it easy for her to settle in. Inglewood does not provide intermediate care. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is excellent. The health and personal needs are well recorded, reviewed and known about by staff, providing residents with safe and effective care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans we examined were designed in a way that made them very easy for staff to follow and find information specific to an area of need for that particular resident. It was good to see the plans word processed as this eliminates any risk of handwritten information being difficult to read, with the potential of staff providing inadequate care to the resident concerned. Care plans contained clearly written information for staff about how they should meet specific needs of residents. We also found a range of risk assessments, including for risk of falls. Care plans were reviewed monthly, updated when necessary, and with copies of previous plans kept in the file. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 11 We found evidence on the files we checked of the promotion of continence and management of pressure sores. We saw evidence of nutritional screening and records showing that residents were regularly weighed. Records kept by the home made it easy to see when health professionals had visited, as every visit and action was recorded in the daily log book and also on every individual resident’s file. We were satisfied that medication practice continues to fully comply with regulations. We observed part of the lunchtime medication round carried out by one of the senior staff. She explained the process used, which was consistent with good practice guidance and which fully safeguarded residents. The blister packs used by the home are supplied by Lloyds pharmacy and our observation confirmed that the transfer from pack to administration is carried out safely. We also checked the storage facilities and medication disposal practice and found these to be in order. We noted that the home has a policy regarding self-administration of medication but none of the current residents self-administer. The home has also completed a policy relating to homely remedies, which incorporates the necessary safeguards. Throughout the day we observed very friendly interactions between staff and residents, which was reinforced by the fact that staff were carrying out their duties with almost constant smiles, indicating satisfaction with their role. Numerous comments from residents confirmed to us that they feel respected and wanted and that nothing is too much trouble. We read a number of excellent quality assurance statements and comments made by residents, their relatives/advocates and health care professionals, consistently rating the home very highly. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. The preferences of residents are listened and responded to, providing a person centred approach to their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a wide range of activities on offer, mostly in-house. The AQAA states that Inglewood provides therapeutic and relaxation activities, including a piano and stereo equipment with a large music collection of all types, audio equipment, weekly bingo sessions with prizes, mobile library, newspaper delivery, weekly hairdressing, jigsaws, dominoes, arts and crafts, needlework, and board games. The manager told us that several of the current residents are hesitant about getting involved in activities within the wider community. This view was reinforced during our conversations with several residents throughout the day, who all seemed more than happy to have activities organised within the home or be left to their own devices. Three residents told us separately that if they wanted to do things in the community then the home Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 13 would organise it for them. The manager and some of the residents informed us that the weekly Bingo session on a Friday was very popular. Visitors are welcome at any time throughout the day and three relatives we spoke to confirmed this and stated they were always made very welcome and were always kept informed and involved in the care of their relatives. We had lunch with the residents and found this to be a very relaxed and pleasant experience. The food was of good quality and was well received. Several residents we spoke to stated that they were not bothered what was served as it was all so good. We were informed though that the menus were designed around the preferences of residents and we saw evidence of a well balanced and nutritious range of foods. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is excellent. Residents and their relatives feel confident about the ability of the manager and staff to provide a good quality and safe living environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When we asked to see the complaints book we were presented with one with no entries at all. The manager confirmed that there have been no complaints. We checked the policy, which explains how the procedure works and this is on display for all to see. Residents and relatives we spoke to were very clear about how to make a complaint if they needed to but stated they had never had reason to do so. Two relatives we spoke to said that when they had any minor concerns or questions they just asked to see the manager who listened to what their concern was and dealt with it quickly and without undue fuss. Protection of Vulnerable Adults training has been completed and our observation throughout the day evidenced good safeguarding practice by all of the staff on duty. Residents were very vocal about how well their needs were Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 15 met and how safe they felt and several were extremely complimentary about the staff and the manager. The interactions between staff and residents were very equal (slightly reminiscent of a mother/daughter relationship), whilst at the same time managing to maintain professional boundaries. The home has a policy for dealing with any physical and/or verbal aggression by residents but the manager could not recall any occasion when it had to be put into practice. There is also a policy on whistle blowing, which staff we spoke to were aware of. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24 and 26 Quality in this outcome area is excellent. Residents are provided with a clean and safe living environment that meets their group and individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Our initial impression upon arrival was very positive and inviting. The home immediately presented as a spotlessly clean and odour free environment. When we looked round the home we found this to be the case in all areas of the home. Floor coverings throughout the home were of good quality. Seating in the lounge areas was of a design suited to the residents, allowing them easy transition from being seated to standing. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 17 The décor throughout the home was fairly simple and was largely based around magnolia walls, but combined with other artistic touches it proved surprisingly effective and pleasing on the eye. The home was light and airy and there was no part of the home that was less pleasing to be in than another. There was a conservatory that led out onto a well maintained garden and patio area. The AQAA states that this area is frequently used by many of the residents during warmer periods of the year. Bedrooms we looked at were spacious, had good quality furnishings and all the necessary safeguards to keep the resident safe from harm. There was evidence that residents could personalise their rooms and this was particularly evident in one room, which was noticeably colder than all other areas of the home, because the female resident insisted that the heating be left off or very low as that was how she liked it. Three rooms were shared and these had screens to provide the necessary level of privacy when needed. Hygiene standards throughout the home were to a very good standard. As people enter the building they are expected to use the hand cleansing dispenser located just inside the entrance. Our observation at various times of the day evidenced that people either did use it or were encouraged to do so if they looked as they were not going to. The laundry area was well ordered and had machines that met requirements for disinfection. The washing machine had a sluicing facility. The home had no requirements from either the Environmental Health Officer (EHO) or the fire officer. The AQAA stated that Inglewood was visited and inspected on a regular basis by the Fire Officer, Water Providers, Electrician, Gas Inspector, Environmental Health and had passed all inspections. The kitchen had high standards of hygiene with all necessary records kept in order and up to date. Most residents have a key to their room but the few that do not, because of dementia, need to have a risk assessment completed identifying this as the reason why. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. The needs of residents are met by a well trained and competent team of staff and a manager committed to ongoing development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The rotas we examined showed good levels of cover throughout the day and night, with senior care workers on duty at all times. At the busiest times of the day there were four care staff on duty to ensure that the needs of residents could be satisfactorily met. We looked at training records and saw evidence of the training that has been undertaken. The layout used made it easy to see dates when staff had attended courses and when they needed to attend refresher courses. The manager explained that Diana Smith, a training officer from Walsall, would be providing the home with a range of free training covering all the mandatory areas. The emphasis on the continuing professional development of the staff team will ensure residents continue to receive good quality care. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 19 Staff records we examined contained all the required information, had evidence of robust recruitment practices and terms and conditions were signed and updated when a member of staff was promoted or changed job role. The home was in the process of introducing the Skills for Care common induction standards, which the manager stated she felt would help to develop new staff more effectively than the induction the home had been using to date. The manager believed it would give new staff a more comprehensive understanding of the needs of residents. We observed the 2pm handover session and evidenced a good range of useful information about the residents being passed over to the oncoming team of staff, which helped to maintain consistent care. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38 Quality in this outcome area is excellent. Residents are cared for by staff who find time to engage with them in between their formal duties. The team is well managed and confident in their roles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is competent and well qualified for the post she holds. She has 18 years of experience of working at Inglewood, both as practitioner and manager. We were shown a very helpful set of bar charts that gave the results of resident, relative, staff and professional surveys that the home has had completed. What was particularly good was that these were linked to sheets on Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 21 which any actions arising from the comments provided were recorded. From these it was easy to see how practice was adapted to provide a better service to the residents. We saw a copy of a very comprehensive fire risk assessment that the home had requested from a professional fire safety service. Actions identified in the report had been completed. We also saw the most recent EHO report, which contained no requirements. The training records we examined provided evidence that all required health and safety related training had been completed or was planned. Our observation of practice confirmed that health and safety issues with regard to fire safety, moving and handling, infection control, food safety and the management and recording of accidents helped to protect residents from preventable harm. We checked the records kept for resident’s money and were satisfied that the recording process being used safeguards them from potential misuse of their money. Our observation of interactions between the manager and her staff and between senior and other staff evidenced a clear understanding of accountability within the whole team. Staff seemed to be confident in the roles they were performing and this allowed them to find space in their busy schedules to engage in an unrushed manner with the residents. Several residents and relatives were extremely complimentary about how well the home is managed. Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 4 x 4 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 4 4 x x x 4 4 x 4 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 4 x 3 x x 4 Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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 Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Inglewood Residential Rest Home DS0000020855.V355445.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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